Annual Report and Accounts 2017/2018 Mid Essex CCG Annual Report and Accounts 2017/18
Contents
Contents...... 2
Chair’s foreword ...... 3
1. Performance Report ...... 5
Accountable Officer’s introduction ...... 5
1.1 Performance Overview ...... 6
1.1.1 What Mid Essex CCG does ...... 6
1.1.2 Key issues and challenges ...... 14
1.1.3 Performance Summary ...... 17
1.1.4 Financial Overview ...... 20
1.2 Performance Analysis ...... 24
1.2.1 Improve quality ...... 24
1.2.2 Health and wellbeing strategy ...... 28
1.2.3 Engaging people and communities...... 29
1.2.4 Reducing health inequality ...... 33
1.2.5 Detailed review of the CCG’s development and performance ...... 35
1.2.6 Sustainable development ...... 41
2. Accountability Report...... 43
2.1 Corporate Governance Report...... 44
2.1.1 Members Report – member practices ...... 44
2.1.2 Composition of Governing Body ...... 45
2.1.3 Board Members and Other Elected GPs ...... 45
2.1.4 Personal-data-related incidents ...... 50
2.1.5 Statement as to disclosure to auditors ...... 50
2.1.6 Donations to political parties and charitable organisations ...... 50
2.1.7 Modern Slavery Act ...... 50
2 Mid Essex CCG Annual Report and Accounts 2017/18
2.1.8 Statement of Accountable Officer’s Responsibilities...... 51
2.2 Governance Statement ...... 54
2.2.1 Introduction and context ...... 54
2.2.2 Governance arrangements and effectiveness ...... 55
2.2.3 Risk management arrangements and effectiveness ...... 62
2.2.4 Other sources of assurance ...... 67
2.2.5 Control Issues...... 70
2.2.6 Review of economy, efficiency and effectiveness of the use of resources ...... 70
2.2.7 Review of the effectiveness of governance, risk management and internal control ...... 73
2.3 Remuneration and Staff Report ...... 75
2.3.1 Remuneration Committee Report ...... 75
2.3.2 CCG staff ...... 85
2.3.3 Off-payroll engagements longer than six months ...... 89
2.3.4 Expenditure on consultancy ...... 90
2.3.5 Pension liabilities ...... 90
2.4 Parliamentary Accountability and Audit Report (subject to audit) ...... 91
3. Independent Auditor’s Report to the Members of the Governing Body ...... 92
4. Annual Accounts ...... 95
Appendix A: Glossary of non-financial terms ...... 96
Appendix B: Glossary of financial terms ...... 98
Chair’s foreword
I am coming to the end of my time as an elected GP and Chair of NHS Mid Essex Clinical Commissioning Group (CCG), since all GP Board members can serve only two terms of three years. I shall begin handing over to my successor next month, but I know they will be brilliantly supported by the very capable leadership of an organisation I have been proud to be part of.
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Mid Essex CCG has helped the people of our area to look after themselves and get the health and care services they need. We work against a background of local financial pressures you can read about in this report, as well as the national issues of rising demand and staffing difficulties – but we are determined to keep patients at the heart of what we do.
I look back with particular pride at the dedication of the whole CCG team, at every level of the organisation, to improving care for patients. Our growing use of patient stories in driving our commitment to deliver improved care has helped all of us to realise that everything we do can help individuals, families and carers.
As an organisation we can also see the bigger picture, including how our local Sustainability and Transformation Partnership (STP) can overcome some of the difficulties we as a single organisation cannot. We have fully engaged with the STP and supported the establishment of a CCG Joint Committee, as we discuss in this report. Now we are undertaking a new and exciting transformation programme as a CCG for out-of-hospital care.
Those who know me well will realise how happy I am to see us take control of the mental health agenda. We have signed up to the Time to Change initiative, focused on reshaping attitudes to mental health, and have started to transform the way care is delivered. Our emotional wellbeing service for children has won national recognition, our perinatal health service is truly integrated with primary care and the Dementia Intensive Support Service, which you can read more about in the Performance Overview below, is off to a great start. All offer easier access to services, helping patients, their carers and the professionals around them.
There are many examples of great practice in mid Essex, from Continuing Health Care and support for our residential and nursing homes to a new dementia-friendly primary school initiative and the palpable improvement in primary care morale. We even have a new medical school in our area!
There are too many things I am proud of to list in full, but I do want to thank everyone at the CCG for their hard work and dedication. People in the CCG have time for each other, too, and, as Chair, I have been touched by instances of individuals helping others who are going through a rough patch. We also support other parts of the health and care system when they struggle.
Improvement happens best when challenges are approached positively. The decisions the CCG has taken while I have been Chair have sometimes been very difficult, but they have all been informed by strong clinical knowledge, in-depth experience of health and care, robust evidence and as far as possible, input from the people affected and the wider community.
This is the way I expect Mid Essex CCG to continue to operate and I wish it and the people it serves the very best for the future. I know they will be in safe hands as I return to my regular role in general practice.
Dr Caroline Dollery Chair
25 May 2018
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1. Performance Report
Accountable Officer’s introduction
The past year has seen some major changes in the way NHS services are planned and how care is offered across the country, with the introduction of 44 new Sustainability and Transformation Partnership, or STPs. These are part of the national NHS Five Year Forward View and Mid Essex CCG has been closely involved in developing our own Mid and South Essex STP.
Our local STP covers people living in Braintree District, Chelmsford City and Maldon District – together making up mid Essex – alongside residents of Brentwood, Castle Point, Southend and Thurrock Boroughs, and the Districts of Basildon and Rochford. There are a great many people living across these areas – about 1.2million in all – and we believe by planning some health services at this scale, people will benefit from better care and a greater depth of clinical expertise.
There is more information about how the STP operates and who is involved later in this report, but it is worth noting that one of the early changes it has brought is a decision from the five CCGs involved, including Mid Essex CCG, to plan and buy hospital services through a Joint Committee. New ways of working bring change and we have been talking to people across mid and south Essex about some initial proposals around hospital care that have emerged from conversations within the STP. You can read more about that later in this report, too.
What has not changed, though, is the commitment of Mid Essex CCG since we were formed in 2013 to continue holding conversations with local people about how we provide them with the best care when they need it, how we help them to be well and stay well, and how we make sure our services stay sustainable.
Such conversations have not always been easy, with concerns from a number of quarters about some of our plans – which we hope we have now addressed – as well as the overall NHS financial picture and very challenging financial settlement we have.
But healthcare is not just about the need to limit costs and make savings. The decision taken by the five CCGs in mid and south Essex to plan hospital care jointly offers Mid Essex CCG a real opportunity to focus our work much more closely on out-of-hospital care. On any given day, out of hospital services account for the largest number of patient contacts with the NHS and when done right, help people stay out of hospital and recover more quickly if they have had a recent hospital stay.
That is going to be our priority going forward, and we have reshaped the CCG to support our new priorities. I am genuinely excited about the opportunities our new focus brings to support our hard- working GP practices, mental health services and community healthcare providers.
Our vision – that “We want everyone in mid Essex to Live Well” – helps us keep our eyes on that goal. Back in 2015, we began planning healthcare around five stages of life, based on an idea
5 Mid Essex CCG Annual Report and Accounts 2017/18 developed by our partners at Braintree District Council. I am delighted that other CCGs and local authorities have seen the benefits of this approach and are adopting the Live Well model in their plans, too.
Live Well has always relied on the CCG talking to our communities and patients about self-care, lifestyles and changing health behaviours. Our new out-of-hospital focus makes participation from our local residents – you – even more important. You are the experts about what is happening in your community and what local needs might be as we develop local NHS services and make sure they are sustainable in the longer term.
The past 12 months have been a very important time for Mid Essex CCG and our communities. And we will continue to deliver safe and high quality services for the present as we look to transform services for the better into the future. We want you to be at the heart of what form that transformation takes to keep our local NHS services here for you in the years to come.
You can follow us @MidEssexCCG on Twitter, like our Facebook page or use any of the other ways listed on our website to stay involved and join us on our journey to give you great care.
Caroline Rassell Accountable Officer
25 May 2018
1.1 Performance Overview
This section offers a snapshot of the CCG’s core work in 2017/18, along with how and why we bring health and care services to the residents and patients of mid Essex. The overview also shows our performance against key NHS targets, the way we work with our many partner organisations and how our funding is used.
1.1.1 What Mid Essex CCG does
NHS Mid Essex CCG is a clinically-led organisation responsible, since April 2013, for the planning, buying and monitoring – a process called commissioning – of most NHS care in Braintree District, Chelmsford City and Maldon District. These three “localities” cover an area of about 520 square miles and are collectively known as mid Essex.
We were set up by the Health and Social Care Act 2012, which introduced a number of major changes to the way the NHS works, locally and nationally. One of the most significant changes the Act made to the NHS was putting GPs at the heart of planning care for their communities, so the CCG is made up of the 45 general practices in mid Essex who elect GPs to represent local views on our governing Board. Our Chair, Clinical Vice Chair and others on the Board are experienced mid Essex GPs.
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You can find out more about CCGs on the NHS Clinical Commissioners website, but as our Accountable Officer explained in her introduction, we can set out our main goal in one sentence:
We want everyone in mid Essex to Live Well
This means making sure that you, your family and loved ones have high-quality health services that support you to stay well throughout your life within the resources we have available. To do that, we buy your NHS hospital care, medicines and prescribing, mental health services, urgent care, community care and ambulance services.
Our Live Well vision and values Our vision for local healthcare reflects our legal obligation and commitment as an organisation to follow the NHS Constitution, alongside national NHS priorities and emerging needs in our own communities. Our Five Year Strategy 2014-19 establishes our main objectives in meeting that vision as:
Improve quality, safety and outcomes and help the people of mid Essex to Live Well Meet the financial challenge through responsible use of resources Achieve transformation, innovation and integration of services, working collaboratively with our STP and other partners Ensure that there is full member practice engagement to inform commissioning Involve and empower patients to use services responsibly and to be better able to self- manage their own conditions Ensure the CCG has the necessary governance, capacity and capability to deliver its duties and responsibilities and maintain its reputation and that of the NHS.
To achieve these objectives, we continue to build on an approach to local health and care initiated by Braintree District Council and which we have championed across our wider area, called Live Well. Live Well means developing care based on the stage of life that someone has reached, with the particular goal of identifying and offering appropriate support to people who are still early in their journey through health and care.
Together with partner organisations we are helping people look after themselves at all stage their life. Live Well has five elements to help achieve this.
Start Well gives children in mid Essex the best possible start in life. It seeks to support families before birth, throughout childhood, adolescence and into adulthood. Be Well helps adults make healthy lifestyle choices and ensures people know how to look after themselves, using health and social care services appropriately. Stay Well supports adults with long-term illness, poor mental health or social care concerns to maintain fulfilling, productive and healthy lives. It does this while making sure plans and services are in place if a person’s health deteriorates.
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Age Well acknowledges that as we age, we are more likely to need the support of others. By helping people to understand and control their own care needs, Age Well helps to build a strong network of support – including family members and voluntary groups – in appropriate settings for older, more frail individuals. Die Well tackles the difficult topic of death head-on, giving people nearing the end of their lives more choice about how they receive end-of-life care, to have a dignified death.
All these “Wells” aim to give patients better health outcomes at lower cost, which in turn makes health and social care in mid Essex sustainable in the years to come. Reducing people’s need for clinical care through early intervention is part of that, alongside strengthening links with non-NHS community and voluntary groups and resources. Our Connect Well scheme offers a good way to signpost people to those resources, a process known as social prescribing.
In the CCG, Board members and staff alike have adopted Live Well values to show we take this approach to health and care seriously and wish to lead by example. These values are: understanding the Live Well agenda, positively promoting it inside and outside the NHS, taking steps to Be Well ourselves, and taking part in initiatives that help us make a personal difference to helping people Live Well.
There are more details of our values in section 2.3.2 and you can find out more about Live Well in mid Essex from its dedicated section on our website and how we have encouraged its rollout across the rest of the county from the Live Well Campaign site at www.livewellcampaign.co.uk.
Organisations we work with The CCG recognises that health and care planning and delivery is most successful when it is collaborative, so working with other organisations that have an interest in local health and care really does benefit our residents.
Our most immediate working relationships are with the CCGs and local authorities covering Basildon and Brentwood; Castle Point and Rochford; Southend; and Thurrock, plus three local hospital trusts and community providers that cover our area. Together, we make up the Mid and South Essex Sustainability and Transformation Partnership (STP) that our Accountable Officer discussed in her introduction. The map over the page shows the STP footprint and there is more information about it in section 1.1.2.
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We also work closely with other organisations that have similar goals. For example, alongside CCGs the Health and Social Care 2012 also created NHS England, a national organisation that allocates resources across the NHS, supports CCGs and checks NHS performance. We share responsibility with NHS England for buying GP services through a process called “co- commissioning” while NHS England leads on buying other sorts of “primary care” – optician, dental and community pharmacy services, along with a variety of specialist services (including certain types of heart, kidney, cancer and genetic services).
The 2012 Act also moved responsibility for Public Health from the NHS to local authorities. Essex County Council’s Director of Public Health works with us to reduce health inequalities – in other words making sure everyone has access to the healthcare they need and experiences the same outcomes.
The county council’s Public Health team provide health intelligence, advice and support to Essex CCGs through a dedicated Consultant in Public Health under a local agreement. This consultant is a non-voting member of our Board, and the Director of Public Health supports a Joint Health and Wellbeing Strategy for Essex under the guidance of the Essex Health and Wellbeing Board (see section 1.2.2).
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Overall, the mid Essex health and social care system is made up of NHS Mid Essex CCG, Essex County Council, Chelmsford City Council, Maldon District Council and Braintree District Council plus key providers Mid Essex Hospital Services NHS Trust, Essex Partnership University NHS Foundation Trust, Provide Community Interest Company, East of England Ambulance Service NHS Trust and a range of smaller providers working together.
We also regularly work with national and local charities, community organisations and voluntary groups on a variety of projects that bring health benefits to local people.
The CCG is in regular contact with Healthwatch Essex, an independent organisation that represents local people’s views about health and care to help improve services. Dr David Sollis, the organisation’s Chief Executive, said: “We have been pleased to maintain our strong working relationship with Mid Essex CCG through 2017/18.
“Healthwatch Essex has seen first-hand the hard work the CCG put into supporting the major public consultation that ended in March 2018 around the future of hospital services in mid and south Essex. They consistently encouraged people on their patch to take part. We know from our own conversations with people from the area that this is a matter of real importance to them, so the determination at mid Essex to keep patient voice central to commissioning decisions is very welcome.
“Alongside their very positive engagement with the Sustainability and Transformation Partnership process, we have been particularly impressed with Mid Essex CCG’s two out-of-hospital programmes. Most significantly, they had wide-ranging discussions with residents around plans to offer patients more rehabilitation care in their own homes. We found this public engagement very insightful and feel it will have a real impact on the final plans.
“It was also great to see how focused the CCG has been on finding ways to find care quickly for the people who need it most at end of life. We look forward to seeing more of this – and further positive engagement – over the coming year.”
What we have achieved together We pride ourselves on the innovation, high quality and good value we bring to local NHS care. Working with our partners, providers and patient representatives, the CCG has taken the Live Well agenda forward in a number of important ways during 2017/18.
Several of these achievements have received national recognition.
We planned and delivered a cancer summit in November 2017 to share good practice in cancer diagnosis and care among mid Essex GP practices. Our speakers included clinicians from our regional Cancer Alliance, Cancer Research UK and Macmillan Cancer Support. The summit had the highest ever attendance for one of our ‘GP shutdown’ events – more than 250 GPs, nurses and administrative staff from across the patch. Feedback was very positive and a number of doctors told us they had learned a lot from the session. We have developed a framework that helps us to buy high quality care at home for people in need of it very quickly, for example if they are at end of life to help them Die Well. Along with meeting an important need, the framework is also projected to save the local NHS about £75,000 compared to buying similar care without the framework in place.
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We commissioned a comprehensive health and wellbeing service for people living with dementia in mid Essex which we have called the Dementia Intensive Support Service, or DISS.
Following its full launch on 1 December 2017, the DISS offers a ‘one-stop shop’ for dementia care, not only crisis support for people with the condition and their families but early intervention and physical health services too, all available by calling a single phone number. People can refer themselves into the DISS without the need for a GP contact first if they are concerned about their health. We are proud to have maintained in 2017/18 the achievement from 2016/17 of avoiding inpatient grade 4 pressure ulcers (the most serious sort associated with breaches in recognised good practice) in all mid Essex acute and community wards.
Such ulcers can cause significant harm to patient welfare and limit positive clinical outcomes as well as adding costs to the healthcare system. Avoiding them is therefore an important goal for the CCG. Together with Castle Point and Rochford CCG, we led an STP-wide campaign to highlight the impact that missing GP appointments can have on the care available to other patients and how people can tell their surgeries if they are unable to secure an appointment.
During the campaign period, indicative numbers suggest missed appointments dropped by 8% across mid and south Essex. We engaged with more patient groups through involving them in our Patient Reference Group, an important channel for discussing our challenges and plans with representatives from our communities. See section 1.2.3 for more details. We took part in a 100-day challenge for CCG Board members and employees to show our commitment to Live Well. The project had two main elements – walking a total of 25million steps across the organisation during the challenge period and different members of staff sharing a particular way they Live Well each day.
Not only did we produce 100 posters showing how we keep active and healthy, we achieved more than double our step target – 58million in all, enough to walk around the whole world. The challenge earned the CCG the NHS Publicity Campaign of the Year prize at the Health Business Awards 2017. The challenge also proved so popular with staff that a follow-up focused on mental health is currently underway, called 100 Days in Mind.
Alongside our Health Business Award noted above, the CCG was honoured to receive a Self Care Innovation Award for the ‘Common Childhood Illnesses’ campaign we ran in 2016 and early 2017.
The CCG organised a series of clinically-led workshops for local parents offering guidance on how to identify children’s ailments and how to treat them at home – or what to do about more serious illnesses. We designed and printed booklets sharing similar clinical advice that we distributed with the help of partner organisations to parents across mid Essex. An electronic version of the booklet remains available on our website.
The CCG was also highly commended at the Public Finance Innovation Awards 2017 for our involvement in an “outstanding procurement initiative” for the Child and Adolescent Mental Health Service that serves mid Essex – see below for more details of that.
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NHS Mid Essex CCG – facts and figures Headquarters Wren House, Hedgerows Business Park, Colchester Road, Chelmsford, Essex, CM2 5PF
Population (registered with a GP) Total Mid Essex GP-registered population is 390,714 (as of 1 January 2018)
Expenditure (for 2017/18) Healthcare expenditure £445.7m STP projects £0.3m Running costs £7.8m
Total £453.8m
Number of GP practices 45 (with about 250 GPs between them)
Number of employees 122.21 Whole Time Equivalents permanently employed on 31 March 2018
Providers of commissioning support services IT and some business information services are purchased from North East London Commissioning Support Unit (CSU). Arden and Greater East Midlands CSU undertake retrospective reviews of Continuing Health Care.
Local Essex CCGs lead on delivering a number of support services across the Essex footprint such as information governance.
Where we buy healthcare: Commissioned services summary for 2017/18 Type of healthcare Where we buy it from on your behalf Community services: Provide Community Interest Company (CIC) This includes district nursing, speech and language therapy, podiatry, community Service agreements with 30+ other providers hospitals, community stroke and rehabilitation including voluntary sector and smaller services organisations
Hospital services: Mid Essex Hospital Services NHS Trust (MEHT) This includes outpatient clinics, planned – mainly from Broomfield Hospital with some inpatient treatment and emergency care services also offered at Braintree Community Hospital and other locations
Colchester Hospital University NHS Foundation Trust (CHUFT)
Ramsay Healthcare Springfield Hospital
Basildon and Thurrock University Hospitals
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NHS Foundation Trust (BHUT)
The Princess Alexandra Hospital NHS Trust (Harlow)
Southend University Hospital NHS Foundation Trust (SUHFT)
Hospitals outside Essex such as Addenbrooke’s Hospital in Cambridge and St Bartholomew’s Hospital in central London – referrals to such hospitals are made for some specialist services such as complex emergency trauma cases or as a result of patient choice
Mental health services: Improving Access to Psychological Therapies This includes psychological therapies, (IAPT) provided by Hertfordshire Partnership community mental health teams and learning University NHS Foundation Trust (HPFT) disability services Secondary Care Mental Health services provided by Essex Partnership University NHS Foundation Trust (EPUT)
Emotional Wellbeing and Mental Health Service for children and young people provided by North East London NHS Foundation Trust (NELFT)
“Locally enhanced” GP services We hold contracts with member GP practices for the provision of add-on services for some areas of mid Essex
Emergency transport service East of England Ambulance Service NHS Trust
Non-emergency transport service ERS Medical Ltd
NHS 111 (commissioned on our behalf by West Integrated Care 24 Essex CCG)
Out-of-hours GP services Prime Care
One CCG may lead the buying of shared services on behalf of several local CCGs:
Emotional Wellbeing and Mental Health Service West Essex CCG leads on behalf of the seven for children and young people (see above) Essex CCGs and three Essex Tier 1 local authorities
Adult Mental Health Services (see above) North East Essex CCG leads on behalf of the three north Essex CCGs
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Services for people with learning disabilities West Essex CCG leads on behalf of the three north Essex CCGs in partnership with Essex County Council
Emergency Health Services and Transport (see All CCGs across the east of England region buy above) as a consortium, which is led by NHS Ipswich and East Suffolk CCG
Children’s continuing care for Essex Mid Essex CCG is the “host commissioner” for this service, which means buying it on behalf of the Essex area
1.1.2 Key issues and challenges
We think our Live Well plan, which you can read more about on our website, is the right way for health and social care in mid Essex to develop. But it is essential that we make it work not only to ensure patients get the right outcomes from their care, but because we face huge challenges as a CCG and a healthcare system.
The winter of 2017/18 has challenged the health system across mid Essex and beyond, as many hospitals struggled to cope with unprecedented patient numbers. This happened amid ongoing pressures on NHS finances and staff numbers across our health and social care system, as well as the wider Essex area.
By 2020, the mid Essex population (currently less than 390,000) is expected to grow to more than 400,000 with the number of frail elderly and chronically ill people rising faster than the national average. This is placing unprecedented pressure on services at a time the NHS has faced a sustained slowdown in spending growth. Substantial cuts in local government spending contribute to the system-wide challenges too.
Mid Essex CCG has to find significant savings each year in order to balance our budget and in 2018/19 we will again have to repay some of our historical deficit that resulted from the CCG receiving less funding than national calculations say we should have.
Recruiting suitably skilled and experienced clinical staff is also difficult for local health and care organisations. NHS and social care providers in mid Essex have many vacancies going unfilled.
There are two ways we are tackling these challenges – leading the mid Essex health and social care system on Live Well, and working with our healthcare partners in south Essex in our Sustainability and Transformation Partnership (STP).
Live Well – the approach As part of the changes within the STP described in the next section, Mid Essex CCG is shifting its focus towards out-of-hospital care and we have a series of projects and work programmes on supporting each element of Live Well.
It is however recognised that without a stable and sustainable primary Care, all this hard work and effort will be wasted. The CCG has therefore invested in primary care, pooling its resources and
14 Mid Essex CCG Annual Report and Accounts 2017/18 work programmes into a single programme of work aimed at supporting primary care to tackle the challenges it faces today, ensuring it can support patients tomorrow.
This will provide the foundation for the future make up of primary and out of hospital care within mid Essex. Throughout the year we will be building on this foundation, exploring with our practices how we can through collaboration start to develop hubs throughout mid Essex to encourage these changes. The hubs will offer places where GPs will work alongside traditional health services, social care and voluntary organisations to create the right package of support for the people who need it most.
Working together will allow health, social care and voluntary organisations to reduce duplication while improving care quality – something two district councils have already seen value in, working in close partnership with us on developing hubs in Witham and Maldon.
Delivering our Live Well vision will need a major change in the way the CCG and others buy services. The traditional divide between primary care, community services, social care and hospitals is becoming a barrier to personalised Live Well services that draw on several or all of those areas. With our partners’ and providers’ help, we are beginning to overcome that barrier.
Commissioning in mid and south Essex During 2017, the five CCGs in mid and south Essex formed a Joint Committee that would enable commissioners to act collectively in the planning, commissioning and monitoring of services to meet the needs of the whole population of mid and south Essex. To enable the Joint Committee to discharge its functions, and following a staff consultation process, relevant staff across the five CCGs have now formed a Joint Commissioning Team.
The Joint Committee comprises the Chairs and Accountable Officers of the five CCGs, as well as the Chief Nurse, Chief Finance Officer, Medical Director and Director of Commissioning for the Joint Commissioning Team. The committee has a lead Accountable Officer, Caroline Rassell, and an independent chair, Professor Mike Bewick.
The functions of the Joint Committee include:
Decisions on STP-wide service configurations Leadership of public consultation activities on significant service change Agreement of STP-wide service restriction policies Agreement of STP-wide outcomes, frameworks and pathways Agreement of the STP local health and care strategy.
The Joint Committee has delegated responsibility for a range of functions including patient safety and quality; commissioning and contracting; and performance management for the following services:
All acute hospitals (NHS and independent sector) Integrated Urgent Care services, including NHS111 Ambulance services
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Patient transport services Learning disability decision-making (with the existing pan-Essex arrangements) Acute mental health services.
Importantly, the formation of the Joint Committee and Joint Commissioning Team enables individual CCGs to focus on developing and enhancing primary, community and local mental health services, and to work closely with member practices and local authority colleagues to build strong localities that deliver a broader range of services outside hospital. Work is underway to develop an STP-wide primary care strategy to be implemented by individual CCGs.
The Mid and South Essex Sustainability and Transformation Partnership (STP) The Mid and South Essex STP is one of 44 such partnerships covering all of England. The STP brings together local NHS organisations and councils to work together to improve health and care in the areas they serve.
In the past year, the mid and south Essex STP has launched a public consultation on proposals to improve hospital services for the 1.2m population who live in its “footprint”. The proposals are that the vast majority of care will remain within each of the three hospitals – including accident and emergency (A&E) and urgent care services, outpatient appointments, tests, scans and day-case surgery. The proposed service changes are based around five key principles, which are:
1. Improvements in A&E in all three hospitals – through the further development of assessment units for older people, children, and those with urgent medical and urgent surgical conditions
2. Some specialist inpatient services will be brought together in one place, where this would improve patient care and outcomes
3. Access to specialist emergency services, such as stroke care, should be via the nearest A&E. There are specific proposals about the model of care for stroke patients
4. Planned operations should, where possible, be separate from patients who are coming into hospital in an emergency
5. Some hospital services should be provided closer to the community – either at home or in a local health centre (with specific proposals about Orsett Hospital)
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The wide-ranging public consultation ran from 30 November 2017 to 23 March 2018. All feedback received from the consultation is being independently analysed and reported as part of the evidence to be reviewed by the STP CCG Joint Committee. The committee will consider the proposed service changes alongside evidence including the consultation feedback, further assurance on clinical pathways, equality impact assessments, and travel and transport plans.
It is expected that the STP CCG Joint Committee will take decisions on service change in summer 2018, with the implementation of any changes proceeding over a number of years.
1.1.3 Performance Summary
The CCG has plans in place to contribute to delivery of the nine national NHS “must dos” as set out in Delivering the Forward View: NHS Planning Guidance 2016/17 – 2020/21. The nine national “must dos” are to:
Develop a high quality and agreed STP with progress towards the “triple aim” of improved health and wellbeing, transformed quality of care delivery and sustainable finances Return the healthcare system to overall financial balance Develop and implement a local plan for general practice sustainability and quality Meet access standards for A&E and ambulance waits Meet a 92% target for the national 18 week Referral to Treatment (RTT) target Deliver cancer standards targets Meet mental health access standards and dementia diagnosis target Transform care for people with learning disabilities Have an affordable plan to make improvements in quality.
The table overleaf shows how all acute trusts in Essex have performed against NHS Constitution benchmarks. The table highlights the continuing levels of severe urgent care pressures in A&E departments across Essex and ongoing challenge of meeting the Cancer 62-day pathway and 18- week referral to treatment (RTT) national standards.
In the table, performance is calculated from the “NUM” figure, which indicates the number of patients for whom targets were met, divided by the “DEN” figure, which is the total number of patients using that service. Boxes in green denote a figure on target, amber is close to target and red is off target.
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Our key performance measures are the 18-week care pathway, four-hour target for A&E wait times and two-week, 31-day and 62-day cancer pathways.
18 weeks pathway Patients have a legal right to start non-emergency NHS consultant-led treatment within 18 weeks of referral, unless they choose to wait longer or it is necessary for better health outcomes.
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Mid Essex Hospital Services NHS Trust (MEHT) has found the standard challenging during 2017/18 and has slipped from achieving the 92% National Standard for the 18-week pathway. This is mainly due to pressures in the amount of activity in two areas:
plastics trauma and orthopaedics.
Patients have had to wait longer in both these specialities and MEHT has recovery plans with actions to improve these wait times, with the national intensive support team contributing its expertise. MEHT is also engaged in work across the STP to improve treatment pathways.
Accident and Emergency – 4-hour wait times The year has again seen increasing demand on NHS services and particularly A&E – attendances at A&E in excess of 300 per day have not been unusual during 2017/18. Such pressure resulted in MEHT not meeting the national standard of 95% of patients at A&E being seen and treated within four hours, as was the case in 2016/17.
With operations cancelled as a result of beds being needed for emergency admissions, there was a consequent effect on the 18-week target, particularly during the winter period when hospitals across the country were similarly affected.
Partner organisations in health and social care offer support to MEHT when their help can reduce the number of people going to or being admitted to hospital. Some of those organisations make up the Mid Essex Urgent Care Board, which continues to implement the local immediate care strategy. There are more details of actions to alleviate A&E pressure at MEHT in section 1.2.5.
Cancer standards – 31-day and 62-day standards These are the principal measures of good cancer care performance in the NHS. The first is a target of no more than 31 days between clinical staff making a decision to treat any patient for cancer and the patient receiving their first treatment. The second is a target of no more than 62 days between a GP’s “2 week wait” referral for urgent cancer care and the first definitive treatment for the patient who was referred.
MEHT has continued to perform below the expected standards but, with support from NHS Improvement, has identified clearly what changes are needed to meet standards in the coming year. These actions include:
Transforming the skin pathway due to high referral volumes Improved diagnostic test turnaround times Installing a new MRI scanner Recruitment of specialist nursing staff Support from NHS Improvement and the local Cancer Alliance to implement a best practice “lung pathway”.
19 Mid Essex CCG Annual Report and Accounts 2017/18
MEHT has been part of a pilot scheme funded by Macmillan Cancer Support for a multi- disciplinary diagnostic team to improve early diagnosis of cancer by offering GPs an alternative to 2 week wait referrals if they have concerns about a patient not showing symptoms. This pilot has been running for a year and recently extended to June 2018 due to positive feedback from GPs and patients. A full evaluation of this pilot has been running from March 2017 to June 2018 and early indications show it has resulted in more patients being diagnosed.
Work is also underway for an STP-wide programme backed by Cancer Research UK and Macmillan. Working together, commissioners within the STP are engaging Macmillan, Cancer Research and the Cancer Alliance to ensure accessible, timely and appropriate diagnostics are commissioned. This in turn will improve outcomes for patients across mid and south Essex.
1.1.4 Financial Overview
Our full statutory financial accounts are included in part four. This section provides a summary of our current financial position.
CCG funding Mid Essex CCG receives funding according to a national formula designed to calculate healthcare needs based on the makeup of the local patient population. Mid Essex’s population is considered to have a relatively low need for healthcare expenditure under the formula so our assessed need to spend (or “target”) per head of population is the lowest in Essex.
We received £447.8m baseline funding for healthcare in 2017/18 (after baseline adjustments for the new rules about acute hospital costs) which was 1.85% (£8.4m) below target funding. In addition to that baseline funding, we received a number of extra one-off allocations (£5.8m) for spending on specific areas of care including:
Project and planning costs on behalf of the Mid and South Essex STP Additional winter funding Allocations for specific GP Five Year Forward View projects.
In 2017/18 those allocations brought our total healthcare funding to £453.6m. Funding for running the CCG (called “running cost expenditure” funding) in 2017/18 was £21.38 per mid Essex resident, or £8.3m.
We have a number of financial duties at the CCG:
To contain revenue expenditure within allocated financial resources and any specified Directions To contain capital expenditure within allocated financial resources and any specified Directions To keep running cost expenditure to a maximum of £21.38 per head.
20 Mid Essex CCG Annual Report and Accounts 2017/18
As of 1 April 2017 the CCG had an accumulated deficit from previous years of £21.9m. We were required by NHS England to underspend against funding in order to generate a £9m surplus towards paying off this deficit.
While we set and delivered a surplus budget in 2017/18, we were unable to deliver the full £9m surplus. In 2017/18 we repaid £8.1m of the accumulated deficit and carried forward into 2018/19 a remaining deficit of £13.8m. We delivered a savings programme of £20.4m (4.64% of our healthcare services funding) to achieve the £8.1m surplus.
How your money was spent In 2017/18 we spent £446.0m on healthcare services including £300k on behalf of the Mid and South Essex Sustainability and Transformation Partnership Out of Hospital project – see section 1.1.2 – and £7.8m on running costs. We have met HM Treasury’s guidelines on cost allocation.
The chart below shows the major areas of expenditure for healthcare in mid Essex. See section 1.2.2 for more details of the Better Care Fund – Protection of Social Care segment.
(£446.0m total)
Capital spending We did not require a CCG capital allocation for 2017/18, but the Mid and South Essex STP footprint was awarded Estates and Technology Transformation Funding (ETTF) towards primary care estates projects and GP IT. ETTF expenditure is accounted for by NHS England.
Since 31 March 2013, clinical premises previously owned or leased by Mid Essex Primary Care Trust have belonged to NHS Property Services or other local NHS providers, but getting the best
21 Mid Essex CCG Annual Report and Accounts 2017/18 use from these resources and keeping buildings fit for purpose are still important roles for the CCG.
Paying our suppliers and providers The national Better Payment Practice Code means we must aim to pay all valid invoices by the due date or within 30 days of receiving them, whichever is later. The NHS aims to pay at least 95% of invoices within 30 days of receipt, or within agreed contract terms. In 2017/18 we met all four targets (based on invoice numbers and value of expenditure) for both NHS and non-NHS invoices – see Note 6 of the Financial Statements for details.
We are also an approved signatory of the Prompt Payment Code. The government designed this initiative with the Chartered Institute of Credit Management to tackle the crucial issue of late payment and to help small businesses. Suppliers can have confidence that any organisation signed up to the code will pay them within clearly defined terms and that proper processes are in place to deal with any disputed payments. Approved signatories have committed to:
Paying suppliers on time Giving clear guidance to suppliers and resolving disputes as quickly as possible Encouraging suppliers and customers to sign up to the code.
The national measures for payment performance do not identify the delays in payment during the time that an invoice is on hold.
2018/19 financial plans and looking to the future In 2018/19 we will receive £462.6m for local healthcare, taking us closer to our target funding – we will be 1.47%, or £6.9m, below our assessed spending need. The increase in funding for 2018/19 is £14.8m. However, NHS England requires that we underspend our allocated resource by £6m (1.3%) in 2018/19 in order to repay a further £6m of the accumulated deficit. Expenditure will therefore need to be capped at £12.9m (2.75%) below target funding.
As a result, 2018/19 will represent another significant financial challenge as the CCG attempts to contain cost pressures, deliver mandated service improvements and service investments and generate a £6m in-year surplus. Based upon our estimates of service demand and cost pressures, we forecast that the CCG will need to deliver £20.5m of savings in 2018/19 (4.43%).
As explained in section 1.1.2, we are part of the Mid and South Essex STP which means individual CCG plans for 2018/19 have been linked to system-wide plans. Our major clinical and service transformation plans will be delivered and monitored partly at a local level and partly across the STP. In 2018/19 we must continue to transform services in a way that relieves pressure on hospital services and reduces cost. We will also be continuing our patient education programme to help patients deal with minor issues and ensure that they know which healthcare professionals and services to contact if symptoms worsen.
We will continue to jointly commission primary care with NHS England over the next 12 months and work closely with them to develop primary care and community-based plans where patients could benefit from care closer to home.
22 Mid Essex CCG Annual Report and Accounts 2017/18
We began developing our Primary Care Foundations programme during 2017/18 and have ring- fenced existing spend on primary care along with substantial additional funding provided by NHS England in 2018/19 through the GP Forward View and Access Funding to create a £4m fund. This will support primary care transformation and deliver the national seven-day access targets.
Although the CCG had a cumulative deficit of £13.8m as of 31 March 2018, for accounting and risk management purposes the CCG is assumed to be a “Going Concern” as it has an agreed deficit repayment plan which has been approved by NHS England and has made a very significant payment to reduce this cumulative deficit in 2017/18.
The scale of the challenge is substantial if we are to meet our financial targets in the coming year.
23 Mid Essex CCG Annual Report and Accounts 2017/18
1.2 Performance Analysis
1.2.1 Improve quality
The CCG has a legal duty under section 14R of the National Health Service Act 2006 to improve the quality of services. Alongside our commitment to measuring our performance against the NHS Constitution and core national measures (see sections 1.1.3 and 1.2.5), we assess the quality of the care we plan and buy in three ways: effectiveness, patient experience and patient safety. To deliver high-quality care, CCGs work to the NHS Outcomes Framework, ensuring improvements in the areas of:
Preventing people from dying prematurely Enhancing quality of life for people with long-term conditions Helping people to recover from episodes of ill health or following injury Offering people a positive experience of care Giving care in a safe environment, protecting patients from avoidable harm.
We are committed to working with all organisations that provide mid Essex health services to make sure patients receive the best possible care, have a positive experience of healthcare and are treated safely and with compassion. Our Quality and Governance Committee is at the centre of this work, as it is responsible for giving our governing Board assurance that appropriate and effective governance mechanisms are in place for all aspects of quality.
The committee also supports the Board to fulfil its statutory functions around quality, which are:
Securing continuous improvement in the quality of services for patients and in outcomes, with particular regard to clinical effectiveness, safety and patient experience Assisting and supporting NHS England in securing continuous improvement in quality.
All main contracts that we issue to healthcare providers contain clear quality requirements, measures and incentives where relevant to ensure that services meet the expectations of both mid Essex patients and the CCG. This process allows us to meet local and national quality standards and to remain focused on getting the best outcomes for the people who live in the area we serve.
Our Nursing and Quality team seeks assurance of quality from a number of sources, including provider reports, feedback from patients using services we commission and our own assurance visits to providers. Quality assurance processes cover acute care, community care, nursing homes, mental health and learning disabilities.
The CCG’s Nursing and Quality team is responsible for:
Ensuring we meet statutory and mandatory patient quality and safety requirements Making sure quality is incorporated into the commissioning and procurement processes Monitoring performance in quality, safety and patient experience for commissioned services’ contracts through formal Clinical Quality Review meetings, patient experience
24 Mid Essex CCG Annual Report and Accounts 2017/18
feedback and both announced and unannounced site visits, more details of which are given later in this section. Performance monitoring includes triangulation of available intelligence.
Our quality monitoring processes are based around principles and recommendations for best practice following a number of high-profile national reviews and reports such as Francis, Berwick, Keogh, Hart and Cavendish, as well as Safer Staffing guidance.
We also have governance arrangements to provide assurance on and support decisions relating to contracts and providers. These arrangements involve working with statutory organisations, partners, patients, carers and providers to give us access to a range of intelligence that can support decisions affected by the quality of services we buy.
National indicators (targets) in the NHS Outcomes Framework cover Clinical Effectiveness, Patient Experience and Patient Safety. These indicators allow us to seek assurance of the quality of services being delivered by our providers and, when necessary, to challenge and intervene.
The Care Quality Commission’s regulations for providers include a requirement to be open and transparent about care and treatment with people receiving the services and with those properly acting on their behalf. The requirements also include specific rules on what providers must do when care and treatment go wrong. In those cases, we check that providers are exercising their duty of candour and being open with patients and their representatives.
The Quality and Governance Committee receives a ‘dashboard’ at each of its quarterly meetings that details key performance measures for all providers.
Quality Assurance ‘deep dives’ – a thorough review of a service that focus on all aspects of quality, patient experience and safety for both NHS and independent providers – take place across commissioned services.
Clinical effectiveness We follow national guidance including the NHS Outcomes Framework and draw on clinical advice from national bodies alongside local priorities to make sure that providers deliver services that follow the latest best-practice guidance and protocols. Examples of this relate to accessing psychological therapies and improving quality of life for people with dementia.
Checking that provider policies consider National Institute for Health and Care Excellence (NICE) guidance through Quality Review meetings is another key element of CCG monitoring. We also review data to measure local providers’ performance. Regional and national comparisons can be drawn against this data to understand where and why we see differences in performance, such as in caesarean section rates.
Our Designated Adult Safeguarding Nurse and Clinical Quality Nurse also work closely with the local authority to monitor services in care homes. Work is underway to include in this assurance process the care agencies that deliver personal care to people in their own homes.
Patient experience This element of the CCG’s performance analysis focuses on our Patient Advice and Liaison Service (PALS) for handling compliments and complaints, plus the Friends and Family Test.
25 Mid Essex CCG Annual Report and Accounts 2017/18
The CCG Patient Experience Team encompasses PALS and complaints. The team responds to patient complaints about decisions the CCG has made, but the NHS Complaints Regulations also give patients and the public the opportunity to complain to the CCG as a commissioner if they do not wish to complain directly to a provider.
The CCG Complaints Policy reflects best practice principles for complaints handling advocated by the Parliamentary and Health Service Ombudsman (Principles for Remedy, Principles of Good Complaint Handling and Principles of Good Administration). To meet the Principles for Remedy, the CCG places a strong emphasis on putting things right, ensuring continuous improvement and learning from complaints.
PALS provides help, information and advice to patients and the public in relation to local health services. During 2017/18, PALS handled a total of 547 contacts, and the CCG received 100 formal complaints from patients or carers, along with 16 compliments. Two cases were referred to the Parliamentary and Health Service Ombudsman (PHSO) in 2017/18. One remains under review by the PHSO, the other was not upheld and the case was closed.
The CCG also received 57 enquiries from MPs making contact on behalf of a constituent. We also log enquiries from local councillors, but no enquiries were made during 2017/2018. During 2017/18, we have reviewed a variety of patient experience reports from all providers. Through the renewal of contracts, we have standardised what information we want reported to us so that we get more than a traditional complaints report and are able to triangulate the full spectrum of patient experience across the entire area we serve.
Relevant mid Essex providers have participated in the Friends and Family Test initiative, asking a simple question: “Would you recommend hospital wards / accident and emergency / community services to a friend or relative based on your treatment?”
The most recently available scores are as follows:
Friends and Family Test Score for MEHT Ramsay Provide February 2018 Springfield In-patient 92% 95% N/A Community (including community wards) N/A N/A 97% A&E 87% N/A N/A
We have continued to present patient stories at each Board meeting to offer an insight into some of our commissioned services. Following the Live Well cycle of stories still available on our website, there was a hiatus, but new stories are now being presented and we continue to seek learning from the lived experience of patients and their families in the mid Essex area.
Patient safety We implement the national serious incident reporting process where all identified actions are closely monitored by a review panel to make sure they are fully addressed before the incident is closed. The CCG also uses a data reporting tool to analyse performance against the five key areas listed in the NHS Outcomes Framework.
The NHS Safety Thermometer Harm Measurement Instrument provides information on all NHS- provided care organisations including acute, mental health, community wards and district nurse
26 Mid Essex CCG Annual Report and Accounts 2017/18 caseloads. All relevant providers are actively involved in submitting performance information they collect.
We also analyse Hospital Standardised Mortality Ratios (HSMR) and data from the Summary Hospital-level Mortality Indicator (SHMI) to support the mid Essex health economy’s strong focus on reducing mortality rates. The CCG is represented at MEHT’s Mortality Review meetings.
During 2017/18 we have been supporting MEHT in undertaking harm reviews for patients whose care breached the 52-week RTT and 104-day cancer standards. These reviews ensure that each patient case is individually assessed to determine if harm has occurred in direct correlation to the NHS not meeting their treatment timeframes.
The outcomes of such reviews enable us to wrap individualised plans around patients to ensure they receive appropriate care, but also enable our commissioning teams to understand why the breaches occurred and how we can commission effectively to prevent recurrence.
Dignity and respect – quality assurance visits We run a programme of Quality Assurance Visits across providers throughout the year, both announced – in other words, notifying the provider we will be attending – and unannounced. The visits, conducted in line with Care Quality Commission (CQC) guidance, are linked to information gathered from incidents or complaints. During visits, we ask patients for their views and other feedback on the service they are using.
Recommendations from the visits are shared with the provider, which is then expected to produce an action plan to address any concerns raised. This plan is checked at the provider’s quality contract review.
Dignity and respect – same-sex accommodation The CCG receives monitoring reports from providers with inpatient facilities to check for mixed sex accommodation breaches. These are monitored and reported at the Clinical Quality Review Group on a monthly basis. Providers are commissioned to deliver care in line with the policy from NHS England (East of England) “Delivering Same Sex Accommodation”.
Through the first four months of 2017/18 there were a number of mixed sex accommodation breaches in the MEHT Intensive Care Unit (ITU). We worked with MEHT to look at solutions to the breaches in line with our zero-tolerance approach. MEHT has shown a mixed sex occurrence of zero since July 2017.
External reviews The CCG plays an active part in the Essex Quality Surveillance Group that highlights and enables the sharing of ‘soft intelligence’ with CCGs, local authorities, NHS England, NHS Improvement, Healthwatch and the CQC. We also monitor reports from the CQC in relation to commissioned providers.
Whenever concerns about a provider are raised by the CQC, we work with the provider and support their production and implementation of an improvement plan.
27 Mid Essex CCG Annual Report and Accounts 2017/18
1.2.2 Health and wellbeing strategy
A key outcome of the Health and Social Care Act 2012 was to establish a statutory Health and Wellbeing Board in every local authority area. Following their establishment on 1 April 2013, these Boards offer system-wide leadership to improve both health and care services. In particular, they have a duty to promote integrated working and drive improvements in health and wellbeing.
In particular, Health and Wellbeing Boards are responsible for:
Leading on the production and regular updates of the Joint Strategic Needs Assessment (JSNA) which reviews local health and wellbeing needs across healthcare, social care and public health Producing and annually reviewing a Joint Health and Wellbeing Strategy in response to the JSNA, which provides a strategic framework for local commissioning plans.
The Essex Health and Wellbeing Board brings together locally elected councillors and key commissioners, including representatives of CCGs, Directors of Public Health, Children’s Services and Adult Social Services and a representative of Healthwatch Essex, which provides an independent voice on healthcare for people in our county.
Dr Caroline Dollery has been a member of the Health and Wellbeing Board since she became Chair of Mid Essex CCG in September 2014 and is currently its Vice Chair. The Health and Wellbeing Board’s Chair is Essex County Council Cabinet Member for Health, Councillor John Spence, and there are 23 voting members, including clinical representation from CCGs and a member from the NHS England Area Team.
There are two non-voting members: the Police, Fire and Crime Commissioner (Police and Crime Commissioner prior to October 2017) for Essex and the independent chair of the Essex safeguarding boards.
The board produced a five-year strategy setting out how partners should work together on improvements up to 2018. The development of this strategy was overseen by a performance sub- group of the board and informed by the JSNA, local authority areas’ Health Profiles, a number of needs assessments and a programme of ‘deep dive’ analysis around key issues for Essex.
As the period covered by that plan nears its end, partners in the health and care system are producing a new strategy for launch in 2018. The CCG has been consulted during the drafting process and considered its response during one of its own Board development sessions in February 2018.
The Health and Wellbeing Board recently reviewed its role with a particular focus on:
How its work programme can be integrated with those of other Essex partnerships Recognising and enhancing the role of district-level health and wellbeing boards via the district county health and wellbeing forum (a member forum) Its role in working effectively with NHS Sustainability and Transformation Partnerships.
28 Mid Essex CCG Annual Report and Accounts 2017/18
Each year, our annual report is offered to board members so they have the opportunity to offer feedback. The Health and Wellbeing Board praised this report for its readability and said it was very comprehensive.
People living in mid Essex and elsewhere can attend Essex Health and Wellbeing meetings. Minutes of previous meetings are also available. See http://tinyurl.com/kn67vnu for further details or email [email protected].
1.2.3 Engaging people and communities
Patients – at the heart of everything we do Every day our GPs are listening to patients and engaging with large numbers of people who use a wide variety of NHS services locally. Being led by these clinicians – both elected GPs on our Board and clinical GP leads working across the CCG – increases our knowledge and helps to embed engagement into our health planning. That in turn allows us to plan for what people need, not just what we think they should have.
Our quarterly reports to Board, published in the Board report papers, provide a detailed record of how we have engaged and involved patients and the public in core CCG business over the past 12 months.
From creating proactive and targeted social media campaigns to having a presence at both large- scale and localised community events; a virtual network of about 500 subscribers informed by regular e-newsletters to individuals sharing their lived experience at public Board meetings, the year has been enriched with public involvement.
Duty to involve Section 14Z2 of the NHS Act 2006 (as amended in the Health and Social Care Act 2012) requires that the CCG must make arrangements to involve the public in the commissioning of health services for patients. It asks CCGs to involve the public in:
the planning of services the development in proposals for changes to services decisions that would have an impact on services
In 2017/18, the CCG senior team; GP leads; clinical leads; commissioners and patient representatives made huge investment in widening public involvement in discussions and decisions on health.
The CCG aims to map the diversity of our local population using intelligence and data from the local Joint Strategic Needs Assessment; user feedback from providers; local authority information and other planning data available. Using this information helps the CCG to target audiences to involve when planning services or proposing change.
Over the past 12 months, the CCG has undertaken a major engagement programme to involve local people in the planning of a new service – Home First – and in a formal consultation regarding proposals for changes to hospital services in mid and south Essex.
29 Mid Essex CCG Annual Report and Accounts 2017/18
How we involve The CCG Board actively reviews and considers reports on community and stakeholder engagement and public involvement every three months when it meets in public. The Board report papers aim to update CCG Board members on key conversations, meetings, involvement and patient experience.
The CCG’s Lay Member for Patient and Public Participation presents the report to Board and is able to give an overview of all involvement for that period.
In the past 12 months, the CCG has also actively asked for the lived experience to be shared at Board – hearing how patients have engaged with services, what works and how we can improve – view our Patient Stories here.
During 2017/18 the CCG received a quarterly report on patient experience including data from the family and friends test, patient complaints and requests.
Patient Reference Group The CCG has a Patient Reference Group (PRG) which is made up of members of our local GP practice Patient Participation Groups and people with a keen interest in reaching out to their local community to gather views on health services. Members of Healthwatch Essex and our local Community and Voluntary Sector are also part of our PRG so that we can make sure patient experience and voice remains core in our focus when shaping services. Our Patient and Public Participation Lay Member chairs the group.
The PRG meets every two months (notes and actions are available here). In the past 12 months, the group has:
actively worked with the CCG’s Chief Pharmacist to develop materials for an Over the Counter medicines campaign aimed at reducing the number of common medicines asked for on prescription. Patients have collaborated on the design and wording of leaflets, posters and signage to ensure that materials are relevant for their local communities. Several members have also initiated events in the community and in their practices to talk to patients directly about the campaign shared lived experience and patient expertise on several groups and forums involved in developing the proposals for the mid and south Essex STP consultation. Their suggestions and feedback throughout the 18-month pre-engagement period has helped to shape the final set of proposals for local NHS services affecting 1.2 million people supported the CCG and STP to develop bespoke focus groups with young disadvantaged mums and people with physical disabilities to ensure their voices are heard as part of the consultation Helped to shape our strategic plans for commissioning by advocating patient voice on a multi-partner plan for a new health hub in Maldon and developing patient voice for our main Live Well committee sharing the impact of patient involvement at regional and national forums including the National Association of Patient Participation (NAPP)
30 Mid Essex CCG Annual Report and Accounts 2017/18
Bespoke engagement programmes In 2016/17, the CCG ran several specific engagement programmes to involve and inform patients and the public about changes to local health:
In the past year, our Continuing Health Care (CHC) team have written to approximately 100 families receiving care for children to gather views on the service. Around one quarter of families (25) responded. Below is a quick review of the outcomes and impact:
You Said We did Pay more money to care staff to reduce We are currently reviewing the “Any the high turnover of staff Qualified Provider” (AQP) tariff for providers Care providers should be monitored as We have established quarterly meetings some services are inadequate with providers to review services Inform parents of the assessment We now send letters out before the first guidelines before the CHC eligibility CHC appointment including information interview so we know what aspects of about continuing care care you are interested in
Our clinical leads have been actively seeking views from patient using A&E services at Mid Essex Hospitals Trust to gain a better insight into reasons for attendance. To date, several of our GPs and clinicians have conducted face-to-face interviews with around 30 families and more sessions are planned in 2018. Information from these interviews will help to shape the CCG’s plans for urgent care and out of hospital services Towards the end of 2017, the CCG ran a 10-week programme of public events, surveys and meetings to find out local peoples’ views of plans for a new service called Home First. More than 250 people got involved in the discussions and around 50 returned online surveys. Six key themes emerged during the engagement (see below) which the CCG has reflected upon and factored these change into its plans. You Said We did We’re concerned over the increased The CCG has mapped staff resources and level of staffing/resources needed for developed a phased roll-out of the service Home First to ensure staffing can be safely provided I’m worried this will increase GP The CCG has worked with our clinical GP workload leads to review the model of care and provide reassurance that this service will only need the normal level of GP input for patients in the community Can you make sure you have good As a result of feedback, the CCG has transport links to the enhanced nursing decided to have enhanced beds in two homes so that relatives/carers can visit homes across the patch. The homes are easily served by good public transport links and we’ll monitor patients’ experience. Please can the value of ‘informal’ The CCG has revised its service carers be considered in your Home specification to ensure carers are fully First plans involved in discussing care plans, part of meetings about care and given
31 Mid Essex CCG Annual Report and Accounts 2017/18
comprehensive information about available support Make sure Home First links in with all The CCG has continued to work through other support services needed for the the Home First service to ensure it is a patient and is monitored carefully fully integrated service and that no patients will be discharged from Home First without confirmation that the next stage of care is in place.
A full outcome report of the engagement was shared with the CCG Board – and is still available online – and sent directly to those people who asked for follow-up information during the engagement.
Stakeholder meetings The CCG has strong representation from local authority partners on its Board – a public health officer from Essex County Council is a member and Cllr Jo Beavis, Vice Chair of Health Overview Scrutiny Committee (HOSC) is a regular attendee.
Members of the CCG Executive team attend a wide variety of partnership meetings including One Board Chelmsford, Healthwatch 555 events, Braintree District’s health and wellbeing committee and Maldon District’ overview and scrutiny. These meetings offer an opportunity to widen our engagement on health service plans and ensure we act on wider feedback.
The CCG also reports regularly to the Essex HOSC – in particular on the STP business case and consultation.
As well as these meetings, the informal relationships with our key stakeholders are strong and there is much collaboration on campaigns, awareness events and information days to ensure local people can access and are informed about health and wellbeing services.
In June 2017, the CCG in partnership with Chelmsford City’s Centre Supporting Voluntary Action organised a summit to strengthen engagement and collaboration with local voluntary groups across mid Essex.
More than 30 organisations attended the summit and feedback was reported to the multi- partnership Live Well Committee. The committee is looking at how it can take action on suggestions and how we can maximise the value of collaborative working between health and the voluntary sector.
Increasing our reach and use of digital media In 2017/18, the CCG has greatly expanded its public engagement through digital media – making use of new techniques to extend our reach into the community and prompt conversation with younger and diverse audiences.
Using Facebook advertising to target specific audiences, we’ve been able to reach more than 500 more parents, grandparents and carers with information about childhood illness – taking the total number of digital downloads of our childhood illness booklet to 7,629 (on top of the 20,000 printed and distributed).
32 Mid Essex CCG Annual Report and Accounts 2017/18
Again, by carefully analysing our social media use, we’ve been able to increase referrals to our first-tier mental health services – doubling the number of people contacting our Improving Access to Psychological Therapies service in just one week.
In May 2017, the CCG led a multi-agency social media engagement across mid and south Essex for Dying Matters week – reaching 161,903 people through digital platforms to engage them in conversation about end of life care. The campaign also helped to get over 300 people along to local events discussing bereavement and dying.
Throughout December 2017, the CCG used social media as its prime method to engage and inform people about Christmas and New Year health and care services. The CCG developed a video advent calendar to let people know where and how they could access support over the holidays and to promote a healthier start to 2018. In total, 8,500 people viewed and shared the videos.
On any one day, the CCG’s information, conversation and messages on Twitter are seen by more than 5,000 people and our network is growing daily.
Supporting wider consultation across mid and south Essex During 2017/18, the CCG has worked incredibly hard to support a huge engagement programme reaching out to 1.2 million people across mid and south Essex.
Our clinicians, nurses, pharmacists and senior team have been involved in dozens of events and focus groups with patients and the public to develop proposals for health and care in the future.
The CCG helped to foster links between our patient representatives and others across south Essex so that they could organise focus groups to share views and discuss proposals.
Several of our patient representatives also helped to set up meetings with hard to reach groups including teenage parents, people with learning disabilities and dementia.
Feedback gathered directly from patients throughout the pre-consultation engagement led to changes in the final proposals for consultation – namely the plans for A&E services at all three hospitals.
A full report on the methods and impact of the pre-consultation engagement is available here.
The formal consultation period ended in March 2018. Although the outcome is not known at the time of writing this annual report, a full report of all public and patient feedback and recommended actions will be shared in the summer and will shape the plans going forwards.
1.2.4 Reducing health inequality
Working towards an NHS that is personal, fair and diverse We are committed to working within the framework of the Equality Act 2010, which replaced previous anti-discrimination laws and aims to protect people from unfavourable treatment. Nine different characteristics are protected under the Act, some of which apply to everyone and some only to specific groups of people. The nine characteristics are:
33 Mid Essex CCG Annual Report and Accounts 2017/18
Age Pregnancy and maternity Disability Religion or belief Gender reassignment Sexuality Marriage and civil partnership Sexual orientation Race (including nationality and ethnicity)
The public sector general Equality Duty applies to all public authorities including CCGs who must, as they carry out their work, take appropriate actions to:
Eliminate unlawful discrimination, harassment and victimisation, and other conduct prohibited under the Act Advance equality of opportunity between people who share a relevant protected characteristic and people who do not Foster good relations between people who share a relevant protected characteristic and people who do not.
The CCG regularly reviews its local Equality and Diversity objectives and monitors its achievement against both these and the NHS Equality and Delivery System (EDS2) goals, which are:
Goal 1 – better health outcomes Goal 2 – improved patient access and experience Goal 3 – a representative and supported workforce Goal 4 – inclusive leadership.
The CCG has self-assessed its performance against these goals as follows:
Goal No. of ‘outcomes’ Final rating* 1. Better Health Outcomes 5 Developing – 0 Achieving – 5 2. Improved patient access and experience) 4 Developing – 0 Achieving – 4 3. A representative and supported 6 Developing – 0 workforce Achieving – 6 4. Inclusive Leadership 3 Developing – 1 Achieving – 2 * The definitions for “Developing” and “Achieving” vary from category to category, but descriptions for these and other EDS2 ratings are available on the NHS England website.
Our overall score of 1 x Developing and 17 x Achieving is an improved position compared to 2016/17 (4 x Developing and 14 x Achieving) with no outcome areas classed as “undeveloped” against any of the four goals. The CCG will continue to seek to improve its EDS2 ratings during 2018/19.
The CCG’s local Equality and Diversity objectives are:
34 Mid Essex CCG Annual Report and Accounts 2017/18
Objective 1 – ensuring there is local engagement from vulnerable and ethnic groups in assessing health needs, service redesign and measuring the impact of commissioned services Objective 2 – improving the individual experiences of the protected groups in accessing and using NHS Services Objective 3 – improving overall staff health and wellbeing within the CCG Objective 4 – the CCG has a representative workforce that suffers no inequality in remuneration, bullying and harassment at work or during the recruitment process and is empowered to promote equality at work Objective 5 – embedding equality and diversity at Board level and at every level within the CCG.
Progress against these objectives was monitored during the year by the Equality and Diversity Sub-Committee and a number of key actions were completed during 2017/18. The CCG’s Annual Equality and Diversity report will be presented to the Board later this year, with a copy of the CCG’s latest EDS2 assessment included.
Duty to reduce inequality The CCG has a duty under Section 149 of the Health and Social Care Act 2012 to reduce inequalities. There have been no serious lapses in the CCG’s fulfilment of that duty, as demonstrated by our EDS2 outcomes for 2017/18 outlined above.
When commissioning, the CCG uses the NHS Standard Contract, which sets out to avoid discrimination through its terms and conditions. There are five provisions to protect equality under Service Condition 13 (“Equity of Access, Equality and Non-Discrimination”), the full text of which is available on the NHS England website. The CCG requires contracted healthcare providers to demonstrate compliance with all relevant provisions as part of the contract monitoring process.
There was an update to the Essex JSNA in 2016 (see section 1.2.2 for more details) that took a similar life course approach to the CCG’s Live Well approach, with some in-depth analysis on topics relevant to the inequalities agenda such as premature mortality and mental health. Two new specialist topics needing assessments – mental health and sensory impairment – were introduced under the JSNA banner in 2016 and the annual district reports identifying variation in needs across the CCG.
In addition to these local analyses, we have begun using the RightCare approach, which highlights local variations in care, compared to data obtained from demographically similar CCGs. This is another example of intelligence-driven commissioning and transformation.
1.2.5 Detailed review of the CCG’s development and performance
MyNHS ratings for the CCG Many of our performance indicators can be found on the MyNHS section of the national NHS website, alongside those of other CCGs and NHS providers. Mid Essex residents can find these by searching using their local postcode on the site.
35 Mid Essex CCG Annual Report and Accounts 2017/18
While some performance measures for the CCG compare favourably with neighbouring CCGs and national targets, there are a number of areas where the CCG is rated as needing improvement. These are dementia and diabetes care, Improving Access to Psychological Therapies (IAPT) and learning disability services.
Dementia In dementia care, where our estimated diagnosis rate is 59.7% and we have the greatest need for improvement, we have implemented a comprehensive and accountable action plan, a review of GP registers, a review of the care pathway, a model to support diagnosis of people living with the condition in care homes and a task-and-finish group to develop a system-wide approach.
We are remodelling a number of NHS posts to provide support to people before formal diagnosis and to ensure people have access to the right information and receive a timely diagnosis. In partnership with the Alzheimer’s Society we have implemented a community dementia support service to support families and carers.
As discussed in section 1.1.1 we also commissioned a Dementia Intensive Support Service offering people living with dementia and their carers a one-stop shop for physical and mental health needs.
Diabetes care In mid Essex, 35.2% of diabetes patients have achieved all the NICE-recommended treatment targets, which is a marginal increase on the 33.6% reported following the 2015/16 National Diabetes Audit. To improve care further, the CCG has developed and is implementing a comprehensive diabetes action plan which has a number of elements:
Providing accurate current information to each GP practice on their diabetes population including information on essential health checks, compliance with standards and monitoring and attainment of treatment targets Supporting rapid identification of patients at most risk so their cases can be reviewed and enhanced support put in place, including development and monitoring of individualised management plans to better control their condition Creating a dynamic centralised database to enable integrated care, remote reviews and efficient use of the extended healthcare team Ensuring patients understand what health checks and other support are available to them annually under NICE recommended care processes, and how to access these Ensuring patients understand the importance of these checks and of good self- management, giving them confidence to take personal responsibility for their health and wellbeing, and when and how to access support if needed Increasing the number of structured education places available to people with diabetes by 400 so more patients have access to information about diabetes, giving them the knowledge and tools to better self-manage their condition whether they are newly diagnosed or have lived with diabetes for some time. We have seen an increase in the uptake and completion of structured education courses from 8% to 14.6% between 2015/16 and 2016/17.
36 Mid Essex CCG Annual Report and Accounts 2017/18
Additionally, we have increased seen an increase in the National Diabetes Audit participation rate among GP practices in mid Essex from 72.3% in 2015/16 to 86.7% in 2016/17.
We continue to make progress against our agreed plans and monitor against delivery.
IAPT – access to treatment The IAPT access target is currently not meeting NHS England prevalence rates – in other words, the proportion of the population in need of the service who are using it. Despite our close work with our providers, we have maintained access of around 11.25%, which is below national expectations.
When people access treatment they do exceptionally well and our recovery rates often exceed 50%, with over 68% of patients experiencing reliable improvement. But we recognise that we need to improve access and have been exploring digital options to increase the service’s reach. In 2018/19 IAPT services are due to be re-procured and we will be taking the opportunity to deliver a new model for the service.
Learning disabilities (LD) The CCG worked with all mid Essex GP practices during 2017/18 to maintain a live LD register. 42 out of the 45 practices are signed up to provide the Learning Disabilities Directed Enhanced Service (DES).
Bespoke LD training targeted both at GPs and nurses has been held in all mid Essex localities, with a second round planned for 2018/19. The training includes elements of what reasonable adjustments the practice needs to do to carry out health checks for patients with LD, such as longer appointment times, times of day, availability of more space and easy-read communication.
Practices have also been given communication tools and guides to encourage patients with LD to attend health check appointments.
Existing meetings like practice managers’ meetings, locality meetings, GP summits and the CCG’s Primary Care Forum will all be utilised to remind practices of the national requirements for delivering the health checks. Findings from these meetings and interfaces with practices will be shared with the trainers, with a view to incorporating it into future training.
Planning for Emergencies Within the Civil Contingencies Act, CCGs have a duty to be prepared for incidents and emergencies. CCGs are classed as a “category two” responder and are seen as a “co-operating body”. This means we are less likely to be involved at the heart of planning, but we will be heavily involved in any incidents that affect the health sector through co-operation in response and sharing information.
The Essex CCGs have an Emergency Preparedness, Resilience and Response (EPRR) and Business Continuity Strategy to ensure that we can respond according to the Civil Contingencies Act 2004, Health and Social Care Act 2012 and NHS England national policy and guidance, including the NHS England EPRR Framework 2015 and NHS England EPRR core standards.
37 Mid Essex CCG Annual Report and Accounts 2017/18
In July 2017, our Emergency Planning team undertook a self-assessment against the NHS England EPRR Core Standards. There were four levels of compliance that could be achieved: full, substantial, partial and non-compliant. The CCG achieved “full” compliance.
Key work undertaken in 2017/18 to ensure continued full compliance included:
business continuity planning training and exercising pandemic flu preparedness mass casualty preparedness.
All CCGs in Essex share a generic Incident Response and Incident Coordination Centre Plan which details the process for establishing an Incident Coordination Centre and an Incident Response Team within the local CCG. These plans have been updated during 2017 to cover the increasing expectations placed upon CCGs by NHS England in the event of an incident and to include key tools introduced to commanders at strategic training.
Business Continuity Management (BCM) is a statutory requirement for all Essex CCGs. Suitable plans aligned to the international Business Continuity Standard ISO22301 have been developed to enable us to respond to an internal incident or disruption.
The BCM process is supported by a CCG Business Continuity Management System and Policy alongside our individual Business Continuity Plan (BCP). The CCG’s BCP outlines response and recovery arrangements and how we would mitigate the impact of a business disruption on our operations and reputation. The BCP was tested during the national “cyber-attack” in May 2017.
The Emergency Planning team enjoys strong partnership working with NHS England Midlands and East (East) and with local providers, ensuring the Essex CCGs are a key partner in the Essex Resilience Forum.
Requests under Freedom of Information rules The Freedom of Information (FoI) Act 2000 gives a general right of access to recorded information held by public authorities, subject to certain conditions and exemptions. The CCG received 267 FoI requests during 2017/18. The CCG responded to 100% of these within the statutory timescale of 20 working days.
We certify that we have complied with HM Treasury’s guidance on setting charges for information.
Serious Incidents and Never Events All mid Essex commissioned providers are required to report Serious Incidents (SIs) and Never Events. SIs are defined as any incident that has a direct or indirect impact on patient safety, or affects the organisation’s ability to deliver ongoing healthcare.
‘Never events’ are defined as “serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented by healthcare providers”.
38 Mid Essex CCG Annual Report and Accounts 2017/18
Type of incident 2015/16 2016/17 2017/18 reported to the CCG Serious Incident (SI) 166 169 187 Never Event 3 4 4
The majority of the SIs reported in 2017/18 – 146 – were attributed to care delivered within MEHT. The greatest number of these occurred in 3 categories: 48 related to the development of grade 3 or above pressure ulcers that resulted from a breach in policy; 26 related to delays in treatment; and 13 to patients who had fallen whilst in the hospital’s care.
A further 28 SIs in 2017/18 were attributed to care delivered by Provide CIC, again most falling into a small number of categories: 16 related to the development of grade 3 or above pressure ulcers as a result of breach in policy and eight to falls. The remaining 13 SIs were reported across five other providers.
All reported Never Events were attributed to surgical intervention, three reported by MEHT and one reported by Ramsay Healthcare.
All SIs are investigated by the provider using the root cause analysis framework, following which they are submitted to the CCG where they are reviewed by the Senior Nursing Team on a weekly basis. This review offers us the chance to request further information from the provider to gain assurance that robust action plans and subsequent review processes are in place to ensure there is learning from the incident and that patient safety is improved.
Value for Money We strive to get the best value for money in the way that we use public funds. In 2017/18 we contained our expenditure within our allocated resources and generated an £8.1m surplus which has reduced our cumulative deficit to £13.8m. Our expenditure per head of population is the lowest in Essex.
Previous national reviews confirmed that we compare well against similar CCGs for the way we use resources.
Even so, we must identify more ways to improve efficiency and reduce our spending as part of the challenge to stay within our limited resources. Preparatory work has shown that a number of the savings programmes identified for the Mid and South Essex STP CCGs have already been made in mid Essex, so finding further savings will be a major challenge.
Appropriate procedures for procurement are in place, including tendering for goods and services and making sure suppliers’ quotes are competitive.
Our overall financial management arrangements were subject to review by our new external auditors, KPMG, as part of their annual review of our accounts.
In 2013/14 and 2014/15 we incurred in-year deficits totalling £24.9m. As a result, we automatically received “qualified value for money opinions” from our previous external auditor, Ernst & Young, for those years. We achieved in-year break-even in 2015/16, a £3m surplus in 2016/17 and an £8.1m surplus in 2017/18.
39 Mid Essex CCG Annual Report and Accounts 2017/18
Better Care Fund The Better Care Fund – Protection of Social Care expenditure shown on the chart in section 1.1.4 reflects money passed from the NHS to pay for adult social care, which the NHS recognises as playing an important part in reducing demand on healthcare services.
In 2017/18 we and Essex County Council had a Mid Essex Better Care Fund totalling £22.8m, of which £8.5m related to protection of social care. The remaining £14.3m related to health services which are included in the relevant healthcare expenditure categories in the same chart.
In 2017/18 Essex County Council received an additional £24m grant (from the Improved Better Care Fund) to help with the growing needs of the adult social care sector and the wider health economy. Expected outcomes from the grant’s use are reduced pressure on the NHS by helping people to stay at home for longer and fewer delayed transfers of care.
Joint social care and health schemes in Essex will receive £8.6m from the improved fund, of which £2.2m is allocated to the mid Essex area. We used £1m of the funding in 2017/18 to deliver schemes including improvements in dementia and end of life services. The balance of the funding and a further 2018/19 allocation will provide a similar sum to continue these schemes in 2018/19.
QIPP and the Health and Social Care Act (2012) QIPP (Quality, Innovation, Productivity and Prevention) is the umbrella term used to describe the approach the NHS is taking locally, regionally and nationally to reform and redesign services in the light of financial challenge.
The Health and Social Care Act 2012 outlined the Government’s commitment to ensuring that QIPP supports the NHS in making efficiency savings that can be reinvested to continue improving the quality of NHS care.
In 2017/18 we were required to set a £9m surplus budget. Achieving that target would have required cost savings of £23.5m. We delivered £20.4m of the planned £23.5m savings and covered some of the cost pressures through non-recurrent solutions. The result was a total in-year surplus for the CCG of £8.1m. It is regrettable that we were not able to deliver the full £9m deficit repayment, but the £8.1m surplus was a very significant achievement in the context of below- target funding and severe cost pressures (see section 1.1.4).
The focus for transformational change in 2017/18 has been the way that the health system looks after the frail elderly, including those with long-term conditions and who attend A&E frequently.
During 2017/18 we introduced a Dementia Intensive Support Service (see section 1.2.5) and a Health Navigator scheme to provide community-based services for patients who might otherwise attend A&E. We also delivered substantial cost improvements, particularly in the areas of prescribing and Continuing Health Care.
We have started to implement the primary care service transformation and are working with GP practices to increase their capacity and resilience (see section 1.1.2). We continue to build awareness of inappropriate A&E attendance through patient engagement with the aim of reducing occurrences so MEHT staff can better prioritise patients who require emergency treatment.
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Some QIPP schemes for 2018/19 have been developed across the organisations in the STP while others are specific to the CCG. This means that some will be implemented only in mid Essex while others are developed across mid and south Essex and will be monitored on a system-wide basis.
During 2018/19 we will continue to work closely with Essex County Council and other partners to identify new ways services can link together and improve their efficiency.
1.2.6 Sustainable development
Environmental sustainability is recognised nationally as an essential part of delivering high-quality healthcare efficiently, so it needs to be part of our everyday work and the work of partner organisations and the wider NHS.
Sustainability is not just about the CCG using its limited financial resources carefully. It is also about ensuring we make the most of existing social and community resources (such as community buildings and local groups) and minimising the impact on the local environment by considering sustainability during commissioning and procurement processes.
The CCG has responsibilities as a commissioner and as a corporate body so we work closely with staff and GP member practices to use resources wisely, minimise waste from day-to-day work and improve the sustainability of services. In 2017/18 we have:
continued to improve our business continuity preparedness both internally and with health and social care partners across Essex to keep services sustainable and resilient in the event of adverse weather conditions, power failure or other major business interruptions made further progress in changing working practices to reduce our paper and fuel consumption and continued to promote sustainable travel promoted the use of video and teleconferencing to reduce staff travel investigated opportunities with GP practices to reduce patient travel through technology use continued to explore opportunities for reducing the amount of paperwork generated for CCG meetings and day-to-day conduct of business.
The data on resource consumption for our headquarters building is based on use, size (measured in “gross internal area”, or GIA) and expected performance.
Electricity data is based on estimates for this building type as the actual data is not available from the suppliers.
Gas data is based on billing and estimated for a full year from a partial year of data available (six months). Water data is based on averages for the past few years.
Wren House – full property Full Consumption Cost Property Electricity Gas Water Electricity Gas Water GIA 1,316 123,940.88 280,202.72 1,065.96 £15,864.43 £6,724.87 £3,006.33
41 Mid Essex CCG Annual Report and Accounts 2017/18
Wren House – CCG Area Tenant Consumption Cost Occupancy Electricity Gas Water Electricity Gas Water GIA 902.28 84,976.73 192,113.46 730.85 £10,877.02 £4,610.72 £2,061.21
The CCG has a commitment to promoting sustainability in the healthcare developments planned for primary care and health hub premises. This is reflected through our adherence to Building Research Establishment Environmental Assessment Method (BREEAM) design and build quality standards for development proposals.
Sustainability is a standard part of our procurement processes to ensure that all providers we contract with are environmentally responsible. The CCG is committed to working with all our partners to commission sustainable healthcare and help make sure that the people of mid Essex receive high-quality services both now and into the future.
The CCG is part of the Mid and South Essex Sustainability and Transformation Partnership and through it we work with other health and social care stakeholders across the STP footprint to ensure that our services remain sustainable in the medium to long term while providing high quality healthcare to our population.
One of the key benefits of system working within the STP footprint will be to ensure that demand is managed consistently across the local system and that the commissioning of healthcare services is undertaken at scale. The acute hospital reconfiguration proposals forming part of the STP will also include a consideration of their environmental impact.
Sustainability information will be included within the annual reports of NHS organisations that we commission services from.
During 2018/19 our focus will be to:
Continue to work with our partner organisations within the Mid and South Essex STP footprint to ensure sustainability of services Ensure that our emergency planning arrangements (see section 1.2.5) continue to develop greater resilience to the increased risk of climate-related impacts such as flooding Further reduce our carbon footprint by continually reviewing the way we work and the opportunities afforded by implementing new technology.
This concludes the 2017/18 Mid Essex CCG Performance Report.
Caroline Rassell Accountable Officer
25 May 2018
42 Mid Essex CCG Annual Report and Accounts 2017/18
2. Accountability Report
The second part of Mid Essex Clinical Commissioning Group’s Annual Report and Accounts 2017/18, the Accountability Report, has several elements.
The Corporate Governance Report (section 2.1 below) explains how the CCG is managed and run (its governance structure) and how that helps meet CCG objectives. The Statement of Accountable Officer’s Responsibilities (section 2.1.8) sets out who is answerable for the CCG’s finances and functions, with outlines of their duties. The Governance Statement (section 2.2) explains how the CCG’s internal controls work. The Remuneration and Staff Report (section 2.3) sets out the CCG’s policy for paying directors and senior managers, and explains the payments made under that policy during 2017/18. CCG Board members’ details, staffing numbers, policies relating to staff and equality and diversity are also included in this element of the Accountability Report.
KPMG are the CCG’s external auditors. The total planned fee for the 2017/18 audit was £49,238 including VAT.
Caroline Rassell Accountable Officer
25 May 2018
43 Mid Essex CCG Annual Report and Accounts 2017/18
2.1 Corporate Governance Report
2.1.1 Members Report – member practices
CCGs are clinically-led membership organisations made up of general practices. The following 45 NHS practices are in mid Essex.
Practice Area served Baddow Village Surgery Great Baddow The Beacon Health Group Danbury and north Chelmsford Beauchamp House Surgery Chelmsford Blackwater Medical Centre Maldon Blandford Medical Centre Braintree Blyth’s Meadow Surgery Braintree Brickfields Surgery South Woodham Ferrers Brimpton House Surgery Kelvedon Burnham Surgery Burnham on Crouch The Castle Surgery Castle Hedingham Chelmer Village Surgery Chelmsford Church Lane Surgery Braintree Coggeshall Surgery Coggeshall Collingwood Surgery Witham Dengie Medical Partnership Tillingham and Maylandsea Dickens Place Surgery Chelmsford Douglas Grove Surgery Witham The Elizabeth Courtauld Surgery Halstead Fern House Surgery Witham The Freshford Practice Finchingfield Greenwood Surgery South Woodham Ferrers Hilton House Surgery Sible Hedingham Humber Road Surgery Chelmsford Kelvedon and Feering Health Centre Kelvedon Kingsway Surgery South Woodham Ferrers Little Waltham and Great Notley Surgeries Little Waltham Longfield Medical Centre Maldon Melbourne House Surgery Chelmsford Moulsham Lodge Surgery Chelmsford Mount Chambers Surgery Braintree North Chelmsford NHS Healthcare Centre Chelmsford The Pump House Surgery Earls Colne Rivermead Gate Medical Centre Chelmsford Sidney House and The Laurels Surgeries Hatfield Peverel and Boreham Silver End Surgery Witham Stock Surgery Stock Sutherland Lodge Surgery Chelmsford Tennyson House Surgery Chelmsford Tollesbury Surgery Tollesbury Trinity Medical Practice Mayland Whitley House Surgery Chelmsford William Fisher Medical Centre Southminster Witham Health Centre Witham Writtle Surgery Writtle Wyncroft Surgery Bicknacre
44 Mid Essex CCG Annual Report and Accounts 2017/18
2.1.2 Composition of Governing Body
The CCG’s Board is the accountable body for the performance of the CCG. It has four GP members elected by their fellow GPs to lead the organisation alongside the Executive membership. One of these elected GPs chairs the Board.
The Board also has three lay members. Their roles include ensuring views and suggestions from patients and the public are properly considered by the CCG, providing independent judgment and sound commercial knowledge, and helping to ensure the CCG is well run and uses public funds properly. The CCG’s constitution also makes provision for local authority and secondary care representation on the Board.
As of 31 March 2018, the Board consisted of 16 members. Of these, 9 are female and 7 are male.
Membership of the Board, together with information on which of the main CCG committees each Board member attends, is set out below and in the Governance Statement in section 223.
Board meetings are held on a quarterly basis and Board papers are published on the CCG website in advance of each meeting. At all formal meetings of the Board and its Committees, members must declare if they have an interest in any agenda items under discussion.
The CCG maintains a register of interests declared by Board members, a copy of which is provided at all Board meetings. The full register of Board members’ interests is available on the CCG’s website.
2.1.3 Board Members and Other Elected GPs
The following people have been CCG Board Members during 2017/18.
Keith Andrew Lay Board Member (Governance)
Keith spent over 30 years in banking and was the Regional Manager for the Co-operative Bank in the Anglian region. He now runs his own business providing management and business advice to clients across the region.
Dr Michael Bailey Elected GP
A GP partner for 35 years, Mike Bailey retired from the Writtle Surgery in 2015. In 2003 he received the Queen’s Jubilee Medal for services to Immediate Care. Throughout his career Mike has been an active member of a number of forums and groups operating within the mid Essex area. He served as Senior Medical Officer at the V Festival for more than 15 years.
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Vivienne Barnes Director of Corporate Services; since January 2018 Director of Governance and Performance
Viv joined the CCG in August 2014 as Director of Corporate Services, following a secondment from NHS England where she was Assistant Director of Clinical Strategy for the Essex Area Team.
She has a background in Corporate Governance and has worked at Board level within a number of Primary Care Trusts in south Essex and a London health authority. Viv began her career in the NHS supporting the development of primary care in Southend. Viv was appointed Director of Governance and Performance on 15 January 2018.
Dr James Booth Elected GP and Vice Chair (Clinical); left CCG Board in March 2018
James is a GP and partner at Melbourne House Surgery in Chelmsford. He qualified from University College London in 2002 and qualified as a Member of the Royal College General Practitioners in 2006.
James has lived in Chelmsford all his life and has also worked at Broomfield and St John’s Hospitals.
Dee Davey Chief Finance Officer
Dee is responsible for financial systems, strategy and reporting and for business information and intelligence. Dee worked in Local Government for 20 years before joining the NHS.
Dan Doherty Director of Clinical Commissioning until January 2017; Director of Clinical Transformation from January 2017
Dan was previously Director of Clinical Commissioning and from 15 January 2018 was appointed Director of Clinical Transformation and Deputy Accountable Officer. In March 2016 Dan was seconded to the Mid and South Essex Success Regime (Locality Health and Care) for 18- months, working on system transformation with a particular focus on innovation in health and care.
Dan is a practising physiotherapist who previously worked at St Peter's Hospital in Maldon.
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Dr Caroline Dollery Chair
Caroline has been a GP at Danbury Medical Centre (now part of Beacon Health Group) for 18 years. Her clinical interests include mental health, learning disability, cardiology and paediatrics.
Caroline was previously the GP Board Member for Governance.
Anne Marie Garrigan Lay Board Member (Patient and Public Engagement Lead)
Anne Marie began work at NatWest Bank, moving into early years and childcare in the 1990s. She worked for Essex County Council from 2000 until 2011 in a number of leadership roles within the Schools, Children and Families Directorate, the last as Extended Services Commissioner.
Melanie Graham Director of Primary Care and Immediate Care; fully seconded to Mid Essex Hospital Services NHS Trust; left CCG Board in October 2017
Melanie was appointed as Director of Primary Care and Immediate Care in February 2016. Melanie has a 25-year history of operating in large, complex health organisations, commissioning and contracting.
Rachel Hearn Director of Nursing and Quality
Rachel is a Registered Nurse and Director of Nursing and Quality at the CCG. Rachel has over 17 years’ clinical experience as a nurse within the NHS. Having worked predominantly in emergency and general medicine, Rachel has led work streams on the changing face of emergency care.
Alan Hubbard Lay Board Member (Commercial)
Alan Hubbard is a former Senior Executive with the Lloyds Banking Group. He has over 30 years’ management experience across a range of functions in the UK and abroad. Alan has served for over 11 years as a public sector non-executive director with the local NHS in various roles, including Vice-Chair. He was previously Chair of Essex Probation Trust and has worked as a part-time consultant supporting Essex businesses. He is an Independent Member of the Joint Audit Committee for the Essex Police, Fire and Crime Commissioner, Chief Constable and Essex County Fire and Rescue Authority.
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Dr Donald McGeachy Medical Director; left CCG Board on December 2017 to become Medical Director of Mid and South Essex STP CCG Joint Committee
Donald has been a GP for more than 30 years, working in Derbyshire, Cumbria, Tonga, New Zealand and Essex. For the past 10 years he has taken an increasing interest in healthcare management and was part of the Board of Mid Essex Primary Care Trust (PCT) then North Essex PCT Cluster. Donald was elected as a GP Board member in April 2012 before being appointed as CCG Medical Director on 1 June 2014.
Donald was seconded from the CCG to work in the Mid and South Essex Success Regime and latterly appointed as Medical Director of the Mid and South Essex Sustainability and Transformation Partnership (STP) CCG Joint Committee from December 2017.
Maggie Pacini Consultant in Public Health at Essex County Council
Maggie became mid Essex’s designated Consultant in Public Health in September 2015. Maggie splits her time between County Hall and local CCGs. She focuses on the planning of services based upon the health needs assessment, evidence-based practice and prioritisation. She also acts as a link back to the rest of the Public Health team at the county council, the other CCG Public Health consultants and the health improvement and health protection teams.
Caroline Rassell Accountable Officer; also SRO – Mid and South Essex STP (Locality Health and Care) and since September 2017 Lead Accountable Officer for STP CCG Joint Committee
Caroline joined the CCG as Interim Accountable Officer in January 2014, on secondment from NHS Property Services Ltd, where she was the Director of Finance. Caroline was appointed as Accountable Officer on a permanent basis on 1 November 2014.
From 2009 Caroline was Deputy Chief Executive at Community Health Partnerships (CHP), an arm’s length Company of the Department of Health. Prior to this, Caroline worked in a number of Primary Care Trusts in Essex as a Director of Finance and Director of Commissioning. Before joining the NHS, she worked for 15 years in local government.
Caroline was seconded to the Mid and South Essex Success Regime on 25 March 2016 as Senior Responsible Officer for Locality Health and Care. In September 2017 she was appointed Lead Accountable Officer for the Mid and South Essex STP CCG Joint Committee.
48 Mid Essex CCG Annual Report and Accounts 2017/18
Dr Elizabeth Towers Elected GP
Dr Towers has been a GP at Whitley House Surgery for 30 years, having spent three years as a junior doctor in the Chelmsford area. Her interests lie particularly in cancer and end of life care and she became a Macmillan GP in 2010.
James Wilson Acting Director of Acute Commissioning; since January 2018 Chief Strategy and Transformation Officer
James began his career on the Surrey County Council fast-track graduate scheme. James has since worked across local government predominantly within social care and education.
In 2013 James moved into the NHS, focusing on health contracting and commissioning. James was appointed to the role of Acting Director of Acute Commissioning from 2 September 2016 and in January 2018 was appointed as Chief Strategy and Transformation Officer.
Dr Daniel Dalton Secondary Care Doctor (assumed role in March 2018)
Dr Daniel Dalton graduated in medicine from St Bartholomew’s and the Royal London School of Medicine and Dentistry in 1999. He then undertook core postgraduate training in psychiatry in east London before moving to higher training in forensic psychiatry on the Eastern Region Training Scheme, achieving a Certificate of Completion of Specialist Training (CCST) in forensic psychiatry in 2009.
Dr Dalton is currently consultant forensic psychiatrist and Clinical Director for Learning Disability and Forensic Strategic Business at Hertfordshire Partnership University NHS Foundation Trust. He joined Mid Essex CCG’s Board as Secondary Care Consultant in March 2018.
Committees A full list of the committees supporting the Board and membership of those committees is provided within the Governance Statement at section 2.2.2. Declaration Each director has confirmed that he or she knows of no information which would be relevant to the auditors for the purposes of their audit report, and of which the auditors are not aware; and has taken all the steps that he or she ought to have taken to make himself/herself aware of any such information and to establish that the auditors are aware of it.
49 Mid Essex CCG Annual Report and Accounts 2017/18
2.1.4 Personal-data-related incidents
There were no serious incidents requiring investigation and involving personal data reported to the Information Commissioner’s Office in 2017/18.
2.1.5 Statement as to disclosure to auditors
Each individual who is a member of the CCG at the time the Members Report is approved confirms:
so far as the member is aware, there is no relevant audit information of which the CCG’s auditor is unaware that would be relevant for the purposes of their audit report the member has taken all the steps that they ought to have taken in order to make him or herself aware of any relevant audit information and to establish that the CCG’s auditor is aware of it.
2.1.6 Donations to political parties and charitable organisations
The CCG does not make donations to political parties.
The CCG has made payments to a number of charitable organisations. The majority of these payments are in relation to Service Level Agreements (particularly to local hospices) or as a result of successful grant applications.
2.1.7 Modern Slavery Act
The Modern Slavery Act 2015 has introduced changes in UK law focused on increasing transparency in supply chains to ensure our supply chains are free from modern slavery – that is, slavery, servitude, forced and compulsory labour and human trafficking.
As both a local leader in commissioning health and care services for the population of mid Essex and as an employer, NHS Mid Essex Clinical Commissioning Group (the CCG) provides the following statement in respect of its commitment to, and efforts in, preventing slavery and human trafficking practices in the supply chain and employment practices.
Our Organisation As an authorised statutory body, the CCG is the lead commissioner for health care services (including acute and community) in the mid Essex area – covering a population of nearly 390,000. You can find out more about us in section 1.1.1 of this report.
Our commitment to prevent slavery and human trafficking The Governing Body, Senior Management Team and all employees are committed to ensuring that there is no modern slavery or human trafficking in any part of our business activity and in so far as is possible to holding our suppliers to account to do likewise.
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Our approach Our overall approach will be governed by compliance with legislative and regulatory requirements and the maintenance and development of good practice in the fields of contracting and employment.
Our policies and arrangements Our recruitment processes are highly mature – requiring practices that adhere to safe recruitment principles. This includes strict requirements in respect of identity checks, work permits and criminal records.
Our policies such as Bullying and Harassment at Work policy, Individual Grievance policy, Equality and Diversity policy and Whistleblowing policy provide an additional platform for our employees to raise concerns about poor working practices
Our procurement approach follows the Crown Commercial Service standard. When procuring goods and services, we apply NHS Terms and Conditions (for non-clinical procurement) and the NHS Standard Contract (for clinical procurement). Both require suppliers to comply with relevant legislation.
During 2017/18, we will continue to raise awareness of the Modern Slavery Act 2015 internally and as part of all procurement processes we will request all providers to set out evidence of their plans and arrangements to prevent slavery in their activities and supply chain.
This statement is made pursuant to section 54(1) of the Modern Slavery Act 2015 and constitutes our slavery and human trafficking statement for the financial year ending 31 March 2018.
Dr Caroline Dollery Chair
25 May 2018
2.1.8 Statement of Accountable Officer’s Responsibilities
The National Health Service Act 2006 (as amended) states that each Clinical Commissioning Group shall have an Accountable Officer and that Officer shall be appointed by the NHS Commissioning Board (NHS England). NHS England has appointed Caroline Rassell to be the Accountable Officer of NHS Mid Essex CCG.
The responsibilities of an Accountable Officer are set out under the National Health Service Act 2006 (as amended), Managing Public Money and in the Clinical Commissioning Group Accountable Officer Appointment Letter. They include responsibilities for:
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The propriety and regularity of the public finances for which the Accountable Officer is answerable Keeping proper accounting records (which disclose with reasonable accuracy at any time the financial position of the Clinical Commissioning Group and enable them to ensure that the accounts comply with the requirements of the Accounts Direction) 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 financial statements in the form and on the basis set out in the Accounts Direction.
The financial statements 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 net expenditure, changes in taxpayers’ equity and cash flows for the financial year.
In preparing the financial statements, the Accountable Officer is required to comply with the requirements of the Group Accounting Manual issued by the Department of Health and in particular to:
Observe the Accounts Direction issued by NHS England, including the relevant accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis Make judgements and estimates on a reasonable basis State whether applicable accounting standards as set out in the Group Accounting Manual issued by the Department of Health have been followed, and disclose and explain any material departures in the financial statements Prepare the financial statements 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.
Disclosure:
the CCG deficit has been reported by the external auditors under Section 30(b) of the Local Audit and Accountability Act 2014.
I also confirm that:
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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 that the Annual Report and Accounts as a whole are fair, balanced and understandable, and that I take personal responsibility for the Annual Report and Accounts and the judgments required for determining that they are fair, balanced and understandable.
Caroline Rassell Accountable Officer
25 May 2018
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2.2 Governance Statement
2.2.1 Introduction and context
Mid Essex Clinical Commissioning Group (“The CCG”) is a body corporate established by NHS England on 1 April 2013 under the National Health Service Act 2006 (as amended).
The CCG’s statutory functions are set out under the National Health Service Act 2006 (as amended). The CCG’s general function is arranging the provision of services for persons for the purposes of the health service in England. The CCG is, in particular, required to arrange for the provision of certain health services to such extent as it considers necessary to meet the reasonable requirements of its local population.
As at 1 April 2018, the CCG is not subject to any directions from NHS England issued under Section 14Z21 of the National Health Service Act 2006.
Managing with relatively low funding per head of population continues to be a significant management challenge to the CCG. In view of the overall scale of the financial and service performance issues facing both commissioners and service providers, in May 2015 mid and south Essex was designated as one of three nationally nominated “Success Regimes”.
Following this, the Mid and South Essex Sustainability and Transformation Partnership (STP) footprint, covering the geographic areas of Mid Essex, Basildon & Brentwood, Castle Point & Rochford, Southend and Thurrock CCGs, was established to develop a radical solution to restore the service performance and financial sustainability of the health economy.
In August 2017 the five CCGs formally established a STP CCG Joint Committee (STPJC) to act collectively in the planning, securing and monitoring of services to meet the needs of the population of mid and south Essex, as well as representing the STP footprint for services commissioned over a larger area. Specifically, the STP CCG Joint Committee commissions and manages the contracts for Acute services (NHS and independent sector), NHS 111 and Out of Hours services, ambulance services, Patient Transport services and acute Mental Health services. The STP Joint Committee will also play a role in decision making about Learning Disability services within the existing pan-Essex arrangements.
All other decisions about healthcare continue to be taken locally by the relevant CCG.
The five CCGs have implemented a revised staffing structure to support the new commissioning arrangements.
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.
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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.
UK Corporate Governance Code The CCG is not required to comply with the UK Code of Corporate Governance. However, we have reported on our Corporate Governance arrangements by drawing upon best practice available, including those aspects of the UK Corporate Governance Code we consider to be relevant to the CCG and best practice.
As part of its annual review of effectiveness, the CCG Board undertook an assessment which encompassed the relevant principles of the UK Corporate Governance Code.
The Board concluded from this assessment that it was generally following best practice in relation to providing effective leadership, having an appropriate balance of skills, experience, independence and knowledge to enable Board members to discharge their duties and responsibilities effectively, presenting a balanced and understandable assessment of the CCG’s position in its financial and other reporting and ensuring that remuneration is set appropriately.
Areas for improvement identified from the review of effectiveness will be incorporated in the Board’s ongoing development programme.
2.2.2 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.
CCGs are clinically-led membership organisations made up of general practices. The members of the Mid Essex CCG have determined the governing arrangements for the CCG as set out in its constitution, which is based on the Model Constitution Framework for CCGs and originally approved on 28 March 2013.
The constitution was amended on 3 occasions during the 2017/18 year. These revisions were made in accordance with the procedures for CCG Constitution Change, Merger or Dissolution and were as follows:
Date Version Amendment June 2017 37 Revised to reflect establishment of STP Joint Committee with Basildon & Brentwood, Castle Point & Rochford, Southend and Thurrock CCGs August 2017 37.1 Further amendments in light of feedback from NHS England on proposed Constitutional changes. March 2018 38 Amendments to the CCG’s Mission Statement, Values and Strategic Objectives, Board membership and voting rights.
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There are 45 member practices within Mid Essex CCG, serving a registered population of 390,714 patients as of 1 January 2018.
The practices work primarily in seven geographical clusters or localities across mid Essex as shown in the table below:
Cluster / Locality Number of Practices Registered Patient Population as at 1 January 2018 Braintree 5 56,621 Colne Valley 8 53,204 Witham 5 42,298 Maldon 3 31,848 Dengie 4 23,999 South Woodham Ferrers 4 22,057 Chelmsford 16 160,687
Practices work together within their localities to collaborate on the effective provision of primary care in their local areas and to engage in the commissioning of services on behalf of their populations.
Locality Leads have standing membership of the CCG’s Primary Care Forum and are accountable to their constituent practices under the Terms of Reference and funding criteria consequent upon that membership. The Primary Care Forum is responsible for engagement with practice members, wider primary care healthcare professionals and NHS England in respect of primary care matters and provides a forum through which primary care can share views and be involved in the decision making process of the CCG.
Governing Body (the Board) The CCG’s constitution sets out the governance arrangements, roles and responsibilities of the Board and its membership. The CCG’s constitution also has a set of Standing Orders, Standing Financial Instructions and a Scheme of Reservation and Delegation. During 2017/18 the Board met quarterly resulting in a total of four publicly held Board meetings during 2017/18, all of which were quorate (there are step-down arrangements in place to maintain a clinical majority or in cases of conflict of interest where voting members of the Board recuse themselves from a relevant vote.)
As at 31 March 2018, the Board membership comprised of the following voting members: Chair (a GP member), Accountable Officer, Chief Finance Officer, three other GP members (one of which was a vacant role), three Lay Members, Secondary Care Specialist , Director of Nursing and Quality (Registered Nurse), Director of Clinical Transformation and the Director of Governance and Performance. The Chief Strategy and Transformation Officer is also a non-voting Board member.
Due to the Accountable Officer’s continued involvement in the Essex Success Regime, the former Director of Nursing and Quality continued to act as Managing Director with responsibility for day- to-day operational issues during the start of the 2017/18 financial year. This enabled the Accountable Officer to focus on strategic planning in line with the objectives of the Mid and South
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Essex Success Regime and Sustainability and Transformation Partnership. The Managing Director was subsequently appointed as Deputy Accountable Officer from 1 June 2017 until her secondment to the post of Chief Nurse to the STP Joint Committee Team, with effect from 1 October 2017.
The Deputy Director of Nursing and Quality continued in the role of Acting Director of Nursing and Quality and was subsequently seconded to the post on 15 January 2018.
The Director of Clinical Commissioning continued to be involved with the STP Team until his appointment as Director of Clinical Transformation on 15 January 2018.
The Deputy Director of Clinical Commissioning continued in the role of Acting Director of Acute Commissioning until his appointment as Chief Strategy and Transformation officer on 21 January 2018.
Board representation also includes a Public Health Consultant from Essex County Council (ECC). An elected county councillor representative also attends as an observer with speaking rights.
The Board undertakes an annual review of its effectiveness and has determined that it fulfils its role effectively either all or most of the time and that there is good engagement of members. Appraisals of Board members are undertaken to evaluate individuals’ contributions and performance and regular group development sessions are held to assist members to address emerging issues and priorities. Board Development sessions also facilitate the provision of a range of training for members.
To support the Board in carrying out its duties effectively, committees reporting to the Board are formally established. The current committee structure was approved at the Board meeting held on 1 December 2016. The remit and terms of reference of committees were reviewed during the year to ensure robust governance and assurance.
The CCG reviewed its committee structure to reflect the establishment of the STP Joint Committee and restructuring of the CCG. The amended structure was approved by the Board on 29 March 2018 and will take effect in 2018/19.
The terms of office of the existing elected GP members and lay members expired on 31 March 2018. A selection process was held by the Essex Local Medical Committee in February 2018 to appoint four GP Board members and interviews were held in March 2018 to appoint three Lay Members.
The Board agreed amendments to the membership of the Board and revised voting rights at its meeting held 29 March 2018 which will take effect from 2018/19.
Each committee submits a summary of discussions and decisions to every Board meeting and reports any key issues. The main committees providing assurance to the Board are as follows.
Audit Committee This Committee provides the CCG’s Board with an independent and objective view of the CCG’s financial systems, financial information and compliance with laws, regulations and directions governing the CCG insofar as they relate to finance, good corporate governance, information governance, emergency planning, response and resilience (EPRR), business continuity
57 Mid Essex CCG Annual Report and Accounts 2017/18 management (BCM) and the CCG’s responsibility to act effectively, efficiently and economically. The Audit Committee is chaired by the Lay Member (Governance)/Deputy Chair of the CCG, Keith Andrew.
As at 31 March 2018, its other members comprised the Lay Member (Commercial), Alan Hubbard, and an elected GP Board member, Dr Mike Bailey. During 2017/18 the Committee met on five occasions and attendance has been quorate in line with its Terms of Reference (minimum of two core members) on all occasions, as shown below (with “Y” denoting attendance and “N” apologies).
Audit Role Present Present Present Present Present Committee 11/5/17 26/5/17 4/9/17 18/12/17 5/3/18 member Keith Andrew Chair (Lay Board Y Y Y Y Y Member – Governance) Alan Hubbard Deputy chair (Lay Board Y N N Y Y Member – Commercial) Dr Mike Bailey Elected GP Y Y Y Y N
During 2017/18 the Audit Committee continued to focus upon ensuring the development of the systems, policies, procedures and processes fundamental to the governance of the organisation. This included a review of the CCG’s suite of Emergency Planning and Business Continuity Management policies and procedures.
The Committee has been receiving assurance from internal audit of key systems and processes and, in addition to routine reporting, including updates on counter-fraud initiatives and investigations, has focused upon ensuring that recommendations made following Audits are implemented and monitoring the signing of contracts and that the CCG has robust emergency planning, resilience and response and business continuity management policies and procedures in place. The Committee reviewed the draft accounts and approved the final accounts and management response to the auditor on behalf of the Board.
The Committee also received a regular report on the CCG’s Assurance Framework, risk registers and risk profile and compliance with the Security Management Standards for Commissioners. The Committee receives minutes of the CCG’s main Committees and the Primary Care Commissioning Committee established between the CCG and NHS England.
In line with NHS England guidance on the management of Conflicts of Interest, the Chair of the Committee acts as the CCG’s Conflicts of Interest Guardian. The Committee approved revised Conflicts of Interest, Gifts and Hospitality and Standards of Business Conduct Policies which were amended to comply with revised NHS England guidance on the management of conflicts of interest issued in June 2017. The Audit Committee Chair regularly met with the Director of Governance and Performance to receive assurance that the guidance was being implemented prior to signing the quarterly and annual conflicts of interest self-certificates submitted to NHS England.
Remuneration Committee This Committee has delegated authority from the Board to make decisions on the remuneration, fees and other allowances and benefits/benefits in kind for employees and for individuals who
58 Mid Essex CCG Annual Report and Accounts 2017/18 provide services to the CCG. It also oversees arrangements for termination of employment and other contractual terms including the proper calculation and scrutiny of termination payments.
In making such decisions the Committee ensures that any relevant national guidance or other guidance is taken into account as appropriate. The Remuneration Committee is chaired by the Lay Member (Governance)/Deputy Chair of the CCG and, as at 31 March 2018, its other membership comprised the Chair of the CCG, the Lay Member (Commercial), the Accountable Officer and the Head of Human Resources. The Committee met on three occasions last year and was quorate on all occasions.
Quality and Governance Committee This Committee provides assurance regarding the quality, safety, effectiveness and performance of services commissioned by the CCG. The Committee also scrutinises and receives assurance regarding the CCG’s corporate governance arrangements including risk management, information governance, equality and diversity, safeguarding, and the organisational development strategy.
The Committee was chaired by the Clinical Vice-Chair of the CCG (an elected GP member) until March 2018, when the Lay Member for Patient and Public Engagement (the Deputy Chair) took on this role. As of 31 March 2018, its other core membership comprised the Director of Nursing and Quality, Director of Governance and Performance, Deputy Director of Nursing and Quality, Chief Pharmacist and Head of Corporate Governance, Resilience and Administration. The committee also has a number of standing members/co-opted members representing the various functions within the remit of the committee.
During 2017/18 areas of particular focus for the Committee have included reviewing key patient safety risks, responding to Care Quality Commission (CQC) concerns about providers, evaluation of patient experience, the development and review of quality and governance related policies and a review of the CCG’s Health and Safety arrangements. The Committee met on a quarterly basis and attendance has been quorate in line with its Terms of Reference on all occasions.
Finance and Performance Committee This Committee scrutinises and provides the CCG Board with assurance on the CCG’s overall financial and service performance for all commissioned services and running costs. The Committee was chaired by the Lay Member (Commercial). As of 31 March 2018 its other membership comprised a GP Representative (Vice Chair), Accountable Officer, Chief Transformation and Strategy Officer, Director of Clinical Transformation, Director of Governance and Performance, Director of Nursing, Chief Finance Officer and Deputy Chief Finance Officer.
During 2017/18 the Committee particularly focused upon the management of the activity of the CCG’s main service providers, financial control to ensure that the CCG remained on track to deliver the planned outturn position and the maintenance of performance and quality indicators. The Committee met bi-monthly with a total of six meetings during the year. Attendance was quorate in line with its Terms of Reference on all occasions.
In addition to regular scrutiny of the CCG’s financial position and performance against contracts, the Committee has received detailed reports on some of the CCG’s major contracts, including:
Mid Essex Hospital Services NHS Trust
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Mental Health contract Patient Transport Services
Live Well Committee This committee provides the main forum for assurance of the delivery of the CCG’s Live Well Strategy, championing the Live Well vision within the mid Essex health and social care system and overseeing and assuring the CCG’s contribution to the implementation of all aspects of the Live Well health and wellbeing programmes. The Committee ensures that all clinical, strategic and operational activity commissioned by the CCG supports and aligns with the Live Well strategy.
The Committee was chaired by the Chair of the CCG, who is an elected GP Board member. As of 31 March 2018 its other membership comprised of the Accountable Officer, Director of Clinical Transformation (Vice Chair), the CCG’s eight Clinical Leads, Medical Director, Director of Governance and Performance, Director of Nursing and Quality, Chief Pharmacist, Consultant in Public Health (ECC), Deputy Chief Finance Officer and the Chief Transformation and Strategy Officer.
During 2017/18 the Committee focused on building partnership working both in the context of the Mid and South Essex Sustainability and Transformation Partnership and with Essex County Council on public health and other matters; Mental Health strategies including Dementia and children’s and young people’s mental health and suicide prevention; Paediatric service improvement; Frailty and End of Life strategies; the practical application of RightCare principles; Primary Care sustainability through the Foundations programme; the shape of community based health services; and a wide variety of other developments to transform care and deliver sustainable efficiencies.
The committee met monthly apart from two occasions, making a total of ten meetings held during the year. Attendance was quorate in line with the committee’s Terms of Reference on all occasions, except the March meeting. On this occasion, decisions required were agreed virtually.
Primary Care Commissioning Committee This committee was originally a joint committee between Mid Essex CCG, North East Essex CCG and NHS England. The role of the committee was to carry out the functions relating to the commissioning of primary medical services in mid and north East Essex CCG areas under section 83 of the NHS Act, except those relating to individual GP performance management, which were reserved to NHS England. In March 2017 a decision was taken to dissolve the Committee following North Essex CCG’s successful application to undertake fully delegated primary care commissioning. Mid Essex CCG and NHS England resumed publicly held committee meetings in respect of their joint primary care commissioning arrangements from July 2017.
During 2017/18 the Committee focused on Primary Care finance, quality, IT and premises developments, local operational issues requiring a decision, e.g. possible practice mergers, reductions in practice opening hours and applications for formal list closures. Public meetings were held on a bi-monthly basis, with a total of five public meetings held during 2017/18. The Committee also meets in private each month if there are confidential matters requiring urgent attention. Attendance was quorate in line with the committee’s Terms of Reference on all occasions.
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Better Care Fund (including Improved Better Care Fund) Governance A Better Care Fund (BCF) Partnership Board meets to fulfil the governance requirements with Essex County Council.
In line with the terms of the Section 75 Better Care Fund Agreement, decision-making relating to the BCF is delegated to two nominated representatives of the CCG and two representatives of Essex County Council. Utilisation of the BCF funds was agreed in the Section 75 Agreement and in-year reporting focused upon expenditure on the approved services and monitoring against agreed performance targets.
Discharge of Statutory Functions The CCG is committed to ensuring that risk management forms an integral part of its philosophy, practices and business plans, rather than viewed or practised as a separate programme, and that responsibility for implementation is accepted at all levels of the CCG.
The Risk Management Policy, which encompasses both clinical and non-clinical risks, was revised in March 2018. The Policy is based on the Australia/New Zealand risk management model and sets out the risk management system, supporting processes and reporting arrangements which aim to protect patients, the public, staff and the CCG’s assets and reputation.
The Board collectively agreed its Risk Appetite levels for risks falling with the categories of quality, safety, regulatory, reputation, innovation, finance or partnerships. This assists managers to identify when risk levels are tolerable or where further action is required to reduce risk ratings to an acceptable level. The Board carried out a review of its risk registers in April 2017 and reviews the strategic risk register at each Board meeting.
Throughout 2017/18 the CCG has had the following arrangements in place: Clear ownership of risks, with responsible Directors and lead officers identified, with escalation arrangements in place to the Board Strategic and Operational risk registers on which the latest updates provided by lead officers were recorded and reported to the Audit Committee, Quality and Governance Committee and Board Accurate reflection of strategic risks to the organisation through the Board Assurance Framework A review of financial risks at each Finance and Performance Committee meeting Recording and investigation processes for incidents, including identification of learning Triangulation of learning from incidents, complaints and claims (should they arise) as a standing item on the agenda of the Quality and Governance Committee Monitoring of completion of Equality Impact Assessments by the Equality and Diversity Sub- Committee.
The CCG’s Whistleblowing Policy, supported by the appointment of a Freedom To Speak Up Guardian (see section 2.1.2) also supports risk management by providing a framework for employees to raise concerns, in line with the Public Interest Disclosure Act 1998, without the perception of being disloyal to colleagues, managers or the organisation. The Whistleblowing Policy was reviewed in September 2017.
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The CCG is committed to identifying the underlying or root causes of incidents, claims and complaints, and the principal objective is to identify ‘system failures’, rather than focusing on individual failures.
Stakeholders, including staff, patients and the public have been involved in the risk management process, for example by ensuring that relevant staff were identified to input into any risk assessments in their function or area of work; that CCG staff and contractors were made aware of agreed risk reporting procedures; that contracts clearly stated the responsibilities of contracted personnel with regard to risk identification, reduction, mitigation and reporting; that feedback on risk issues was encouraged via the CCG’s complaints and enquiries services and through its public engagement and consultation mechanisms, e.g. patient stories at Board meetings, engagement with the public and other stakeholders on future plans for services. Risk management awareness training was provided to members of CCG staff in February and March 2018.
The CCG has led several large engagement programmes this year including a 10-week Home First programme involving five public workshops, online survey and bespoke meetings; led on many STP consultation events across the patch; continued to collaborate on community events promoting all aspects of NHS care to Live Well; held its first Community and Voluntary sector summit and continued to work with local authority partners and Healthwatch Essex to hear more lived experience from seldom heard groups in mid Essex – including those with hearing and visual impairments
The effectiveness of these risk management arrangements are summarised under the ‘Review of the Effectiveness of Governance, Risk Management and Internal Control’ section, which includes the monitoring, review and management of the Assurance Framework in its entirety by the Audit Committee, Quality and Governance Committee and Board. The annual audit of risk and governance was carried out by the CCG’s Internal Auditor in February 2018 and identified ‘substantial’ assurance.
2.2.3 Risk management arrangements and effectiveness
The CCG is committed to ensuring that risk management forms an integral part of its philosophy, practices and business plans, rather than viewed or practised as a separate programme, and that responsibility for implementation is accepted at all levels of the CCG.
The Risk Management Policy, which encompasses both clinical and non-clinical risks, was revised in March 2018. The Policy is based on the Australia/New Zealand risk management model and sets out the risk management system, supporting processes and reporting arrangements which aim to protect patients, the public, staff and the CCG’s assets and reputation.
The Board collectively agreed its Risk Appetite levels for risks falling within the categories of quality, safety, regulatory, reputation, innovation, finance or partnerships. This assists managers to identify when risk levels are tolerable or where further action is required to reduce risk ratings to an acceptable level. The Board carried out a review of its risk registers in April 2017.
Throughout 2017/18 the CCG has had the following arrangements in place:
Clear ownership of risks, with responsible Directors and lead officers identified, with escalation arrangements in place to the Board
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Strategic and Operational risk registers on which the latest updates provided by lead officers were recorded and reported to the Audit Committee, Quality and Governance Committee and Board Accurate reflection of strategic risks to the organisation through the Board Assurance Framework A review of financial risks at each Finance and Performance Committee meeting Recording and investigation processes for incidents, including identification of learning Triangulation of learning from incidents, complaints and claims (should they arise) as a standing item on the agenda of the Quality and Governance Committee Monitoring of completion of Equality Impact Assessments by the Equality and Diversity Sub-Committee.
The CCG’s Whistleblowing Policy, supported by the appointment of a Freedom To Speak Up Guardian (see section 2.1.2 below) also supports risk management by providing a framework for employees to raise concerns, in line with the Public Interest Disclosure Act 1998, without the perception of being disloyal to colleagues, managers or the organisation. The Whistleblowing Policy was reviewed in September 2017.
The CCG is committed to identifying the underlying or root causes of incidents, claims and complaints, and the principal objective is to identify ‘system failures’, rather than focusing on individual failures.
Stakeholders, including staff, patients and the public have been involved in the risk management process, for example by ensuring that relevant staff were identified to input into any risk assessments in their function or area of work; that CCG staff and contractors were made aware of agreed risk reporting procedures; that contracts clearly stated the responsibilities of contracted personnel with regard to risk identification, reduction, mitigation and reporting; that feedback on risk issues was encouraged via the CCG’s complaints and enquiries services and through its public engagement and consultation mechanisms, e.g. patient stories at Board meetings, engagement with the public and other stakeholders on future plans for services. Risk management awareness training was provided to members of CCG staff in February and March 2018.
The CCG has led several large engagement programmes this year including a 10-week Home First programme involving five public workshops, online survey and bespoke meetings; led on many STP consultation events across the patch; continued to collaborate on community events promoting all aspects of NHS care to Live Well; held its first Community and Voluntary sector summit and continued to work with local authority partners and Healthwatch Essex to hear more lived experience from seldom-heard groups in mid Essex – including those with hearing and visual impairments.
The effectiveness of these risk management arrangements are summarised under the ‘Review of the Effectiveness of Governance, Risk Management and Internal Control’ section, which includes the monitoring, review and management of the Assurance Framework in its entirety by the Audit Committee, Quality and Governance Committee and Board.
Prevention of Risk The application of this framework enabled the prevention of risk through:
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Commitment to identifying the underlying or root causes of incidents, complaints and claims (should they arise) Promoting an open, just and non-punitive culture Driving an on-going information and education programme which empowers and supports staff in the risk management process generally and in relation to specific areas of risk Updating and maintaining the knowledge of Board members, including regular training at Board development sessions on specific areas of risk All staff being familiar with the terms of the Anti-fraud and Anti-bribery policy through promotion and training, and the issuing of fraud alerts, with the help of counter-fraud services All staff being familiar with the terms of the Conflicts of Interest, Gifts and Hospitality and Standards of Conduct Policies. Registers of Interests being produced for Board and Committee meetings and those sub committees with decision-making powers, or capacity to influence decisions made by the CCG, so that the relevant Chair can ensure that potential conflicts are managed appropriately.
The CCG Internal Control Framework The system of internal control is the set of processes and procedures in place in the CCG to ensure it delivers its policies, aims and objectives. It is designed to identify and prioritise the risks, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically.
The system of internal control allows risk to be managed to a reasonable level rather than eliminating all risk; it can therefore only provide reasonable and not absolute assurance of effectiveness.
The system of control in place is set out within the Board, the Committee and Risk Management sections of this statement.
Financial arrangements The CCG’s key financial systems are operated by third party providers. The CCG Finance team oversee the operation of internal financial control arrangements and the dissemination of good financial management and professional standards. The CCG’s financial arrangements are assessed annually by external parties as part of the internal and external audit functions.
The Finance and Performance Committee exercises the Board’s functions in respect of the oversight of financial control and the Savings Programme Board provides detailed scrutiny and impetus to the delivery of the Quality, Innovation, Productivity and Prevention (QIPP) programme (see section 1.2.5).
The Savings Programme Board reports to the Finance and Performance Committee and provides a report directly to Board.
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Risk Assessment Risks included on the CCG’s risk registers are identified via a number of routes, including horizon scanning by Board/ senior managers, by committees/sub-Committees/working groups, financial analysis, impact assessments and specific risk assessments.
From 2017/18 the CCG classified risks as either Strategic or Operational (previously Strategic, Corporate or Directorate), with red rated risks being automatically escalated to Strategic level.
Strategic Risks
New Strategic Risks during 2017/18 were as follows: Risks associated with infection prevention and control standards Risks associated with the implementation of the Lorenzo patient administration system at Mid Essex Hospitals Trust Risks associated with the CCG’s ability to prevent or respond to cyber-attacks Risks associated with the impact of a mass casualty incident on the CCG and its providers Risks associated with the CCG’s capacity to deliver ‘business as usual’ following implementation of revised staffing structures for the CCG and STP Joint Commissioning Team. Risks associated with NHS Property Services charging arrangements (escalated from operational level) Risks associated with the CCG’s ability to draw down cash to pay its creditors (escalated from operational level) Risks associated with information governance and information technology procedures (escalated from operational level) Risks associated with increased A&E attendances and admissions at Mid Essex Hospitals Trust (escalated from operational level) Risks associated with Mid Essex Hospitals Trust’s ability to meet the NHS Constitution 62 day cancer pathway standard Risks associated with the ability of CCG on-call staff to effectively respond to incidents (escalated from operational level). Risks associated with ambulance turnaround times (escalated from operational level).
The profile of the risks to achieving the CCG’s strategic objectives at the end of March 2018 was:
Extreme High Moderate Low Total (Red) (Amber) (Yellow) (Green) 8 8 3 0 19
This represents an increase in both the number of risks and an increase in extreme risk ratings compared to the position as at March 2017. Progress on the controls and mitigating actions being implemented to address the identified risks to achieving our strategic objectives was reported through the Assurance Framework to the Quality and Governance Committee, Audit Committee and Board.
65 Mid Essex CCG Annual Report and Accounts 2017/18
Despite the robust efforts made to manage or reduce the risks, the following red risks remained at the end of the year with a resulting impact on the overall achievement of our strategic objectives: Risk of not containing revenue expenditure within approved Financial Plan Risks associated with unplanned costs Risks associated with infection prevention and control standards Risks associated with the implementation of the Lorenzo patient administration system at Mid Essex Hospitals Trust Risks associated with increased A&E attendances and admissions at Mid Essex Hospitals Trust Risks associated with Mid Essex Hospitals Trust’s ability to meet the NHS Constitution 62 day cancer pathway standard Risks associated with the impact of a mass casualty incident on the CCG and its providers Risks associated with ambulance turnaround times
Operational Risks
The table below sets out the number of operational risks as at the end of March 2018:
Extreme High Moderate Low Total (Red) (Amber) (Yellow) (Green) 0 10 11 0 21
This represents a decrease in the number of Operational risks (previously those risks identified as Corporate or Directorate) and the number of Amber risks compared to the position at March 2017.
Risks that remain open will be carried forward to the 2018/19 risk registers and monitored by the appropriate committees and responsible lead directors and managers. The Audit Committee will provide scrutiny and challenge to the management of these risks and provide an assurance opinion to the Board. The Board will ensure that any additional measures are fully explored in order to manage or reduce the identified risks.
Financial Risks
The CCG had flagged during the Plan development phase that it was unlikely to be able to meet the mandated financial Control Total of an in-year £9m surplus and was in close dialogue with the NHS England DCO office in this respect throughout the year.
As the year progressed, QIPP slippage and cost pressures contributed to a year-to-date overspend against the control total and in month 9 NHSE agreed that the CCG could move the forecast surplus to £6.4m. National recognition of the cost pressures caused by a number of generic drugs not being available at tariff prices meant that the CCG was further authorised to move the forecast surplus to £5.4m.
Towards the end of the financial year, once the value of the main acute contract was capped following arbitration, there was reasonable confidence that, although the CCG would not meet the
66 Mid Essex CCG Annual Report and Accounts 2017/18 control total, it would meet the forecast outturn of a £5.4m surplus. The reported year-end position was an £8.1m surplus as, in addition to the £5.4m, NHS England permitted all CCGs to release the 0.5% risk share reserve (£2.2m) and repaid the Category M benefit clawback (£0.5m).
2.2.4 Other sources of assurance
Annual Audit of Conflicts of Interest Management Revised statutory guidance on managing conflicts of interest for CCGs (published June 2017) requires CCGs to undertake an annual internal audit of conflicts of interest management. To support CCGs to undertake this task, NHS England has published a template audit framework.
The annual audit of conflicts of interest was carried out in February 2017 and identified ‘substantial’ assurance.
Data quality The CCG Board can have confidence that the CCG reports data after establishing that the data is precise, inclusive, and meets particular criteria. The CCG’s data validation procedures are designed to improve the quality of data by finding inconsistencies in the data.
The CCG is continually looking for ways of improving data monitoring. The CCG continues to scrutinise and challenge data and seek daily and weekly ‘raw’ data to learn its parameters of accuracy before validation so it can be used to provide an early indication of any issues. This has proven very helpful for monitoring the elective and non-elective pathways, particularly the 18 week, cancer and urgent care pathways.
This process then supports data validation and helps in the reduction of errors. In seeking as much invalidated raw data as frequently as possible, data variances have been identified early, easily and challenged. Spot checking by auditing a sample of data periodically is also built into our systems.
MEHT installed a new Patient tracking system in May 2017. This has resulted in a larger waiting list and therefore the Trust has been validating the full Patient Tracking List with support from the National Intensive Support Team. An action plan and data monitoring is being scrutinised by NHSI and the CCG with an expectation to get to a correct position by August 2018.
For contracts and billing the CCG undertakes numerous validation checks which are built into our data processing methodology to ensure providers are billing correctly. This includes monitoring and challenging contracted performance through the data validation process.
All contracts have an expectation to have a data improvement plan, with agreed actions and timelines to improve data quality and completeness if required.
Information Governance The NHS Information Governance Framework sets the processes and procedures by which the NHS handles information about patients and employees, in particular personal identifiable information. The NHS Information Governance Framework is supported by an information governance toolkit and the annual submission process provides assurances to the CCG, other
67 Mid Essex CCG Annual Report and Accounts 2017/18 organisations and to individuals that personal information is dealt with legally, securely, efficiently and effectively.
We place high importance on ensuring there are robust information governance systems and processes in place to help protect patient and corporate information. We have reviewed our information governance management framework and have developed information governance processes and procedures in line with the information governance toolkit.
We have ensured that all staff have access to information governance training, including training on the General Data Protection Regulations and the outcome of the National Data Guardian Review, and have achieved the attainment threshold as required by the NHS Information Governance (IG) Toolkit and have implemented a staff information governance handbook to ensure staff are aware of their information governance roles and responsibilities. There are processes in place for incident reporting and investigation of serious incidents.
No serious incidents requiring investigation involving personal data were reported to the Information Commissioner in 2017/18.
The CCG has nominated information asset owners who have completed the new data flow mapping and information asset registers to ensure compliance with the General Data Protection Regulations. This was done with support from the IG Team to ensure consistency of approach. In 2017/18 the CCG met, on all criteria, the requirements of the IG Toolkit for level 2 compliance, which is the minimum level that the CCG must achieve for it to continue receiving the information it requires to operate. For 2018/19 the CCG will work with the IG Team to ensure compliance with the requirements of the new Data Security and Protection Toolkit and will as a minimum provide assurance for all the mandatory assertions.
The CCG’s Caldicott Guardian attended training in January 2018. The CCG’s Senior Information Risk Owner (SIRO) attended training in October 2016 and is due to attend renewal training in 2018/19.
The CCG and the IG Team will continue to work with NHS England and NHS Digital (NHSD) to provide assurance to the Confidentiality Advisory Group on the requirements of the s251 agreements in place to ensure that the CCG retains its interim Accredited Safe Haven (ASH) and Controlled Environment for Finance (CEfF) status
Business-critical models The CCG supports the principles of the Macpherson Report and is committed to embedding best practice in relation to quality assuring our prioritised business critical models and other functions. We continue to improve certain business critical systems, for example on acute hospital activity reporting and forecasting and financial planning by way of peer review and version control.
The Essex CCGs each have a Business Continuity Plan supported by an overarching Essex-wide Business Continuity Policy, both of which have been approved by CCG Boards. Although the documents are updated on a constant basis, a comprehensive annual review takes place each year.
A memorandum of understanding has been signed by the Essex CCGs which sets out the intentions of the CCGs to provide mutual aid and assistance to each other during a business continuity incident which cannot be managed internally within each CCG’s own business continuity
68 Mid Essex CCG Annual Report and Accounts 2017/18 arrangements and which involves one or more of the following: critical loss of key staff, temporary loss of premises or loss of a significant amount of IT hardware.
Third-party assurances The CCG relies on a number of third party providers which are listed below, together with information on how assurance is received from each provider, the effectiveness of these arrangements and whether any improvements are planned in the future.
Human Resources transactional, recruitment and workforce services and occupational health advice are provided by Anglian Community Enterprise (ACE). This arrangement has been in place since October 2014, and the relationship between the two organisations continues to grow positively. Both the CCG and ACE have received good internal and external audit reviews of their HR/recruitment functions. The CCG receives regular KPI data regarding the performance of the ACE service and monthly client/provider meetings are held. Payroll and pension services are provided to MECCG by Whittington Health NHS Trust. This arrangement came into force on 1 March 2018, with support provided to the CCG from the Whittington Health Head office in North London. Already a positive relationship is forming and Whittington Health have worked to assess the ‘set up’ of the CCG’s payroll, making adjustments to element setup to make the information on payslips clearer for staff.
The Employment Services Lead (ACE) will lead the monthly client ‘conference call’ with Whittington – involving the HR Manager and Head of HR at MECCG where necessary and face to face meetings with Whittington will occur on a quarterly basis. In addition the Employment Services Lead (ACE) will liaise with the Whittington team on behalf of the CCG to address payroll and ESR issues as and when they arise. The annual audit of payroll identified ‘good’ assurance. Arden and GEM Commissioning Support Unit was commissioned until 31 March 2017 to complete the CCG’s retrospective Continuing Health Care (CHC) caseload. Up to October 2016 weekly assurance reports on progress were received. In addition, monthly assurance/performance telephone conversations took place. On cessation of the formal contract with Arden and GEM in March 2017 updates are received on an ad-hoc basis in relation to cases that are being finalised outside of the contract. The CCG retains the services of a procurement expert company (Attain) to ensure probity during procurement processes. The Finance and Performance Committee receive procurement reports at each meeting. A Register of procurement decisions is reviewed at each meeting of the Audit Committee to ensure rigour is being applied and published on the public facing website. North East London Commissioning Support Unit (NELCSU) provides Information Technology (IT) services to the CCG as well as part of its Business Intelligence service. NELCSU have updated their IT Disaster Recovery Plan, which was shared with the CCG. Monthly IT update meetings are held to discuss performance and any on-going concerns.
At these meetings, assurances have been received regarding the robustness of back-up procedures. Similar assurances have also been sought and received by the CCG’s Head of Emergency Planning in relation to business continuity management arrangements.
69 Mid Essex CCG Annual Report and Accounts 2017/18
2.2.5 Control Issues
Mid Essex Hospitals Services NHS Trust, in May 2017, implemented a new Patient Administration System (Lorenzo). This has impacted on the MEHT’s ability to produce accurate and timely data for managing patient care and has also impacted on their ability to meet both local (CCG) and national reporting requirements. MEHT have been given permission to pause some elements of national reporting until August 2018 to give them the opportunity to resolve data recording issues. This risk has been highlighted on the CCG’s risk register which is reviewed at each Audit Committee meeting. An action plan has been developed and is monitored weekly.
There are no major control issues other than as outlined above.
2.2.6 Review of economy, efficiency and effectiveness of the use of resources
The CCG was pleased to be able to repay £8.1m of the accumulated deficit in 2017/18 despite recurrent healthcare funding being £8.4m below target funding. This was less than the £9m target set by NHS England although still a very significant achievement. Regrettably the CCG still has a £13.5m accumulated deficit from previous years.
The CCG compares favourably with peer CCGs in benchmarking exercises of service utilisation and health outcomes and in 2017/18 these outcomes have been achieved in the context of per capita funding £73 below the Essex CCG average and lower than all other Essex CCGs. The CCG must continue to look for significant cost reduction opportunities in order to contain expenditure within allocated resources. In 2017/18 the CCG delivered £20.4 million of new savings (4.64% of resource allocation).
The savings included those arising from prescribing reviews and medicines optimisation, development of primary care and community services to prevent use of expensive secondary care services where appropriate, and review of the operational delivery of continuing health care and a number of the CCG’s small community and diagnostic services. The CCG also had a key role developing a co-ordinated and consistent approach across the Sustainability and Transformation Partnership footprint.
The Finance and Performance Committee, Savings Programme Board, Audit Committee and CCG Board have each received regular financial reporting and had the opportunity for detailed review of the CCG’s position.
The Finance and Performance Committee has been reviewing the CCG’s procurement planning arrangements in order to ensure that the CCG is in the best possible position to ensure value for money from commissioned services. The CCG has also been using benchmarking data across service areas to help inform the QIPP planning process. In 2017/18 the CCG has been working closely with the national Rightcare programme in order to identify and prioritise opportunities for further improvement in value for money.
The Finance and Performance Committee receives detailed reporting on financial and service performance and has received a number of “deep dive” reports on key priority areas.
The CCG’s 2017/18 Running (management) costs were more than 6% below permitted expenditure.
70 Mid Essex CCG Annual Report and Accounts 2017/18
The CCG was red rated for its leadership as of Quarter 2 2017/18. Our year end assessment will be published in July 2018 in the MyNHS section of the NHS website.
The Internal Auditor has reviewed the CCG’s financial systems and processes, including the arrangements for financial reporting and confirmed that the CCG has satisfactory arrangements in place.
Delegation of functions Mental health services are commissioned on behalf of the three north Essex CCGs by a central commissioning team hosted by North East Essex CCG. The individual placements team which commissions placements for individuals with Section 117 after care rights, as well as specialist placements for children and for adults requiring tertiary care, is also hosted by North East Essex CCG and provides this function on a pan-Essex basis
The previously commissioned Tier 2 (Social Care) and Tier 3 Community Secondary Mental Health Services for Children, previously known as Children and Adolescent Mental Health Services (CAMHS), was replaced from November 2015 by the Emotional Wellbeing and Mental Health Service (EWMHS) and was commissioned on a pan Essex basis. West Essex CCG is the co-ordinating commissioner for this service. Children’s in-patient services continue to be commissioned by NHS England.
Learning Disability (LD) services continue to be commissioned by Essex County Council, with the Health lead for the North Essex CCGS being West Essex CCG.
Better Care Fund resources have been managed through partnership arrangements.
The CCG has been part of a quality collaborative with North East Essex CCG in year, which provides a forum for discussion about the quality of hosted services. Additionally any serious incidents arising in mid or north east Essex have been subject to scrutiny at a weekly serious incident panel. The development of Sustainability and Transformation Partnerships (STPs) has seen Mid Essex CCG withdraw from this panel as both parties wished to form closer working relationships with the other members of its own STP.
The CCG also attends the Quality Review Group for Mental Health services and has oversight reports submitted to its Quality and Governance Committee for Mental Health and Learning Disabilities. In common with other CCGs, the Mid Essex Director of Nursing is a member of the Quality Surveillance Group which allows intelligence to be shared across Essex with other commissioners and with the CQC.
No adverse information has been received from third party assurance reports relating to West Essex’s host commissioner role for Learning Disability and EWMHS, or North East Essex CCG’s host commissioner role for mental health services.
Counter fraud arrangements An Accredited Counter Fraud Specialist, who is an employee of the CCG’s internal auditors, is contracted to undertake counter fraud work proportionate to identified risks.
71 Mid Essex CCG Annual Report and Accounts 2017/18
The CCG Audit Committee receives an update from the LCFS regarding any counter-fraud initiatives or investigations at each meeting and a report against each of the NHS Protect Standards for Commissioners: Fraud, Bribery and Corruption, at least annually.
There is executive support and direction from the Chief Finance Officer and Director of Governance and Performance for a proportionate proactive work plan to address identified risks. The Chief Finance Officer is the identified member of the executive team named within the Anti- Fraud, Bribery and Corruption Policy who is proactively and demonstrably responsible for tackling fraud, bribery and corruption.
There were no NHS Protect quality assurance recommendations received by the CCG during 2017/18.
Head of Internal Audit Opinion Following completion of the planned audit work for the financial year for the CCG, the Head of Internal Audit issued an independent and objective opinion on the adequacy and effectiveness of the clinical commissioning group’s system of risk management, governance and internal control.
The Interim Head of Internal Audit Opinion concluded that satisfactory assurance can be given that there is a generally sound system of internal control, designed to meet the CCG’s objectives, and that controls are generally being applied consistently. However, some weakness in design and/or inconsistent application of controls put the achievement of particular objectives at risk.
The Head of Internal Audit’s opinion also concluded that he can provide substantial assurance that the Assurance Framework and associated processes are sufficient to meet the requirements of the 2017/18 Governance Statement and contribute to an effective system of internal control designed to manage the significant risks identified by the CCG.
During the 2017/18 year Internal Audit issued the following audit reports:
Area of audit Level of assurance given Financial Systems Key Controls Substantial (including Payroll) Governance, Assurance Framework Risk Management and Conflicts of Substantial Interest Procurement Governance Satisfactory Lead Commissioner Governance Satisfactory Business Continuity Management Satisfactory No opinion required Information Governance Toolkit (No recommendations made) Continuing Health Care Claims Limited Assurance
Medicines Management Limited Assurance
72 Mid Essex CCG Annual Report and Accounts 2017/18
The number and priority rating of recommendations made within the two audit reports that identified Limited assurance are as follows:
Audit of Continuing Health Care Claims
Internal Audit raised a total of 4 x priority 2 and 1 x priority 3 recommendations. There were no priority 1 recommendations.
Audit of Medicines Management
Internal Audit raised a total of 1 x priority 1 and 4 x priority 2 recommendations.
The priority 1 recommendation raised was:
The CCG should keep its arrangements for self-reported controls for the 2017/18 Medicines Optimisation Local Enhanced Services (MOLES) under review throughout the year.
Where it is considered that the information provided does not allow for effective oversight and identification of issues, further work should be undertaken to strengthen the reporting arrangements, including the validation of the data used to support self- reporting.
The CCG had established a process for liaising with Internal Audit in order to respond to and verify the implementation of recommendations raised in a timely manner. As a result, the majority of recommendations raised during the course of the year had been verified as implemented, including all priority 1 recommendations.
2.2.7 Review of the effectiveness of governance, risk management and internal control
My review of the effectiveness of the system of internal control is informed by the work of the internal auditors, executive managers and clinical leads within the clinical commissioning group who have responsibility for the development and maintenance of the internal control framework. I have drawn on performance information available to me. My review is also informed by comments made by the external auditors in their annual audit letter and other reports.
Our assurance framework provides me with evidence that the effectiveness of controls that manage risks to the clinical commissioning group achieving its principles objectives have been reviewed.
I have been advised on the implications of the result of this review by: The Board The Audit Committee Quality and Governance Committee Internal Audit
73 Mid Essex CCG Annual Report and Accounts 2017/18
Other explicit review/assurance mechanisms.
Conclusion I concur with the Head of Internal Audit Opinion that during the 2017/18 year there has been a generally sound system of internal control, designed to meet the organisation’s objectives, and that controls have been generally applied consistently. Action plans to implement any outstanding recommendations from audits are in place and will continue to be monitored during the 2018/19 year.
I confirm that there are no risks which may affect the CCG’s Licence or serious lapses in control.
Caroline Rassell Accountable Officer
25 May 2018
74 Mid Essex CCG Annual Report and Accounts 2017/18
2.3 Remuneration and Staff Report
2.3.1 Remuneration Committee Report
For 2017/18 the membership of the Remuneration Committee was as follows:
Keith Andrew – Committee Chair, Lay Member (Governance), Deputy Chair (Lay Member) of the CCG Board and Audit Committee Chair Dr Caroline Dollery – Elected GP and Chair of the CCG Alan Hubbard – Lay Member (Commercial) Julie Burton – Head of Human Resources Caroline Rassell – Accountable Officer
(The Accountable Officer withdrew at any time that her own remuneration and performance were discussed)
The Committee met on three occasions in 2017/18. The Committee Chair was present at each meeting and additional representation was brought in when necessary to ensure quoracy in line with the Committee’s Terms of Reference. The Committee received advice from the Chief Finance Officer (or her deputy) as required. The Committee also relied upon national guidance and documentation relating to subjects brought to the Remuneration Committee.
Policy on remuneration of senior managers All the CCG’s Executive Directors are subject to Agenda for Change terms and conditions. The Lay Members and the elected GP members of the CCG Governing Body are remunerated under a locally agreed pay framework and the Accountable Officer is remunerated in accordance with the NHS Very Senior Managers (VSM) pay framework. The salaries of all Governing Body members are determined by the Remuneration Committee, with national and local guidance (provided by the Chief Finance Officer and Head of Human Resources) being taken into account in all decisions.
Remuneration of Very Senior Managers The CCG does not employ any Very Senior Managers (VSMs) on a salary exceeding £150,000. The CCG does however have four clinicians whose payment level for their Board role, when represented as a full-time notional salary, exceeds the given threshold of £150,000. They are all engaged as Office Holders (Elected GP members) – a statutory position for the CCG.
The rate payable for the CCG’s Elected GPs is set at £303 per session and is for work undertaken by Office Holders who are not entitled to ‘employed’ benefits – in other words, no contractual/NHS sickness or maternity pay or holiday over and above the statutory minimum.
Market forces coupled with a desire to attract already stretched GPs to consider working with the CCG with the aim of making services better for the population for mid Essex are a significant factor in setting the sessional rate. It is considered that the sessional rate (based on £303 per session / £157,993 per annum FTE) shows parity with those across the Essex region. None of the elected GPs works more than an average of six sessions per week for the CCG.
75 Mid Essex CCG Annual Report and Accounts 2017/18
Senior managers’ performance-related pay The performance of all staff (including the Accountable Officer, Directors and senior managers) is monitored and assessed through the use of a robust appraisal system. A formal appraisal review is undertaken at least annually (see section 2.3.2). There are no performance-related pay elements contained in any contracts for 2017/18.
Agenda for Change contracts do not contain provision for performance-related remuneration. There is, therefore, no proportion of remuneration that is subject to performance conditions. However, under the VSM pay framework, there is the potential for performance-related pay under the terms and conditions of the contract.
Policy on the duration of contracts, notice periods and termination payments The duration of contracts is determined by the duration of the roles and responsibilities to be undertaken. The contracts of the Accountable Officer, Directors and other CCG staff are permanent unless applicable to a time-limited project or funding, in which case contracts will be offered on a fixed term.
The notice period applying to the substantive Accountable Officer is six months. For Directors and other Senior Managers it is three months. Any termination payments would be in accordance with relevant contractual, legislative and Inland Revenue requirements.
Salary and pension entitlements The following tables set out information in relation to salaries, benefits in kind and pension entitlements of the decision makers of the organisation. There are no elements of remuneration outside the standard terms and conditions of the contracts of employment of senior managers.
Tables and narrative from this point until the end of the “Staff numbers” subsection of section 2.3.2 are subject to independent audit by KPMG.
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Salaries and allowances 2017/18 2016/17 Name and Title Salary Expense Other Perfor- Long-term All Total Salary Expense Other Perfor- Long-term All Total (bands Payments Remun- mance Performance pension (bands (bands Payments Remun- mance Performance Pension (bands of (taxable) eration Pay and Pay and Related of of (taxable) eration Pay and Pay and Related of £5,000) (total to (bands Bonuses Bonuses Benefits £5,000) £5,000) (total to (bands Bonuses Bonuses Benefits £5,000) nearest of (bands of (bands of (bands of nearest of (bands of (bands of (bands of £100) £5,000) £5,000) £5,000) £2,500) £100) £5,000) £5,000) £5,000) £2,500)
£000 £ £000 £000 £000 £000 £000 £000 £00 £000 £000 £000 £000 £000
Caroline Rassell Accountable Officer 55-60 400 0 0 0 10-12.5 65-70 65-70 600 0 0 0 15-17.5 85-90 CCG to 31 August 2017 (1.0wte*)
From 1 September 45-50 700 0 0 0 7.5-10 55-60 2017 Accountable Officer CCG (0.5wte) and
Lead Accountable 0 0 0 0 0 0 0 0 0 0 0 0 0 Officer Joint Committee (0.5wte) (Note 1)
Carol Anderson
Managing Director to 31 May 2017 45-50 500 0 0 0 0 45-50 105-110 800 0 0 0 125-127.5 230-235 Deputy Accountable Officer from 1 June 2017 to 30 September 2017
From 1 October 2017 Chief Nurse 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Joint Committee (Note 2)
Viv Barnes 90-95 0 0 0 0 22.5-25 110-115 85-90 100 0 0 0 27.5-30 115-120 Director of Corporate Services to 14 January 2018
From 15 January 2018 Director of Governance and Performance
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2017/18 2016/17 Name and Title Salary Expense Other Perfor- Long-term All Total Salary Expense Other Perfor- Long-term All Total (bands Payments Remun- mance Performance pension (bands (bands Payments Remun- mance Performance Pension (bands of (taxable) eration Pay and Pay and Related of of (taxable) eration Pay and Pay and Related of £5,000) (total to (bands Bonuses Bonuses Benefits £5,000) £5,000) (total to (bands Bonuses Bonuses Benefits £5,000) nearest of (bands of (bands of (bands of nearest of (bands of (bands of (bands of £100) £5,000) £5,000) £5,000) £2,500) £100) £5,000) £5,000) £5,000) £2,500)
£000 £ £000 £000 £000 £000 £000 £000 £00 £000 £000 £000 £000 £000
Dee Davey 95-100 1,600 0 0 0 0 100-105 100-105 500 0 0 0 132.5-135 235-240 Chief Finance Officer
Melanie Graham (nee Crass) 50-55 200 0 0 0 7.5-10 60-65 90-95 200 0 0 0 80-82.5 175-180 Director of Primary Care and Resilience to 24 October 2017
Dan Doherty Director of Clinical Commissioning 95-100 1,200 0 0 0 25-27.5 125-130 0 0 0 0 0 0 0 to 14 January 2018
From 15 January 2018 Director of Clinical Transformation
Rachel Hearn Acting Director of 85-90 600 0 0 0 35-37.5 120-125 80-85 1,100 0 0 0 52.5-55 135-140 Nursing and Quality to 14 January 2018
From 15 January 2018 Director of Nursing and Quality Seconded In
Donald McGeachy Medical Director CCG 85-90 2,200 25-30 0 0 0 120-125 0 0 25-30 0 0 0 25-30 to 30 November 2017 (Note 4)
From 1 December 2017 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Medical Director Joint Committee (Note 3)
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2017/18 2016/17 Name and Title Salary Expense Other Perfor- Long-term All Total Salary Expense Other Perfor- Long-term All Total (bands Payments Remun- mance Performance pension (bands (bands Payments Remun- mance Performance Pension (bands of (taxable) eration Pay and Pay and Related of of (taxable) eration Pay and Pay and Related of £5,000) (total to (bands Bonuses Bonuses Benefits £5,000) £5,000) (total to (bands Bonuses Bonuses Benefits £5,000) nearest of (bands of (bands of (bands of nearest of (bands of (bands of (bands of £100) £5,000) £5,000) £5,000) £2,500) £100) £5,000) £5,000) £5,000) £2,500)
£000 £ £000 £000 £000 £000 £000 £000 £00 £000 £000 £000 £000 £000
James Wilson Interim Director of Acute Commissioning 2 September 2016 to 20 January 2018 85-90 1,900 0 0 0 22.5-25 110-115 45-50 900 0 0 0 50-52.5 100-105 From 21 January 2018 Chief Transformation and Strategy Officer
Caroline Dollery 90-95 0 0 0 0 65-67.5 155-160 90-95 0 0 0 0 2.5-5 95-100 CCG Chair (Clinical)
James Booth 5-10 0 20-25 0 0 27.5-30 60-65 5-10 0 40-45 0 0 80-82.5 130-135 CCG Deputy Chair (Clinical) and GP Board Member to 31 March 2018 (Note 5)
Mike Bailey 10-15 400 25-30 0 0 0 40-45 10-15 300 30-35 0 0 0 40-45 GP Board Member to 31 March 2018 (Note 6)
Elizabeth Towers 5-10 0 55-60 0 0 0 60-65 5-10 0 35-40 0 0 0 45-50 GP Board Member (Note 7)
Keith Andrew 10-15 100 0 0 0 0 10-15 10-15 100 0 0 0 0 10-15 Lay Member Governance Lead and Deputy Chair (Lay Member)
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2017/18 2016/17 Name and Title Salary Expense Other Perfor- Long-term All Total Salary Expense Other Perfor- Long-term All Total (bands Payments Remun- mance Performance pension (bands (bands Payments Remun- mance Performance Pension (bands of (taxable) eration Pay and Pay and Related of of (taxable) eration Pay and Pay and Related of £5,000) (total to (bands Bonuses Bonuses Benefits £5,000) £5,000) (total to (bands Bonuses Bonuses Benefits £5,000) nearest of (bands of (bands of (bands of nearest of (bands of (bands of (bands of £100) £5,000) £5,000) £5,000) £2,500) £100) £5,000) £5,000) £5,000) £2,500) £000 £ £000 £000 £000 £000 £000 £000 £00 £000 £000 £000 £000 £000
Anne-Marie Garrigan 5-10 0 0 0 0 0 5-10 5-10 0 0 0 0 0 5-10 Lay Member PPE to 31 March 2018
Alan Hubbard 10-15 300 0 0 0 0 10-15 10-15 200 0 0 0 0 10-15 Lay Member Commercial
Daniel Dalton Secondary Care 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Consultant from 1 March 2018 (Note 6) * Whole time equivalent
Notes Note 1: With effect from 1 September 2017, Caroline Rassell was seconded to the Joint Committee as Lead Accountable Officer (0.5wte), whilst retaining her substantive role as Accountable Officer (reduced to 0.5wte) of the CCG. From 1 October the costs of her Joint Committee role were shared across the five CCGs which make up the Mid and South Essex STP, and the Mid Essex share of these costs was in the remuneration band £10-15k. The total remuneration band (inclusive of Pension benefits and Expense payment) for Caroline Rassell was £165-170k. Note 2: With effect from 1 October 2017, Carol Anderson was seconded to the Joint Committee as Chief Nurse. The costs of her Joint Committee role were shared across the five CCGs which make up the Mid and South Essex STP, and the Mid Essex share of these costs was in the remuneration band £20-25k. The total remuneration band (inclusive of Pension benefits and Expense payment) for Carol Anderson was £105-110k. Note 3: With effect from 1 December 2017, Donald McGeachy was formally seconded to the Joint Committee as Medical Director. From 1 October the costs of his Joint Committee role were shared across the five CCGs which make up the Mid and South Essex STP, and the Mid Essex share of these costs was in the remuneration band £15-20k. The total remuneration band (inclusive of Pension benefits and Expense payment) for Donald McGeachy was £120-125k.
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Note 4: Donald McGeachy’s Other Remuneration, in the band £25-30k is payment for his role as Project Lead for the 111 service. This amount is recharged to West Essex CCG as the host organisation and subsequently a share (based on capitation) is charged back to Mid Essex CCG as part of the cost of the overall Project Team. Note 5: James Booth’s Other Remuneration relates to work undertaken for: CCG Clinical Lead (to 30 June 2017) and Named GP for Safeguarding Children. The Named GP for Safeguarding Children role is paid to Melbourne House Surgery, where James Booth is the Senior Partner. The remuneration to Melbourne House Surgery for Named GP for Safeguarding Children, which is in the band £25-30k is paid as an Off-Payroll engagement. Note 6: Mike Bailey’s Other Remuneration relates to work undertaken for: CCG Clinical Lead. Note 7: Elizabeth Tower’s Other Remuneration relates to work undertaken for: CCG Clinical Lead, Macmillan GP Facilitator and as GPwSI for the Cancer Vague Symptoms pilot. The Macmillan GP Facilitator role is largely funded by Macmillan Cancer Support, with The Ipswich Hospital NHS Trust fully funding the Cancer Vague Symptoms pilot. Note 8: Daniel Dalton employed by Hertfordshire Partnership University NHS Foundation Trust, is a member of the CCG’s Governing Body, no remuneration has yet been paid to his employer. Note 9: Maggie Pacini employed by Essex County Council, is a member of the CCG’s Governing Body, but no remuneration is paid to her employer and she is therefore not included in the Remuneration Report. Note 10: Louis Kamfer and Karen Wesson, both employed by Basildon and Brentwood CCG, were seconded to the Joint Committee as Chief Finance Officer (0.8wte) and Director of Commissioning and Performance respectively, with effect from 1 October 2017. Their Joint Committee costs were shared across the five CCGs which make up the Mid and South Essex STP, and the Mid Essex share of these costs were in the remuneration band £15-20k and £20-25k respectively. Full information of their total remuneration can be found in the Annual Report for Basildon and Brentwood CCG. Note 11: Professor Mike Bewick, Independent Chair of the Joint Committee with effect from 7 July 2017, is on the payroll of Mid Essex CCG, but is not a member of the CCG’s Governing Body and is therefore not included in the Remuneration Report. From 1 October the costs of his Joint Committee role were shared across the five CCGs which make up the Mid and South Essex STP, and the Mid Essex share of these costs was in the remuneration band £10-15k. The total remuneration band for Mike Bewick was £55-60k. There were no Pension benefits or Expense payments.
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Pension benefits
Real Name and Title Lump sum increase Total Real Real at age 60 Cash Employer’s in accrued increase in increase related to Cash Equivalent contribution pension pension at Cash in accrued Equivalent Transfer to lump sum age 60 at Equivalent pension pension at Transfer Value at 31 stakeholder at aged 31 March Transfer at age 60 31 March Value at 1 March 2018 pension 60 (bands 2018 Value (bands of 2018 April 2017 of £2,500) (bands of £2,500) (bands of £5,000) £5,000)
£000 £000 £000 £000 £000 £000 £000 £000
Carol Anderson Deputy Accountable Officer to 30 September 2017 0 0 25-30 60-65 403 417 14 0 From 1 October 2017 Chief Nurse Joint Committee (Note 1)
Caroline Rassell Accountable Officer CCG to 31 August 2017 (1.0wte)
From 1 September 2017 0-2.5 0 15-20 30-35 313* 355 42 0 Accountable Officer CCG (0.5wte) and
Lead Accountable Officer Joint Committee (0.5wte) (Note 1)
Viv Barnes Director of Corporate Services to 14 January 2018 0-2.5 0-2.5 30-35 85-90 537 595 58 0 From 15 January 2018 Director of Performance and Governance
Dee Davey 0 0 45-50 140-145 1,003 1,052 49 0 Chief Finance Officer
Dan Doherty Director of Clinical Commissioning to 14 January 2018 0-2.5 0-2.5 20-25 45-50 230 268 38 0
From 15 January 2018 Director of Clinical Transformation
Melanie Graham (nee Crass) Director of Primary Care 0-2.5 0-2.5 30-35 80-85 525 583 33 0 and Resilience to 8 October 2017 (Note 3)
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Rachel Hearn Interim Director of 0-2.5 0-2.5 15-20 45-50 218 261 43 0 Nursing
James Wilson Interim Director of Acute Commissioning 2 September 2016 to 22 January 2018 0-2.5 0 5-10 0 36 50 14 0
From 23 January 2018 Chief Transformation and Strategy Officer
James Booth CCG Deputy Chair (Clinical) and GP Board 0-2.5 2.5-5 5-10 20-25 91 111 20 0 Member to 31 March 2018
Caroline Dollery CCG Chair (Clinical) 2.5-5 10-12.5 20-25 60-65 350 444 94 0 (Note 2) * The Cash Equivalent Transfer Value for 2016/17 has been restated by NHS Pensions.
Notes Note 1: The Pension Benefits show the amount accrued due to membership of the pension scheme, and no adjustment has been made to reflect secondments to the Joint Committee. Note 2: Elected GP members are paid through the payroll and this pay is pensionable to the NHS officer pension scheme. GP members can opt out of the NHS officer pension scheme. Note 3: The Real Increases in Pension, Lump Sum and Cash Equivalent Transfer Value are pro rata for the time Melanie Graham was a Director of the CCG.
Lay Members do not receive pensionable remuneration so there are no disclosures in respect of Lay Members.
Cash Equivalent Transfer Values A cash equivalent transfer value (CETV) is the actuarially assessed capital value of the pension scheme benefits accrued by a member at a particular point in time. The benefits valued are the member’s accrued benefits and any contingent spouse’s (or other allowable beneficiary’s) pension payable from the scheme.
A CETV is a payment made by a pension scheme or arrangement to secure pension benefits in another pension scheme or arrangement when the member leaves a scheme and chooses to transfer the benefits accrued in their former scheme. The pension figures shown relate to the benefits that the individual has accrued as a consequence of their total membership of the pension scheme, not just their service in a senior capacity to which disclosure applies.
The CETV figures and other pension details include the value of any pension benefits in another scheme or arrangement which the individual has transferred to the NHS pension scheme. They also include any additional pension benefit accrued to the member as a result of their purchasing additional years of pension service in the scheme at their own cost. CETVs are calculated within the guidelines and framework prescribed by the Institute and Faculty of Actuaries.
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Real increase in CETV This reflects the increase in CETV effectively funded by the employer. It takes account of the increase in accrued pension due to inflation, contributions paid by the employee (including the value of any benefits transferred from another scheme or arrangement) and uses common market valuation factors for the start and end of the period.
Discount rate calculations On 16 March 2016, the Chancellor of the Exchequer announced a change in the Superannuation Contributions Adjusted for Past Experience (SCAPE) discount rate from 3.0% to 2.8%. This rate affects the calculation of CETV figures in this report.
Fair Pay Disclosure (Pay Multiples) Reporting bodies are required to disclose the relationship between the remuneration of the highest-paid director in their organisation and the median remuneration of the organisation’s workforce.
The banded remuneration of the highest paid member of the Governing Body in the CCG in the financial year 2017/18 was £155k-£160k (2016/17, £155k-£160k) excluding employer on-costs. This was 4.32 times (2016/17, 4.44 times) the median remuneration of the workforce, which was £36,612 (2016/17, £35,225). All staff remuneration was within the range of £8,040 to £157,993.
In 2017/18, 0 (2016/17: 0) employees received remuneration in excess of the highest-paid member of the Governing Body.
Total remuneration includes salary, non-consolidated performance-related pay and benefits-in- kind. It does not include severance payments, employer pension contributions and the cash equivalent transfer value of pensions.
Payments for Loss of Office Name and Title Details Amount £s Melanie Graham Redundancy Payment 13,333 (previously Director of (1 month per year of Primary Care and service) Resilience) Lieu of Notice (3 24,629 months’ notice) Total 37,962
The redundancy payment was made in accordance with contractual entitlements.
Payments to Past Senior Managers There have been no payments to Past Senior Managers in 2017/18.
Exit packages In total there were three Exit Packages. These are disclosed in the Annual Accounts Note 4.4.
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2.3.2 CCG staff
Number of senior managers There were six senior managers employed by the CCG as of 31 March 2018, with a 5.6 Whole Time Equivalent (WTE).
Staff numbers As of 31 March 2018, there were 122.21 WTE employees / Office Holders within the CCG. The actual headcount stands at 149.
Information of our staffing numbers according to occupation code as recorded on the Electronic Staff Record (ESR) can be found below, as of 31 March 2018:
Occupatio Job Role Female Male Total Total n code Total WTE Total WTE staff WTE staff staff 921 Medical – Gen. Medical 4 1.00 2 0.40 6 1.40 Practitioners G0A Senior Manager 4 4.00 2 1.60 6 5.60 G1A Manager 13 11.04 5 4.00 18 15.04 G2A Admin and Clerical – Central 64 58.48 10 10.00 74 68.48 Functions N0A Nurse Manager – General 4 4.00 4 4.00 N6A Qualified Nurse – General 3 2.75 3 2.75 N6H Qualified Nurse – Community 18 14.28 2 2.00 20 16.28 S0C Occupational Therapist 1 1.00 1 1.00 Manager S0E Physiotherapist Manager 1 1.00 1 1.00 S0P Pharmacist Manager 2 1.80 2 1.80 S2P Pharmacist 4 3.53 4 3.53 Z2E Non Executive Members or 3 0.65 7 0.68 10 1.33 Chair Grand 120 102.53 29 19.68 149 122.21 Total
Please note that Occupational Group codings are given to show the specialist background as required in the role. Where General Medical Practitioners are stated above, it is a requirement of the role that they have this specialist knowledge to undertake a specialist Commissioning or Elected Member role, as opposed to working in the capacity of a GP in a primary care setting.
This concludes the independently audited elements of the Accountability Report, with the exception of the Parliamentary Accountability and Audit Report at section 2.4.
Staff gender ratios At 31 March 2018, the breakdown of CCG (Governing body and rest of CCG) gender ratios was:
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Female Female Male Male Total Total (Total (WTE) (Total (WTE) Staff WTE Staff) Staff) Governing Body (senior managers with 7 4.65 7 2.12 14 6.77 significant financial responsibility) All Other Staff 113 97.88 22 17.56 135 115.44 Grand Total 120 102.53 29 19.68 149 122.21
Staff and CCG values Our staff are committed to ensuring that the population of mid Essex (which includes a majority of our staff) Live Well.
Staff continued to embraced our Live Well values throughout 2017/18 and have participated in a number of initiatives to personally Live Well, and to support others to do so.
Our recruitment and appraisal systems incorporate the following core values for all staff:
Understand the ‘Live Well’ agenda – including its main components, how it affects the way the CCG aims to commission services for (or deliver services to) the mid Essex population Positively promote the Live Well philosophy internally and externally to Mid Essex CCG Take steps to Be Well – following relevant medical advice and taking healthy choices to Be Well, and support colleagues to Be Well Participate positively in strategies and initiatives that support staff to achieve the steps above, which in turn will help them to “Work Well” and thus make a personal difference to the work of the CCG and the success of the Live Well agenda.
At the start of the 2017/18 financial year we launched a CCG-wide initiative – a 100-day challenge from March 2017 that we split into two areas:
100 Days, 100 Ways – this saw staff sharing what they did to Live Well, with a different CCG employee holding the title of ‘Live Well Ambassador’ for each of the 100 days and sharing inspirational stories of what was important to them and what they did to look after their own wellbeing Walk the World – staff were challenged to walk 25 million steps collectively over the 100 days, virtually walking around the world. Steps were plotted on a world map and each week a league table showed the number of steps each participant had completed.
This challenge proved so popular with staff that at the beginning of March 2018 the CCG began a new challenge, called “100 days in Mind”, focusing on mental health and wellbeing. We have also overseen the training of a number of staff to be Mental Health First Aiders, empowering them to provide support to colleagues and signpost to appropriate services where required.
Equal opportunities The organisation is committed to equal opportunities for all staff. As of 31 March 2018, 4% of all staff employed by the CCG (six staff in total) had declared (as part of workforce disclosures) that they have a disability.
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All recruitment and selection processes (including both external and internal recruitment and promotion) follow the NHS employment standards, NHS Employers “good practice guidance” and meet NHS employment checks standards. Where job applicants declare a disability, we ensure that appropriate arrangements are made throughout the interview and selection process.
The CCG is also a ‘Mindful Employer’, which means that the CCG demonstrates a commitment to supporting people with mental health illnesses both during the recruitment process and during the course of their employment with the CCG.
The CCG has access to Human Resources and Occupational Health advice to support any employees who fall within the scope of the Equality Act 2010. Each employee is different and so this support is tailored to individual circumstances.
Training and development opportunities are open to and accessible by all, including those with long-standing or newly acquired disabilities.
We have an Equality and Diversity (E&D) working group that addresses all issues relating to E&D within the CCG and is responsible for implementing the NHS Equality Delivery System (EDS2 – see section 1.2.4) and giving due regard to the NHS Workforce Race Equality Standards.
Staff sickness Sickness absence levels for the CCG for 2017/18 are again well below the NHS average rate of 4.15% (2016/17). They are also below the national CCG average for 2016/17 which stands at 2.61% (figures from NHS Digital). We have seen a reduction in our overall absence rates this year.
Average sickness days Date range % Absence rate lost per employee* 1 January 2017 – 31 December 2017** 5 days 2.22
Source: NHS Digital – Sickness Absence Publication, based on data from the ESR Data Warehouse
* Based on an average FTE of 131.9 ** These figures are for a different reporting period from those appearing in Note 4.3 of the Financial Statements and will therefore not match
Absence is supportively managed within the CCG and we have an Absence Management Policy that addresses both short-term and long-term issues. Staff are supported through any absences, with return-to-work meetings held following periods of absence and referrals made to Occupational Health for support in achieving regular, sustained attendance at work.
Persistent short-term absence is addressed through formal procedures.
Where staff members have been significantly unwell or developed a disability during the course of their employment, measures are taken to facilitate reasonable adjustments as recommended by Occupational Health.
The CCG’s absence rates overall have remained consistently ‘low’ as compared to national NHS comparator figures and in particular national CCG average figures for sickness absence.
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Employee engagement The CCG continues to involve staff in CCG activities through its staff engagement group – known as the Work Well Engagement Group – which comprises a representative from each Directorate, along with Communications, HR and Governance and Resilience managers. The Executive lead for this group is the Director of Nursing and Quality.
The CCG carried out a formal follow-up staff survey between September and December 2017. Results have recently been received and shared with staff, with key messages emerging including:
The responses to 82 out of the 88 questions showed no significant difference between Mid Essex CCG and the national average for CCGs, while four questions showed a significantly better result 98% of participants are aware of the organisation's statement of values 96.93% of participants felt that the CCG had taken positive action on health and wellbeing in the workplace 91% of staff said their managers were supportive with 83% reporting that they could be relied upon to help 99% of staff had at the time of completing the survey undertaken an appraisal Respondents felt that the CCG is a personal, friendly environment Respondents agreed the CCG encourages teamwork and collaboration The unifying force that holds the CCG together is an emphasis on tasks and goal accomplishment and a focus on results being commonly shared.
The CCG continues to promote staff engagement in a number of other ways too, including regular briefing sessions, an internal newsletter called Digest, email updates, all-staff away days, and the continuation of a Joint Staff Forum involving union colleagues and staff representatives along with our neighbouring CCG, North East Essex CCG.
Organisational change Between November 2017 and January 2018 the CCG undertook two major consultation exercises with staff. The first was an STP-wide consultation on the formation of a Joint Commissioning Team (see section 1.1.2) which would see all staff who work on projects or business areas that could collectively be “done once” across the STP coming together as a virtual team, working in a matrix- managed fashion for one of the three Joint Commissioning Team Directors.
Staff across Mid Essex CCG, and at the four south Essex CCGs, were consulted about this proposal and the new ways of working took effect from 15 January 2018.
The second consultation was specifically about the structure of Mid Essex CCG in light of potential changes to be made around the Joint Commissioning Team. This consultation proposed a realignment of directorates across our organisation to make it clear to all staff whether they were aligned to the work of the CCG or of the Joint Commissioning Team.
An accommodation ‘shuffle’ across our CCG office space within Wren House allowed the staff aligned to the Joint Commissioning Team to be based together on first floor while the core Mid Essex CCG staff are now based on the second floor.
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Organisational development The CCG offers a wide range of development opportunities to staff, including the opportunity for formal development in a relevant subject area (leading to professional qualification such as CIMA), in addition to a number of ‘skills’ sessions, the in-house HR team also runs sessions on: Bullying and harassment Contact officers Appraisals (for managers and staff) Job description writing EmPerform (CPD and goal setting) Investigation skills
We have sourced a number of ‘expert’ sessions from external providers on the following topics: Stress management Procurement training Mental Health First Aider Security awareness IAPT – stress and anxiety Information governance
Health and safety The CCG’s health and safety policy sets out our responsibilities and those of employees under the Health and Safety Work Act 1974. Health and safety, fire safety and manual handling are included in the mandatory training programme for all CCG staff.
Risk assessment and inspections identify health and safety issues to enable appropriate action to be taken to reduce risks to staff and other users of CCG premises.
Trade Union Facility Time There was no Trade Union Facility Time in 2017/18.
2.3.3 Off-payroll engagements longer than six months
For all off-payroll engagements as of 31 March 2018, for more than £245 per day and that last longer than six months:
Numbers of existing engagements as of 31 March 2018 16
Of which, the number that have existed:
• For less than one year at the time of reporting 3
• For between one and two years at the time of reporting 1
• For between two and three years at the time of reporting 4
• For between three and four years at the time of reporting 3
• For four or more years at the time of reporting 5
The clinical commissioning group’s Central Referral Service engages 12 GPs and other clinicians to remotely triage GP referrals. Contracts have been assessed using the government’s off payroll test as falling outside of IR35 (a UK anti-avoidance tax rule) and therefore the clinical triagers are 89
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not required to be paid through the payroll. The number of clinical triagers engaged is usually approximately 12 and they account for the majority of off payroll engagements disclosed above.
New off-payroll engagements For all new off-payroll engagements, or those that reached six months in duration, between 1 April 2017 and 31 March 2018, for more than £245 per day.
Number of new engagements, or those that reached six months in 3 duration, between 1 April 2017 and 31 March 2018
Of which…
No. assessed as caught by IR35 1
No. assessed as not caught by IR35 2
•
• No. engaged directly (via PSC contracted to department) and are on the 1 departmental payroll
• No. of engagements reassessed for consistency/assurance purposes during the year 1
• No. of engagements that saw a change to IR35 status following consistency review 0
For any off-payroll engagements of board members, and/or senior officials with significant financial responsibility, between 1 April 2017 and 31 March 2018:
Number of off-payroll engagements of Governing Body members and/or senior 0 officials with significant financial responsibility during 2017/18
Number of individuals on payroll and off-payroll deemed to be “board members 17 and/or senior officials with significant financial responsibility” during 2017/18
2.3.4 Expenditure on consultancy
The CCG paid the following for consultancy in 2017/18 (with the previous year’s figures included for comparison).
Year Administrative Programme 2017/18 £249k £603k 2016/17 £111k £393k
2.3.5 Pension liabilities
The CCG’s annual accounts detail the accounting policy adopted regarding the NHS pension scheme liabilities. This can be found in Note 4.5 of the Financial Statements. 90
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2.4 Parliamentary Accountability and Audit Report (subject to audit)
Mid Essex 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 in the Financial Statements of this report at Notes 31 and 40.1. An audit certificate and report are also included in this Annual Report, from the next page.
This concludes the 2017/18 Mid Essex CCG Accountability Report.
Caroline Rassell Accountable Officer
25 May 2018
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INDEPENDENT AUDITOR’S REPORT TO THE MEMBERS OF THE GOVERNING BODY OF NHS MID ESSEX CLINICAL COMMISSIONING GROUP REPORT ON THE AUDIT OF THE FINANCIAL STATEMENTS opinion We have audited the financial statements of NHS Mid Essex Clinical Commissioning Group (“the CCG”) for the year ended 31 March 2018 which comprise the Statement of Comprehensive Net Expenditure, Statement of Financial Position, Statement of Changes in Taxpayers Equity and Statement of Cash Flows, and the related notes, including the accounting policies in note 1. In our opinion the financial statements:
give a true and fair view of the state of the CCG’s affairs as at 31 March 2018 and of its income and expenditure for the year then ended; and
have been properly prepared in accordance with the accounting policies directed by the NHS Commissioning Board with the consent of the Secretary of State as being relevant to CCGs in England and included in the Department of Health Group Accounting Manual 2017/18. Basis for opinion We conducted our audit in accordance with International Standards on Auditing (UK) (“ISAs (UK)”) and applicable law. Our responsibilities are described below. We have fulfilled our ethical responsibilities under, and are independent of the Trust in accordance with, UK ethical requirements including the FRC Ethical Standard. We believe that the audit evidence we have obtained is a sufficient and appropriate basis for our opinion. Going concern We are required to report to you if we have concluded that the use of the going concern basis of accounting is inappropriate or there is an undisclosed material uncertainty that may cast significant doubt over the use of that basis for a period of at least twelve months from the date of approval of the financial statements. We have nothing to report in these respects. Other information in the Annual Report The Accountable Officer is responsible for the other information presented in the Annual Report together with the financial statements. Our opinion on the financial statements does not cover the other information and, accordingly, we do not express an audit opinion or, except as explicitly stated below, any form of assurance conclusion thereon. Our responsibility is to read the other information and, in doing so, consider whether, based on our financial statements audit work, the information therein is materially misstated or inconsistent with the financial statements or our audit knowledge. Based solely on that work we have not identified material misstatements in the other information. In our opinion the other information included in the Annual Report for the financial year is consistent with the financial statements. Annual Governance Statement We are required to report to you if the Annual Governance Statement does not comply with guidance issued by the NHS Commissioning Board. We have nothing to report in this respect. Remuneration and Staff Report In our opinion the parts of the Remuneration and Staff Report subject to audit have been properly prepared in accordance with the Department of Health Group Accounting Manual 2017/18.
Accountable Officer’s responsibilities As explained more fully in the statement set out on page 51, the Accountable Officer is responsible for the preparation of financial statements that give a true and fair view. They are also responsible for such internal control as they determine is necessary to enable the preparation of financial statements that are free from material misstatement, whether due to fraud or error; assessing the CCGs ability to continue as a going concern, disclosing, as applicable, matters related to going concern; and using the going concern basis of accounting unless they have been informed by the relevant national body of the intention to dissolve the CCG without the transfer of its services to another public sector entity. Auditor’s responsibilities Our objectives are to obtain reasonable assurance about whether the financial statements as a whole are free from material misstatement, whether due to fraud or error, and to issue our opinion in an auditor’s report. Reasonable assurance is a high level of assurance, but does not guarantee that an audit conducted in accordance with ISAs (UK) will always detect a material misstatement when it exists. Misstatements can arise from fraud or error and are considered material if, individually or in aggregate, they could reasonably be expected to influence the economic decisions of users taken on the basis of the financial statements. A fuller description of our responsibilities is provided on the FRC’s website at www.frc.org.uk/auditorsresponsibilities
REPORT ON OTHER LEGAL AND REGULATORY MATTERS Opinion on regularity We are required to report on the following matters under Section 25(1) of the Local Audit and Accountability Act 2014. In our opinion, in all material respects, the expenditure and income recorded in the financial statements have been applied to the purposes intended by Parliament and the financial transactions conform to the authorities which govern them. Report on the CCG’s arrangements for securing economy, efficiency and effectiveness in its use of resources Under the Code of Audit Practice we are required to report to you if the CCG has not made proper arrangements for securing economy, efficiency and effectiveness in its use of resources. We have nothing to report in this respect. Respective responsibilities in respect of our review of arrangements for securing economy, efficiency and effectiveness in the use of resources As explained more fully in the statement set out on page 70, the Accountable Officer is responsible for ensuring that the CCG exercises its functions effectively, efficiently and economically. We are required under section 21(1)(c) of the Local Audit and Accountability Act 2014 to be satisfied that the CCG has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources. We are not required to consider, nor have we considered, whether all aspects of the CCG’s arrangements for securing economy, efficiency and effectiveness in the use of resources are operating effectively. We have undertaken our review in accordance with the Code of Audit Practice, having regard to the specified criterion issued by the Comptroller and Auditor General (C&AG) in November 2017, as to whether the CCG had proper arrangements to ensure it took properly informed decisions and deployed resources to achieve planned and sustainable outcomes for taxpayers and local people. We planned our work in accordance with the Code of Audit
Practice and related guidance. Based on our risk assessment, we undertook such work as we considered necessary. Statutory reporting matters We are required by Schedule 2 to the Code of Audit Practice issued by the Comptroller and Auditor General (‘the Code of Audit Practice’) to report to you if:
we refer a matter to the Secretary of State under section 30 of the Local Audit and Accountability Act 2014 because we have reason to believe that the CCG, or an officer of the CCG, is about to make, or has made, a decision which involves or would involve the body incurring unlawful expenditure, or is about to take, or has begun to take a course of action which, if followed to its conclusion, would be unlawful and likely to cause a loss or deficiency; or
we issue a report in the public interest under section 24 of the Local Audit and Accountability Act 2014; or
we make a written recommendation to the CCG under section 24 of the Local Audit and Accountability Act 2014. We have nothing to report in these respects. THE PURPOSE OF OUR AUDIT WORK AND TO WHOM WE OWE OUR RESPONSIBILITIES This report is made solely to the Members of the Governing Body of NHS Mid Essex CCG, as a body, in accordance with Part 5 of the Local Audit and Accountability Act 2014. Our audit work has been undertaken so that we might state to the Members of the Governing Body of the CCG, as a body, those matters we are required to state to them in an auditor’s report and for no other purpose. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the Members of the Governing Body, as a body, for our audit work, for this report or for the opinions we have formed. CERTIFICATE OF COMPLETION OF THE AUDIT We certify that we have completed the audit of the accounts of NHS Mid Essex CCG in accordance with the requirements of the Local Audit and Accountability Act 2014 and the Code of Audit Practice.
Stephanie Beavis for and on behalf of KPMG LLP, Statutory Auditor Chartered Accountants Botanic House 100 Hills Road Cambridge CB2 1AR
25 May 2018
NHS MID ESSEX CLINICAL COMMISSIONING GROUP
ANNUAL ACCOUNTS 2017-18
. NHS Mid Essex CCG - Annual Accounts 2017-18
CONTENTS Page Number
The Primary Statements:
Statement of Comprehensive Net Expenditure for the year ended 31st March 2018 1 Statement of Financial Position as at 31st March 2018 2 Statement of Changes in Taxpayers' Equity for the year ended 31st March 2018 3 Statement of Cash Flows for the year ended 31st March 2018 4
Notes to the Accounts Accounting policies 5 Other operating revenue 10 Revenue 10 Employee benefits and staff numbers 11 Operating expenses 14 Better payment practice code 15 Income generation activities 15 Investment revenue 15 Other gains and losses 15 Finance costs 15 Net gain/(loss) on transfer by absorption 16 Operating leases 16 Property, plant and equipment 17 Intangible non-current assets 18 Investment property 18 Inventories 19 Trade and other receivables 19 Other financial assets 19 Other current assets 19 Cash and cash equivalents 19 Non-current assets held for sale 19 Analysis of impairments and reversals 19 Trade and other payables 20 Deferred revenue 20 Other financial liabilities 20 Borrowings 21 Private finance initiative, LIFT and other service concession arrangements 21 Finance lease obligations 21 Finance lease receivables 21 Provisions 22 Contingencies 22 Commitments 23 Financial instruments 23 Operating segments 24 Pooled budgets 25 NHS Lift investments 25 Related party transactions 26 Events after the end of the reporting period 28 Third party assets 28 Financial performance targets 28 Impact of IFRS 28 Analysis of charitable reserves 28
Please note that occassionally £1k differencies occur between the primary statements and the notes to the accounts and within individual lines which is unavoidable due to rounding discrepancies. NHS Mid Essex CCG - Annual Accounts 2017-18
Statement of Comprehensive Net Expenditure for the year ended 31 March 2018 2017-18 2016-17 Note £'000 £'000
Income from sale of goods and services 2 (1,940) (1,869) Other operating income 2 (846) (931) Total operating income (2,786) (2,800)
Staff costs 4 7,390 7,734 Purchase of goods and services 5 448,387 443,489 Depreciation and impairment charges 5 36 36 Provision expense 5 471 1,336 Other Operating Expenditure 5 298 230 Total operating expenditure 456,582 452,825
Net Operating Expenditure 453,796 450,025
Comprehensive Expenditure for the year ended 31 March 2018 453,796 450,025
The notes on pages 5 to 28 form part of this statement.
1 NHS Mid Essex CCG - Annual Accounts 2017-18
Statement of Financial Position as at 31 March 2018 2017-18 2016-17
Note £'000 £'000 Non-current assets: Property, plant and equipment 13 10 25 Intangible assets 14 7 27 Total non-current assets 17 52 Current assets: Trade and other receivables 17 4,434 5,368 Cash and cash equivalents 20 0 1 Total current assets 4,434 5,369
Total assets 4,451 5,421
Current liabilities Trade and other payables 23 (29,407) (28,960) Borrowings 26 (740) (619) Provisions 30 (1,797) (1,523) Total current liabilities (31,944) (31,102)
Non-Current Assets less Net Current Liabilities (27,493) (25,681)
Non-current liabilities Provisions 30 (729) (1,320) Total non-current liabilities (729) (1,320)
Assets less Liabilities (28,222) (27,001)
Financed by Taxpayers’ Equity General fund (28,222) (27,001) Total taxpayers' equity: (28,222) (27,001)
The notes on pages 5 to 28 form part of this statement
The financial statements on pages 1 to 28 were approved by the Governing Body on 25 May 2018 and signed on its behalf by:
Caroline Rassell Accountable Officer 25 May 2018
2 NHS Mid Essex CCG - Annual Accounts 2017-18
Statement of Changes In Taxpayers Equity for the year ended 31 March 2018
Total General fund reserves £'000 £'000 Changes in taxpayers’ equity for 2017-18
Balance at 01 April 2017 (27,001) (27,001) Transfer between reserves in respect of assets transferred from closed NHS bodies 0 0 Adjusted NHS Clinical Commissioning Group balance at 31 March 2018 (27,001) (27,001)
Changes in NHS Clinical Commissioning Group taxpayers’ equity for 2017-18 Net operating expenditure for the financial year (453,796) (453,796)
Net Recognised NHS Clinical Commissioning Group Expenditure for the Financial Year (453,796) (453,796)
Net funding 452,574 452,574 Balance at 31 March 2018 (28,222) (28,222)
Total General fund reserves £'000 £'000 Changes in taxpayers’ equity for 2016-17
Balance at 01 April 2016 (27,108) (27,108) 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 2017 (27,108) (27,108)
Changes in NHS Clinical Commissioning Group taxpayers’ equity for 2016-17 Net operating costs for the financial year (450,025) (450,025)
Net Recognised NHS Clinical Commissioning Group Expenditure for the Financial Year (450,025) (450,025) Net funding 450,132 450,132 Balance at 31 March 2017 (27,001) (27,001)
The notes on pages 5 to 28 form part of this statement
3 NHS Mid Essex CCG - Annual Accounts 2017-18
Statement of Cash Flows for the year ended 31 March 2018 2017-18 2016-17 Note £'000 £'000 Cash Flows from Operating Activities Net operating expenditure for the financial year (453,796) (450,025) Depreciation and amortisation 5 36 36 (Increase)/decrease in trade & other receivables 17 934 624 Increase/(decrease) in trade & other payables 23 448 (1,179) Provisions utilised 30 (788) (850) Increase/(decrease) in provisions 30 471 1,336 Net Cash Inflow (Outflow) from Operating Activities (452,695) (450,058)
Net Cash Inflow (Outflow) before Financing (452,695) (450,058)
Cash Flows from Financing Activities Grant in Aid Funding Received 452,574 450,132 Net Cash Inflow (Outflow) from Financing Activities 452,574 450,132
Net Increase (Decrease) in Cash & Cash Equivalents 20 (121) 74
Cash & Cash Equivalents at the Beginning of the Financial Year (619) (693)
Cash & Cash Equivalents (including bank overdrafts) at the End of the Financial Year (740) (619)
The notes on pages 5 to 28 form part of this statement
4 NHS Mid Essex CCG - Annual Accounts 2017-18
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 2017-18 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 the going concern basis. The clinical commissioning group delivered an £8.1m surplus in 2017-18 which has reduced the accumulated deficit to £13.8m.
Public sector bodies are assumed to be going concerns where the continuation of the provision of a service in the future is anticipated, as evidenced by inclusion of financial provision for that service in published documents.
1.2 Accounting Convention These accounts have been prepared under the historical cost convention modified to account for the revaluation of property, plant and equipment, intangible assets, inventories and certain financial assets and financial liabilities.
1.3 Pooled Budgets Where the clinical commissioning group has entered into a pooled budget arrangement under Section 75 (s75) of the National Health Service Act 2006 the clinical commissioning group accounts for its share of the assets, liabilities, income and expenditure arising from the activities of the pooled budget, identified in accordance with the pooled budget agreement.
The clinical commissioning group has not been part of any pooled budget arrangements in 2017-18. Mid Essex clinical commissioning group and Essex County Council have continued to operate a Better Care Fund during 2017-18 under a Section 75 agreement. The arrangements under which the Better Care Fund has operated during 2017-18 do not constitute a pooled budget as the risks of each scheme have remained with the respective commissioners. Each scheme within the Better Care Fund has been reviewed and accounted for on an appropriate basis (see Note 35).
The clinical commissioning group (along with 5 other Essex clinical commissioning groups and 2 local authorities) has embodied the principles of a proposed s75 agreement in determining for the costs of discharged long-term in-patients with learning disabilities as identified by the Transforming Care programme. Essex County Council and the clinical commissioning group have agreed that Joint Control will not exist as both health and community packages continue to be commissioned by the respective partners.
1.4 Critical Accounting Judgements & Key Sources of Estimation Uncertainty In the application of the clinical commissioning group’s accounting policies, management is required to make judgements, estimates and assumptions about the carrying amounts of assets and liabilities that are not readily apparent from other sources. The estimates and associated assumptions are based on historical experience and other factors that are considered to be relevant. Actual results may differ from those estimates and the estimates and underlying assumptions are continually reviewed. Revisions to accounting estimates are recognised in the period in which the estimate is revised if the revision affects only that period or in the period of the revision and future periods if the revision affects both current and future periods.
1.4.1 Critical Judgements in Applying Accounting Policies The following are the critical judgements, apart from those involving estimations (see below) that management has made in the process of applying the clinical commissioning group’s accounting policies that have the most significant effect on the amounts recognised in the financial statements:
Mid Essex clinical commissioning group and Essex County Council have continued to operate a Better Care Fund during 2017-18 under a s75 agreement. The arrangements under which the Better Care Fund has operated during 2017-18 do not constitute a pooled budget as the risks of each scheme have remained with the respective commissioner.
1.4.2 Key Sources of Estimation Uncertainty The following are the key estimations that management has made in the process of applying the clinical commissioning group’s accounting policies that have the most significant effect on the amounts recognised in the financial statements:
Where possible the value of end of year transactions has been agreed with NHS counter parties on an estimated basis. Where information is not available, the clinical commissioning group has made estimates of the value of liabilities in respect of activity in the final weeks of the year.
Asset life assumptions are based on standard assumptions for each category of non-current asset. The clinical commissioning group has made a number of provisions which are reflected in Note 30. A number of high value accruals have been made which include a prescribing accrual - the amount of £4.8m reflects the amount needed to bring the ledger position to the latest forecast from the NHS Business Services Authority.
5 NHS Mid Essex CCG - Annual Accounts 2017-18
Notes to the financial statements
1.5 Revenue Revenue in respect of services provided is recognised when, and to the extent that, performance occurs, and is measured at the fair value of the consideration receivable. Where income is received for a specific activity that is to be delivered 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 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 Scheme. The scheme is an unfunded, defined benefit scheme that covers NHS employers, General Practices and other bodies, allowed under the direction of the Secretary of State, in England and Wales. The scheme is 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 scheme is accounted for as if it were a defined contribution scheme: the cost to the clinical commissioning group of participating in the scheme is taken as equal to the contributions payable to the scheme for the accounting period. For early retirements other than those due to ill health the additional pension liabilities are not funded by the scheme. The full amount of the liability for the additional costs is charged to expenditure at the time the clinical commissioning group commits itself to the retirement, regardless of the method of payment.
1.7 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. Expenses and liabilities in respect of grants are recognised when the clinical commissioning group has a present legal or constructive obligation, which occurs when all of the conditions attached to the payment have been met.
1.8 Property, Plant & Equipment
1.8.1 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.
1.8.2 Valuation All property, plant and equipment are 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. All assets are measured subsequently at valuation.
All property is owned by NHS Property Services or local providers and therefore not recorded as assets in the clinical commissioning group's accounts.
Fixtures and equipment are carried at depreciated historic cost as this is not considered to be materially different from current value in existing use.
1.8.3 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.
1.9 Intangible Assets
1.9.1 Recognition Intangible assets are non-monetary assets without physical substance, which are capable of sale separately from the rest of the clinical commissioning group’s business or which arise from contractual or other legal rights. They are recognised only: · When it is probable that future economic benefits will flow to, or service potential be provided to, the clinical commissioning group; · Where the cost of the asset can be measured reliably; and, · Where the cost is at least £5,000. Intangible assets acquired separately are initially recognised at fair value. Software that is integral to the operating of hardware, for example an operating system, is capitalised as part of the relevant item of property, plant and equipment. Software that is not integral to the operation of hardware, for example application software, is capitalised as an intangible asset. Expenditure on research is not capitalised but is recognised as an operating expense in the period in which it is incurred. Internally-generated assets are recognised if, and only if, all of the following have been demonstrated: · The technical feasibility of completing the intangible asset so that it will be available for use; · The intention to complete the intangible asset and use it;
6 NHS Mid Essex CCG - Annual Accounts 2017-18
Notes to the financial statements
· The ability to sell or use the intangible asset; · How the intangible asset will generate probable future economic benefits or service potential; · The availability of adequate technical, financial and other resources to complete the intangible asset and sell or use it; and, · The ability to measure reliably the expenditure attributable to the intangible asset during its development.
1.9.2 Measurement The amount initially recognised for internally-generated intangible assets is the sum of the expenditure incurred from the date when the criteria above are initially met. Where no internally-generated intangible asset can be recognised, the expenditure is recognised in the period in which it is incurred.
Following initial recognition, intangible assets are carried at current value in existing use by reference to an active market, or, where no active market exists, at the lower of depreciated replacement cost or the value in use where the asset is income generating . Internally-developed software is held at historic cost to reflect the opposing effects of increases in development costs and technological advances.
1.10 Depreciation, Amortisation & Impairments Depreciation and amortisation are charged to write off the costs or valuation of property, plant and equipment and intangible non-current assets, less any residual value, over their estimated useful lives, in a manner that reflects the consumption of economic benefits or service potential of the assets. The estimated useful life of an asset is the period over which the clinical commissioning group expects to obtain economic benefits or service potential from the asset. This is specific to the clinical commissioning group and may be shorter than the physical life of the asset itself. Estimated useful lives and residual values are reviewed each year end, with the effect of any changes recognised on a prospective basis. Assets held under finance leases are depreciated over their estimated useful lives.
At each reporting period end, the clinical commissioning group checks whether there is any indication that any of its tangible or intangible non- current assets have suffered an impairment loss. If there is indication of an impairment loss, the recoverable amount of the asset is estimated to determine whether there has been a loss and, if so, its amount. Intangible assets not yet available for use are tested for impairment annually.
A revaluation decrease that does not result from a loss of economic value or service potential is recognised as an impairment charged to the revaluation reserve to the extent that there is a balance on the reserve for the asset and, thereafter, to expenditure. Impairment losses that arise from a clear consumption of economic benefit are taken to expenditure. Where an impairment loss subsequently reverses, the carrying amount of the asset is increased to the revised estimate of the recoverable amount but capped at the amount that would have been determined had there been no initial impairment loss. The reversal of the impairment loss is credited to expenditure to the extent of the decrease previously charged there and thereafter to the revaluation reserve.
1.11 Donated Assets The clinical commissioning group does not have any donated assets.
1.12 Government Grants The value of assets received by means of a government grant are credited directly to income. Deferred income is recognised only where conditions attached to the grant preclude immediate recognition of the gain.
1.13 Non-current Assets Held For Sale The clinical commissioning group does not have any non-current assets for sale.
1.14 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.
1.14.1 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.
The clinical commissioning group does not have any finance leases.
1.14.2 The Clinical Commissioning Group as Lessor Amounts due from lessees under finance leases are recorded as receivables at the amount of the clinical commissioning group’s net investment in the leases. Finance lease income is allocated to accounting periods so as to reflect a constant periodic rate of return on the clinical commissioning group’s net investment outstanding in respect of the leases. Rental income from operating leases is recognised on a straight-line basis over the term of the lease. Initial direct costs incurred in negotiating and arranging an operating lease are added to the carrying amount of the leased asset and recognised on a straight-line basis over the lease term.
The clinical commissioning group does not have any finance leases.
1.15 Inventories The clinical commissioning group does not have any inventory.
1.16 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.
7 NHS Mid Essex CCG - Annual Accounts 2017-18
Notes to the financial statements
In the Statement of Cash Flows, cash and cash equivalents are shown net of bank overdrafts that are repayable on demand and that form an integral part of the clinical commissioning group’s cash management.
1.17 Provisions Provisions are recognised when the clinical commissioning group has a present legal or constructive obligation as a result of a past event, it is probable that the clinical commissioning group will be required to settle the obligation, and a reliable estimate can be made of the amount of the obligation. The amount recognised as a provision is the best estimate of the expenditure required to settle the obligation at the end of the reporting period, taking into account the risks and uncertainties.
When some or all of the economic benefits required to settle a provision are expected to be recovered from a third party, the receivable is recognised as an asset if it is virtually certain that reimbursements will be received and the amount of the receivable can be measured reliably.
1.18 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 the clinical commissioning group.
1.19 Non-clinical Risk Pooling The clinical commissioning group participates in the Property Expenses Scheme and the Liabilities to Third Parties Scheme. Both are risk pooling schemes under which the clinical commissioning group pays an annual contribution to NHS Resolution and, in return, receives assistance with the costs of claims arising. The annual membership contributions, and any excesses payable in respect of particular claims are charged to operating expenses as and when they become due.
1.20 Continuing healthcare risk pooling In 2014-15 a risk pool scheme was introduced by NHS England for continuing healthcare claims, for claim periods prior to 31 March 2013. Under the scheme clinical commissioning groups contributed an annual amount to the risk pool each year up to 2016-17 although no further contributions were required in 2017-18. (See note 30)
1.21 Contingencies 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, contingencies are disclosed at their present value.
1.22 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 fair value through profit and loss; · Held to maturity investments; · Available for sale financial assets; and, · Loans and receivables. The classification depends on the nature and purpose of the financial assets and is determined at the time of initial recognition.
1.22.1 Financial Assets 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 assets at fair value through profit and loss. They are held at fair value, with any resultant gain or loss recognised in calculating the clinical commissioning group’s surplus or deficit for the year. The net gain or loss incorporates any interest earned on the financial asset.
The clinical commissioning group doesn't hold any financial assets at Fair Value through Profit and Loss.
1.22.2 Held to Maturity Assets Held to maturity investments are non-derivative financial assets with fixed or determinable payments and fixed maturity, and there is a positive intention and ability to hold to maturity. After initial recognition, they are held at amortised cost using the effective interest method, less any impairment. Interest is recognised using the effective interest method. The clinical commissioning group does not hold any held to maturity investments.
1.22.3 Available For Sale Financial Assets Available for sale financial assets are non-derivative financial assets that are designated as available for sale or that do not fall within any of the other three financial asset classifications. They are measured at fair value with changes in value taken to the revaluation reserve, with the exception of impairment losses. Accumulated gains or losses are recycled to surplus/deficit on de-recognition. The clinical commissioning group does not have any available for sale financial assets.
1.22.4 Loans & Receivables Loans and receivables are non-derivative financial assets with fixed or determinable payments which are not quoted in an active market. After initial recognition, they are measured at amortised cost using the effective interest method, less any impairment. Interest is recognised using the effective interest method. Fair value is determined by reference to quoted market prices where possible, otherwise by valuation techniques.
8 NHS Mid Essex CCG - Annual Accounts 2017-18
Notes to the financial statements
The effective interest rate is the rate that exactly discounts estimated future cash receipts through the expected life of the financial asset, to the initial fair value of the financial asset. At the end of the reporting period, the clinical commissioning group assesses whether any financial assets, other than those held at ‘fair value through profit and loss’ are impaired. Financial assets are impaired and impairment losses recognised if there is objective evidence of impairment as a result of one or more events which occurred after the initial recognition of the asset and which has an impact on the estimated future cash flows of the asset. For financial assets carried at amortised cost, the amount of the impairment loss is measured as the difference between the asset’s carrying amount and the present value of the revised future cash flows discounted at the asset’s original effective interest rate. The loss is recognised in expenditure and the carrying amount of the asset is reduced through a provision for impairment of receivables. If, in a subsequent period, the amount of the impairment loss decreases and the decrease can be related objectively to an event occurring after the impairment was recognised, the previously recognised impairment loss is reversed through expenditure to the extent that the carrying amount of the receivable at the date of the impairment is reversed does not exceed what the amortised cost would have been had the impairment not been recognised.
1.23 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.
1.23.1 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. The clinical commissioning group does not have any financial liabilities at fair value through profit and loss.
1.23.2 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.
1.24 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.
1.25 Foreign Currencies The clinical commissioning group did not have any foreign currently transactions.
1.26 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. The clinical commissioning group does not have any third party assets.
1.27 Losses & Special Payments Losses and special payments are items that Parliament would not have contemplated when it agreed funds for the health service or passed legislation. By their nature they are items that ideally should not arise. They are therefore subject to special control procedures compared with the generality of payments. They are divided into different categories, which govern the way that individual cases are handled. Losses and special payments are charged to the relevant functional headings in expenditure on an accruals basis, including losses which would have been made good through insurance cover had the clinical commissioning group not been bearing its own risks (with insurance premiums then being included as normal revenue expenditure). The clinical commissioning group's losses and special payments are disclosed in Note 39.1 1.28 Accounting Standards That Have Been Issued But Have Not Yet Been Adopted The DHSC Group accounting manual does not require the following Standards and Interpretations to be applied in 2017-18. These standards are still subject to FREM adoption and early adoption is not therefore permitted.
· IFRS 9: Financial Instruments ( application from 1 January 2018) · IFRS 14: Regulatory Deferral Accounts ( not applicable to DH groups bodies) · IFRS 15: Revenue for Contract with Customers (application from 1 January 2018) · IFRS 16: Leases (application from 1 January 2019) · IFRS 17: Insurance Contracts (application from 1 January 2021) · IFRIC 22: Foreign Currency Transactions and Advance Consideration (application from 1 January 2018) · IFRIC 23: Uncertainty over Income Tax Treatments (application from 1 January 2019)
The application of the Standards as revised would not have a material impact on the accounts for 2017-18, were they applied in that year.
9 NHS Mid Essex CCG - Annual Accounts 2017-18
2 Other Operating Revenue 2017-18 2017-18 2017-18 2016-17 Total Admin Programme Total £'000 £'000 £'000 £'000
Education, training and research 18 0 18 0 Non-patient care services to other bodies 1,922 149 1,773 1,868 Other revenue 846 302 544 931 Total other operating revenue 2,786 451 2,335 2,799
Admin Revenue is revenue received that is not directly attributable to the provision of healthcare or healthcare services
Allocation funding received from NHS England is not included in this note as it is drawn down directly into the bank account of the clinical commissioning group and credited to the General Fund.
3 Revenue 2017-18 2017-18 2017-18 2016-17 Total Admin Programme Total £'000 £'000 £'000 £'000 From rendering of services 2,786 451 2,335 2,799 Total 2,786 451 2,335 2,799
All the clinical commissioning group's revenue is generated from the supply of services and there is no revenue from the sale of goods.
10 NHS Mid Essex CCG - Annual Accounts 2017-18
4. Employee benefits and staff numbers
4.1.1 Employee benefits 2017-18 Total
Permanent Total Employees Other £'000 £'000 £'000 Employee Benefits Salaries and wages 6,123 5,250 873 Social security costs 555 555 0 Employer Contributions to NHS Pension scheme 647 647 0 Other pension costs 1 1 0 Apprenticeship Levy 13 13 0 Termination benefits 51 51 0 Gross employee benefits expenditure 7,390 6,517 873
Less recoveries in respect of employee benefits (note 4.1.2) 0 0 0 Total - Net admin employee benefits including capitalised costs 7,390 6,517 873
Less: Employee costs capitalised 0 0 0 Net employee benefits excluding capitalised costs 7,390 6,517 873
4.1.1 Employee benefits 2016-17 Total
Permanent Total Employees Other £'000 £'000 £'000 Employee Benefits Salaries and wages 6,574 5,149 1,425 Social security costs 548 548 0 Employer Contributions to NHS Pension scheme 612 612 0 Gross employee benefits expenditure 7,734 6,310 1,425
Less recoveries in respect of employee benefits (note 4.1.2) 0 0 0 Total - Net admin employee benefits including capitalised costs 7,734 6,310 1,425
Less: Employee costs capitalised 0 0 0 Net employee benefits excluding capitalised costs 7,734 6,310 1,425
In 2017-18 no employee benefits were recovered from third parties not capitalised (2016-17 £Nil)
Employee benefits have decreased in 2017-18 due to the prior year's out of hospital project costs of the Mid and South Essex Success Regime (as reported in 2016-17), not being repeated in 2017-18.
11 NHS Mid Essex CCG - Annual Accounts 2017-18
4.2 Average number of people employed 2017-18 2016-17 Permanently Total employed Other Total Number Number Number Number
Total 140 129 11 155
Of the above: Number of whole time equivalent people engaged on capital projects 0 0 0 0
4.3 Ill health retirements There were no persons retired early on health grounds in 2017-18 or 2016-17.
4.4 Exit packages agreed in the financial year *
2017-18 2017-18 2017-18 Compulsory redundancies Other agreed departures Total Number £ Number £ Number £ Less than £10,000 0 0 1 4,627 1 4,627 £10,001 to £25,000 3 50,600 1 24,629 4 75,229 Total 3 50,600 2 29,256 5 79,856
There were no exit packages agreed in 2016-17.
There were no departures where special payments were made in 2017-18 or 2016-17. Analysis of Other Agreed Departures 2017-18 2016-17 Other agreed departures Other agreed departures Number £ Number £ Contractual payments in lieu of notice 2 29,256 0 0 Total 2 29,256 0 0
* As a single exit package can be made up of several components each of which will be counted separately in this table, the total number will not necessarily match the total number in the table above, which will be the number of individuals.
These tables report the number and value of exit packages agreed in the financial year. The expense associated with these departures may have been recognised in part or in full in a previous period.
Redundancy and other departure costs have been paid in accordance with the provisions of Agenda for Change.
There were no payments made which required HM Treasury approval.
Exit costs are accounted for in accordance with relevant accounting standards and at the latest in full in the year of departure. Where the clinical commissioning group has agreed early retirements, the additional costs are met by the clinical commissioning group and not by the NHS Pension Scheme, and are included in the tables. Ill-health retirement costs are met by the NHS Pension Scheme and are not included in the tables.
No non-contractual payments (£nil) were made to individuals where the payment value was more than 12 months’ of their annual salary.
The Remuneration Report includes the disclosure of exit payments payable to individuals named in that Report.
12 NHS Mid Essex CCG - Annual Accounts 2017-18
4.5 Pension costs Past and present employees are covered by the provisions of the two NHS Pension Schemes. Details of the benefits payable and rules of the Schemes can be found on the NHS Pensions website at www.nhsbsa.nhs.uk/pensions.
Both are unfunded defined benefit schemes that cover NHS employers, GP practices and other bodies, allowed under the direction of the Secretary of State in England and Wales. They are not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities.
Therefore, each scheme is accounted for as if it were a defined contribution scheme: the cost to the NHS body of participating in each scheme is taken as equal to the contributions payable to that scheme for the accounting period.
In order that the defined benefit obligations recognised in the financial statements do not differ materially from those that would be determined at the reporting date by a formal actuarial valuation, the FReM requires that “the period between formal valuations shall be four years, with approximate assessments in intervening years”. An outline of these follows:
4.5.1 Accounting valuation
A valuation of scheme liability is carried out annually by the scheme actuary (currently the Government Actuary’s Department) as at the end of the reporting period. This utilises an actuarial assessment for the previous accounting period in conjunction with updated membership and financial data for the current reporting period, and is accepted as providing suitably robust figures for financial reporting purposes. The valuation of the scheme liability as at 31 March 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.
4.5.2 Full actuarial (funding) valuation The purpose of this valuation is to assess the level of liability in respect of the benefits due under the schemes (taking into account recent demographic experience), and to recommend contribution rates payable by employees and employers.
The last published actuarial valuation undertaken for the NHS Pension Scheme was completed for the year ending 31 March 2012. The Scheme Regulations allow for the level of contribution rates to be changed by the Secretary of State for Health, with the consent of HM Treasury, and consideration of the advice of the Scheme Actuary and employee and employer representatives as deemed appropriate.
The next actuarial valuation is to be carried out as at 31 March 2016 and is currently being prepared. The direction assumptions are published by HM Treasury which are used to complete the valuation calculations, from which the final valuation report can be signed off by the scheme actuary. This will set the employer contribution rate payable from April 2019 and will consider the cost of the Scheme relative to the employer cost cap. There are provisions in the Public Service Pension Act 2013 to adjust member benefits or contribution rates if the cost of the Scheme changes by more than 2% of pay. Subject to this ‘employer cost cap’ assessment, any required revisions to member benefits or contribution rates will be determined by the Secretary of State for Health after consultation with the relevant stakeholders.
For 2017-18, employers’ contributions of £647,988 (2016-17: £612,480) were payable to the NHS Pension Scheme at the rate of 14.38% of pensionable pay. The scheme’s actuary reviews employer contributions, usually every four years and now based on HMT Valuation Directions, following a full scheme valuation. The latest review used data from 31 March 2012 and was published on the Government website on 9 June 2012. These costs are included in the NHS pension line of note 4.1.1
13 NHS Mid Essex CCG - Annual Accounts 2017-18
5. Operating expenses 2017-18 2017-18 2017-18 2016-17 Total Admin Programme Total £'000 £'000 £'000 £'000 Gross employee benefits Employee benefits excluding governing body members 6,491 4,592 1,899 6,674 Executive governing body members 899 899 0 1,060 Total gross employee benefits 7,390 5,491 1,899 7,734
Other costs Services from other CCGs and NHS England 1,433 306 1,126 1,966 Services from foundation trusts 69,045 5 69,040 67,021 Services from other NHS trusts 198,514 0 198,514 200,288 Purchase of healthcare from non-NHS bodies 112,579 0 112,579 110,030 Chair and Non Executive Members 231 198 32 155 Supplies and services – general 1,199 553 646 1,014 Consultancy services 852 248 603 503 Establishment 1,039 457 582 797 Transport 2,648 0 2,648 325 Premises 881 436 445 753 Depreciation 15 15 0 16 Amortisation 20 20 0 20 Audit fees 49 49 0 74 Other non statutory audit expenditure · Other services 0 0 0 (6) Prescribing costs 57,114 0 57,114 57,796 Pharmaceutical services (1) 0 (1) 28 General ophthalmic services 5 0 5 5 GPMS/APMS and PCTMS 2,503 0 2,503 1,134 Other professional fees excl. audit 410 355 55 531 Legal fees 68 71 (3) 0 Grants to Other bodies 53 0 53 65 Education and training 49 47 2 175 Provisions 471 16 455 1,336 CHC Risk Pool contributions 0 0 0 1,053 Other expenditure 14 14 0 9 Total other costs 449,192 2,792 446,400 445,090
Total operating expenses 456,582 8,283 448,299 452,824
The clinical commissioning group’s external auditors are KPMG. The external audit contract limits KPMG’s liability for losses in connection with this engagement to a maximum aggregate of £1,000,000. Any claim must be brought within 4 years. The fee for auditing the 2017-18 accounts was £40,268.00 +VAT of £8,053.60.
Legal fees - in 2016-17 legal fees were included in other professional fees.
Chair and non-executive members - in 2017-18 the clinical commissioning group funded its share of the Joint Committee Chair's costs (£40k) as well as the full costs of the clinical commissioning group's Board chair
Transport - the main patient transport contract was included in 'Services received from non-NHS bodies in 2016-17' (£2.0m, 2017-18 £1.9m).
GPMS/APMS and PCTMS - GP Forward View funding and expenditure is included in 2017-18
CHC risk pool contributions - NHS England did not require any contributions to the CHC risk pool in 2017-18
In 2017-18 expenditure on provisions is the net of £1.7m provisions arising and £1.2m provisions released unused. Provisions arising are mostly an increase in CHC retrospective claims made for periods since March 2013 which are the responsibility of the clinical commissioning group (£980k) and provision for correcting the 2017-18 estimate for charge exempt overseas visitors (£570k) as elements of this will be reclaimed in 2018-19. The provisions reversed unused largely relate to the provision for a further CHC retrospectives' close down which has not been announced during 2017-18 as anticipated (£540k) and provision for a CSU to administer these claims (£354k). In 2016-17 provisions arising included an increase for CHC retrospectives (£350k) and a provision for charge exempt overseas visitors (£600k) and there were no significant provisions reversed unused.
14 NHS Mid Essex CCG - Annual Accounts 2017-18
6.1 Better Payment Practice Code
Measure of compliance 2017-18 2017-18 2016-17 2016-17 Number £'000 Number £'000 Non-NHS Payables Total Non-NHS Trade invoices paid in the Year 14,450 147,557 13,899 142,593 Total Non-NHS Trade Invoices paid within target 14,228 141,570 13,633 139,343 Percentage of Non-NHS Trade invoices paid within target 98.46% 95.94% 98.09% 97.72%
NHS Payables Total NHS Trade Invoices Paid in the Year 2,779 280,135 3,014 284,235 Total NHS Trade Invoices Paid within target 2,702 278,580 2,895 277,960 Percentage of NHS Trade Invoices paid within target 97.23% 99.44% 96.05% 97.79%
7 Income Generation Activities The Clinical Commissioning Group does not undertake any income generation activities.
8. Investment revenue There is no investment revenue to report.
9. Other gains and losses There is no gains or losses to report.
10. Finance costs There are no finance costs to report.
15 NHS Mid Essex CCG - Annual Accounts 2017-18
11. Net gain/(loss) on transfer by absorption
There are no gains or losses on transfer by absorption to report.
12. Operating Leases
12.1.1 Payments recognised as an Expense 2017-18 2016-17 Buildings Other Total Buildings Other Total £'000 £'000 £'000 £'000 £'000 £'000 Payments recognised as an expense Minimum lease payments 821 7 828 703 9 712 Total 821 7 828 703 9 712
The clinical commissioning group occupies property owned and managed by NHS Property Services Ltd (NHSPS). In 2016-17 NHSPS moved to billing on a market rent basis which includes charges for void space, any subsidies to occupants and management overheads for the property company. The costs are reflected in Note 12.1.1
Whilst our arrangements with NHS Property Services Ltd fall within the definition of operating leases, rental charge for future years has not yet been agreed . Consequently this note does not include future minimum lease payments for those arrangements only. Other leases are for printers and a franking machine
12.1.2 Future minimum lease payments 2017-18 2016-17 Buildings Other Total Buildings Other Total £'000 £'000 £'000 £'000 £'000 £'000 Payable: No later than one year 0 0 0 0 7 7 Between one and five years 0 0 0 0 7 7 After five years 0 0 0 0 0 0 Total 0 0 0 0 14 14
12.2 As lessor 12.2.1 Rental revenue The Clinical Commissioning Group did not receive any revenue as lessor.
16 NHS Mid Essex CCG - Annual Accounts 2017-18
13 Property, plant and equipment
2016-17 Furniture & Furniture & 2017-18 fittings Total fittings Total £'000 £'000 £'000 £'000 Cost or valuation at 01 April 2017 78 78 78 78
Cost/Valuation at 31 March 2018 78 78 78 78
Depreciation 01 April 2017 53 53 37 37
Charged during the year 15 15 16 16 Depreciation at 31 March 2018 68 68 53 53
Net Book Value at 31 March 2018 10 10 25 25
Purchased 10 10 25 25 Total at 31 March 2018 10 10 25 25
Asset financing:
Owned 10 10 25 25 Total at 31 March 2018 10 10 25 25
The clinical commissioning group does not hold any revaluation reserve balances for property, plant and equipment.
13.1 Additions to assets under construction There are no assets under construction to report.
There are no donated assets to report.
13.3 Government granted assets There are no government granted assets to report.
13.4 Property revaluation The clinical commissioning group has no property assets to report.
13.5 Compensation from third parties There was no compensation from third parties to report.
13.6 Write downs to recoverable amount No assets were written down to recoverable amount.
13.7 Temporarily idle assets There are no temporarily idle assets to report.
13.8 Cost or valuation of fully depreciated assets There are no fully depreciated assets still in use to report.
13.9 Economic lives
Minimum Maximum Life (years) Life (Years) Furniture & fittings 2 2
17 NHS Mid Essex CCG - Annual Accounts 2017-18
14 Intangible non-current assets 2016-17 Computer Purchased Software: Computer 2017-18 Purchased Total Software £'000 £'000 £'000 Cost or valuation at 01 April 2017 61 61 61
Cost / Valuation At 31 March 2018 61 61 61
Amortisation 01 April 2017 34 34 14
Charged during the year 20 20 20 Amortisation At 31 March 2018 54 54 34
Net Book Value at 31 March 2018 7 7 27
Purchased 7 7 27 Total at 31 March 2018 7 7 27
The clinical commissioning group does not hold any revaluation reserve balances for intangible assets.
14.1 Donated assets There are no donated assets to report.
14.2 Government granted assets There are no government granted assets to report.
14.3 Revaluation Assets were not revalued in year.
14.4 Compensation from third parties There was no compensation from third parties for assets impaired, lost or given up.
14.5 Write downs to recoverable amount No intangible non current assets were written down to recoverable amounts during the year and there were no reversals of previous write downs.
14.6 Non-capitalised assets There are no significant intangible assets controlled by the clinical commissioning group but not recognised as assets because they didn’t meet the recognition criteria of IAS38.
14.7 Temporarily idle assets There are no temporarily idle assets.
14.8 Cost or valuation of fully amortised assets There are no fully depreciated intangible assets still in use to report.
14.9 Economic lives Minimum Maximum Life (years) Life (Years) Computer software: purchased 1 1
15 Investment property The clinical commissioning group does not have any property for investment.
16 Inventories The clinical commissioning group had no inventories at 31 March 2018 or 31 March 2017.
18 NHS Mid Essex CCG - Annual Accounts 2017-18
17 Trade and other receivables Current Non-current Current Non-current 2017-18 2017-18 2016-17 2016-17 £'000 £'000 £'000 £'000
NHS receivables: Revenue 725 0 911 0 NHS prepayments 1,060 0 1,482 0 NHS accrued income 716 0 1,794 0 Non-NHS and Other WGA receivables: Revenue 1,396 0 225 0 Non-NHS and Other WGA prepayments 68 0 37 0 Non-NHS and Other WGA accrued income 377 0 726 0 VAT 91 0 192 0 Other receivables and accruals 2 0 0 0 Total Trade & other receivables 4,434 0 5,368 0
Total current and non current 4,434 5,368
There are no prepaid pension contributions included in the above figures.
17.1 Receivables past their due date but not impaired 2017-18 2017-18 2016-17 £'000 £'000 £'000 Non DH DH Group Group All receivables Bodies Bodies prior years
By up to three months 260 (22) 83 By three to six months 3 600 (3) By more than six months 2 8 0 Total 265 586 80
£440k of the amount above has subsequently been recovered post the statement of financial position date.
The clinical commissioning group did not hold any collateral against receivables outstanding at 31 March 2018.
17.2 Provision for impairment of receivables
No receivables have been impaired.
18 Other financial assets The clinical commissioning group had no other financial assets as at 31 March 2018.
19 Other current assets The clinical commissioning group had no other current assets as at 31 March 2018.
20 Cash and cash equivalents 2017-18 2016-17 £'000 £'000 Balance at 01 April 2017 (619) (693) Net change in year (121) 74 Balance at 31 March 2018 (739) (619)
Made up of: Cash in hand 0 1 Cash and cash equivalents as in statement of financial position 0 1
Bank overdraft: Government Banking Service (740) (619) Total bank overdrafts (740) (619)
Balance at 31 March 2018 (740) (619)
No patients’ money is held by the clinical commissioning group.
The clinical commissioning group's cash position is reported in the financial statements as an overdraft at 31 March 2018 due to outstanding payments clearing after the year end. As at 31 March 2018, the clinical commissioning group had a net positive cash balance deposited in its Government Banking Service bank account of £91k.
21 Non-current assets held for sale There are no non current assets held for sale to report.
22 Analysis of impairments and reversals There are no impairments or reversals to report.
19 NHS Mid Essex CCG - Annual Accounts 2017-18
Current Non-current Current Non-current 23 Trade and other payables 2017-18 2017-18 2016-17 2016-17 £'000 £'000 £'000 £'000
NHS payables: revenue 5,525 0 3,313 0 NHS accruals 2,696 0 4,403 0 NHS deferred income 68 0 0 0 Non-NHS and Other WGA payables: Revenue 1,973 0 4,044 0 Non-NHS and Other WGA accruals 18,803 0 16,429 0 Non-NHS and Other WGA deferred income 16 0 206 0 Social security costs 80 0 84 0 Tax 73 0 75 0 Other payables and accruals 172 0 406 0 Total Trade & Other Payables 29,407 0 28,959 0
Total current and non-current 29,407 28,959
Other payables include £97k outstanding pension contributions at 31 March 2018 (£98k - 31 March 2017)
24 Other financial liabilities There are no other financial liabilities to report.
25 Other liabilities There are no other liabilities to report.
20 NHS Mid Essex CCG - Annual Accounts 2017-18
Current Non-current Current Non-current 26 Borrowings 2017-18 2017-18 2016-17 2016-17 £'000 £'000 £'000 £'000 Bank overdrafts: · Government banking service 740 0 619 0 Total overdrafts 740 0 619 0
Total Borrowings 740 0 619 0
Total current and non-current 740 619
The clinical commissioning group's cash position is reported in the financial statements as an overdraft at 31 March 2018 due to outstanding payments clearing after the year end. As at 31 March 2018, the clinical commissioning group had a net positive cash balance deposited in its Government Banking Service bank account of £91k.
26.1 Repayment of principal falling due Department of Department of Health Other Total Health Other Total 2017-18 2017-18 2017-18 2016-17 2016-17 2016-17 £'000 £'000 £'000 £'000 £'000 £'000
Within one year 0 740 740 0 619 619
Total 0 740 740 0 619 619
27 Private finance initiative, LIFT and other service concession arrangements The clinical commissioning group does not have any PFI, LIFT or other concession arrangements to report.
28 Finance lease obligations There are no finance lease obligations to report.
29 Finance lease receivables There are no finance lease receivables to report.
21 NHS Mid Essex CCG - Annual Accounts 2017-18
30 Provisions Current Non-current Current Non-current 2017-18 2017-18 2016-17 2016-17 £'000 £'000 £'000 £'000 Continuing care 915 729 205 1,024 Other 882 0 1,318 296 Total 1,797 729 1,523 1,320
Total current and non-current 2,526 2,843
Continuing Care Other Total £'000 £'000 £'000
Balance at 01 April 2017 1,229 1,614 2,843
Arising during the year 980 677 1,658 Utilised during the year (25) (762) (788) Reversed unused (540) (647) (1,187) Balance at 31 March 2018 1,644 882 2,526
Expected timing of cash flows: Within one year 915 882 1,797 Between one and five years 729 0 729 Balance at 31 March 2018 1,644 882 2,526
Under the Accounts Directions issued by NHS England on 12 February 2014, NHS England is responsible for accounting for liabilities relating to NHS continuing healthcare claims related to periods of care before establishment of the clinical commissioning group. However, the legal liability remains with the clinical commissioning group. The total value of the legacy continuing healthcare provisions accounted for by NHS England on behalf of this clinical commissioning group at 31 March 2018 is £1,046k (2016-17 £2,496k).
The decrease is due to a further reduction in the number of cases awaiting financial settlement. Of the 61 cases found eligible or part-eligible a further 14 were settled in 2017-18 leaving 8 to be settled in 2018-19. The NHSE risk pool arrangement continues to operate and will meet the costs of financial settlement for these cases. In addition, there were 49 appeals in process as at 31 March 2018 and a further 10 cases remain in the 6 month window to make an initial appeal. Of the 49 appeals in progress, 24 are with the NHS England Independent Review Panel for decision. Financial settlement of any cases that are upheld on appeal will be made from the NHS England risk pool arrangement.
The main provisions held by the clinical commissioning group as at 31 March 2018 include:
· Estimate of the costs of settling 32 continuing healthcare retrospective claims received since 31 March 2013 and which are outside of the NHS England risk pool arrangement and the liability of the clinical commissioning group (£1,644k)
· Provision for the repayment of charge exempt overseas visitor allocation in 2018-19 due to the 2017-18 estimate being significantly higher than actual costs (£570k)
31 Contingencies There are no contingencies to report.
22 NHS Mid Essex CCG - Annual Accounts 2017-18
32 Commitments
32.1 Capital commitments There are no capital commitments to report.
32.2 Other financial commitments The clinical commissioning group has not entered into any non-cancellable contracts (which are not leases, private finance initiatives contracts or other service concession arrangements).
33 Financial instruments
33.1 Financial risk management Financial reporting standard IFRS 7 requires disclosure of the role that financial instruments have had during the period in creating or changing the risks a body faces in undertaking its activities.
As the clinical commissioning group is financed through parliamentary funding, it is not exposed to the degree of financial risk faced by business entities. Also, financial instruments play a much more limited role in creating or changing risk than would be typical of listed companies, to which the financial reporting standards mainly apply. The clinical commissioning group has limited powers to borrow or invest surplus funds and financial assets and liabilities are generated by day-to-day operational activities rather than being held to change the risks facing the clinical commissioning group in undertaking its activities.
Treasury management operations are carried out by the finance department, within parameters defined formally within the clinical commissioning group standing financial instructions and policies agreed by the Governing Body. Treasury activity is subject to review by the clinical commissioning group and internal auditors.
33.1.1 Currency risk The clinical commissioning group is principally a domestic organisation with the great majority of transactions, assets and liabilities being in the UK and sterling based. The clinical commissioning group has no overseas operations. The clinical commissioning group and therefore has low exposure to currency rate fluctuations.
33.1.2 Interest rate risk The clinical commissioning group borrows from government for capital expenditure, subject to affordability as confirmed by NHS England. The borrowings are for 1 to 25 years, in line with the life of the associated assets, and interest is charged at the National Loans Fund rate, fixed for the life of the loan. The clinical commissioning group therefore has low exposure to interest rate fluctuations.
33.1.3 Credit risk
Because the majority of the clinical commissioning group's revenue comes from parliamentary funding, the clinical commissioning group has low exposure to credit risk. The maximum exposures as at the end of the financial year are in receivables from customers, as disclosed in the trade and other receivables note.
33.1.3 Liquidity risk
The clinical commissioning group is required to operate within revenue and capital resource limits, which are financed from resources voted annually by Parliament. The clinical commissioning group draws down cash to cover expenditure, as the need arises. The clinical commissioning group is not, therefore, exposed to significant liquidity risks.
23 NHS Mid Essex CCG - Annual Accounts 2017-18
33 Financial instruments cont'd
33.2 Financial assets
Loans and Receivables Total 2017-18 2017-18 £'000 £'000 Receivables: · NHS 1,441 1,441 · Non-NHS 1,772 1,772 Other financial assets 2 2 Total at 31 March 2018 3,216 3,216
Loans and Receivables Total 2016-17 2016-17 £'000 £'000 Receivables: · NHS 2,705 2,705 · Non-NHS 951 951 Cash at bank and in hand 1 1 Total at 31 March 2017 3,658 3,658
33.3 Financial liabilities
Other financial liabilities Total 2017-18 2017-18 £'000 £'000 Payables: · NHS 8,220 8,220 · Non-NHS 20,949 20,949 Other borrowings 740 740 Total at 31 March 2018 29,909 29,909
Other financial liabilities Total 2016-17 2016-17 £'000 £'000 Payables: · NHS 7,717 7,717 · Non-NHS 20,878 20,878 Other borrowings 619 619 Total at 31 March 2017 29,214 29,214
33.4 Maturity of Financial Liabilities Payable to non DH other bodies 2017-18 £'000
In one year or less 29,909
34 Operating segments The clinical commissioning group considers that it only has one operating segment; commissioning of healthcare services.
24 NHS Mid Essex CCG - Annual Accounts 2017-18
35 Pooled budgets The clinical commissioning group was not party to any pooled budget arrangements during 2017-18.
Better Care Fund The clinical commissioning group has operated a Better Care Fund of £22.8m during 2017-18 (2016-17 £22.7m) together with Essex County Council under a section 75 agreement. This arrangement has been reviewed and both parties have agreed that it does not constitute a pooled fund. This conclusion has been reached as both parties have retained the financial risks associated with each of the schemes as existed before the fund was set up.
The arrangements for each scheme within the Better Care Fund have been reviewed to determine the appropriate accounting treatment by the clinical commissioning group and agreed with Essex County Council.
Control of the commissioning arrangements has been key to determining the nature of each scheme within the fund. Where Essex County Conucil has been identified as Lead Commissioner or Principal, the accounting treatment has been for the transaction with Essex County Council to be recorded in the clinical commissioning group ledger - £9.5m (2016-17 £9.3m). Where the clinical commissioning group has control over the commissioning of the service the transactions with the individual provider(s) are recorded in the ledger - £13.3m (2016-17 £13.4m).
In addition to the £22.8m accounted for as above, Essex County Council has received disabilities facilities grants which have been passed to housing authorities in accordance with allocations determined by the Department for Communities and Local Government.
The amount of disabilites facilities grant aligned to the clinical commissioning group's localities was £2.1m (2016-17 £1.9m). This scheme is technically within the Better Care Fund but as the clinical commissioning group has no control or input into how this is spent, it is not recorded within the clinical commissioning group's accounts.
Transforming Care Partnership
The planned Transforming Care Partnership section 75 with Essex Council has not yet been signed but all parties have embodied the principles of the agreement in determining the funds released from discharged long-stay in-patients with learning disabilities as identified by the national Transforming Care programme. The costs of health packages for this cohort of patients have been accounted for by the clinical commissioning group on a net accounting basis as the clinical commissioning group is acting as Principal. Where funding is released to Essex County Council to fund community packages for patients who have been discharged this would have been accounted for by the clinical commissioning group on a gross accounting basis as the local authority is acting as Principal. The arrangement is not considered to be one of Joint Control as both health and community packages continue to be commissioned by the respective partners, the local authorities take the risk of releasable funding being insufficient for community packages and the role of the health partners on the Transforming Care Partnership board is one of oversight and to check that the pooled fund manager is spending the funds on the agreed purposes.
For 2017-18 the amount to be transferred to the fund by the clinical commissioning group to fund Community packages for discharged patients from this cohort was £86k. The amount paid by the clinical commissioning group on health packages pre-discharge date for the patients discharged in 2017-18, and therefore accounted for net, was £186k. As the agreement was not signed as at 31 March 2018 and Essex County Council had not invoiced for the costs the amounts have been fully accrued and accounted for net in the individual placements budget paid to North East Essex CCG.
36 NHS Lift investments The clinical commissioning group does not have any LIFT investments.
25 NHS Mid Essex CCG - Annual Accounts 2017-18
37. Related Party Transactions The clinical commissioning group is a body corporate established by order of the Secretary of State for Health.
Members of the decision making forums are required to complete a formal declaration of interest statement annually and to notify the clinical commissioning group of any changes between declarations as they occur. Declarations relate to themselves, interests of close family members and associates. This disclosure enables the clinical commissioning group to ensure that the accounts disclose transactions with related parties declared in those annual statements.
The Department of Health and NHS England are regarded as related parties. During 2017-18 the Clinical Commissioning group has had a significant number of material transactions with the Department of Health and NHS England and with other entities for which these organisations are regarded as the parent organisation. These entities are:
Mid Essex Hospital Services NHS Trust Colchester Hospital University NHS Foundation Trust Barts Health NHS Trust Basildon & Thurrock University Hospital NHS Foundation Trust Barking Havering & Redbridge University Hospitals NHS Trust Cambridge University Hospital NHS Foundation Trust University College London Hospitals NHS Foundation Trust Essex Partnership University NHS Foundation Trust Hertfordshire Partnership University NHS Foundation Trust East of England Ambulance Service NHS Trust North East Essex CCG West Essex CCG Basildon & Brentwood CCG Castlepoint & Rochford CCG Southend CCG Thurrock CCG Other East of England and London Acute Trusts and CCGs The NHS Resolution NHS Business Services Authority North & East London Commissioning Support Unit Arden & Greater East Midlands Commissioning Support Unit
In addition the CCG has had a significant number of material transactions with other government departments and other central and local government bodies. Most of these transactions have been with Essex County Council, Braintree District Council, Chelmsford City Council and government bodies. Most of these transactions have been with Essex County Council, Braintree District Council, Chelmsford City Council and Maldon District Council
During the year and in addition to the transactions reported in the Remuneration Report in the Annual Report the following GP and other clinical leads had significant transactions with the clinical commissioning group in respect of their practices and private accounts. These transactions were in accordance with the usual arrangements with practices for the provision of services.
Details of Related Party Transactions with individuals are as follows:
Receipts Amounts Amounts Payments to from owed to due from Related Related Related Related Party Party Party Party £'000 £'000 £'000 £'000
Writtle GP Surgery - Mike Bailey - Former GP Partner 39 0 0 0 Fern House Surgery- Ahmed Mayet - GP Partner 58 0 14 0 Beacon Health Group - Dr Sam Bhima - GP Partner; Caroline Dollery - 70 0 18 0 Salaried GP Melbourne House Surgery - Dr.James Booth - GP Partner 17 0 2 0
Coggeshall Surgery - Anna Davey - GP Partner 27 0 7 0
Whitley House Surgery - Dr.Elizabeth Towers - GP Partner 33 0 8 0
Dengie Medical Partnership - Donald McGeachy - Spouse is a GP Partner 52 0 16 0
Baddow Village Surgery - Dr.Waseem Ahmed - GP Partner 50 0 11 0 346 0 76 0
26 NHS Mid Essex CCG - Annual Accounts 2017-18
37. Related Party Transactions cont'd
The CCG also had transactions with the following organisations with whom decision makers of the CCG have declared an interest:
Receipts Amounts Amounts Payments to from owed to due from Related Related Related Related Party Party Party Party £'000 £'000 £'000 £'000
East London FT - Dr. Sam Bhima - GP with Special Interest 3 0 0 0
North East London FT - Daniel Doherty - Spouse is a Community 2,640 0 0 0 Physiotherapist Provide CIC - Daniel Doherty - Honorary Clinical Contract 34,775 0 303 0 East of England Ambulance NHS Trust - Karl Edwards - Deputy Director 14,678 0 0 0 of Service Delivery Essex County Council - Maggie Pacini - Consultant in Public Health 14,312 (1,604) 582 0 West Essex CCG - Maggie Pacini - Board Member 107 (17) 0 0 Care UK Ltd - Caroline Rassell - Spouse is an employee 510 0 0 0 Macmillan Cancer - Dr Elizabeth Towers - Macmillan GP 0 (78) 0 0 Farleigh Hospice - Dr Elizabeth Towers - Trustee 2,031 0 0 0
69,056 (1,699) 885 0
Details of Related Party Transactions with individuals are as follows:
Comparative Figures for 2016-17
Payments to Receipts Amounts Amounts due Related from Related owed to from Related Party Party Related Party Party £'000 £'000 £'000 £'000 Danbury Medical Centre - Dr Caroline Dollery - salaried GP 59 0 0 0 Writtle Surgery - Dr Mike Bailey was a GP partner until 31 March 2015 0 0 0 0 Beacon Health Group - Mountbatten House Surgery - Dr Sam Bhima is a 0 0 0 0 GP Partner
Coggeshall Surgery - Dr Anna Davey (start date 09 January 2017) is a GP 19 0 0 0 Partner Fern House Surgery - Dr Ahmed Mayet is a GP Partner 75 0 18 0 The Elizabeth Courtland Surgery - Dr Bryan Spencer (retired 30 June 2016) & Dr Anna Davey (leaving date 31 December 2016) were salaried 42 0 0 0 GPs The Baddow Village Surgery - Dr Waseem Ahmed is a GP Partner 0 (22) 0 0 The Dengie Medical Partnership, Tillingham Medical Centre - Dr Donald 59 0 0 0 McGeachy has a close family member employed by The Melbourne House Surgery - Dr James Booth is a GP Partner 4 0 0 0 The Whitley House Surgery - Dr Elizabeth Towers is a GP Partner 16 0 0 0
274 (22) 18 0
The CCG also had transactions with the following organisations with whom decision makers of the CCG have declared an interest:
Comparative Figures for 2016-17
Payments to Receipts Amounts Amounts due Related from Related owed to from Related Party Party Related Party Party £'000 £'000 £'000 £'000
Chelmer Healthcare Ltd - Dr James Booth, Dr Elizabeth Towers & Dr 0 0 0 0 Caroline Dollery are shareholders Essex County Council - Maggie Pacini is employed by 13,910 (799) 2,377 0 Farleigh Hospice - Dr Elizabeth Towers is a Trustee 1,860 0 0 0 Macmillan - Dr Elizabeth Towers is a Macmillan GP 0 (22) 0 0 North East London Foundation Trust - Dan Doherty has a close family 2,543 0 97 0 member employed by Provide Community Services - Dan Doherty has an honorary contract 34,780 0 1,360 0 St Helens and Knowsley Teaching Hospitals - Dee Davey has a close 2 0 0 0 family member employed by West Essex CCG - Maggie Pacini is a member of the Board 63 (838) 116 41
53,158 (1,659) 3,950 41
27 NHS Mid Essex CCG - Annual Accounts 2017-18
38 Events after the end of the reporting period There are no past balance sheet events which will have a material effect on the financial statements of the clinical commissioning group.
39 Third party assets The clinical commissioning group does not hold any assets on behalf of other parties.
40 Losses and special payments
40.1 Losses The total number of NHS clinical commissioning group losses and special payments cases, and their total value, was as follows:
Total Number Total Value of Total Number of Total Value of of Cases Cases Cases Cases 2017-18 2017-18 2016-17 2016-17 Number £'000 Number £'000 Administrative write-offs 4 4 0 0 Total 4400
41 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:
2017-18 2017-18 2016-17 2016-17 Target Performance Target Performance Expenditure not to exceed income - 223H(1) 464,700 456,582 430,921 452,824 Revenue resource use does not exceed the amount specified in Directions - 223I(3) 461,914 453,796 428,122 450,025 Revenue administration resource use does not exceed the amount specified in Directions - 223J(3) 8,361 7,860 8,345 7,357
In 2016-17 finanical performance targets (223H(1) and 223I(3)) were required to be disclosed net of any carried forward cumulative deficit (£21,903k). For 2017-18 the disclosure guidance has changed and targets are shown before the cumulative deficit has been deducted. The difference between the target and performance for 2017-18 is £8,118k surplus that was generated and reduced the carried forward cumulative deficit to £13,785k.
28 Mid Essex CCG Annual Report and Accounts 2017/18
Appendix A: Glossary of non-financial terms
Term Definition Care pathway The route that a patient will take from their first point of contact with an NHS or Social Services member of staff (usually their GP), through referral, to the completion of their treatment. Clinical Commissioning Group Formally established on 1 April 2013, Clinical Commissioning (CCG) Groups (CCGs) are statutory bodies responsible for commissioning most healthcare – planning, buying and monitoring services to meet the needs of their local communities. Civil Contingencies Act 2004 Provides a single framework for UK civil protection against any challenges to society – it focuses on local arrangements and emergency powers. Commissioning The review, planning, purchasing and monitoring of health and social services. Community services Health or social care and services provided outside of hospital. They can be provided in a variety of settings including clinics and in people's homes. Community services include a wide range of services such as district nursing, health visiting services and specialist nursing services. Commissioning Support Units Commissioning Support Units provide capacity to clinical (CSU) commissioners as an extension of their local team to ensure that commissioning decisions are informed and processes structured. Enhanced services Enhanced services are: i. essential or additional services delivered to a higher specified standard, for example, extended minor surgery ii. services not provided through essential or additional services They are services provided by GPs, over and above the core (essential and additional) services to their patients. Equality Delivery System (EDS2) The EDS2 has been designed nationally as an optional tool launched in 2011 to support NHS commissioners and providers to deliver better outcomes for patients and communities and better working environments for staff, which are personal, fair and diverse. The EDS2 is all about making positive differences to healthy living and working lives.
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Term Definition Equality Impact Assessment (EIA) An equality impact assessment involves assessing the likely or actual effects of policies or services on people in respect of disability, gender and racial equality. It helps us to make sure the needs of people are taken into account when we develop and implement a new policy or service or when we make a change to a current policy or service. NHS111 NHS 111 makes it easier for people to access local NHS healthcare services. People can call 111 when they need medical help fast but it is not a 999 emergency. NHS 111 is available 24 hours a day, 365 days a year. Calls are free from landlines and mobile phones. Palliative Care The total care of patients whose disease is incurable. Control of pain, of other symptoms, and of psychological, social and spiritual problems is paramount. The goal of palliative care is achievement of the best quality of life for patients and their families. Primary Care Trust (PCT) Primary Care Trusts were abolished on 31 March 2013. Prior to that they were responsible for the planning and securing of health services and improving the health of the local population. Whole Time Equivalent (WTE) The WTE is a workforce term. The WTE for each person is based on their hours worked as a proportion of the contracted hours normally worked by a full-time employee in the post.
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Appendix B: Glossary of financial terms
Term Definition Current Assets Assets held for less than one year that can be converted to cash such as stocks of consumables, monies held in the CCG’s bank account and the amount of money that is owed to the CCG by individuals or organisation. Capital Expenditure Items of expenditure that have a useful life of more than one year and are individually valued at £5k or more e.g. large pieces of equipment. It is possible to capitalise smaller items but they have to be over £250 in value and be interdependent. Capital expenditure purchases non-current assets (fixed assets) or adds to the value of an existing fixed asset. Capital Resource Limit The total amount of capital expenditure (see above for definition) that the CCG can incur in the financial year. The CCG has a duty to not spend above its allocated Capital Resource Limit. Cash Limit The Government sets the amount of cash which the CCG may spend during a given financial year – the Cash Limit (CL). The CCG must ensure that the net amount of cash flowing out of the CCG over the financial accounting period is not more than the CL. Depreciation The annual charge in relation to the utilisation/wearing out of non-current assets. The charge for the non-current assets is spread over the useful life. Financial Instrument A contract that gives rise to a financial asset of one entity and a financial liability of another entity e.g. cash and a contractual right to receive cash. Finance Lease An arrangement that transfers substantially all the risk and rewards related to ownership of an asset to the CCG although title may not have transferred.
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Term Definition General Fund The General Fund is similar to a Profit and Loss reserve, the operating cost of the CCG is charged here as well as an opposite entry for the Net Parliamentary Funding (amount of cash drawn down from the Department of Health). Intangible Assets An invisible or ‘soft’ asset that has been purchased using capital expenditure and has a real current market value and contributes to the (future) operation of the CCG e.g. IT software. IFRS – International Financial The principles-based standards, interpretations and Reporting Standards framework which govern the production of the CCG’s accounts. Impairment A decrease in the values of non-current assets compared to those values recorded on the Statement of Financial Position. A CCG is required to undertake routinely revaluation reviews of its fixed assets or undertake an impairment review when there is a decline in an asset’s value. The impairment (loss) is treated in the same way as depreciation, as a cost in the Statement of Comprehensive Net Expenditure (SCNE), if the change in the value of the asset is permanent. Losses and Special Payments Payments that Parliament would not have foreseen healthcare funds being spent on, for example fraudulent payments, personal injury payments or payments for legal compensation. Miscellaneous Income Income that the CCG receives over and above its revenue resource limit, e.g. room rental and training income. Net Cash Outflow from Operating This is the amount of cash actually paid out less Activities miscellaneous income actually received. It differs from the Net Operating Cost which includes non-cash items such as depreciation and movements in Debtors and Creditors. Net Parliamentary Funding This is the amount of cash drawn down by the CCG from the Department of Health for payments relating to commissioning services and running the CCG. Non-Current Assets Tangible assets that have been purchased using Capital Expenditure (see definition above). (Previously known as Fixed Assets). The CCG does not hold the leases for or own any buildings – all building assets are owned or leased by NHS Property Services.
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