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Contents

Chair’s Introduction ...... 4 Performance Report ...... 6 Overview: About Stoke-on-Trent CCG ...... 6 Accountable Officer’s Introduction ...... 8 Performance Analysis ...... 11 Our principal risks ...... 11 Going concern ...... 11 Performance overview ...... 11 Performance against key performance indicators ...... 21 The CCG’s position at the end of the financial year ...... 22 Sustainable Development ...... 26 Discharge of statutory duties ...... 28 Key Achievements in 2018/19 ...... 53 Accountability Report ...... 68 Corporate Governance Report ...... 68 Statement of Accountable Officer’s Responsibilities ...... 74 Governance Statement ...... 76 Head of Internal Audit Opinion ...... 99 Remuneration and Staff Report ...... 102 Remuneration Report ...... 102 Staff Report ...... 115 Parliamentary Accountability and Audit Report ...... 126 List of acronyms ...... 127

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Chair’s Introduction

This year marked the 70th anniversary of the NHS and my first as Chair of Stoke-on-Trent Clinical Commissioning Group (CCG), both landmarks of which I am extremely proud.

The year 2018/19 has been both a challenging and a productive one for Stoke-on-Trent CCG, with our focus being very much on working as part of the wider Staffordshire health and care system and reinvigorating our engagement with our stakeholders and patients.

As six CCGs across Staffordshire and Stoke-on-Trent operating under one Accountable Officer and executive team, we are working closely with our local authorities, hospital and community provider trusts, GP practices and the Third Sector. This is to create a more joined-up health and care system with the need for a seamless patient journey and more care delivered closer to home at its heart.

We presented our proposed new model of care as part of our public consultation about the Future of Local Health Services in Northern Staffordshire. With an ageing population, and higher proportion of the population living with a long-term condition such as diabetes or heart disease, we need to find better ways to support patients to manage their health and stay well and independent for as long as possible.

Our vision is that more care is delivered closer to patient’s homes, by a multi-disciplinary team of healthcare professionals considering the holistic needs of the patient, rather than the traditional condition-focussed approach. This should mean that patients feel better supported to managed their long-term conditions and that they need to go to hospital less often. When patients do need to go to hospital, they will need to spend less time there because there will be skilled teams working in the community to support them to recover at home and maintain their independence, or care for them whilst they regain it.

We listened to the views of patients and the public at over 60 public events, as well as market stalls, outreach meetings and a paper and online survey over 14 weeks. The consultation closed on 17 March 2019 and we would like to thank all of the residents and patients of Northern Staffordshire who took the time to share their views with us, and indeed all of our staff who helped to deliver these events. We look forward to reading and considering all of the feedback that we have received and sharing the results in due course.

We have developed new Membership Engagement Groups where the CCG meets monthly with GPs and practice managers from all of the practices in Stoke-on-Trent to ask their views on our plans and services. I attend as many of these as I can in person, to make sure that the CCG continues to live up to its fundamental design principle: that GPs are experts on the needs of their patients and our grassroots clinicians must be able to influence the health services that we commission.

We have just emerged from winter where the healthcare system coped much better than it has done in the past. This year we saw patients waiting for less time in the Emergency Department and to be admitted and discharged from hospital beds; and no planned operations were cancelled this year. While there are still a lot of improvements to be made to our urgent and emergency care system, this is a hugely positive change compared with previous years and we look forward to building on these successes. I would like to personally thank all of our hard-working NHS staff across the hospital, community, general practice and social care services in Stoke-on-Trent for the continued dedication they show particularly during difficult times.

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In January, we received the NHS Long Term Plan, which sets us challenges in terms of improving prevention of disease, as well as care quality and outcomes; and to deliver care in different ways using upgraded technology and digital solutions as well as new types of healthcare professionals. Locally, we have seen the variety of healthcare professional roles expand from Advanced Nurse Practitioners that most of us have become familiar with, to include: practice-based Pharmacists, Paramedic Practitioners, Physicians Associates and now Social Prescribers. These new roles are vital in our new model of community-based care, to ensure that patients receive the right care, in the right place at the right time - and to meet the growing healthcare needs of our population.

In Stoke-on-Trent, we are also fortunate that we have a very active technology-enabled care (TECs) programme, which has received national plaudits for their innovative scheme to provide GP support to care homes via Skype. We are finalising plans for an Integrated Care Record which will make your important information available to health and care professionals working in whichever service you need to access, reducing the need to tell your story multiple times and keeping you safer.

As I look forward to 2019/20 which is set to be challenging and exciting in equal measure, it would be remiss of me not to thank my predecessor Professor Ruth Chambers who stepped down as Chair at the end of December 2018. Ruth has been a champion for patient care in Stoke-on-Trent and she leaves big shoes to fill, but fortunately she continues to lead our TECs programme and so her wealth of experience and knowledge will not be lost to us.

Dr Lorna Clarson Clinical Chair, Stoke-on-Trent Clinical Commissioning Group (CCG)

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Performance Report

Overview: About Stoke-on-Trent CCG Stoke-on-Trent CCG plans and buys (commissions) health services for local people. The membership of the CCG is made up of the GP practices – as GPs, they are best placed to understand what services their patients need.

We are run by a ‘Governing Body’ that includes a mix of GPs, a secondary care consultant and local lay members. We buy services from hospitals, mental health and community health bodies and charities. We do this alone or in partnership with other local CCGs. We check how services are run and if patients are happy with them.

We design new services that are better for patients and better value for money. We also buy support services from Midlands and Lancashire Commissioning Support Unit (MLCSU).

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National Health Service (NHS) England is responsible for CCGs. It pays for NHS care from dentists, pharmacists and opticians. This year we have worked with NHS England to buy GP services under “delegated commissioning of general practice”. We follow strict rules to make sure we do this fairly when buying services from our own GP members.

We buy services mainly from:

• University Hospitals of North Midlands (UHNM) • North Staffordshire Combined HealthCare NHS Trust (NSCHT) • Midlands Partnership NHS Foundation Trust (MPFT) • West Midlands Ambulance NHS Foundation Trust • Vocare - including NHS 111 service • Local hospices.

The progress we have made during 2018/19 derives from our commitment to good clinical engagement, strong programme management, a robust approach to contract management and the new relationships that we have developed with providers and other CCG commissioners. This has ensured the services we commission and strategies we have for improving services are appropriate to meet local needs, have been enacted through our contract with providers and are performance-managed to ensure services are delivered to the required standard.

We are committed to delivering our priorities and addressing the challenges we face by:

• Focusing to secure progress towards a sustainable balance by eliminating the underlying financial deficit • Directing the resources at our disposal to maximise the potential health gain for our community • Ensuring high quality, safe and sustainable services through organisational transition and service transformation • Developing an improved approach to prevention • Testing and trialling the services we commission to ensure they are effective and deliver the intended outcomes.

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Accountable Officer’s Introduction It’s been a busy but productive year, the latest in what feels like a continual process of significant change; for ourselves, our providers and the NHS more widely. Never before have we worked more closely together as Clinical Commissioning Groups (CCGs), with our partners and with patients. We are united in our goal to integrate services, so people receive better care that is financially sustainable for the future – and what momentum has been achieved in our journey.

The six CCGs in Staffordshire and Stoke-on-Trent all now have a single Accountable Officer, leadership and management team. This means that there has been a management of change process. This has been difficult and challenging, but I would like to thank everyone for their dedication and professionalism. Some valued colleagues have left and would like to thank them for their enormous contribution.

Now we are more efficient in how we organise ourselves and make decisions as one single team, yet we have maintained a strong element of locally-based focus through the work of our managing directors, clinical leads and lay members. I believe this balance is key to success and there have been lots of them in 2018/19. Implementation of the national CCG Improvement & Assessment Framework (IAF) and the work of our performance team are already delivering good outcomes for our patients.

The urgent and emergency care system has performed well this winter with an emphasis on improved performance at our main provider University Hospitals North Midlands (UHNM), especially in relation to 12-hour breaches. While the weather has largely been favourable and we have not had a major incident, this is still a very considerable achievement and the result of careful planning. Daily reported escalation levels in the hospitals have generally been 1 and 2 throughout the winter which indicates they have been performing well (in contrast to the winter of 2017/18 when they were largely levels 3 and 4). We need to remember, however, that pressures do not just begin and end in winter but need to be managed year-round. Last summer’s record heatwave created extremely high levels of activity, particularly with frail and elderly patients suffering from dehydration.

The CQC carried out a system review of services for over 65s in Staffordshire and revisited a review of services for patients aged 65+ in Stoke-on-Trent, following an initial review process in 2017. The review into Staffordshire had many positive things to say, including the Frailty Hub being developed in Lichfield. It came to a number of conclusions, including:

• People are mainly satisfied with the quality of services provided once they received them • Older people had varied experiences of health and social care services • Leaders are working together with strong leadership and clear shared vision • People were being supported to remain in their own home but provision varies • A&E attendances for people over 65 were similar to the national average but higher than comparator area averages • There had been improvements but older residents can still experience delay coming out of hospital and accessing suitable care and support in the community • Care home choice can be restricted and quality varies.

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We now have an action plan in place to address areas of concern. The re-review of Stoke- on-Trent showed dramatic improvements, including improved joint working with the city council and senior leaders and joint strategic commissioning wherever possible.

The Home First service and D2A (Discharge to Assess) have been performing well and we are seeing fewer patients kept in beds when they are clinically fit for discharge. This is cutting the risk that frail patients will suffer from deconditioning that can lead to long-term loss of independence.

The CCGs are very much clinically-led organisations. During the last 12 months Dr Rachel Gallyot has become Chair of East Staffordshire CCG following the retirement of Dr Charles Pidsley. At the New Year, Dr Ruth Chambers stood down as Chair of Stoke-on-Trent CCG being replaced by Dr Lorna Clarson; and in March this year, Dr Mo Huda was replaced as Chair of Cannock Chase CCG by Dr Gary Free. All those Chairs who have left had been with us from the early days of the CCGs and their contribution has been enormous.

The provider landscape has also changed during the last 12 months. Midlands Partnership NHS Foundation Trust (MPFT) was formed last summer, following a merger between South Staffordshire and Shropshire Healthcare NHS Foundation Trust and Staffordshire and Stoke-on-Trent Partnership NHS Trust. MPFT provides physical and mental health, learning disability and adult social care services across Staffordshire and Stoke-on-Trent. The University Hospitals of Derby and Burton NHS Foundation Trust has also been formed, bringing together Queen’s Hospital Burton, the community hospitals in Tamworth and Lichfield with the Royal Derby Hospital, which is expected to bring long-term improvements for patients.

So, what’s next for our improvement journey in 2019/20? Finance is still a key challenge with only Cannock Chase, East Staffordshire and Stafford & Surrounds CCGs meeting their control totals. Next year is set to be even more challenging. Providers and partners within the system have come together to produce a Sustainability Plan with the aim of bringing us back into financial balance.

During the next 12 months, the ‘Together We’re Better’ Sustainability Transformation Partnership (STP) will be carrying out pre-consultation on its proposals to transform outcomes, care and services for the people of Staffordshire and Stoke-on-Trent and will be working very closely with communities and stakeholders. This discussion will be based around four key areas: simplifying urgent and emergency care; developing a new vision for health and care; reviewing Community Hospitals in South Staffordshire; and identifying additional priorities that will deliver clinical and financial stability.

On 17 March 2019, we completed a 14 week consultation into the Future of Health Services in North Staffordshire and Stoke-on-Trent. This looked particularly at the future of the five community hospitals and community rehabilitation beds and other services. I’d like to thank everyone who took part. This has been a long process that began in 2014, but we should be able to make decisions this year following the consultation about how we go about introducing a new model of care, based around more closely integrated services delivered from integrated care hubs.

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The Performance Report outlines a number of areas where standards are not being met by providers. As referenced in the detail of this section, the CCG is working with partners to facilitate required improvements against these standards.

No one said that transformation is easy, but together we’ve shown what’s possible in a relatively short space of time. With our clear local vision (guided by the NHS Long Term Year Plan), strong partnership working and continuous listening to local patients; our directions of travel and how we can get there together are clear.

Marcus Warnes Accountable Officer, Stoke-on-Trent Clinical Commissioning Group (CCG)

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Performance Analysis

Our principal risks These are covered in greater detail within the Governance Statement section.

Going concern In light of the 2018/19 deficit and the referral to the Secretary of State under Section 30 of the Local Audit and Accountability Act, that will be issued, the CCG has undertaken an assessment of its status as a going concern. In conjunction with the STP, the CCG and providers across the system are currently working on the development of a medium-term financial recovery plan that is targeted with the objective of returning the system to an in- year financial balance. This is based upon an innovative approach to contracting which will enable all the system partners to focus upon delivering a collaborative transformation plan. This has been supported internally by strengthened governance measures, including the appointment of a Turnaround Director and the establishment of a Turnaround Board, to enable the CCG to make rapid progress with its journey back to a position of financial sustainability.

In the short term, the CCG faces a very challenging period pending the delivery of transformation programme and has submitted a deficit plan for 2019/20. Whilst this exceeds the control total set by NHS England, there is no indication that NHS England will not continue to support the CCG with the additional cash consequences of delivering this plan. Consequently, the CCG has prepared its Annual Report and Accounts on a going concern basis.

Performance overview As a statutory body we recognise the importance of providing assurance to our stakeholders and the public so that they have confidence in our ability to commission safe, high-quality and sustainable services within the resources that we have available.

A regular assessment by NHS England of our operational effectiveness is part of this process of assurance. Our performance is assessed against a wide range of indicators that reflect whether standards set out in the NHS Constitution and the CCG Improvement and Assessment Framework (IAF) are being delivered and whether health outcomes are improving for local people.

Performance against the NHS Constitution Standards and the IAF are reported and reviewed monthly and quarterly respectively at our Divisional Committee and Governing Body meetings – both held in common with North Staffordshire CCG. This is presented as a performance dashboard, providing an ‘at a glance’ view of performance across the range of indicators.

CCG Improvement and Assessment Framework

NHS England assess each CCG annually against four key domains comprising of 54 indicators with the annual results published on ‘MyNHS’ website (www.nhs.uk/mynhs), to provide the public with information on how well CCGs are performing their functions.

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The IAF covers four domains and four clinical priorities:

• Better Health: this domain assesses how the CCG is contributing towards improving the health and wellbeing of its population and managing demand • Better Care: this domain covers care redesign, performance of constitutional standards and outcome indicators • Sustainability: this domain assesses the CCG’s financial performance including its ability to maintain financial balance and securing good value for patients and the public through the money it spends • Leadership: this domain assesses the quality of the CCG’s leadership, the quality of its plans, how the CCG works with its partners and the governance arrangements that the CCG has in place to ensure it acts with probity (for example in managing conflicts of interest).

The four clinical priority areas include: dementia, diabetes, learning disabilities and mental health. Against each of these areas, the CCG receive an annual assurance rating. The categories are: ‘outstanding’, ‘good’, ‘requires improvement’, and ‘inadequate’.

The table below demonstrates the CCG’s performance in the four clinical priority areas:

Mental Health Dementia Learning Diabetes Disabilities Stoke-on-Trent Good Requires Requires Outstanding CCG Improvement Improvement

There has been significant challenge in improving health services and outcomes for local people against a backdrop of increasing demand and pressure on services. We have seen many achievements but there have also been challenges. The CCG continues to work closely with system partners to improve our performance in areas we are currently under- delivering against. At all times our first priority is to assure the safe delivery of patient care.

The CCG’s Annual Assessment against the IAF for 2017/18 was undertaken on 9 April 2018 and the outcome for Stoke-on-Trent CCG was a ‘good’ overall rating, an improvement on last year’s ‘requires improvement’ rating. The Annual Assessment for the CCG under the 2018/19 IAF was undertaken on 8 April 2019 and the CCG is awaiting the outcome.

A high-level summary of our performance across the range of IAF indicators (Quarter 2 dashboard) presented in the End of Year review 2018/19 is outlined in the table below:

Area Total In the best In the In the worst No data indicators performance interquartile performance available/ quartile (middle) range quartile not nationally nationally nationally applicable Better Health 10 2 5 3 0

Better Care 35 8 11 10 6

Sustainability 3 1 0 0 2

Leadership 5 0 1 2 2

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Constitutional Standards

The CCG has monitored and mitigated performance across the NHS Constitution standards and the Assurance Framework.

Total indicators Achieved Failed Constitutional Standards 15 7 8 Year-End 2018/19

Stoke-on-Trent CCG’s main acute services contract is with University Hospitals of North Midlands (UHNM) and performance by this provider largely determines our ability to meet NHS constitutional standards.

During 2018/19, we have not achieved a number of our constitutional targets due to capacity pressures and patient flow issues throughout the health and social care system. Of the 15 constitution measures, Stoke-on-Trent CCG has successfully met seven overall targets, but both 18 weeks Referral to Treatment (RCA) and the zero-tolerance of 52-week waits remain areas of concern.

Measures requiring continuous focus for 2019/20 are:

• The 18-week RTT standards • Zero-tolerance of 52-week waits • A&E four hour and 12-hour trolley waits • Cancer RTT targets.

Accident and Emergency

Patients who spent less than four hours in A&E Accident and Emergency department (A&E) performance is reported at Trust level rather than CCG. For Stoke-on-Trent CCG most A&E patients use UHNM.

University Hospitals of North Midlands NHS Trust (UHNM) has failed to achieve the 95% of patients seen within four hours target, with a year-end position of 83.33%. Overall A&E performance has improved significantly over the past year with performance reaching 90.4% in August 2018. The highest A&E performance recorded for UHNM over the year.

Poor performance is driven by increases in the overall number of people attending hospital, the complexity of conditions that patients attend with and higher than average numbers of delayed transfers of care - meaning that providers have struggled to manage patient flow.

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Significant improvements have been made at UHNM as a ‘system approach’ has been applied including:

• The development of an escalation trigger tool to monitor key system metrics with associated action cards for when a metric exceeds thresholds • The establishment of a new Urgent and Emergency Care (UEC) Programme Board in summer 2018, to replace A&E Delivery Boards at UHNM and the former Burton Hospitals NHS Foundation Trust respectively. This is one board across Staffordshire, including all system partners to discuss UEC Programme and Performance • The development of a UEC Programme dashboard to give high level performance information across all system partners.

The progress was recognised in a letter of commendation from NHS Improvement and NHS England for the strong level of tangible progress. UHNM is highlighted as the fourth most improved in the country and the Urgent Care Escalation meetings were stood down in March 2019, with successful management of winter pressures. See Case Study 1.

Case Study 1:

In January 2019, Staffordshire and Stoke-on-Trent STP received a letter of commendation by NHS Improvement and NHS England for the strong level of tangible progress delivered in 2018/19 in comparison to 2017/18. Some of the achievements are highlighted below:

• Between November 2017 and January 2018, there were 384 12-hour breaches. Between November 2018 and January 2019, there were zero 12-hour breaches.

• Between November 2017 and January 2018, Emergency Department (ED) performance for all types was 73%. Between November 2018 and January 2019, it has been in the region of 82.4% – a 9.4% improvement.

• The system has delivered improvements in the context of a 17% year-on-year increase in front-door demand during December and January.

• UHNM has continued a full elective programme during winter to date, with no cancer patients cancelled.

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• The January follow-up to the CQC System Review of Stoke-on-Trent reported that: “system leaders should be commended on the progress they have made to build relationships and enable more effective communication across the system… CQC’s review found a system that was working together more effectively and improving care for people across Stoke-on-Trent.”

We have continued to work across the health and social care system to ensure patients can access a resilient and responsive urgent care service, including a series of ‘Winter Schemes’ as in previous years. These schemes have focused on reducing avoidable emergency admissions and keeping people well at home. This reduces the need for unexpected hospital admissions and managing the amount of time patients have to stay in hospital once they are there. The focus on the Discharge to Assess (D2A) work programme moves assessment of patients for their ongoing care needs out of acute hospital beds to home or, where required, to a community bed. This leads to better outcomes for patients and increases bed capacity.

Total number of patients who have waited over 12 hours in A&E from decision to admit to admission As with the A&E standard, the number of 12-hour trolley breaches is reported at provider trust level and not by CCG.

At UHNM, 12-hour trolley breaches have also declined dramatically through the year-to- date, from 410 in 2017/18 to three in 2018/19. As mentioned in the previous A&E standard, UHNM have been commended by NHS Improvement and NHS England for the progress in A&E.

An individual clinical review of each 12-hour trolley breach is undertaken to assess the reasons for the breach. The reviews ascertain if there were any detrimental impacts on the patient’s health outcome and any learning which can be applied in future. These reviews are known as a Root Cause Analysis (RCA). The CCG’s Quality Team works closely with the providers, undertaking quality visits to gain further assurance and develop action plans linked to the outcomes of the RCAs.

Referral to Treatment (RTT) within 18 weeks The RTT standard is part of the NHS Constitution and requires that 92% of patients should wait no more than 18 weeks from referral to the start of their treatment; and that no patients should wait over 52 weeks for treatment. RTT continues to be a challenge locally, reflecting the national picture, however progress has been made month-on-month throughout the year. Although Stoke-on-Trent CCG reached 80.63% in 2018/19 and demonstrated an improving trend over the year, it is one of the worst performing CCGs from Staffordshire and Stoke-on- Trent.

UHNM has struggled to meet this standard throughout the year which has led to an increase in waiting time for some patients. There has been an improving trend over the year, with the 2018/19 year-end position of 79.0% compared to 74.2% in April 2018. However, 18-week wait performance is the worst at UHNM out of all of the Staffordshire and Stoke-on-Trent providers.

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A joint investigation with UHNM and the CCG has taken place as part of the contract performance notice on RTT and performance is monitored closely through contract review meetings. The CCG will continue to work with UHNM to understand the actual position (validation). UHNM’s Recovery Plan includes a ‘planned care delivery model’ with a focus on demand and capacity modelling. A range of demand and capacity models have been explored with UHNM, including, the development of a Clinical Assessment Service (CAS) model for gastroenterology.

Stoke-on-Trent CCG has worked in collaboration with the local hospital providers to achieve the national target of zero people waiting over 52 weeks for non-urgent treatment. The CCG has significantly reduced the number of people waiting from 137 (year end 2017/18) to zero in March 2019, with the year-end figure being 254. Most of these breaches occurred during April – October 2018. The majority of these breaches occurred at UHNM in general surgery, urology and trauma and orthopaedics.

The CCG continues to proactively monitor the wait times of patients waiting more than 40 weeks and works directly with providers to ensure that plans are in place to ensure that patients are treated as soon as possible. All 52-week breaches are subject to further assurance sought from the CCG. The CCG also monitors RTT Remedial Action Plans with providers who are underperforming. to ensure assurances are in place to minimise 52-week breaches.

UHNM are undertaking weekly 52-week meetings. These involve each specialty where there has been a patient who has breached the 52-week standard. Patients who have breaches are targeted to treat and discharge as a matter of urgency. Patients waiting more than 40 weeks are also discussed to ensure that they too are treated in a more timely manner.

A detailed Root Cause Analysis is carried out when breaches happen in order to help understand the lessons that can be learned. The RCA is subject to review within our Quality Team and will continue to take place throughout 2019/20.

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Mixed-Sex Accommodation Breaches There is a zero-tolerance for mixed-sex accommodation breaches, defined as the number of occurrences of unjustified mixing in relation to sleeping accommodation.

During 2018/19, Stoke-on-Trent CCG had two mixed-sex accommodation breaches, which is the same number of breaches as last year. This is a very positive achievement compared to other local CCGs. For example, North Staffordshire CCG reported 25 mixed-sex accommodation breaches in 2018/19.

Mixed-sex accommodation breaches are reviewed as part of monthly Clinical Quality Review Meetings (CQRM). All breaches were the result of bed capacity pressures which have impacted on the timely step down of patients from the critical care units. All patients were transferred to wards at the earliest and safest opportunity.

Healthcare-associated infections Healthcare-Associated Infections (HCAI) are a major cause of avoidable patient harm. The CCG has maintained its focus on the reduction of HCAIs, and a robust collaborative approach exists to review cases with established pathways for learning in place.

NHS England has a zero-tolerance policy for Methicillin-Resistant Staphylococcus Aureus (MRSA) infections. There has been one MRSA infection recorded for Stoke-on-Trent CCG in 2018/19. There were 54 Clostridium Difficile (C.difficile) incidents, within the year-end target of 86. In particular, we have undertaken assurance visits to areas where more than one case of C.difficile has been reported.

All cases are subject to a root cause analysis and scrutiny and assurance via the monthly Clinical Quality Review Meetings. The CCG has an infection control lead who works closely with infection control subject matter experts and providers. The lead proactively monitors providers and CCG performance against set trajectories and reviews the outcomes of Root Cause Analyses for our patients.

Diagnostic test waiting times The target for the percentage of patients waiting six weeks or more for a diagnostic test is 99%.

Stoke-on-Trent CCG failed the target with a year-end position of 98.52% YTD with nine months of consecutive underperformance, although there has been some improvement and the provider reports they are on track to achieve the target.

At provider level in March 2019 there were 2/21 breaches at East Cheshire Trust with underperformance in Colonoscopy and Flexi-Sigmoidoscopy. At UHNM, 75/5687 patients breached the target with the main underperformance was in Cytoscopy, Gastroscopy, Flexi- sigmoidoscopy and Respiratory Sleep Studies. This is the result of capacity issues due to annual leave, staff sickness and vacancies resulting in short notice cancellations. There also has not been enough diagnostic equipment to meet demand for sleep studies, however patients are seen and treated by clinical priority.

A variety of initiates are being undertaken to improve the performance. For example, UHNM continue to confirm patients’ attendances to maximise waiting lists and adherence to the Access Policy so that patients that did not attend are not offered another appointment, a complete review of sleep study referrals and criteria.

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East Cheshire Trust’s performance is being monitored regionally and an Action Plan has been agreed with East Cheshire Trust to improve performance.

Cancer targets

In Stoke-on-Trent CCG, of the eight cancer wait targets, the CCG met five at the end of 2018/19 with variable performance throughout the year. Small patient numbers in some of these targets means that performance can fluctuate month-on-month.

The table below highlights each of the cancer standards that Stoke-on-Trent CCG has achieved or failed in 2018/19:

Cancer Standards Year-End position (2018/19) Cancer Two Week Wait (93% target) 95.56%

Breast Symptoms (93% target) 96.54%

31-day first definitive treatment (96% target) 96.82%

31-day subsequent treatment – surgery (94% target) 93.48%

31-day subsequent treatment – drugs (98% target) 99.71%

31-day subsequent treatment – radiotherapy (94% target) 96.04%

62-day standard (85% target) 81.87%

62-day screening (90% target) 88.61%

The majority of these breaches are attributable to UHNM for Stoke-on-Trent CCG and North Staffordshire CCG. The CCGs have worked with core Staffordshire providers to put plans in place to recover performance on the cancer wait standards. Stoke-on-Trent CCG has a Senior Commissioning Manager who leads on Cancer to ensure a Staffordshire-wide approach to improving performance.

UHNM is failing the 62-day standard at Trust level. Colorectal and urology are the most challenged pathways due to an increase in demand (referrals) generally and also capacity issues for robotic surgery. There have been a number of actions undertaken and Cancer Performance improved markedly at UHNM over the first half of the year, however has deteriorated during Q3 and Q4.

Staffordshire and Stoke-on-Trent STP has been awarded a significant amount of funding by the West Midlands Cancer Alliance to transform cancer services. The transformation plans which will run through to March 2020 will support improvements in a number of priority areas. In addition, the six CCGs from Staffordshire and Stoke-on-Trent have been provided with funding by Macmillan Cancer Support to drive improvements in the level of early diagnosis of cancer and in the care and support available to people living with and beyond cancer.

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Ambulance NHS England has introduced new ambulance standards across the country. The changes focus on making sure the best, high quality, more appropriate response is provided for each patient first time.

Ambulance services are measured on the time it takes from receiving a 999 call to a vehicle arriving at the patient’s location. There are four categories. WMAS is consistently meeting the Key Performance Indicators and performing well against National averages.

The Category 1 response target (within 7 minutes) was achieved for Stoke on Trent CCG recording a 06:05 minutes average response time. Stoke-On-Trent CCG and North Staffordshire CCG were the only two Staffordshire CCGs to meet the Category 1 response target at year end. Performance in Categories 2-4 is consistently meeting the target and well below the England average.

The CCG has a number of initiatives and services in place to try to reduce the number of ambulance conveyances. The CCG has a dedicated Urgent Care commissioner who works collaboratively with hospitals and the ambulance service to monitor urgent care performance and to deliver a timely turnaround of ambulances.

Work has been ongoing with the West Midlands Integrated Urgent Care (IUC) Alliance to develop the WMAS specification and contract for 2019/20.

A five-day test of change pilot ran from 28 January to 1 February 2019. An additional seven days were added to the initiative. The pilot was testing the ability to reduced conveyances to Royal Stoke University Hospital by transferring appropriate patients to the community. Early data has shown that 64% of patients who paramedics referred to the admission avoidance line were able to stay at home and remained at home after seven days. This learning is being reflected in the strategic plans.

We are committed to reaching our performance requirements and we will continue to work closely with our service providers to meet national targets throughout 2019/20.

Mental Health Overall the Staffordshire and Stoke-on-Trent CCGs are performing well across mental health standards for 2018/19.

Improving Access to Psychological Therapies (IAPT) All Staffordshire and Stoke-on-Trent CCGs were in the highest performing quartile or interquartile range for the Improving Access to Psychological Therapies (IAPT) Access standard and each CCG performed better than the national average (IAF End of Year Review Q2, 2018/19).

Stoke on Trent CCG did not meet the IAPT Access annual target of 19% achieving 17.26% YTD at February 2019.

Stoke on Trent CCG has met the IAPT Recovery target of 50% and the national average achieving 60.45% YTD at February 2019. SOT CCG was ranked 1st out of 195 CCGs in the country with NS CCG ranked 2nd (IAF End of Year Review Q2, 2018/19).

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Dementia Stoke on Trent CCG has consistently met and exceeded the target for the estimated dementia diagnosis rate during 2018/19 and is the best performing Staffordshire CCG for this standard.

Early Intervention Psychosis The Early Intervention Psychosis standard relates to the number of people experiencing a first episode of psychosis that will be treated with a National Institute of Health and Care Excellence (NICE) approved care package within two weeks of referral. All Staffordshire CCG’s are meeting the required standard of 50%.

Stoke on Trent CCG recorded a vast improvement of 81.9% this reporting period (IAF Quarter 3, February 2019), maintaining its position well above the standard (50%), and above the national average (75.90%).

We are committed to reaching our performance requirements and we will continue to work closely with our service providers to meet national targets throughout 2019/20.

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Performance against key performance indicators

There is no mandated threshold for Cancer 62-day upgrade standard. Therefore, this indicator is not one of the eight national cancer indicators, but is monitored by the CCG for quality.

**New Ambulance Response Programme (ARP) Category Definitions: Category 1 – Immediately life threatening (seven-minute response i.e. mean average national target) and 15-minute 90th percentile measurement).

Accident and Emergency Provider Performance

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The CCG’s position at the end of the financial year Financial Performance Targets

CCGs have a number of financial duties under the NHS Act 2006. NHS England, in exercise of powers conferred on it by Section 223l of the Act, directs that the revenue resource use shall not exceed £448.6m

The CCG is almost entirely funded by a central allocation by NHS England based upon a weighted capitation funding formula which adjusts funding per head of population registered with our GP practices to reflect local age and need profiles. The funding formula establishes a target level of funding.

In 2017/2018, the CCG’s actual allocated core funding baseline was £386.7m, which was 1.51% below the target level of funding. Despite this, the CCG received a marginally below national average uplift in growth funding allocated to the CCG in 2018/2019 of £10.9m (2.83%). However, this partially reduced the shortfall from the published target, which was also increased to reflect changes in the population and cost inflation. Consequently, in 2018/2019 the CCG’s funding allocation shortfall was reduced to 1.24% which would mean that in the coming years, the CCG should expect circa £5.0m of real funding growth.

The CCG also receives a separate allocation for Primary Care Co-Commissioning, bringing in an additional ring-fenced recurrent allocation of £39.6m. We also receive a separate financial allocation to spend on Running Costs (e.g. directly employing staff, running the CCG and buying support services). Our allocation was £5.995m, which equates to £20.25 per head of CCG population.

Our performance against 2018/19 2018/19 Duty 2017/18 2017/18 Notes the financial duties: Target Actual Achieved Target Actual Expenditure not to exceed 450,037 479,582 437,328 436,733 income No Capital resource use does not exceed the amount set 0 0 Yes 0 199 out in Directions Revenue resource use does not exceed the amount set 448,577 478,123 No 436,229 435,634 out in Directions Capital resource use on specified matters does not 0 0 Yes 0 0 exceed the amount set out in Directions Revenue resource use on specified matters does not 0 0 Yes 0 0 exceed the amount set out in Directions Revenue administration resource use does not 5,995 5,616 Yes 5,986 5,152 exceed the amount set out in Directions

The financial rules set by NHS England for CCGs dictate that CCGs must not overspend their total revenue resource allocation. To do so constitutes a breach of statutory duties under the Health & Social Care Act 2012. The CCG is reporting a cumulative deficit position

22 of £31.4m, (£29.5m in-year deficit) which is an adverse variance of £35.3m against the financial plans approved by NHS England for 2018/19.

We can use any underspend on our running costs allocation to fund expenditure on healthcare. However, the CCG cannot use any underspend on its healthcare allocation to fund any overspend on running costs.

The table below summarises our performance against our allocation at the end of the 2018/19 financial year. This reflects the financial position reported in the CCG’s Annual Accounts, although the table below is broken down over the CCG’s main contract areas in the format reported to the CCG’s Governing Body.

Stoke on Trent CCG Annual Budget Outturn Variance Finance Report

Month 12 (1st April 2018 - 31st £,000 £,000 £,000 March 2019)

Revenue Resource Allocation 448,577 448,577

Expenditure

Mental Health 50,452 59,847 9,395

Acute 187,583 202,851 15,268

Primary Care (incl. Co- 100,964 99,965 -999 Commissioning)

Continuing Care & FNC 26,804 31,145 4,341

Community 66,802 74,776 7,974

Other 5,113 3,922 -1,190

Total HCHS 437,717 472,507 34,790

Corporate / Running Costs 5,060 5,616 556

Total Expenditure 442,777 478,123 35,346

Total (Surplus)/Deficit Reported -5,800 29,546 35,346

The most significant financial risk arising in-year for the CCG was the growing demand for services which are remunerated largely on a cost per episode of treatment basis. This pressure largely relates to the acute hospital sector where activity greater than planned levels, partly due to increases in waiting list backlogs in certain hospital specialties and some shortfalls in the delivery of QIPP schemes.

In addition, the CCG experienced significant overspends in community, mental health and continuing care programmes which reflect a deliberate investment in capacity to alleviate the pressures in the acute hospital sector concerning delayed transfers of care.

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Our plans for 2019/20 show an in-year £22.0m deficit position against a £16.0m deficit control total. If the plan is achieved, the CCG will deliver a £32.2m cumulative deficit. This means that the CCG will not be able to meet its statutory responsibility to not exceed its Revenue Resource Limit. Whilst the plan does ensure that the NHS England’s business rule to establish a 0.5% contingency for unexpected pressures is met, the pressure on CCG resources means that the CCG is not planning to comply with the business rule to achieve the Mental Health Investment Standard.

Therefore, 2019/20 will clearly be a very challenging year. In addition to ensuring that NHS Constitutional Standards are met, the CCG will need to achieve an overall 2.7% QIPP savings target in order to deliver the Plan.

Financial Plans for 2019/20 were formally approved by the 17 April 2019 Governing Body and can be obtained from the Governing Body section of our website: https://www.stokeccg.nhs.uk/your-ccg-stoke/board-meetings

We recognise our responsibility to live within our allocated resources and are resolved to drive an innovative programme of quality and value improvements to ensure sustainable high quality services for our population, working with partners to maximise impact and success across the whole of Staffordshire. Further details about our Financial Performance Duties (under the NHS Act 2006, as amended) are included in the Accounts.

In terms of our performance in managing our principal areas of risk, the Governance Statement section describes in greater detail our approved policy for this. However, a brief overview of the major risks we faced in 2018/19 that might have significantly affected our performance or our organisational development are as follows:

• Delivering all of our challenging strategic objectives within the finite resources available to us • Ensuring that the CCG, our Local Health Economy (LHE) and our stakeholders all have the capacity to change behaviours in ways we hope will transform services locally • Unexpected delays in delivering these transformational changes (e.g. taking longer than planned to embed new ways of working and operating cultures) • Ensuring that we / our partners have the capacity to deliver the transformational change, including working co-productively to share these risks wherever feasible • The medium to longer-term financial sustainability of the CCG and the LHE, including cost containment to live within our finite resources

The Better Care Fund (BCF)

The Better Care Fund (BCF) and the Improved Better Care Fund (iBCF) have been established by Government to provide funds to local areas to support integration of Health and Social Care, and to seek to achieve the national conditions / local objectives. It is a requirement of the BCF that CCGs and the Council establish a Pooled Fund for this. Section 75 of the 2006 Act gives powers to Local Authorities and CCGs to establish and maintain Pooled Funds, out of which payment may be made towards expenditure incurred in the exercise of prescribed in the exercise of prescribed Local Authority and NHS functions. The aims and benefits of the partners in entering into this agreement are to:

• Improve the quality and efficiency of services for service users • Meet the national conditions and local objectives

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• Make more efficient use of resources through the establishment and maintenance of a pooled fund for revenue expenditure on the services

The following principles were agreed by the Staffordshire Health and Well-Being Board:

• The BCF must support the priorities in the Joint Health & Wellbeing Strategy as well as align with the CCG’s and the Council’s BCF plans, NHS England’s operational plan, the council’s strategic plans and District / Borough strategic plans where relevant • Application of the BCF should be based on clear evidence including cost / benefit analysis of funding early intervention and prevention services to achieve greater long-term sustainability and reduce pressure on acute / specialist services • Services should be encouraged through the BCF to work in different and innovative ways, rather than simply creating new services as the Pooled Funds itself is bringing together resources already committed to existing core activity • “Do no harm”: i.e. the use of the BCF should add value and not impact adversely on core budgets

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Sustainable Development As an NHS organisation, spending public funds, we have an obligation to work in a way that has a positive effect on the communities for which we commission and procure healthcare services. Sustainability means spending public money well, the smart and efficient use of natural resources and building healthy, resilient communities. By making the most of social, environmental and economic assets we can improve health both in the immediate and long term even in the context of rising cost of natural resources.

The CCG continues to demonstrate a commitment to actively promote environmental and social sustainability through our actions as a corporate body as well as a commissioner. The CCG recognises that everything it does has an impact on the environment, which in turn affects people’s health and wellbeing.

As six CCGs in Staffordshire and Stoke-on-Trent are working together to make the most efficient use of our resources, including the estate. Our headquarters is located at Staffordshire Place in Stafford with offices in Edwin House, Burton, and Smithfield One in Hanley; and smaller satellite offices in Codsall, Tamworth and Cannock. Staff are encouraged to work flexibly from any of our sites to reduce travel and make best use of the available meeting spaces.

All of our offices are situated in purpose-built office blocks, designed to high environmental standards to reduce the CCGs’ carbon footprint. Staffordshire Place includes a range of features to maximise natural lighting and minimise heat loss, including lights automatically switching off in areas where there is no movement and atmosphere control to deliver a 3% reduction in carbon dioxide emissions per annum. Smithfield One has been built to a Building Research Establishment Environmental Assessment Method ‘Excellent’ standard. Energy consumption, water consumption and waste are all monitored and the Energy Performance Certificate for the building shows the building performing at a ‘B’ Standard.

All of our sites operate:

• Resource Efficiency Management Systems – in terms of waste, water, energy, fuel and paper by ensuring that these resources are used efficiently • Travel and Transport schemes – to reduce the burden of rising fuel costs by actively targeting travel /transport with schemes such: as car-sharing; encouraging the use of more sustainable modes of transport; supporting the increased use of tele- conferencing; and improving access to mobile IT devices to achieve “paper-light” or paperless working wherever possible • Waste Management – improving recycling rates and minimising confidential shredding • Procurement and Supply Chain Management – ensuring that procured / commissioned goods and services are as energy-efficient as possible and seek to reduce carbon emissions (included within the CCG’s Procurement Strategy); including the use of contractual provisions to ensure that providers adopt sustainable business practices and implement the carbon reduction strategy • Managing System Risk – taking a whole-systems approach to our commissioning work and actively looking to manage future risks • Staff Training and Attitudes - actively engaging our staff in delivering our Sustainable Development Plan objectives • QIPP and Transformation Work – designing and implementing schemes that support the delivery of good quality healthcare, delivered at the right time and in the

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right place to the right person to help reduce the use of resources, carbon and improve sustainability.

Events such as heatwaves, cold snaps and flooding are expected to increase as a result of climate change. To ensure that the CCG will continue to meet the needs of our local population during such events, we have developed and implemented a number of policies and protocols in partnership with other local agencies, included within our Business Continuity and Emergency Resilience Response Plans.

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Discharge of statutory duties The CCG has a number of statutory duties under section 14Z15(2)(a) of the Health and Social Care Act 2012 and section 116B(1)(b) of the Local Government and Public Involvement in Health Act relating to:

• Improving the quality of services (Duty 14R) • Reducing inequalities (Duty 14T) • Public involvement and consultation (Duty 14Z2) • Contributing to the delivery of any joint health and wellbeing strategy • Section 116B(1)(b) of the Local Government and Public Involvement in Health Act 2007

The CCG also has a number of statutory duties relating to Safeguarding Adults and Children which are as follows:

• The Children Act 1989 • The Children Act 2004 • Adoption and Children Act 2002 • The Care Act 2014 • Working Together to Safeguard Children 2018

The following sections of this report focus on quality, partnerships and public and patient involvement, and explain how the CCG has discharged its statutory duties in these areas during 2018/19.

The CCG certifies that we have complied with the statutory duties laid down in the National Health Service Act 2006, as amended by the Health and Social Care Act 2012.

Maintaining and improving the quality and safety of services

When the CCG began working with the other five CCGs in Staffordshire and Stoke-on-Trent as a single strategic commissioning organisation, the Joint Quality Committees in both the North and South of the county joined. They came together to create the newly formed Staffordshire and Stoke-on-Trent CCGs Quality and Safety Committees in Common (QSCC).

Quality is everyone’s business and the patient journey today often involves multiple providers. It’s therefore important that all organisations and individuals involved have strong relationships and work together in a systematic way to understand the patients’ needs and ensure that care is safe, effective and provides a positive experience. Therefore, it is only when all strands of quality come together that high quality care is achieved. We have well- established working relationships and we will continue to work proactively with our main providers via clinical quality review meetings, to ensure that our vision for quality patient care is delivered.

The CCG is committed to continually work with all providers as we move into 2019/20, as they aspire to achieve the high levels of quality and safety of care provided for our local population and external regulators. The CCG recognises the importance of working together to achieve the best health and wellbeing outcomes for the people of Staffordshire and Stoke- on-Trent, building on the progress and work currently being undertaken.

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General quality improvement The CCG has much to celebrate however, we recognise the need to continuously strive to work with our providers to systematically embed quality improvement methodology for the benefit of patients. The main providers of healthcare services across Staffordshire and Stoke-on-Trent consist of the following:

• University Hospital of North Midlands NHS Trust (UHNM) • North Staffordshire Combined HealthCare NHS Trust (NSCHT) • University Hospital of Derby and Burton NHS Foundation Trust (UHDB) • Midland Partnership NHS Foundation Trust (MPFT) • Virgin Care Service Limited (VCSL) • Vocare - NHS 111 • Vocare - Stafford Doctors Urgent Care Limited

The CCG’s Quality Team has identified the following quality improvements with our main providers throughout 2018/19.

Please note, all Patient Led Assessments of Care Environment (PLACE) scores for providers, which the CCG commissions services, can be found at the following: https://digital.nhs.uk/data-and-information/publications/statistical/patient-led-assessments-of- the-care-environment-place/2018---england

UHNM The target set by NHS England for Trust acquired Clostridium difficile cases for 2018/19 was 81. The Trust reported a total of 56 cases, which is a 21% reduction on the previous year 2017/18.

The Trust is participating in a national CQUIN for sepsis care. The Trust’s Sepsis team have raised awareness around sepsis, educating staff, promoting optimal treatment and auditing results. The Trust’s Sepsis team has rolled out sepsis screening and treatment education to all clinical areas.

During December 2018, clinical inpatient areas have achieved 92.5% for sepsis screening and 75% for antibiotics within an hour, whilst emergency portals have achieved 99.1% and 97.6% respectively, which is a major achievement for the Trust and patients. The Trust is continuing to sustain this progress and is working towards improving these targets to greater than 90%.

The annual PLACE inspections are compulsory for every NHS organisation and site. The Trust achieved above the national average for each of the domains inspected as a Trust overall and for each site respectively. Of particular note is the 100% cleaning score achieved at the County Hospital site.

NSCHT The Trust achieved PLACE scores well above the national average in all domains inspected for Mental Health and Learning Disabilities across all Trust sites. The Trust also achieved the annual national staff flu vaccination target.

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UHDB The Trust was newly formed on the 1 July 2018, bringing together the depth of experience in their five hospitals in Derby, Burton, Lichfield and Tamworth to provide the highest quality of care to patients across southern Derbyshire and south east Staffordshire.

Throughout this time, the CCGs in Staffordshire and Trust have worked closely together to establish relationships and embed quality assurance monitoring processes. Clinicians from the Trust have presented at CQRM to support areas of discussion which has provided additional assurances. Areas include: Emergency Department, Maternity, Oncology and Ophthalmology.

In July 2018, the Trust’s follow up backlog in Ophthalmology was growing and a quality assurance visit was undertaken by the Trust and CCGs. Since the visit, the Trust and CCGs have worked closely together throughout 2018/19, and as a result the Trust has implemented a number of actions to reduce the backlog which includes:

• Additional clinics • Virtual clinics for glaucoma patients • New harm review process • Training of nurses and orthoptists to assist with the backlog and a new locum consultant.

These actions have seen a significant reduction in the ophthalmology backlog. Furthermore, the visit identified a need for a Glaucoma Referral Refinement Service (GRR), which the CCGs agreed to commission in October 2018. The Trust agreed that a GRR service would reduce demand in Ophthalmology and thereby increase clinical capacity within the department which could be focussed on reducing the Ophthalmology backlog.

MPFT MPFT was formed on 1 June 2018, following a merger between South Staffordshire and Shropshire Healthcare NHS Foundation Trust (SSSFT) and Staffordshire and Stoke-on- Trent Partnership NHS Trust (SSOTP). The CCGs in Staffordshire and Trust have worked closely together since the merger to re-align quality assurance monitoring processes. The CCG has received various presentations from the Trusts clinical care groups and clinical care directorates to provide assurance of how quality and patient safety will be monitored by the newly formed organisation.

Prior to the merger of SSOTP and SSSFT, the CQC re-inspected the two service areas of SSOTP previously rated as ‘Inadequate’ - which consisted of the Community Health Services for Adults and End of Life (EOL) Care. The reports were published by the CQC on 2 July 2018 and both service areas achieved a rating of ‘good’ for each of the five domains (Safe, Effective, Caring, Responsive and Well Led); resulting in both services being rated as ‘good’ overall. The CQC identified the District Nursing Caseload Review Tool, Wellbeing Cafes and implementation of the Home First Model as areas of good practice.

Suicide Prevention Strategy The CCG is an active member of the Staffordshire and Stoke-on-Trent Suicide Prevention Strategy, which has included the development of an action plan for the area. Suicide prevention training is being provided for primary care and a number of frontline services, and draft guidance is being produced for the development/construction industry to address

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suicide risks in public buildings. In November 2018, a Staffordshire and Stoke-on-Trent Suicide Conference was attended by over 300 delegates bringing together a whole range of experts, service users, clinicians and others from across Staffordshire and Stoke-on-Trent to share perspectives and knowledge.

The most impactful part of the day was the sharing of personal stories from service users and carers, to aid reflection about the personal and emotional consequences of suicide and what could be done better as both organisations and the wider community. The CCG joined other local organisations in signing of the Staffordshire and Stoke-on-Trent Suicide Charter which exemplifies the collaborative way Staffordshire and Stoke-on-Trent are working together to ensure the ambition of zero suicides is realised in the area. Building on the developments made across England to improve the quality of physical health care for people with serious mental in primary care the CCG has provided support to improve communications between primary and secondary care to further alignment and collaboration of services. A CCG workshop was undertaken to build positive relationships between mental health and primary care clinicians and improve patient wellbeing, reduce duplication and design flexible services around local population need. Work is continuing with an aim of mental health reviews to become normal practice mirroring that of physical health reviews, which will be delivered together in local GP practices, closer to home and in familiar surroundings for patients ensuring continuity of care.

Quality Visits The CCG’s Quality Team has undertaken a range of announced, unannounced, responsive and planned visits to our main providers and nursing homes in collaboration with local partners such as the local authority, Healthwatch Staffordshire and Healthwatch Stoke-on- Trent. These visits focused on quality assurance, infection control and winter bed capacity, enabling the visiting team to capture the views of our patients, staff and carers. As part of our quality assurance and quality improvement process the CCG’s Quality Team agreed to attend the provider internal assurance meetings to ensure robust scrutiny and the appropriate learning and actions are embedded to drive quality improvement and ensure patient safety. These internal meetings include: harm reviews, pressure ulcers, falls, 12-hour wait breaches and NHS Constitution breach panels e.g. 52 weeks.

The CCG’s Quality Team has undertaken quality visits to NSCHT services jointly with the Trust, Healthwatch Staffordshire and Healthwatch Stoke-on-Trent. The Trust received a further CQC inspection in October 2017 with an overall rating of ‘good’ with some services rated outstanding.

The CCG’s Quality Team has joined many of the UHNM’s internal quality visit including scheduled safety focused visits to the Emergency Department (ED) areas throughout the winter period. Whilst the Urgent Care System is in a better position than last year, the CCG’s Quality Team continues with regulators (NHS England/NHS Improvement) and the Trust to visit the ED throughout the winter period to monitor quality and safety.

During April 2018, Vocare’s Urgent Care Centre (UCC) located at UHNM received a CQC inspection where quality and safety improvements were identified. The CCG’s Quality Team worked closely with the provider of the service and UHNM to address the quality concerns raised and ensure robust pathways and processes were established. A subsequent report, following an inspection in September 2018, published an overall rating of ‘good’ for the

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service with each key line of enquiry rated as ‘good’ which demonstrated the positive collaborative working between partners to improve services for patients.

The CCG’s Quality Team has also undertaken a range of quality assurance visits to UHDB, VCSL and associate providers. These visits have been undertaking in collaboration with CQC, Healthwatch and the relevant CCGs. These visits primarily focus on quality and safety assurance, infection control, patient, staff and carers experience.

Delivery of the Quality Strategy The CCG has been working to their existing Quality Strategies since March 2018. A review is being undertaken to produce a combined Quality and Safety Strategy that will be applicable to all six CCGs in Staffordshire and Stoke-on-Trent, aligning the core values, priorities and commissioning intentions as a single Strategic Commissioning Organisation.

The CCGs’ Quality and Safety Strategy will include the quality priorities included within the ‘The NHS Long Term Plan’ - www.longtermplan.nhs.uk - published in January 2019. The progress against the delivery of the newly formed strategy will be reported to the Quality and Safety Committees in Common.

During 2018/19, the CCG’s Quality Team has continued to support the delivery of the existing operational plans and provide regular updates with regards to such areas as: Clinical Quality Review Meetings (CQRMs), Maternity Transformation, Safeguarding, Transforming Care Programme for People with Learning Disabilities and Special Educational Needs and Disability. In preparation for the operational plan for 2019/20, the Quality Team has reviewed and aligned all the actions to ensure that they are clear, coherent and support the CCG priorities. An aligned quality strategy will be the focus for 2019/20 and beyond, which will pull together a clear plan for quality over the coming years and in line with the vision in The NHS Long Term Plan.

During 2018/19, a “Learning from Experience” report was introduced and presented quarterly to the Quality and Safety Committees in Common. The report focuses on the most frequently reported harms experienced by patients using the services from our main providers. The CCG seeks assurance with regard to serious incidents and work with our providers to support and ensure learning, appropriate actions and improvements. The report focuses on a different harm each quarter and the impact it has on patients and their family’s wellbeing, considering the national and local context and best practice providing both a qualitative and quantitative view.

The Director of Clinical Commissioning and Service Development/Executive Nurse for West Midlands Ambulance Service NHS Foundation Trust (WMAS) attended the QSCC in December 2018. They provided a presentation on the Quality Improvement currently being undertaken by the Trust, including pilots of joint working with General Practice, WMAS becoming a Teaching Trust and other quality initiatives. Assurance was provided to members of the QSCC in relation to quality issues previously raised at the previous meetings regarding conveyancing.

The CCG has aligned the individual Serious Incident Reporting processes during 2018/19, including: centralising reporting; aligning paperwork; working to a single process; futureproofing the Serious Incident processes for identification, reporting, investigation and learning themes against the anticipated changes to the Serious Incident National Framework in April 2019. This has included reviewing the process of reporting serious incidents for

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General Practice, Care Homes and small providers. In readiness for the National Serious incident Framework changes, the Quality Team has attended a number of events organised by the Healthcare Safety Investigation Branch, NHS England and Health Education England.

NHS Improvement published in June 2018, a Pressure Ulcers revised definition and measurement (Summary and Recommendations). The Quality Team has liaised with all providers they commission with to seek assurance that the providers are working to implement the new Pressure Ulcer guidance. This is monitored by the Quality Team at the provider Clinical Quality Review Meeting (CQRM). The Pressure Ulcers revised definition and measurement (Summary and Recommendations) can be found here: https://improvement.nhs.uk/documents/2932/NSTPP_summary__recommendations_2.pdf

A key strand of the Quality Strategy delivery plan has been to work with local education providers to support the nursing workforce of the future. In June 2017, we welcomed the first student nurse placements from Keele University. The week-long placement allows the students the opportunity to understand and consider the essential roles of the CCG and how we all work together, to best meet the healthcare requirements of the local population. Subsequent students nurse placements to the CCGs in Staffordshire were in May and July 2018. with more students requesting nursing placements in 2019.

The CCG’s Director of Nursing and Quality is working closely with Staffordshire University on many aspects of the quality and patient safety agenda, to develop a patient safety briefing. She was awarded a Visiting Fellowship by Staffordshire University with effect from 6 March 2019 and for a period of three years.

Subsequently, a learning event is planned for early summer 2019, which she will present the learning from local quality and safety experiences. The Director of Nursing and Quality and the University Dean for the School of Health will be working together to explore emerging workforce needs, linked to key working programmes such as the Maternity Transformation Programme.

The Director of Nursing and Quality is also currently exploring the development of further student nurse work placements within the CCG and with the associated organisations. They have also been invited to participate in events when the School of Nursing from the University of Alabama will visit Staffordshire University in early May 2019. It is expected that further joint working between the CCGs in Staffordshire and University will stem from this visit.

Additional members of the Quality Team have recently met with Staffordshire University to discuss students engaging in practice learning experiences. Within those discussions we explored the potential of a more strategic and collaboratively approach to student learning in practice across the CCG and universities. Particularly, given the wealth and diversity of practice learning experiences, the potential to share good practice and explore a more strategic approach to learning on practice including publication/research opportunities. Students have a quality learning experience within their CCG placements; this is acknowledged by the very positive evaluations the CCG receives and the personal feedback from students. The CCG’s Strategic Improvement Lead for Nursing and Patient Care regularly delivers nursing lectures at Keele University throughout the year to district nursing students and Student Nurses (Adults) on the subject of nursing and quality working in the CCG. The following positive feedback was received from nurse students following completion of their CCGs work placement:

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“At meetings I observed the CCG Quality staff advocating for patients and wanting reassurance about their patients, their care and the prevention of harm.”

“I understood the role that quality plays in the clinical effectiveness of care a patient receives.”

“CCG staff viewpoints differed at times but ultimately they demonstrated that patient care is at the heart of the work undertaken.”

Leading Change Adding Value Professor Jane Cummings, former Chief Nursing Officer for England launched a five-year framework for nursing, midwifery and care staff entitled ‘Leading Change, Adding Value’ (LCAV) in 2016. The framework highlighted the contribution and leadership that nursing, midwifery and care staff make to delivering the Five Year Forward View (5YFV) and other national transformation programmes. Aligned to the vision of the 5YFV, the aim of LCAV is to integrate health and social care services, improve the adoption of preventative measures and narrow three crucial gaps referred to as the ‘Triple Aim’ in:

• Health and wellbeing: A greater focus on prevention is needed to enable health improvements to continue and to counter pressure on services • Care and quality: Health needs will go unmet unless we reshape care, harness technology and address variations in quality and safety • Funding and efficiency: Without efficiencies, a shortage of resources will hinder care services and progress.

Work undertaken as part of the LCAV framework by the six CCGs across Staffordshire and Stoke-on-Trent continue to be instrumental in leading quality improvement which aligns to both the ethos of LCAV and also the CCG’s Quality Strategy. There are examples of pilots that have been undertaken and have proved positive in evaluation and have been endorsed by both Health Education England and NHS England and continue to be promoted at national level as innovative and best practice programme areas. Examples include:

• The North Staffordshire and Stoke-on-Trent General Practice Nurse (GPN) Evidence-Based Practice (EBP) group - formed in June 2015, to identify areas of uncertainty and clinical variation in day to day practice that impacts on patient care and to develop the EBP awareness and skills of the workforce. The nurses are supported by clinical academics at Keele University’s Research Institute for Primary Care and Health Sciences and together the group identifies, appraises and uses best available evidence to influence practice at the point of care through the exploration of critically appraised topics (CATs). More information can be found on https://www.keele.ac.uk/ebp/multidisciplinarygroups/practicenursegroup/

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This website demonstrates the reach the group has at national level through conferences, publications and poster presentations. The group was also a finalist at the General Practice Nursing Awards (2017) in the ‘Innovators of the Year’ category.

• Technology Enabled Care (TEC) - the CCG has been heralded as innovators in digital solutions that enable patient self-care and shared care approaches to be used to support patients with varying levels of digital proficiency. With this background credibility, NHS England funded a pilot project across the Staffordshire STP area progressing TEC across General Practice Nursing and District Nursing, developing confidence, capability and capacity for delivery of technology enabled care.

The pilot focussed on supporting nurses to become proficient in digital technology through nurse education and mentorship, to ensure that nurses have the confidence and capability to deliver healthcare that supports national priorities. The six-month programme commenced in March 2018 and promoted the development of practice nurses to become digital nurse champions.

• Quality Outcomes Framework 2017/18 data – this shows unwarranted clinical variation for all long-term conditions across the county that is not explained by deprivation. The pilot was successful and is now a blueprint that is being rolled out at national level. The LCAV Case Study Template will be available on the LCAV Atlas of learning, National Research Portfolio and e-Learning Tool (LCAV) below. https://www.england.nhs.uk/leadingchange/atlas-of-shared-learning/

The pilot has generated several published articles featured in a wide range of nursing journals as well as the British Medical Journal, including an article co-authored by the CCG’s Executive Director of Nursing and Quality, Strategic Improvement Lead for Nursing and Patient Care and Clinical Quality Improvement Manager – called ‘The role of technology-enabled care in high-quality patient care’.

• National events - the CCG’s Quality Team has been asked to support ongoing national events to mark the formal ending of the co-implementation approach of LCAV. This is to demonstrate the contribution that nursing, midwifery and care staff can make to the ongoing transformation of the health and care system and their key contribution to delivering the NHS Long Term Plan. These events will support an aim of Leading Change, Adding Value becoming business as usual and way of practice beyond March 2019

Patient Feedback The Quality Team understands how fundamental patient feedback is to the monitoring and influencing of high quality and safe patient care that the CCG commissions. The patient voice/stories have the potential to identify any gaps and/or best practice in the quality of services commissioned. The patient feedback received by the QSCC is evaluated and triangulated which informs CCG quality visits to providers or quality improvement work that is required to be undertaken between the CCGs and providers.

The Quality Team gathers patient feedback from a variety of sources, some examples include:

• Feedback from patients group meetings • Patient Experience Report

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• Healthwatch and Soft Intelligence Reports Datix soft intelligence reporting • CCG Quality Visits • Joint CCG/provider collaborative working • GP 60 second reporting • Maternity Voices Partnership

Patient feedback is communicated via the lay members’ representatives at the Quality and Safety Committees in Common and if any patient quality/safety issues are identified they are reviewed at the QSCC. Patient stories and feedback are also discussed at the Quality and Safety Committee in Common, which also receives patient engagement and experience reports.

Patient Experience Report The QSCC receive a quarterly Patient Experience Report which includes an overview of the key themes and trends of patient feedback received in relation to all providers. The report also includes an overview of actions taken by providers in response to the patient/public complaints - also incorporating Members of Parliament Letters, Patient Advice and Liaison Service and complaints received directly by the CCG.

Soft Intelligence Monitoring soft intelligence allows patients, the public and healthcare professionals to provide their feedback to CCGs regarding healthcare services within their local area. Soft intelligence is triangulated with other forms of quality data to inform the Quality Team of any areas of quality and safety and/or good practice which require further attention. The Quality Team has been successful in aligning the General Practice Event Reporting processes across Staffordshire and Stoke-on-Trent during 2018/19. Soft intelligence is reported on Datix and reviewed regularly to identify any themes, trends and potential serious incidents and never events. The CCG has developed a Datix Monitoring Group covering Northern and Southern Staffordshire. The aim of the group is to improve patient care and safety and has representation from General Practitioners, members of Medicines Optimisation and the Primary Care Teams, patient representatives, members of the Nursing and Quality Team and lay members. The groups meet on a monthly basis and provide robust governance and assurance.

Learning Disabilities Mortality Review (LeDeR) LeDeR is being delivered in local areas across the country by CCGs, on behalf of NHS England. The programme is supported nationally by Bristol University. LeDeR aims to drive the following:

• Improve the quality of health and social care service delivery for people with learning disabilities • Reduce premature mortality and health inequalities • Influence practice at individual, operational and strategic levels.

In order to achieve these aims the programme undertakes a review of all deaths involving individuals with learning disabilities aged four years and over. The reviews seek to identify the potential avoidable factors that may have contributed to the death. The learning from reviews is collated and used to guide improvements in health and social care services.

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In Staffordshire and Stoke-on-Trent, LeDeR has been active since October 2017 and the local LeDeR Steering Group meets on a regular basis. The Group membership includes: representatives from all local health and social care organisations, voluntary sector organisations and representatives of individuals with Learning Disabilities. The Group has been instrumental in developing and supporting the delivery of LeDeR in Staffordshire and Stoke-on-Trent.

The national LeDeR Annual Report was published in May 2018 and includes a number of recommendations to address premature mortality for individuals with Learning Disabilities. The Group is also working to implement actions to address recommendations from the LeDeR Annual Report, including learning that has been identified following completed local reviews. The focus of the group moving into 2019/20 is to analyse local context and develop effective actions.

Special Educational Needs and Disabilities (SEND) SEND applies to all children and young people in education and training with special educational needs and disabilities from age 0-25 years. The support received by a child or young person with a learning disability will vary significantly depending on their needs. It may involve a range of professionals across the education, health and social care systems. The CCG’s Director of Nursing and Quality has overall responsibility for SEND at Governing Board level. Designated Clinical Officers (DCO) work collaboratively on behalf of the six CCGs in Staffordshire and Stoke-on-Trent with partner organisations and health provider services.

Section 26 Children and Families Act 2014, outlines that Local authorities and CCGs must make joint commissioning arrangements for education, health and care provision for children and young people with SEND or disabilities. Joint commissioning should be informed by a clear assessment of local need; forming part of the Joint Strategic Needs Assessments to support prevention, identification, assessment and early intervention and collaborative working between all partner organisations.

The NHS Mandate outlines that CCGs must follow a specific objective on supporting children and young people with SEND. Joint commissioning arrangements should enable partners to make best use of all the resources available in an area to improve outcomes for children and young people in the most efficient, effective, equitable and sustainable way. Partners must agree how they will work together. They should aim to provide personalised, integrated support that delivers positive outcomes for children and young people - bringing together support across education, health and social care from early childhood through to adult life; and improving planning for transition points such as between early years, school and college, between children’s and adult social care services, or between paediatric and adult health services. The Children Young People and Families Commissioning Group has been re-established to bring together senior managers from across the city council, CCGs, NHS England and external partners that commission or manage internally provided services for children, young people and their families. The purpose of the re-established Commissioning Group is as follows:

• Develop a strategic approach across services for children and young people • Share best practice • Optimise opportunities to improve outcomes by creating innovative solutions

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• Ensure commissioned services include early identification, prevention and intervention approaches ensuring children have the best start in life. • Promote the development of an integrated and streamlined approach to the commissioning of services for children and young people; this includes health and social care, prevention and treatment.

Infection Prevention and Control In 2018/19, the CCG has seen a continuation of improvements made to reduce the number of avoidable healthcare associated infections (HCAI). These improvements have been achieved by collaboratively working with the other five CCGs in Staffordshire and Stoke-on- Trent and local providers to ensure that lessons learned from HCAI cases in previous years are disseminated across the health economy and embedded in clinical practice by implementation of action plans. The Quality Improvement Manager supports their provider organisations and receives regular updates at the Clinical Quality Review (CQRM). NHS England’s national ambition is to reduce healthcare associated Gram-negative Blood Stream Infections (GNBSIs). The aim of the CCG is to reduce the number of gram negative blood stream infections, with a focus on E.coli blood stream infections, across the Staffordshire and Stoke-on-Trent Health Economy by 50% by 2021. The CCG has been working with all Staffordshire and Stoke-on-Trent providers to improve and refresh the system-wide action plan which sits across the whole health and social care sector to contribute to this ambition.

Quality Impact Assessment (QIA) The CCG is committed to ensuring that any service change, both temporary and permanent, is evaluated for its impact on the quality of care provided for patients. The Quality Team has produced a single QIA Policy across the six CCGs Staffordshire and Stoke-on-Trent, with a single QIA sub-group including representation from the Medical Director, lay members of the Governing Bodies and members of the Quality Team to ensure quality remains at the heart of any proposal for service change.

The QIA sub-groups role is to scrutinise the commissioning activity and challenge decision making, so that those carrying out change ensure that quality is not compromised beyond safe and effective levels and prevent or minimise consequences for the patients that the CCGs serve. QIA sub-groups have been held regularly throughout 2018/19, with outcomes and monitoring of the quality impacts of schemes reported to Quality and Safety Committees in Common on a quarterly basis. A QIA template pilot was undertaken in 2018/19 to align the various QIA documents into a single, easy to use template. Further development of the QIA process is in line with the development of the Quality Innovation Productivity and Prevention process to ensure that processes are streamlined, efficient and timely.

Maternity Transformation Programme (MTP) The CCG, along with the other five CCGs in Staffordshire and Stoke-on-Trent, are actively supporting the implementation of the recommendations within the National Maternity Review, Better Births and The Saving Babies Lives Care Bundle.

The CCGs successfully launched the Staffordshire and Stoke-on-Trent Maternity Transformation Programme with members including: the local authority, NHS providers, NHS England and women who use the services.

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The Staffordshire and Stoke-on-Trent MTP have developed a Transformation Plan for the Local Maternity System (LMS), which is an integral part of a workstream of the Sustainability and Transformation Programme (STP). A benchmarking exercise was undertaken as part of the development of the Transformation Plan to determine where Staffordshire and Stoke-on- Trent are against the recommendations of Better Births. Further stakeholder engagement events have been held to ensure that the work of the Staffordshire and Stoke-on-Trent MTP reflected not only the recommendations within Better Births, but also the expectations of all stakeholders across Staffordshire and Stoke-on-Trent.

The Transformation Plan outlines a significant programme of work and sets out a number of improvements to be made in the five years since the publication of Better Births and Saving Babies Lives and five workstreams have been established as follows:

• Staffordshire and Stoke-on-Trent Maternity and Newborn Quality and Safety Network - this workstream aims to reduce stillbirths, neonatal deaths and focus on clinical safety for women and their babies and improve overall outcomes. • Staffordshire and Stoke-on-Trent Maternity Voices Partnership – this workstream aims to work with the women and families of Staffordshire in co- producing the Transformation Plan. The group will ensure the voice of women and their families is at the heart of any transformation. We have now recruited fifteen Maternity Champions from across Staffordshire and Stoke-on-Trent to gather feedback from service users and help co-produce transformation. • The Staffordshire and Stoke-on-Trent Maternity and Newborn Service Reconfiguration Group - this workstream aims to work with the providers of maternity and newborn services to explore and implement new ways of working. Specifically, the group is focused on providing Continuity of Carer and a Single Point of Access for Pregnant Women across Staffordshire. • Staffordshire Early Years Advisory Board and Stoke-on-Trent Children and Young People Strategic Partnership - working in partnership with the local authority’s public health service to undertake a broad spectrum of health improvement measures such as smoking cessation, breast feeding support and healthy lifestyles. • Staffordshire and Stoke-on-Trent Perinatal Mental Health Network - this workstream aims to improve women’s access to specialist community perinatal mental health services and to align services across the LMS footprint. New investment will increase the number of women that can access the services across Staffordshire and Stoke-on-Trent. We will also be working to address Perinatal Mental Health.

With funding received from NHS England a project team is now well established and working in partnership with our NHS providers, clinical leaders, local authorities and others (including the voluntary sector) to deliver Better Births to the people of Staffordshire and Stoke-on- Trent.

In conjunction, as part of the STP, we will be working with specialists in workforce and estates to look at how roles can be developed and transformed to improve access to services. We will be looking at where we deliver services and see if further improvements can be made in accessibility.

Further funding from NHS England and NHS Digital has allowed us to establish dedicated project teams, to develop the use of digital technology in women’s electronic records which

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will allow women and their families to have greater input into their care and the ability to make informed choices along the way.

Maternity Voices Partnership Maternity Voices Partnership (MVP) is groups that have been set up in Local Maternity System (LMS) in England. They were formed as a result of the recommendation set out in ‘Better Births’ (2016) following the National Maternity Review. The aim is to have a core team of women, their families, commissioners and providers (midwives and doctors) working together to review and contribute to the development of local maternity care. Locally in Staffordshire and Stoke-on-Trent, the CCGs decided to implement a model where we would seek to recruit Maternity Champions from across the county who, not only have experience of local services, but know their locality well. Working in partnership with Engaging Communities Staffordshire, appropriate training and support was provided and the CCGs now have fifteen champions. The group meets formally four times a year with the service providers. In January 2019, the CCGs had their first meeting which was chaired by a new Maternity Champion. The CCGs are receiving a steady stream of feedback which is now being collated. The next scheduled meeting, in March 2019, will decide how to manage the feedback received and ensure this in included in shaping and influencing the future of local maternity services.

Safeguarding Children and Vulnerable Adults Safeguarding is a statutory responsibility for the CCG led by the Executive Director of Nursing and Quality, supported by the Designated Safeguarding Nurses for Children, Looked after Children and Adults. CCG Safeguarding responsibilities are covered within key legislation. The CCG is a statutory partner of both the Adult and Children’s Local Safeguarding Boards and the safeguarding arrangements of our most vulnerable remain a key priority for the CCG. The Designated Nurses for Safeguarding Children and Adults are officers on their respective boards and remain committed to working with our multi-agency partners and neighbouring CCGs to ensure that our children and adults at risk are protected from harm.

The CCG has a robust governance and contractual arrangements in place for the reporting of and for responding to safeguarding issues which fulfil the national and local safeguarding requirements. The CCG’s Safeguarding Dashboard, with agreed trajectories for each metric, is now fully embedded within provider organisations and reviewed by our Safeguarding leads -enabling the CCG to view performance, quality and trends, highlighting a need to target areas for action. This process has been strengthened following the commissioning of an Internal Audit of safeguarding arrangements that remain the responsibility of the Designated Professionals to monitor.

Safeguarding Children The updated released Statutory Guidance ‘Working Together to Safeguard Children’ (2018) outlined that the CCG is to become one of three key partners (alongside Local Authorities and the Police), with lead responsibility for the arrangements in safeguarding children. As part of the new guidance a bid was submitted by the CCG, along with the other five CCGs in Staffordshire and Stoke-on-Trent, to apply to become an early adopter for the new style of Safeguarding Board. The bid was successful and work has been undertaken throughout late 2018 and early 2019, to ensure that the existing arrangements make a smooth and safe transition to the new style of working with effect from April 2019. This workstream will continue to grow and evolve throughout 2019 and thereafter.

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The Designated Nurses for Safeguarding Children have been actively involved with priority safeguarding workstreams across Staffordshire and Stoke-On-Trent. This includes: partnership working with multi-agencies on the Domestic Abuse Strategic Commissioning Board, developing and supporting the domestic abuse strategy; the Child Sexual Abuse Forum, developing the Child Sexual Exploitation Strategy; and the Female Genital Mutilation (FGM) Steering Group, steering and contributing to the workstreams and contribution towards the neglect strategy. This year has also required a safeguarding focus on children who are vulnerable to trafficking, criminal exploitation via county lines activity and modern slavery. The Designated Nurses have continued to support and guide the six CCGs regarding their statutory safeguarding duties in this respect. Safeguarding children policies have been developed and updated including the: Safeguarding Children Policy, Safeguarding Children Supervision Policy, Managing Safeguarding Allegations against Staff and Domestic Abuse Policy.

The Designated Nurses for Safeguarding Children remain committed to implementing the changes Working Together to Safeguard Children (2018), stipulated as part of the six CCGs’ responsibilities outlined in the Children and Social Work Act 2017. This work is ongoing and involves development of a revised Safeguarding Partnership Board, Child Death Overview Panel and Serious Case Review modernisation. The Designated Nurse for Looked After Children has embedded processes across Staffordshire and Stoke-on-Trent, working in partnership with the Local Authority and provider organisations. A robust quality assurance system is in place to monitor the quality of health assessments and she continues to be an expert source of advice and guidance to medical staff completing the assessments.

Safeguarding Adults The Executive Lead for Safeguarding is the Director of Nursing and Quality and the responsibility for ensuring the delivering our statutory duties lies with the Accountable Officer (AO). The adult safeguarding team comprise 1.6 WTE Designated Nurses, a WTE Senior Safeguarding Nurse, three Adult Safeguarding and Care Home Quality Nurses, a Named GP for adult safeguarding (at two sessions per week) and a Safeguarding Support Officer who deliver adult safeguarding for the six CCGs in Staffordshire and Stoke-on-Trent. The safeguarding team have delivered against the statutory duties and responsibilities detailed within the Care Act 2014 and in accordance with the NHS England Safeguarding Accountability Framework to demonstrate CCGs compliance with statutory functions.

The collaborative working with Staffordshire and Stoke-on-Trent Local Authorities Quality Teams and also the Local Authority’s Adult Specialist Safeguarding Enquiry Team (ASSET) has gathered real pace – with the three adult safeguarding and care home quality nurses becoming integral members of those teams. The teams undertake safeguarding enquiries in accordance with the Care Act 2014 and also quality monitoring visits with our nurses providing clinical support and oversight to the quality monitoring programmes. The Designated Nurses are Officers of the Staffordshire and Stoke-on-Trent Adult Safeguarding Partnership Board (SSASPB) and - together with the Senior Adult Safeguarding Nurse - contribute to and support the sub-groups of the Board. The CCGs have received the SSASPB Annual Report which is discussed in detail at the CCGs Safeguarding Group, a sub-group of the Quality Committee in Common.

The Safeguarding Group is chaired by the Clinical Chair and Executive GP Lead for Adult Safeguarding. This Group agrees the workstreams and work plans for the safeguarding team and discusses safeguarding issues for adults, children and young people in detail and escalates relevant matters to the Quality Committee in Common. This has strengthened safeguarding throughout the CCGs and ensured robust governance and reporting.

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The Designated Nurses, supported by the Senior Adult Safeguarding Nurse, have undertaken several Domestic Homicide Reviews (DHRs) and Safeguarding Adult Reviews (SARs). These are statutory reviews the safeguarding nurses undertake on behalf of primary care general practice. ‘The Adult Safeguarding Roles and Competencies for Healthcare Staff’ intercollegiate document was published in August 2018 and is endorsed by NHS England and Royal Colleges. It has been designed to guide professionals and the teams they work with to identify the competencies they need, in order to support individuals to receive the personalised and culturally sensitive safeguarding. The impacts of this document both internal to the CCGs and our health providers will be significant. The adult safeguarding team will work with an action plan derived from this document in order to ensure the CCGs’ compliance. The CCGs have had a high number of Section 21a Deprivation of Liberty Challenges which have had clinical oversight by the safeguarding team. The Prevent assurance across the health economy continues to be monitored and we are supporting a national pilot with the multi-agency team.

Transforming Care Partnership The Staffordshire and Stoke–on-Trent Transforming Care Partnership continues to progress the ambitions set out in the ‘Building the Right Support’ document. The number of patients in Staffordshire and Stoke-on-Trent with a learning disability, autistic spectrum disorder or both that have received inpatient care in a hospital setting has continued to reduce in numbers and further progress with this reduction is expected during the coming year. Patients in Staffordshire and Stoke–on-Trent that have received inpatient care in a hospital setting for more than five years have now been successfully discharged from hospital. These patients could now lead longer, happier and healthier lives in their own homes in the community. The Transforming Care Partnership will continue to work to discharge patients from inpatient hospitals back out into the community, to improve their quality of life and reduce length of inpatient stay.

Hospices One of the CCG’s priority areas is end of life care. As a result, there has been a renewed focus of the quality of hospice care within the Staffordshire and Stoke-on-Trent area. Members of the Quality Team alongside GPs and commissioners have conducted quality visits to all adult and children’s hospices, spending an afternoon understanding processes, meeting staff and having a tour of the services provided. The overall findings of these visits were extremely positive. There was evidence of learning and development as a result of any complaints or incidents. The environments were of an excellent standard and there were no formal concerns raised as a result of the visits. In addition, patient feedback is extremely positive for the hospices and the patients spoken to during the visits were complimentary of the staff and the services that they received.

Nursing Homes One of the CCG’s priority areas is quality improvement in nursing/care homes. As a result, there has been a renewed focus of the quality assurance of nursing/care homes within the Staffordshire and Stoke-on-Trent area. The CCG, along with the other five CCGs in Staffordshire and Stoke-on-Trent, have co-designed a new integrated service with the Local Authority that will support the quality of care to residents and patients residing in care homes across Staffordshire. This new service will be delivered as a 12-month pilot and will provide additional support to existing commissioned services. The service will be known as the Provider Improvement and Response Team (PIRT) and is due to commence in March 2019. The team will work with the wider CCG teams including Commissioning, Quality and

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Safeguarding and across the health economy with key providers of care. The PIRT will offer support to care homes that are highlighted as experiencing difficulties including those identified by the CQC as ‘Requires Improvement’. The team will support providers by offering advice and day to day leadership to ensure that patients/residents’ needs and quality standards are met. This new quality improvement initiative is currently at the recruitment phase and will commence in 2019. PIRT has been developed as a ‘proof of concept’ model. It has been designed to support care homes that are experiencing difficulties and before they reach the point of urgent closure. The project demonstrates integration across health and social care and is jointly funded between the six CCGs from Staffordshire and Stoke-on-Trent and Staffordshire County Council.

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Reducing health inequalities

Stoke-on-Trent CCG has put governance and reporting arrangements in place to ensure reducing health inequalities is central to commissioning better outcomes for our patients: There is an Executive Board-level responsibility for health inequalities. The board member is supported by identified CCG officers and the local authority Public Health Department. Both health and social care services are held to account for reducing health inequalities through the Health and Wellbeing Board (HWBB).

Partners across the system have undertaken an in-depth piece of work to understand health inequalities across the whole of Staffordshire to inform the Case for Change for the Sustainability and Transformation Partnership (STP). By overlaying public health, geographic and demographic data with system and service use data we have been able to analyse patterns of health inequalities with heat maps of social deprivation and economic profiling. As a system, we are developing transformational change upon which we will involve patients and the public in developing solutions to the problems we have identified, and we will work with local people to develop the options that we will present in the Pre- Consultation Business Case. This is not a quick programme of work but something that is becoming embedded in the way that we do business to reduce health inequalities for our population.

Work has been underway recently to prepare data and information in a way that is meaningful to local people about the place that they live in order that they can make an informed contribution to pre-consultation on future plans. Each local area has a profile and data to support the discussions we will have.

From a commissioning perspective, the six CCGs from Staffordshire and Stoke-on-Trent have increasingly commissioned services across Staffordshire, with some commissioning being locality specific if health inequalities have been identified in our data analysis.

The CCGs have worked together to develop the first collaborative Equality and Inclusion Strategy 2018 to 2021, following internal and external stakeholder engagement. We are keen to involve local stakeholders in the continuing development and monitoring of our Equality and Inclusion Strategy to ensure that we commission the right health care services and work towards reducing health inequalities between patients in access to, and outcomes from healthcare services, and to ensure services are provided in an integrated way where this might reduce health inequalities.

The Equality and Inclusion Annual Publication 2018/19 for all six CCGs should be approved by the Communications, Engagement, Equality and Employment (CEEE) Committee, as a sub-committee of the Governing Bodies in Common, in early 2019/20.

The publication will report on how each of the six CCGs are meeting their PSED and agreed Equality Objectives over a four-year cycle.

This includes information on how North Staffordshire CCG and Stoke-on-Trent CCG took part in a one-year programme with NHS England and four other CCGs. This looked at Equality in Cancer services and the production of a guide for all CCGs which aims to capture this shared learning.

The CCG has adopted a vigorous Equality Impact and Risk Assessment (EIRA) process to understand the potential impact of proposed service change on both protected groups and how any policy or service may affect health inequalities or human rights.

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A common database is used across all six CCGs in Staffordshire which asks assessors to consider key questions in order to demonstrate how they have considered any unintended consequences and mitigations required to exercise their duty to reduce health inequalities, promote equality and protect human rights. Key staff have received training and the number of stage 1 and stage 2 EIRAs has increased significant during the past 12 months.

Governing Body papers front sheets now state whether an impact assessment has been undertaken and Governing Body members have been briefed on their non-delegable duty to consider the information provided to inform their decision making.

The CCGs established a Local Equality Advisory Forum (LEAF) for North of Staffordshire and Stoke-on-Trent in 2016 and were pleased to extend the group to cover all six CCGs in Staffordshire and Stoke-on-Trent in early 2019. The forum is a group of people who represent communities with protected characteristics and vulnerabilities and act as critical friends to the CCGs. They advise on policies, public campaign material, service change proposals and inform our decision making. The group also includes representatives from vulnerable communities (such as the homeless and asylum seekers and refugees) and it includes people who can help us to think more broadly about how we can reduce health inequalities.

Image: Protected Characteristics, Equality Act 2010

As the members of LEAF are asked to join from local organisations who support people from seldom heard groups, we have access to their wider networks and they kindly support us by promoting information or circulating consultations on our behalf. This means we can gather views and feedback from a wide range of diverse people. Our commissioners attend the meetings when they are considering changing the way health services are delivered so that

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we can understand whether there would be any unintended consequences from the changes or any mitigations we would need to put in place to minimise adverse impact on particular groups. The Forum is chaired by a CCG lay person with responsibility for Patient and Public Involvement and we make sure that there is a clinician (doctor) at each meeting to answer any medical questions.

Some of the areas of work that LEAF have influenced include:

• Our Equality and Inclusion Strategy • ‘It’s OK to Ask’ – our health literacy work • Medicines Matter – our campaign to reduce waste medicine • Proposals to change pathways in dermatology, physiotherapy, podiatry, musculoskeletal, Improving Access to Psychological Therapies (IAPT), cancer and end of life services amongst many others • Health services for older people • Access to adult mental health services with the Citizen’s Jury • Transgender, Lesbian, Gay and Bisexual issues in primary care • Pregnancy and maternity • Extended Access to GP Services • Integrated Care Hubs and the Future of Local Health Services • Cervical screening campaign messages • Deaf awareness and BSL video • Our stakeholder mapping • Access and contact methods • Faith and belief with regard to clinical procedures

Stoke-on-Trent CCG and North Staffordshire CCG are piloting a Digital Reach programme with around 40 patients and their carers - supporting the work of the Together We’re Better health and care partnership’s digital programme. The digital work-stream: Long-Term Health Conditions - accelerating inclusion includes the work of digital champions from a range of Staffordshire and Stoke-on-Trent based general practices and community services, alongside clinicians from other healthcare areas. This will showcase how voice-assisted technology such as Amazon’s Alexa device can be used to improve health and wellbeing.

Alexa devices will be used to support about 40 patients with one or more long-term condition, adverse lifestyle habits and/or frailty who are not currently using their own devices or technology equipment (such as a mobile phone, tablet and computer) for health related purposes – training (patient and carers / clinician) and set up will be included; with a ‘buddy’ available to provide ongoing informal support if required.

The six CCGs have also worked closely with NHS England on the above programme to support development of a new Equality and Health Inequalities Right Care Pack which were published to all CCGs in December 2018.

Contributing to the delivery of our joint Health and Wellbeing Strategy

The CCG is an active player with a seat at the table of the Staffordshire Health and Wellbeing Board which brings together key health and care organisations to improve the health of local people and ensure fair access to services.

The Health and Wellbeing Board meets to understand local needs, agree priorities and ensure that NHS organisations and the council work more closely, including commissioning

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services together where possible. The Health and Wellbeing Board is key to delivering integrated health and social care through strong local leadership across health, local authority and voluntary sector partners.

The Board’s key functions are:

• To undertake a Joint Strategic Needs Assessment (JSNA) • To develop a joint health and wellbeing strategy • To ensure that the commissioning plans and activities of clinical commissioning groups and the council are consistent with the JSNA and the health and wellbeing strategy • To support development of joint commissioning, integrated delivery and pooled budgets • To assess the need for pharmaceutical services in its area, and publish a statement of its first assessment and of any revised assessment • To encourage integrated working under the Health and Social Care Act 2012

Examples of the CCGs contribution to the Health and Wellbeing Board include:

• The CCG is a key contributor to the delivery of the Joint Health and Wellbeing Strategy 2016-2020. • Work is ongoing to develop a new Joint Strategic Needs Assessment which reflects the changing needs of the local population • The CCG presented its commissioning intentions for 2019/20 to the Health and Wellbeing Board, demonstrating the strong alignment between the Health and Wellbeing Strategy, the STP and the CCG’s commissioning intentions. • A national Care Quality Commission (CQC) review was carried out in Stoke-on-Trent to look at how well older people and specifically those over 65 can move through the health and social care system. Significant improvements were noted between the first and follow up inspections in terms of partnership working, joint commissioning and outcomes. Health and care leaders have pledged to work together to improve services for Stoke-on-Trent residents.

This information has been developed in conjunction with the Health and Wellbeing Board and was agreed to be included in this year’s Annual Report.

Overview and Scrutiny

Adults and Neighbourhoods Committee is responsible for scrutiny of matters relating to the planning, provision and operation of health services in the Authority's area, including public health, in accordance with regulations made under the Health and Social Care Act 2001 and subsequent guidance.

The Committee has the power to make reports and recommendations to NHS bodies conferred by the Health and Social Care Act 2001 and may, respond independently to health-related consultations from Government and external agencies.

The Committee takes the lead in scrutinising the work of the CCG which has been actively engaged with the Committee throughout the year in formal meetings and informal briefings - to make sure that Committee members are able to scrutinise our plans and proposals in a public forum.

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The Stoke-on-Trent City Council Adults and Neighbourhoods Committee has undertaken its own scrutiny of:

• Access to General Practice • Voluntary Sector Commissioned services • Care Navigation – the patient experience – a review which the CCG commissioned from Healthwatch

In addition, the Committee has regularly scrutinised areas of CCG business such as Discharge to Assess, CCG financial position and the STP work programmes.

The Local Authority (Public Health, Health and Wellbeing Boards and Health Scrutiny) Regulations 2013 aims at supporting local authorities to discharge their scrutiny functions effectively. As such, the CCGs’ Governing Body in common on 5 December 2017 agreed that it would inform Stoke-on-Trent City Council and Staffordshire County Council that under Part 4 Health Scrutiny by Local Authorities, regulation 30 (5), local authorities should appoint a joint health scrutiny committee where a ‘responsible person’ (in our case the CCG) informs affected local authorities that it has under consideration a proposal which would affect more than one local authority area, namely the future of Local health Services which affects five community hospitals.

Staffordshire County Council and Stoke-on-Trent City Council established a mandatory joint scrutiny panel to scrutinise and provide formal feedback on the Future of Local Health Services in Northern Staffordshire.

Staffordshire Sustainability and Transformation Partnership

Together We’re Better is the Staffordshire and Stoke-on-Trent Partnership transforming health and social care for the people of Staffordshire and Stoke-on-Trent. The CCG is working closely together to ensure that people have access to high quality, sustainable services and we have been implementing plans to improve the quality of health and social care tailored around local population needs and to reduce financial deficits.

This partnership work focuses on how the local health and social care services will evolve and become sustainable over the next five years in alignment with the NHS Long Term Plan.

The CCG is working with the Partnership towards achieving this transformation through a series of work programmes. Each programme is clinically-led and focussed on its own aims and objectives to ensure local needs are met.

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The Partnership is overseen by the Health and Care Transformation Board and is governed by the following:

• One vision: Working with you to make Staffordshire and Stoke-on-Trent the healthiest places to live and work • Three aims: improved health and wellbeing, transformed quality of care (clinical sustainability) and within the money available (financial sustainability).

The CCG has been working to develop the clinical case for change with clinicians and partners and as the statutory consultors, the six CCGs in Staffordshire and Stoke-on-Trent will be commencing pre-consultation engagement with the public in the following areas during 2019/20:

As part of the Staffordshire STP, grouping the CCGs play an integral part in the development of the future of the health and social care provision across not only the North of the county and the City of Stoke-on-Trent, but also across the fuller footprint of Staffordshire. The STP is itself a composite of commissioning and provider organisations and as such is

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resourced from the member organisations. The resource contributions into the STP for all partners come in two forms.

• Resources in kind – the secondment, in part or in full, of staff time to support specific roles, functions and workstream within the STP – this contribution is valued as the cost is to the host organisation providing the input; • Cash – the balance of the costs of the STP, after deducting the use of resource in kind, is made up of cash paid to the STP to support the delivery of the STP objectives and programmes of work as agreed within the STP documentation supported by all member parties.

Patient and public involvement

Evidence shows that involving patients and the public in decisions about their health care increases their confidence, empowers them to consider how to stay healthy and ultimately, leads to better health outcomes. The CCG has therefore made a commitment to patient and public involvement at all stages of the commissioning cycle, not just because it is our statutory duty, but because it is the right thing to do. We must commission health services which meet patient needs and we must ask people what those services should look like and how they feel when they are in place. This, balanced with clinical evidence and academic research, will mean that we commission efficient and effective services.

Our Communication and Engagement Strategy sets out the principles and approaches that the CCG uses to communicate our messages, so that we talk to people early enough for them to make informed decisions when we involve them in influencing the health services in our area. In our implementation of this strategy, we are open and honest and accountable for the way we use public money to commission health services. We do this by supporting our commissioners to listen to public opinion and expert citizens at every stage of the commissioning cycle. This year, 70 staff have received training on the legislation and practicalities of public involvement.

We use a wide range of tools and channels to make sure that our messages are accessible to everyone and this year we have developed a Digital Communication Strategy, following engagement with young people. We have also increased the channels of communication with local people so that they can better understand our proposals and get involved in informing our decision making. We have introduced new social media channels across the six CCGs including single Twitter, Facebook and Instagram accounts. We have made extended use of video content and clear documents to make sure that the information we provide on a digital platform is accessible. The CCG live tweets from all Governing Body meetings in public, highlighting key information for people who would not be able to attend and links to the relevant papers under the #StaffsGB.

We provide feedback on what we have done with the information that people give us and let them know how we have changed services as a result, through regular newsletters and on our website.

We have refreshed our website which is centred around providing meaningful public information and feedback in accessible formats. The website is AA standard compliant. The site map and functionality were co-designed with patients who told us what they needed to know from the website and how they wished to access the information they seek.

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Our work on Health Literacy has been included in a National NHS England Toolkit, has been independently evaluated from an academic perspective and has been shortlisted for a Health Services Journal Award.

Patient Participation Groups (PPGs) attached to GP practices provide an opportunity for all member practices to involve their registered patients in discussions relating to local health services generally, as well as practice-specific.

The CCG introduced a Patient Congress to develop a forum of informed participants to contribute to the strategic planning, development and delivery of the most effective health services for the local population. The Congress includes PPG representatives to ensure a local focus to strategic discussions, as well as representatives from the community and voluntary sector. The Patient and Public Involvement lay member chairs the Patient Congress and is integral to the assurance and governance processes of the CCG. There is an embedded process for them to bring patient stories to each meeting and they feedback through their local patient groups. They bring patients’ voices to the table and are able to influence decisions taken at a strategic level. Through the newly established Communication, Engagement, Equality and Employment Committee, equality and inclusion are woven through our day-to-day practice.

We continue to support PPG members by: maintaining and updating a password protected area of the website to access toolkits, guidance and good practice; and a newsletter sent to PPG Chairs called ‘Your Voice’ to keep them updated and support with setting up local virtual PPGs on Facebook.

Patient representatives also get involved by:

• Attending our Clinical Priorities Advisory Group (CPAG) to decide on which services will be invested / disinvested; this is a crucial role for the CCG. • Evaluating tenders from potential providers on significant contracts.

For every engagement process we undertake, we endeavour to gather (on an optional basis) equality and diversity monitoring data, so that we can assure ourselves that we are gathering information from a representative sample group and reaching out for feedback to all sections of our local communities.

We have further strengthened our work over the past year to build on our previous patient and public involvement mechanisms:

• Our Patient Congress continues to thrive and has its membership renewed during the year - to ensure that we continue to refresh the patient voice and perspective brought to our decision-making processes • The CCG reviewed its face to face engagement model - seeking feedback from those involved and reviewing its key performance indicators that had been developed by the groups. A report was presented to the Patient Congress in January 2019 and further work will take place during 2019/20 • All decision-making committees of the CCG include lay member representatives to ensure patient and public views are heard in all aspects of the CCG's business including the Governing Body. The front cover of all Governing Body papers requires officers to provide assurance about patient and public involvement activity undertaken to support the proposals being made. The CCG's lay member for Patient and Public Involvement has a key role to play in assuring the CCG in relation to public involvement and holds the CCG to account on its involvement activity. A video

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was produced where the lay member for Patient and Public Involvement described their role in representing the public on key decision-making committees • The Primary Care Commissioning Committee reviews public involvement undertaken by GP practices in relation to potential changes to services i.e. branch closures and mergers. The CCG also live tweets from all Primary Care Commissioning Committee meetings in public, highlighting key information for people who would not be able to attend and links to the relevant papers under the #StaffsPCCC • There is a dedicated Consultation and Engagement section on the CCG’s website containing information about consultations and engagement opportunities including the outcomes • The Extended Access to Primary Care Services was shaped following engagement with patients and the public - including an extension to interpreter services following feedback from deaf patients • In order to align communication and engagement activity across all six CCGs from Staffordshire and Stoke-on-Trent, an Associate Director of Communication and Engagement was appointed. They also work closely with the STP to ensure that the CCGs are able to resource and meet their statutory duties with regards to Patient and Public Involvement. Assurance processes have been introduced to ensure that this area of work is carefully planned and scrutinised by the PPI lay members. Knowledge and guidance has been imparted to Commissioners through training and awareness sessions.

We are proud of our public and patient involvement and are committed to embedding this as a golden thread through all of our decision-making processes.

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Key Achievements in 2018/19

18-Week RTT – wheelchairs for Paediatrics In Quarter 2 2017/18, the percentages of wheelchairs for Paediatrics delivered within 18 weeks of initial referral across Staffordshire ranged from 44.44% (Stafford and Surrounds CCG) to 77.78% (Cannock Chase CCG). By Quarter 3 2018/19, these figures had improved significantly with 100% of wheelchairs for Paediatrics being delivered within 18 weeks of initial referral across all six CCGs in Staffordshire and Stoke-on-Trent.

This was achieved by:

• Engaging with the provider to fully understand the service and patients’ needs • Taking a multi-disciplinary, collaborative approach within both the CCG and provider • Robust and ongoing dialogue between provider and commissioner to ensure continuing proactive assurances were obtained • Waiting list management investigations and associated remedial initiatives • Utilising robust clinical prioritisation.

Diabetes During the recent CCG Assessment ratings; the CCG secured an ‘outstanding’ rating for diabetes care.

National Diabetes Prevention Programme

The ‘Healthier You’ National Diabetes Prevention Programme was launched in Staffordshire in May 2018 as part of the wave three roll out of the NHS England Initiative. The Programme is aimed specifically at patients with a high risk of developing diabetes. It uses a behaviour change approach which has been highly effective in waves one and two; and is backed up with strong evidence for its effectiveness at supporting people to maintain a healthy weight and be more active, which can significantly reduce the risk of developing diabetes.

The programme has been implemented in phases to allow learning and to continue to improve the process for practices and patients, including understanding the implications of the new General Data Protection Regulation (GDPR) requirements. So far, 1,246 patients have been referred into the programme by their GPs from trailblazer practices in Staffordshire and Stoke-on-Trent.

Locally 96 people from trailblazer practices in Stoke-on-Trent have been referred into the programme to date with 55 already attending the sessions.

There are just over 5,600 places available on the programme which is funded for three years and it is hoped that referrals will increase following the roll out to all practices from February 2019.

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Structured education for patients with type 2 diabetes

The CCG received funding from the NHS England Transformation Fund for the second year to increase the uptake rates of structured education for patients with type 2 diabetes. Bitesize education sessions were available for patients, such as focusing on diet or physical activity. The CCG has seen significant increases in the uptake rates for structured education.

Improving the quality of cancer services In 2018/19, the CCG was awarded funding by Macmillan to drive improvements in the level of early diagnosis of cancer and in the care and support available to people living with cancer. This funding will be used to support the following key priority areas.

• Working with GP practices to provide support and advice in making appropriate referrals into cancer services and in improving cancer screening uptake rates. This will support early diagnosis of cancer and reduce levels of cancer being diagnosed following emergency presentation. For example, GP protect learning time events include updates on the signs and symptoms that indicate cancer is a possible diagnosis. • Utilising CCG communication channels to raise public and community awareness of cancer symptoms and the importance of participating in national screening programmes. For example, in January we used social media platforms to raise awareness of cervical screening at the same time as a national campaign led by Jo’s Cervical Trust. Cervical screening uptake across the UK has been reducing and evidence suggests that young women who attend their first cervical screening appointment are more likely to carry on attending in future, so the targeted social media campaign enabled access to this patient group. • Implementing nationally or regionally agreed best practice pathways for four cancer types; lung, colorectal, prostate and upper GI (stomach and oesophagus). These best practice pathways are designed to ensure that patients are able to move through the diagnostic tests required more quickly and if cancer treatment is required, ensure that it can start as soon as possible. • Improving the services for people who have been treated for breast cancer, prostate cancer and colorectal cancer, so that where it is clinically appropriate, patients won’t need to attend hospital as often but will still be able to access services without delay if there are warning signs that the cancer has returned. • Offering holistic needs assessments to more patients at the time they are diagnosed with cancer and ensuring that more patients will receive appropriate care after their treatment finishes in the community. • Improving the way in which pathology services in different hospitals work together using the latest digital technology, to avoid delays or need for repeat tests if patients need to be seen in more than one hospital.

In addition, as part of the work undertaken locally, the Staffordshire and Stoke-on-Trent STP has been awarded a significant amount of funding by the West Midlands Cancer Alliance to transform cancer services. The transformation plans, which will run through to March 2020, will support improvements in a number of priority areas.

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Lung health check pilot West Midlands Cancer Alliance allocated additional funding to Staffordshire and Stoke-on- Trent STP. Part of this funding has been allocated to piloting a clinical service to offer people in some areas of Stoke-on-Trent access to a lung health check. This pilot service will be rolled out in conjunction with University Hospitals North Midlands (UHNM) and Stoke-on- Trent GP practices.

The service will involve inviting particular patients from the participating GP practices to attend a simple lung health check with nursing staff from UHNM. The patients invited will be those who might be at higher risk of lung disease. This assessment takes into account factors like age and smoking history. The lung health check will include a face to face discussion with a specialist nurse and it may also involve a simple lung function test spirometry. Some of the patients will then be offered an appointment for a CT scan of their chest.

We expect this pilot will identify lung disease at an early stage, before the patient is experiencing serious symptoms. This will mean that the patient will be able to have care plans in place and get the correct treatment as early as possible. There is very strong evidence that this type of lung health check leads to much better outcomes for patients.

The Future of Digital Nursing Care The General Practice Nursing Pilot Project was launched in March 2018 to develop the confidence, capability and capacity for delivering technology enabled care; promoting the development of practice nurses to become digital nurse champions.

As the pilot progressed a practical focus emerged that included action learning sets and good practice being shared between colleagues.

Using Flo (Florence Simple Telehealth) a text messaging system, the practice nurses were able to help patients understand their condition, with support to measure levels of pain, remote monitoring, appointment reminders and encouraging messaging.

During the six-month period staff observed that patients and their families became more engaged and were empowered to manage their own symptoms at home. There was also an improved access to monitoring and treatment, whilst unnecessary treatments were avoided.

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The future of local health services in Northern Staffordshire consultation The health and care system in Stoke-on-Trent and North Staffordshire faces many challenges. The CCG, along with North Staffordshire CCG, wanted to look at ways to deliver services differently to ensure the very best health services meet the needs of local people within a finite budget.

This consultation formed the first part of plans to transform health and care across the whole of Staffordshire, as part of a partnership called ‘Together We’re Better’.

The CCGs have been working for the past two years with local people, local health partners, GPs, health professionals and local politicians to look at delivering better community services. Together the CCGs have developed proposals and options for how this could be done.

Over a 14-week period the CCGs held public events, attended focus groups and hosted community stands to gather as much valuable feedback from the local population as possible. The consultation ended on 17 March 2019 and responses are being analysed independently and will be shared in a report. This report will be presented to the two CCGs for consideration before any decisions are made.

Digital Technologies Staffordshire and Stoke-on-Trent received £1.2m of new NHS funding to utilise innovative digital technologies and treatments that could lead to thousands of fewer hospital admissions nationally.

More than 15 million people in England have a long-term condition (such as high blood pressure, depression, dementia, diabetes and arthritis) – a health problem that can’t be cured but can be controlled by medication or other therapies. This figure is set to increase over the next ten years, particularly those people with three or more conditions at once. These need to be monitored regularly and lifestyle changes often need to be made to help. This is increasingly being done through app-based technology using a patient’s own mobile phone.

Three digital technologies were combined to help reduce A&E admissions for patients with chronic long-term heart failure. They have coordinated community-based clinical interventions with patients who report deteriorating symptoms.

The project has already enhanced patient knowledge and the ability to safely ‘self-care’, using bespoke patient-education materials and referrals to appropriate third-sector services. When it is rolled out nationally it is estimated the project could lead to 24,000 fewer hospital admissions, 240,000 less bed days and save £60m.

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North Midlands Brest Screening Service The North Midlands Breast Screening Service, based at University Hospital of North Midlands, has successfully aligned with the government’s digital by default strategy by using Facebook to help reverse a 10-year decline in uptake. Its social media initiative has led to a 13% increase in first time breast screening attendances in Stoke-on-Trent since a low point of 2016.

The project is part of NHS Digital’s Widening Digital Participation Programme, which aims to make digital health services and information accessible to everyone – particularly the most excluded in society.

The team posts information aimed at encouraging women to spread the message about the benefits and importance of screening. The posts include women explaining the screening process and their personal experience of it, as well as videos showing the rooms where screening takes place.

Additionally, the service answers questions from the group using the Facebook page and by direct messaging. This helps reduce anxiety around breast examinations and enables women to book appointments more easily.

The North Midlands Breast Screening team also uses Facebook to link with health inclusion groups which share its information and videos. These include transgender, learning disability and carer organisations.

Mental Health Crisis Centre The Department of Health and Social Care has approved two separate capital funding bids from Together We’re Better, the local health and care partnership of NHS and local government, alongside a number of independent organisations.

£1.6m has been approved to develop a mental health crisis care centre and detoxification suite at Harplands Hospital in North Staffordshire, as well as four crisis cafes in the county. The crisis care centre will include a crisis lounge and three places of calm for people experiencing mental health issues. It will also provide working space for social care staff, police and voluntary sector workers so they can support patients once they are ready for discharge.

The urgent care and detoxification centre will allow people experiencing substance misuse issues to recover in safety and for care and support to be planned once they are ready to go home. The crisis cafes will be located in East Staffordshire, Stoke-on-Trent, Stafford and Staffordshire Moorlands and support people experiencing mental health problems.

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Improving mental health services

Trailblazer project is helping transform mental health for young people Children and young people in Stoke-on-Trent and North Staffordshire will benefit from a pioneering scheme delivered by North Staffordshire Combined Healthcare NHS Trust, in partnership with commissioners and local government to improve mental health in schools.

One in nine young people aged five to 15 are thought to have a mental health condition. Teenagers with a mental health disorder are far more likely to suffer from mental health problems as an adult.

The new NHS funding announced by the Government in 2018 will allow the formation of a “trailblazer” project that will increase the support that is available in a number of schools by December 2019.

The announcement means Stoke-on-Trent and North Staffordshire are among 25 national trailblazers for the transforming children’s and young people’s mental health programme.

Mental Health funding A grant of £242,000 has been awarded by the Department of Health to support the development of new mental health support services. This will be led by non-profit organisation Brighter Futures, for people in crisis in Staffordshire and Stoke-on-Trent.

The funding will cover a new ‘Place of Calm’ service which will provide another option to both crisis services and people in mental distress. The service will provide de-escalation from crisis and suitable escalation where needed. The funding will also be used to buy a customised outreach vehicle. This vehicle will provide both physical and mental health support at a time and location to better engage with homeless people, initially in Stoke-on- Trent.

The new partnership will see agencies including the six CCGs in Staffordshire and Stoke-on- Trent and local authorities come together, to improve the health and wellbeing of the most vulnerable people in the area.

The outreach vehicle was operational from late 2018, and the ‘Places of Calm’ service will be completed by April 2019. A similar project will be launched in South Staffordshire in 2019/20.

Mothers and mums-to-be benefit from extra mental health funding Around 20% of women experience mental health difficulties while they are planning a pregnancy, are pregnant or during the first year following the birth of their baby. This covers a wide range of conditions and, if left untreated, can have significant and long-lasting effects on the woman and her family.

£833,000 will be invested in improving perinatal mental health services across Staffordshire, Stoke-on-Trent and Shropshire that will directly help around 850 mothers by 2021.

The funding will help develop specialist community perinatal mental health teams to offer psychiatric and psychological assessments and care for women with complex or severe mental health problems. They can also provide pre-conception advice for women with a current or past severe mental illness who are planning a pregnancy. Teams can be made up of doctors, nurses, midwives, social workers, psychologists, psychiatrists, occupational therapists, nursery nurses and administrative staff - who all work together to provide a comprehensive service to mums, depending on what their individual needs are.

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Primary Care developments

Delegated commissioning The CCG has been the delegated commissioner since April 2017. The overall aim of delegated commissioning is to harness the energy of Clinical Commissioners to create a joined up, clinically-led commissioning system which delivers seamless, integrated out-of- hospital services based around the needs of local populations. It also provides a greater opportunity to develop sustainable primary care services tailored to local needs.

The Primary Care Commissioning Committee continues to meet, chaired by a lay member as well as clinical representation. The papers are forward looking focusing on primary care transformation along with broader primary care strategic issues.

GP Forward View (GPFV) We continue to build on progress made on areas of the GPFV as part of the primary care work programme aligning with CCG delivery and operational plans and priorities as well as the Staffordshire and Stoke-on-Trent STP. The plan focuses on six programme areas:

1. New models of care – transforming primary and community services across Staffordshire 2. Access to general practice 3. Workforce 4. Workload 5. Quality 6. Infrastructure: • Estates reconciliation and development; • Digital / Information Management and Technology improvements.

Primary care workforce The primary care workforce is under significant pressure in terms of the lack of numbers of GP graduates entering the profession and the ability to recruit and retain. Therefore, having a sustainable workforce model is key for primary care delivery in the future.

The CCG is a member of a Staffordshire primary care workforce group chaired by NHS England and has a wealth of other representatives relating to primary care workforce. The group has developed the following workforce vision: “To develop a sustainable general practice workforce for today and the future, which will form the foundation to enable the delivery of the future new models of integrated, collaborative care”. A workforce plan has been developed across the Staffordshire and Stoke-on-Trent STP to assess the current workforce baseline the proposed new models of care and the actions needed to ensure that Staffordshire and Stoke-on-Trent have a sustainable workforce in the future. The plan will be monitored via the workforce group.

The plan includes a range of key work programmes with actions to support including:

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Innovative ways to recruit and retain GPs: BMJ Recruitment Campaign

To support sustainable general practice in Northern Staffordshire, the CCG ran a recruitment campaign with the British Medical Journal (BMJ). To date this has resulted in 1,516 views online and 25 applications have been received. The CCG hopes this will result in successfully filling vacancies in North Staffordshire and Stoke-on-Trent.

General Practice Nurse (GPN) ten-point plan

A focus on a ten-point plan to increase the numbers and the skill set of practice nurses (and an associated implementation and delivery plan to support this).

In the last 12 months there has been a collaborative approach to the delivery of the ten-point plan across Staffordshire. There are six Primary Care Nurse Facilitators supporting the development of General Practice Nurses and Health Care Support Workers across the CCGs in Staffordshire and Stoke-on-Trent.

Highlights from the first half of the year included the largest numbers on the Fundamentals of General Practice Nursing programme across Staffordshire Health Education Institutes (HEIs), four of whom were newly qualified nurses commencing their career in General practice. This continues to reflect the need for a structured education programme for those new into the role and the fact that general practice remains an attractive speciality.

The area saw growing numbers of General Practice Nurses (GPNs) supported to be Independent Prescribers and Physical Assessors accompanied by the first cohort of Advanced Clinical Practitioners supported by HEE to complete this year. This not only aids to release GP capacity but is developing attractive roles that results in increased retention of staff.

The priorities for the second half of the year focus on education, leadership and facilitating the opportunities to develop existing HCSWs into Trainee Nurse Associates. Two funded leadership workshops are running in May. One focuses on leadership for all aimed at raising the aspirations and motivation of both existing HCSWs and GPNs to use their voice, while the second is about supporting existing lead GPNs to put their ideas into action in line with the emerging Primary Care Networks. Interest has been scoped in the role of the Trainee Nurse Associate and September 2019 should see at least five students commence this new trainee nursing role in Primary Care.

Two GPN annual updates will be available to all GPNs across the area, providing a convenient one stop shop of evidence-based learning.

The “General Practice Nursing – Make a real difference as a digital nurse champion” conference was held in Birmingham on 20 November. The conference showcased the digital achievements of GPNs in Staffordshire. The digital agenda will help to meet a number of actions on the GPN ten-point plan including: Action 2: Extend Leadership and Educator Roles; Action 6: Embed and Deliver a Radical Upgrade in Prevention; and Action 10: Improve Retention and the digital agenda will be championed at the GPN Regional Board on the 13 December 2018.

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Developing and increasing other alternative roles within general practice such as physicians associates and clinical pharmacists Developing practice managers

Practice Manager Development funding has been made available for all practices to support with developing advanced skills to manage change and new models of care.

Practice Manager Development Funding was secured for 2018/19. The final element of the allocation focuses on local development for Practice Managers where we share innovation and positive learning with a view to upskilling experienced managers further and to offer peer support and advice to those with less experience.

The following events have been arranged:

• GP Forward View Share and Learn Event: Experience sharing and reflective learning event for all Practice and Business Managers in the Staffordshire localities. The opportunity to grow understanding of lean working and quality improvement tools aligned to the ten high impact actions. • Practice Manager Development Day: The CCG has commissioned an event entitled “Working at Scale”. Practice Managers will receive a copy of the Working at Scale Handbook which acts as a tool for future references and attendees will also receive 12 months subscription to www.gpcpd.com, home of The Handbook Online; complete with pre-prepared focused learning activities to support them. The CCG will contact attendees after the event to understand how the course has helped and anything implemented or changed as a result of the course.

Training and Education Protected learning time (PLT)

PLT sessions for clinicians have continued to successfully grow this year and provides an excellent opportunity to participate in relevant clinical education. Topics are linked to national and local priorities and are led, on the whole, by local GPs, consultants and teams. This allows the ability to network and build relationships between primary and secondary care colleagues.

Examples of some of the education sessions that have taken place this year include end of life are and long-term conditions.

Supporting the general practice nursing workforce

The CCGs are committed to supporting the general practice nursing workforce through the roles of nurse facilitators. The nurse facilitators are pivotal in developing, educating and supporting the expansion of the general practice nursing workforce and acts as a link between the nurses and the CCG. A rolling training and education programme is established with input and suggestions from practices informing relevant topic areas.

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Primary Care Workload GP Resilience Programme

The GP Resilience Programme was launched by NHS England in 2016 as part of the GPFV. The purpose of the fund is to deliver a wide menu of support that will help practices to become more sustainable and resilient, better placed to tackle the challenges they face now and into the future and securing continuing high-quality care for patients.

Resilience funding was also made available for practices to bid towards in 2018/19. Initiatives were agreed for funding mainly focusing on developing innovative clinical workforce initiatives such as utilising physiotherapists. These initiatives will be evaluated, and positive learning will be distributed via case studies.

Ten high impact actions

As part of the GPFV, ten high impact actions were nationally identified to improve ways of working to help to manage the rising workload in general practice releasing time to care. Examples of the work underway are as follows:

Active signposting

In North Staffordshire and Stoke-on-Trent, signposting is continuing to be rolled out to practices. This provides patients with a first point of contact which directs them to the most appropriate source of help – this can be within the practice such as appointments with Advance Nurse Practitioners or directing patients to pharmacy services. Active signposting supports creating capacity within general practice to save GP hours. In North Staffordshire active signposting began with a phased approach in September 2017. This provides patients with a first point of contact which directs them to the most appropriate source of help. To date 50/75 practices actively signpost and record data using a template, in that time 42,849 signposts have been made by reception staff and 6,443 GP hours have been saved. Healthwatch Stoke-on-Trent conducted a survey that showed 78.7% of patients were comfortable being asked questions by receptionists. The staff will continue to be supported with ongoing training booked throughout 2019.

Workflow Optimisation

GP Practices have been given the opportunity to undertake Workflow Optimisation Training. Workflow optimisation has been funded by NHS England and training and support is provided to GP Practices from Practice Unbound (previously Brighton and Hove).

Workflow optimisation looks how to manage clinical correspondence differently through the utilisation of administration staff to safely redirect correspondence from GPs. This change of practice allows for a more effective same-day turnaround for clinical correspondence review. Practice Unbound have developed effective governance protocols and audits to support workflow optimisation to be embedded safely in to practice systems and processes - in turn freeing up clinical capacity for patient care. Some items of correspondence will still require GP review. However, many other items can be dealt with by administrators and other non- clinical members of the GP practice workforce.

Participating practices across Staffordshire have embraced the new way of working and a survey undertaken by the CCGs reported that 91% of GPs would recommend workflow optimisation to other GPs and that the difference made in General Practice is very positive. Feedback from practice managers is also positive, with 72% reporting that the impact made in practice is very good or good. Workflow optimisation is reported to save one to five hours

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per week in practice and one large practice in Staffordshire has reported that an impressive 25 hours per week is saved, freeing up clinical capacity. Feedback from one practice reported that:

“Whilst it has increased workload for the administration staff, it has allowed the GPs extra time to spend on their other tasks. Coding is now more consistent, and documents are always dealt with on the day they are received.”

The CCGs recognise the significant positive impact that workflow optimisation has made in Staffordshire for the majority of participating GP practices and work will be taking place to build on the positive impact already made. In addition, the CCGs will be working closely with those practices identified as requiring additional support, who have not yet undertaken the training or have not fully embedded process, by arranging access to additional training and ‘facilitating shared learning and best practice case studies.

Clinical outcomes

Over the last 12 months the CCG and its member practices have been working hard to improve a number of clinical measures. These include:

• Participation in the flu campaign - to increase flu vaccination uptake ensuring that our population is healthy and to prevent patients from attending hospital when this could have been prevented; • Improved detection of patients with Chronic Obstructive Pulmonary Disease (COPD) - to ensure that these patients receive the management and treatment that they require and prevent exacerbation which accounts for unnecessary admissions to hospital; • Maintained management of blood pressure for patients with diabetes - which should have benefits for preventing vascular complications (such as strokes) which are more commonly experienced by people with diabetes • Improved identification of patients on Palliative Care register - to ensure End of Life wishes are recognised • Increased number of Learning Disability Annual Health Checks.

Quality Improvement Framework (QIF) evaluation (2009-2015) publication

As a response to the deprivation and poor outcomes for health and lifestyle indicators, the QIF was established in 2009 for the Stoke-on-Trent GP practices. This was more than a pay for performance scheme. It was designed to deliver a ranging approach to quality improvement including: identification of undiagnosed patients with long-term conditions and their subsequent management and treatment; an education programme to support the clinical targets (training and development), pre-requisites for entry into the scheme alongside individualised support for practices including development plans, practice reports and practice visits.

The evaluation looked at mortality data across 326 local authorities in England across seven long-term conditions (Coronary Heart Disease, Stroke, Diabetes, Epilepsy, COPD, Asthma and CKD). This was compared against national, regional (West Midlands) and localities with similar population demographics/characteristics.

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The results have demonstrated a positive downward trend in cardiovascular deaths compared with the national mean particularly for patients with Coronary Heart Disease and Stroke with some smaller reductions in mortality for patients with Diabetes, Asthma and Chronic Kidney Disease. By 2014/15, the detection and control of patients with hypertension were better than peers across England.

The QIF scheme continues and is refreshed on an annual basis to ensure it is fit for purpose and a further review may be planned in the near future

Quality monitoring, improvement and support

A primary care quality assurance schedule was established across Staffordshire which outlines the CCGs’ approach to quality and safety for primary care general practice including an accountability structure, a robust process and consistent approach to the management, monitoring and improvement of quality.

A quarterly primary care quality group is established to provide assurance to the Primary Care Commissioning Committee of the quality of its membership practices and a dashboard of information is produced to support this process which identifies where practices may require support.

All practices have now received a CQC inspection and have been rated accordingly. Most of the practices have been rated as ‘good’ overall. The CCGs, along with NHS England, work hard to support any practices who are rated less than good to develop action plans to improve their overall ratings.

The CCG continues to work with NHS England to share learning from inspections that have taken place locally to support future inspections.

Primary Care Infrastructure: Estates The CCG is working with other public sector partners across Staffordshire under the One Public Estate Programme to ensure estates are optimised, to help deliver a high-quality service to patients within the primary care setting. The CCG, as part of the pan-Staffordshire Local Estates Forum, aims to identify and progress all necessary schemes, ensuring that partners work together to maximise the use and efficiency of public sector estate. This includes working with local councils to identify the health impacts of housing developments and ensure adequate services are available for the increasing population.

The CCG has received funding under the Estates and Technology Transformation Fund (ETTF) for several projects. These include the Longton South project which aims to deliver a new primary care centre in the Longton area of Stoke-on-Trent by March 2021. In addition to this, the CCGs have also started working on the Chadsmoor ETTF project, looking to develop a new primary care centre within the Cannock Chase district of South Staffordshire. Other CCG supported projects include Greenwood House (Burntwood) led by NHS England and Outwoods (Burton), led by University Hospitals of Derby and Burton NHS Foundation Trust.

The CCG has also supported 18 practices in obtaining over £200k funding from NHS England around improvements in current primary care estates.

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Information Management and Technology (IM&T) The CCG has actively worked with its localities to implement clinical system resources to support delivery of extended hours across localities. The resources implemented can also be used to deliver other centralised services such as diabetic reviews, care home services as the systems now provide a clinician access to the full patient record that is held with the patients host practice within each locality. Some of the benefits are listed below:

• Consulting GPs can access a patient’s full medical information ensuring there is better information to support clinical decisions • Patients are not passed between their host practice and out of hours (OOH) support due to information not being available which ensure services are convenient for patients • Audit trails are recorded and reviewed to ensure records are only viewed where patient consent is given across the locality services • All activity in the extra services (i.e. extended hours) is automatically saved against the host practice record ensuring that any activity added to a patient’s record is immediately available to the host practice; and the locality should the patient be seen in another service in the locality. This ensures patients records are updated efficiently and securely.

e-Referrals Through collaborative working, the CCG and Staffordshire secondary care providers have achieved 100% use of e-Referral service (e-RS) for first outpatient consultant appointments. This was completed as part of the national Paper Switch-Off Programme to support compliance against the NHS standard contract 2018/19. The delivery of this programme across the NHS promotes:

• Increased efficiency for providers by reducing the number of referral routes that need to be managed • Increased efficiency for referrers by simplifying the referral route • Increased efficiency within provider organisations by allowing stronger and more dynamic management of capacity.

IT network and Wi-Fi access In 2018/19, the CCG continued to transfer practices to the same IT network, which also aligned with the national roll out of Wi-Fi network capability for clinical services and free Wi- Fi access for patients.

Wi-Fi is now available across all practices and this access allows patients, visitors, and staff to connect to the internet using their digital devices (including computers, tablets and smart phones) and supports clinicians to better utilise mobile devices to support care delivery. Citizens will be able to utilise the Wi-Fi network to access the internet whilst waiting for an appointment or test in the practice

Electronic Prescribing Services (EPS) The EPS enables prescribers such as GPs and practice nurses to send prescriptions electronically to a dispenser (such as a pharmacy) of the patient's choice. This makes the prescribing and dispensing process more efficient and convenient for patients and staff. Practices continue to make good use of this resource for patients and overall usage is some of the highest in our region. Practices that are not achieving the high activity levels are

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supported by a Project team, CCG Medicines Optimisation team, Local Pharmacy Committee and pharmacies.

CCG % EPS prescription items Practices active with EPS

Stoke-on-Trent 75.68% 43/43 practices

GP online access GP online is designed to support practices in offering online services to patients including the ability to book appointments, order repeat prescriptions and have access to coded information within their records. Some of the key benefits documented to date include improved and convenient access to care services, patient empowerment of increased knowledge and information sharing, reduced administration workload for the GP practice, reduced DNAs, reduced travelling time - for example to request a prescription - and increased patient satisfaction improving and speeding up access to expertise within the practice. If you would like access to your record which includes the ability to book appointments and request repeat prescriptions, please speak with your practice reception staff who will be able to explain the process to get this activated.

Staffordshire was one of five areas across the country to pilot the new NHS App during 2018/19. The NHS App is being made available to support patients with the GP Online services and provides a simple and secure way for people to access a range of NHS services on their smartphone or tablet. When practices are live with NHS App, patients can register and verify their identity so they can use GP Online services, check your symptoms, find out what to do when you need help urgently, register as an organ donor and choose whether the NHS uses their data for research and planning.

Commissioning the foundations from which to implement new models of care (Right care, Right place, Right time) The New Models of Care (NMC) Programme has continued as part of the STP response to transforming primary care and community services across Staffordshire. It sits alongside other areas of development including Long-Term Conditions and Frailty, Community Hospitals and elements of primary care prevention. The programme is in place to address the sustainability of General Practice alongside the development and transformation of the system - to achieve better outcomes for patients, reduce reliance on hospital care and

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provide more services closer to home. As well as developing locality care hubs, we have also been working with provider organisations towards forming alliances.

Significant progress will be made in 2019/20 across the Staffordshire area in defining networks of practices. This includes:

• Continued multi-disciplinary team meetings of healthcare professionals, mental health teams and social care. Proactive care planning approaches have been undertaken supporting elderly frail patients, those with long-term conditions or those that have other health or social needs that place them at risk of emergency hospital admissions.

Extended Access to Primary Care This programme focused on commissioning extended access services for the registered population of Staffordshire, a key requirement of the GP Forward View. The CCG commissioned service provision across Staffordshire for 100% of the registered patient population and service delivery commenced on the 1 September 2018, thereby achieving the national target.

The services deliver access to primary care seven days a week and include bank holiday provision. Resources were developed to support the advertising of the services which included physical and online resources and the CCG’s Communication and Engagement Team regularly updates its social media platforms. Providers regularly request patient feedback on the service received and the CCGs are undertaking a feedback exercise now the service has been operational for six months.

Further service development is ongoing to secure the IT functionality to enable NHS111 to book appointments directly into the service.

Marcus Warnes Accountable Officer 23 May 2019

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Accountability Report Corporate Governance Report The Corporate Governance Report seeks to explain the composition and organisation of the CCG’s governance structures and how they support the achievement.

Member profiles

Dr Lorna Clarson became Chair of Stoke-on-Trent CCG from January 2019. Prior to this, Dr Ruth Chambers held the position.

Marcus Warnes became the single Accountable Officer for Cannock Chase CCG, North Staffordshire CCG, South East Staffordshire and Seisdon Peninsula (SESSP) CCG, Stafford and Surrounds CCG and Stoke-on-Trent CCG on 1 November 2017 and became Accountable Officer for East Staffordshire CCG on 1 April 2018.

Member practices

Practice Name Address Post Code Abbey Surgery 77 Woodhead Road, Stoke- ST2 9DH on-Trent

Branch Surgery: Hanley Health Centre, ST1 2BN Upper Huntbach Street, Hanley Adderley Green Surgery Longton Health Centre, ST3 1EQ (Adderley Green Medical Drayton Road, Longton, Surgery Ltd) Stoke-on-Trent

Branch Surgery: 28-30 Weston Street, ST3 5DQ Adderley Green, Stoke-on- Trent Apsley House Practice Cobridge Primary Care ST6 2JN Centre, Church Terrace, Cobridge

Branch Surgery: 62 Knypersley Road, ST6 8HZ Norton, Stoke-on-Trent Baddeley Green Surgery 988 Leek New Road, ST9 9PB Stockton Brook, Stoke-on- Trent Belgrave Medical Centre 116 Belgrave Road, ST3 4LR Dresden, Stoke-on-Trent Birches Head Medical Diana Road, Birches Head, ST1 6RS Centre Stoke-on-Trent

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Branch Surgery: ST2 8DA Hulton House Surgery, 1479 Leek Road, Abbey Hulton Blurton Medical Practice Blurton Health Centre, ST3 3BS Ripon Road, Blurton, Stoke- on-Trent Borse and Partners Meir Primary Care Centre, ST3 6AB Weston Road, Meir, Stoke- on-Trent Brinsley Avenue Medical 11 Brinsley Avenue, ST4 8LT Practice Trentham, Stoke-on-Trent

Branch Surgery: The Health Centre, Old ST12 9EP Road, Barlaston, Stoke-on- Trent Brook Medical Centre 98 Chell Heath Road, ST6 7NN Bradeley, Stoke-on-Trent

Branch Surgery: Smallthorne Site Surgery, 2 ST6 1SA Baden Road, Smallthorne, Stoke-on-Trent Cambridge House Surgery Cambridge House, 124 ST2 9AJ Werrington Road, Bucknall Cobridge Surgery Cobridge Community Health ST6 2JN Centre, Church Terrace, Cobridge Dunrobin Street Medical Dunrobin Street, Stoke-on- ST3 4LL Centre Trent Five Towns GP Surgery Shelton Primary Care ST1 4PB Centre, Norfolk Street, Shelton Foden Street Surgery 32 Foden Street, Stoke-on- ST4 4BX Trent Furlong Medical Centre Furlong Road, Tunstall ST6 5UD Glebedale Medical Practice Glebedale Road, Fenton, ST4 3AQ Stoke-on-Trent Goldenhill Medical Centre High Street, Goldenhill, ST6 5QJ Stoke-on-Trent Harley Street Medical Harley Street, Hanley ST1 3RX Centre Branch Surgery: Student Health Services, ST4 2YJ Coalport Building, Leek Road, Stoke-on-Trent Hartshill Medical Centre Ashwell Road, Hartshill, ST4 6AT Stoke-on-Trent Haymarket Health Centre Dunning Street, Tunstall ST6 5BE

Branch Surgery: Stoke Health Centre, ST4 7JB Honeywall, Stoke-on-Trent Longton Hall Surgery 186 Longton Hall Road, ST3 2EJ Blurton, Stoke-on-Trent

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Lucie Wedgwood Health Chapel Lane, Burslem, ST6 2AB Centre (Lucie Wedgwood Stoke-on-Trent Surgery Ltd) Mayfield Surgery 54 Trentham Road, ST3 4DW Longton, Stoke-on-Trent Meir Park and Weston Meir Park Surgery, ST3 7TW Coyney Medical Practice Lysander Road, Meir, Stoke-on-Trent

Branch Surgery: ST3 6AB Meir Primary Care Centre, Weston Road, Meir, Stoke- on-Trent Merton Street Surgery Merton Street, Longton, ST3 1LG Stoke-on-Trent Middleport Medical Centre Newport Lane, Middleport ST6 3NP Miles and Partner Meir Primary Care Centre, ST3 6AB Weston Road, Meir Millrise Medical Practice 12 Millrise Road, Milton, ST2 7BW Stoke-on-Trent Moorcroft Medical Centre Botteslow Street, Hanley ST1 3NJ

Branch Surgeries: Bentilee Neighbourhood Centre, Dawlish Drive, ST2 0ES Bentilee Norfolk Street Surgery, ST1 4PB Shelton Orchard Surgery Knypersley Road, Norton, ST6 8HY Stoke-on-Trent

Branch Surgery: Endon Surgery, Station ST9 9DN Road, Endon Potteries Medical Centre Beverley Drive, Bentilee, ST2 0JG Stoke-on-Trent Drs Rees, Lefroy and Aw Stoke Health Centre, ST4 7JB Honeywall, Stoke-on-Trent Dr S B Kulkarni Stoke Health Centre, ST4 7JB Honeywall, Stoke-on-Trent Drs Shah and Talpur Hanford Health Centre, New ST4 8EX Inn Lane, Hanford Dr Sinha 16 Rosslyn Road, Longton, ST3 4JD Stoke-on-Trent Snowhill Medical Centre Shelton Primary Care ST1 4PB Centre, Norfolk Street, Shelton Trent Vale Medical Practice 876 London Road, Stoke- ST4 5NX on-Trent Trentham Mews Surgery The Surgery, Trentham ST4 8PX Mews, New Inn Lane, Trentham Trinity Medical Centre Uttoxeter Road, Blythe ST11 9HQ Bridge, Stoke-on-Trent Tunstall Primary Care Alexandra Park, Scotia ST6 6BE Centre Road, Tunstall

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Branch Surgery: Packmoor Medical Centre, ST7 4SS Thomas Street, Packmoor Willow Bank Health Centre Meir Primary Care Centre, ST3 6AB Weston Road, Meir

Composition of the Governing Body

Voting Number Board Nurse/Secondary Care Consultant 2 GPs 2 Executive Clinical Directors 4 Officers 6 Lay Members – statutory 3 In attendance – non-voting LMC Representative 1 Officers 4

Title First name Surname Position Date of Date of joining the leaving the committee* committee* Dr Ruth Chambers Clinical Chair December 2018 Dr Lorna Clarson Clinical Chair January 2019 Mr Marcus Warnes Accountable Officer Mr Alistair Mulvey Chief Finance Officer Mrs Heather Johnstone Director of Nursing and Quality Dr John Gilby Clinical Director for Primary Care Dr Steve Fawcett Medical Director Dr Waheed Abbasi Clinical Director Dr Simon Mellor Clinical Leader September 2018 Dr Doug Robertson Secondary Care October Consultant 2018 Dr Latif Hussain Non-executive GP Board Member Mr John Howard Lay Member for Governance Mrs Margy Woodhead Lay Member for PPI Mr Tim Bevington Lay Member * Dates only included if there has been a change in-year

Governing body profiles can be viewed online: https://www.stokeccg.nhs.uk/your-ccg-stoke/meet-the-board

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Committee(s) including Audit Committee

Audit Committee (This is a committee held in common with North Staffordshire CCG. Only North Staffordshire or Stoke-on-Trent CCG members vote on North Staffordshire or Stoke-on-Trent issues.)

Title First name Surname Position Date of Date of joining the leaving the committee* committee* Mr Neil McFadden Chair and Lay Member for Governance (North Staffordshire only) Dr Latif Hussain Non-Executive GP Board Member (North Staffordshire and Stoke- on-Trent) Dr Doug Robertson Secondary Care Consultant (North Staffordshire only) Mr Peter Dartford Lay Member for PPI (North Staffordshire only) Mr Mike Edgley Lay Member (North Staffordshire only) Dr Simon Mellor Secondary Care Doctor (Stoke-on-Trent only) Mr John Howard Chair and Lay Member for Governance (Stoke-on- Trent only) * Dates only included if there has been a change in-year

Remuneration Committee Members The Remuneration Committee has met twice as a single Committee, and then met once in common with the other five CCGs in Staffordshire and Stoke-on-Trent during 2018/19.

Details of membership can be found in the Remuneration and Staff Report.

Further details of the sub-committees of the Governing Body can be found in the Annual Governance Statement.

Register of Interests

Details of company directorships and other significant interests held by members of the Governing Body which may conflict with their management responsibilities, as well as details of how we manage these conflicts, can be viewed online: https://www.stokeccg.nhs.uk/stoke-governance/declaration-of-interests

Please see the Governance Statement for more information.

Personal data related incidents

Please see the Governance Statement for more information.

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Statement of Disclosure to Auditors

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

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

Modern Slavery Act 2015

The Modern Slavery Act 2015 establishes a duty for commercial organisations with an annual turnover in excess of £36m to prepare an annual ‘Slavery and Human Trafficking Statement’. This is a statement of the steps the organisation has taken during the financial year to ensure that slavery and human trafficking is not taking place in any of its supply chains or in any part of its own business. Income earned by NHS bodies from government sources, including CCGs and Local Authorities, is considered to be publicly funded and is therefore outside the scope of these reporting requirements.

After discussion with our Auditors, the CCG does not consider that it has any activities that requires it to be treated as a commercial organisation for the purpose of the Modern Slavery Act 2015. We do not engage in profit-making activities, and so do not trigger the mandatory reporting requirements.

However, we fully support the Government’s objectives to eradicate modern slavery and human trafficking. Even though we do not meet the requirements for producing an annual statement, as best practice, we have produced one and made it available on our website: https://www.stokeccg.nhs.uk/your-ccg-stoke/sot-publications/generic-publications- 2/newsletters-alerts-and-publications/1030-modern-slavery-act-2017-statement-north-staffs- stoke-ccg-final/file

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Statement of Accountable Officer’s Responsibilities

The National Health Service Act 2006 (as amended) states that each Clinical Commissioning Group shall have an Accountable Officer and that Officer shall be appointed by the NHS Commissioning Board (NHS England). NHS England has appointed Mr Marcus Warnes to be the Accountable Officer of Stoke-on-Trent CCG.

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

• the propriety and regularity of the public finances for which the Accountable Officer is answerable • 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 a statement of accounts in the form and on the basis set out in the Accounts Direction. The accounts are prepared on an accruals basis and must give a true and fair view of the state of affairs of the Clinical Commissioning Group and of its income and expenditure, Statement of Financial Position and cash flows for the financial year.

In preparing the accounts, the Accountable Officer is required to comply with the requirements of the Government Financial Reporting Manual and in particular to:

• observe the Accounts Direction issued by NHS England, including the relevant accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis • make judgements and estimates on a reasonable basis • state whether applicable accounting standards as set out in the Government Financial Reporting Manual have been followed, and disclose and explain any material departures in the accounts • prepare the accounts on a going concern basis.

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The CCG has received a qualified audit opinion for the value for money conclusion. As such, the CCG has not complied with Section 14q of the National Health Service Act 2006 (as amended). Furthermore, as the CCG is in deficit, it has not complied with its financial duties under Section 223H to 223J of the National Health Service Act 2006 (as amended). In all other respects to the best of my knowledge and belief, I have properly discharged the responsibilities set out under the National Health Service Act 2006 (as amended), Managing Public Money and in my Clinical Commissioning Group Accountable Officer Appointment Letter.

I also confirm that:

• as far as I am aware, there is no relevant audit information of which the CCG’s Auditors are unaware, and that as Accountable Officer, I have taken all the steps that I ought to have taken to make myself aware of any relevant audit information and to establish that the CCG’s Auditors are aware of that information • the Annual Report and Accounts as a whole is fair, balanced and understandable. I take personal responsibility for the Annual Report and Accounts and the judgments required for determining that it is fair, balanced and understandable.

Marcus Warnes Accountable Officer

23 May 2019

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Governance Statement

Introduction and context

Stoke-on-Trent CCG is a corporate body 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 2019, the CCG is not subject to any directions from NHS England issued under Section 14Z21 of the National Health Service Act 2006. However, in July 2018 the CCG was placed in special measures regime for its financial operational performance.

Scope of responsibility

As Accountable Officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of the CCG’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 CCG Accountable Officer Appointment Letter.

I am responsible for ensuring that the CCG 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 CCG as set out in this Governance Statement.

Governance arrangements and effectiveness

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

This has been achieved by:

Key features of the CCG’s constitution in relation to governance The CCG will promote good governance and proper stewardship of public resources in pursuance of its goals and in meeting its statutory duties.

The principles of good governance are established in our Constitution: https://www.stokeccg.nhs.uk/stoke-governance/constitution

The CCG will at all times observe these generally accepted principles in the way it conducts its business.

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These include:

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

Information about the Governing Body, the Membership Board and the Committees The Governing Body has an ongoing role in reviewing the CCG’s governance arrangements, to ensure that they continue to reflect the principles of good governance. The CCG has a programme of organisational development (OD) sessions for the Governing Body held bi- monthly to strengthen commissioning arrangements and provide mandatory training.

There are four new Membership Engagement Groups made up from a clinician from each of the 44 practices in the Stoke-on-Trent CCG. The Membership Engagement Groups provide the professional clinical expertise and scrutiny to ensure the CCG’s decisions are clinically led.

Formal Committees of the CCG Audit Committees April 2018 – March 2019 Remuneration and Terms of Service April 2018 – March 2019 Committee in common Primary Care Committee April 2018 – March 2019 Joint Quality Committee April 2018 – March 2019 Joint Finance and Performance April 2018 – November 2018 Organisational Development Committee April 2018 – November 2018 Joint Planning and Commissioning April 2018 – November 2018 Committee Strategic Commissioning Committee December 2018 – March 2019 Communication, Engagement, Equality and December 2018 – March 2019 Employment Committee North Divisional Committee December 2018 – March 2019

Joint arrangements with other CCGs The CCG has worked closely with North Staffordshire CCG and since 2015/16. As part of the relationship, the CCG operated the formal Committees of their Governing Body as committees in common or joint committees. However, each CCG sub-committee still have the ability to meet as a separate committee should it be necessary.

On 3 December 2018, Stoke-on-Trent CCG was a signatory to a letter from the six CCGs from Staffordshire and Stoke-on-Trent, to NHS England, informing them that they “wish to submit an expression of interest to explore the option of developing a single strategic commissioning organisation in April 2020.”

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To reflect the closer working in the second half of the year there were changes in the governance arrangements.

As part of the development towards a strategic commissioning organisation, from September 2018 until March 2019 Stoke-on-Trent CCG held its Governing Body sub-committees in common or jointly with the other five CCGs in Staffordshire. The CCG will be making amendments to its Constitution to reflect this, as detailed in the chart below.

Meetings of the Governing Body The CCG has a duty to demonstrate accountability to its key stakeholders. It achieved this by holding eight Governing Body meetings in public, ten in private, and an Annual General Meeting held in public.

Two Extraordinary Governing Body meetings were held in common with North Staffordshire CCG in May and June and four Extraordinary Governing Body meetings were held in common with the other five CCGs in Staffordshire and Stoke-on-Trent in September and December 2018 and February and March 2019.

Information about the committees The Joint Finance, Performance & Contracts Committee, North Divisional Committee (as successor to the Joint Finance, Performance & Contracts Committee) and Quality Committee all have at least one clinician, executive and lay member as part of their membership. The Audit Committee, Remuneration Committee, Communication and Engagement Committee and the Primary Care Committee membership consist of the CCG’s lay members. The Organisational Development (OD) Committee consisted of one lay member, and officers.

The Terms of Reference for each of the CCG’s committees, providing further details of their membership, roles and responsibilities, can be found in the Constitution. The Constitution can be found on the CCG’s website: https://www.stokeccg.nhs.uk/publications-library/constitution-1/1174-stoke-on-trent-ccg- constitution/file

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Information about the new committees A draft set of Terms of Reference for the Committees have been developed and are under review by the Governing Body.

The Strategic Commissioning Committee and Quality Committee all have at least one clinician, executive and lay member as part of their membership. The Audit Committee, Remuneration Committee and the Primary Care Committee membership consist of the CCG’s lay members. The Communication, Engagement, Equality and Employment (CEEE) Committee consist of one lay member, officers and staff representatives.

Performance of the Membership Body and Governing Body, including their own assessment of their effectiveness Each committee meeting has a standing agenda item at the end of the meeting to review its effectiveness (against Terms of Reference, objectives for the meeting etc). A series of self- assessment questions are completed by all members present and noted within the minutes – with any issues escalated by the Chair through routine “Highlight Reports” that go to subsequent Governing Body meetings for information. The questions are:

• Did we achieve what we set out to do linking back to the agenda? • Was the information presented appropriate / easy to understand? • Was the information received in a timely manner prior to the meeting? • Do we need to inform any of our decisions / actions (sub-committees, staff, Regulator etc?) • Are we assured? • Do we need any more information / require a further progress report at a later date? • Agreed actions captured in the minutes? • Were there any risks raised in the meeting that should be captured in the risk register?

The CCG has now had six years’ experience of delivering its functions as a statutory organisation and a review of performance against key standards and domains designed by NHS England have been used to evaluate the effectiveness and impact of the CCG.

As part of ensuring that the required professional standards are achieved, the CCG’s Governing Body and committees adhere to the following principles, drawn from our Constitution and their Terms of Reference.

The Governing Body audits its own and its committees’ performance and effectiveness in a number of ways:

• According to provisions within our Constitution • Governing Body and committee members abide by the ‘Nolan Principles’ • Quoracy and Conflicts of Interest are recorded at the start of each meeting and throughout and include details of how conflicts are managed • Draft minutes of each preceding meeting are approved at each subsequent meeting • Approved minutes of committees are submitted to each Governing Body meeting • Delegation of powers to committees from the Governing Body to manage certain items: for example, policy approvals (Governing Body still formally ratifies these) • Board observations have been carried out by our Internal Auditors

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• Escalation and highlights report submitted for each subsequent GB meeting and Chair raises any issues by exceptions.

Deloitte, our OD partner conducted observations of the CCG Governing Body during 2018/19 and will use the observation to shape the OD Plan.

An observation of the Governing Body’s approach to managing risk was undertaken by our Internal Auditors Pricewaterhouse Coopers (PwC). The risk observation will form part of the reports on the CCG’s overall risk management arrangements and the recommendations will be overseen by the Audit Committee.

There is also provision in our Constitution for our member practices to call a meeting of the Governing Body (where due process has been followed). Member practices have not called for a meeting of the Governing Body in 2018/19, nor have any formal constructive votes of no confidence been held by the CCG’s membership.

The names of all members present at Governing Body, the Membership Board and formally- constituted committee meetings in 2018/19 are routinely recorded in the minutes of these meetings. Attendance has been of a satisfactory level throughout 2018/19.

All papers for the meetings held in public can be found on the website: https://www.stokeccg.nhs.uk/your-ccg-stoke/board-meetings

Where quoracy has not been maintained for meetings, the arrangements to mitigate this have been set out in the minutes.

The Governing Body meeting held on 18 April was not quorate for all items. It was agreed that any decisions made by the Governing Bodies would be ratified outside of the meeting with absent members.

The CCG Governing Body can confirm that it has received verbal reports from the CCG committees, along with approved minutes and it is satisfied with the composition, attendance and efficacy of these committees.

Highlights of the work of all the above committees, sub-committees and joint committees: Stoke-on-Trent CCG has four Membership Engagement Groups, which meet on a monthly basis.

Issues discussed include:

• Clinical pathways related to cancer services, physiotherapy, phlebotomy and mental health • Integrated Care Teams • Primary Care Networks • Developing a strategic commissioning organisation • Finance report.

The Audit Committee meetings in common with North Staffordshire CCG were held in April and May and in common with the other five CCGs from Staffordshire and Stoke-on-Trent in September, December 2018 and February and March 2019.

The Committee’s role is to provide assurance to the Governing Body on systems of internal control through the independent, objective review of financial and corporate governance /

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risk management arrangements (including internal and external audit matters, compliance with the law, guidance and regulations pertinent to the NHS).

All meetings were quorate for Stoke-on-Trent CCG, with the exception of the meeting in March 2019. The views were sought from colleagues in respect of the agenda items which require a decision.

The Audit Committee focused on:

• The Freedom of Information (FOI) Annual Report • Internal Audit Plan • The receipt and scrutiny of reports from both External and Internal Auditors and the scrutiny of action plans to address these reports • Annual Report for 2017/18 • The ongoing review of fraud prevention including the summary reports from any investigations • The Governance work programme • The ongoing review of the CCG’s Assurance Framework and the management of risk, including the oversight of the Risk Group • Scrutiny of CCG registers for Conflicts of Interest, and Gifts and Hospitality • The oversight of the Policy Group and the scrutiny of Governance Policies • Information Governance (IG) Annual Report • Annual Governance Statements • Conflicts of Interest • Single Tender Actions / Waivers.

Membership of the CCG’s Audit Committee is sighted as part of the Members’ Report within this Annual Report.

The Remuneration Committee met alone in July and August, and in common with the other five CCGs from Staffordshire and Stoke-on-Trent in September and December 2018.

The Committee’s role is to make recommendation to Governing Bodies on determinations about remuneration, conditions of service, benefits and allowances for Very Senior Managers and any alternative to the NHS scheme for employees and members of the Governing Bodies. All meetings were quorate.

The Committee dealt with:

• Governing Body appointments • An update on Clinical Associates • The IR35 process • Review of the Accountable Officer’s pay • Review of Executive Directors’ pay • 1% payment to Gold and Silver On Call • Development of Remuneration Framework.

The Quality Committee met ten times in 2018/19. Three meetings were held jointly with North Staffordshire CCG between April and June 2018. The Committees from all six CCGs from Staffordshire and Stoke-on-Trent met seven times between June 2018 and March 2019.

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The Committee’s role is to provide assurance to individual Governing Bodies on the quality and safety of all services commissioned for local patients, including those led by other CCGs where the CCGs from Staffordshire and Stoke-on-Trent are an ‘Associate Commissioner’.

It also leads on other joint commissioning duties relating to pan-CCG Quality Strategy elements such as the assurance of non-clinical services (including Commissioning Support Unit Quality KPIs, approval of QIAs for QIPP schemes, research governance matters, the agreement of policies, receipt / management of clinical risk registers).

All meetings, with the exception of that held in December, were quorate. Following the December meeting the Chair contacted the voting members of the Committee, by email, to receive their votes on items where a decision was required.

The Committees focused on:

• Examination of quality data from commissioned provider organisations • Management of clinical risks • Adult and Children’s Safeguarding • Quality performance • Identified quality risks.

The Committee also received reports on:

• UHNM Risk Review Action Plan • Patient Safety • Transforming Care Programme • Primary Care Quality • Patient Engagement • Complaints and Soft Intelligence • Medicines Optimisation • Serious Incidents • QIA sub-group.

The Committee also approved Quality Account Summary Statements for UNNM, North Staffordshire Combined Healthcare Trust and NHS 111.

The Primary Care Commissioning Committee met 12 times.

The Committee is responsible for corporate decision making in the management of the delegated functions / exercise of delegated powers in relation to primary medical services review, planning and procurement.

The meetings in May and June 2018 and January 2019 were not quorate. Papers were distributed after the meeting for virtual ratification.

The meetings have focused on:

• Primary care quality • Social prescribing • Implementation of the GP Forward View • Primary care finances • Enhanced Services • GP Extended Access

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• Membership agreements.

The Primary Care Commissioning Committee has also held 12 confidential meetings. The meetings focused on local primary care issues.

The Communications, Engagement, Equality and Employment Committee met six times.

The Committee’s role is to support strategic commissioning by feeding in local views. It also provides a vehicle for PPI Lay Members from the six CCGs from Staffordshire and Stoke-on- Trent to agree common approaches. It covers all CCGs’ statutory duties, pertinent to title, including the Equality Act 2010.

It provides meaningful and timely communication to stakeholders, and engagement with communities, clinicians and staff (including consultation arrangements for changes to healthcare services in line with legislation). It oversees the joint OD Plan to develop and empower Governing Bodies, Senior Leadership Team and staff to deliver strategic objectives. It provides oversight of aspects of employment (including labour law compliance, employment standards and employee relations).

The meeting in January 2019 was not quorate and the decisions were sent to the voting members for approval.

The Committee focused on:

• Internal and external communications • Updates from the STP • Clinical engagement • Public engagement • Development of the Equality Strategy and objectives • Review of the Management of Change • Staff morale • Workforce statistics • Levels of compliance with statutory and mandatory training • The development of an OD Plan • Health and Safety updates.

The Joint Strategic Commissioning Committee met five times between April and August 2018.

Four meetings were quorate. The August meeting was not quorate, so the decision was deferred to the Governing Body.

The Committee focused on:

• OD Plan • Management of Change • Workforce • Equality Impact Process Governance • HR Policies.

The Joint Planning and Commissioning Committee met five times between April and November 2018.

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The April and November meetings were quorate, but the May, June and July meetings were not. Items for decision were sent to voting members for decision outside of the meeting.

The Committee focused on:

• The Operational Plan • Medicines optimisation • Prescribing Local Improvement Scheme • Hanley Primary Care Hub • Mental health • Clinical services • North Staffordshire Alcohol Improvement Plan • Commissioning intentions.

The Joint Finance and Performance Committee met six times between April and June 2018. Four meetings were quorate and two were not quorate. Items requiring a decision were taken by voting members outside of the meeting.

The Committee focused on:

• Finance • Planning • Contract activity • Performance • Quality, Innovation, Productivity and Prevention (QIPP) • and received business cases for scrutiny.

The Joint Strategic Commissioning Committee met five times.

The Committee’s role is to take a strategic approach to formulating and managing the strategy of the six CCGs from Staffordshire and Stoke-on-Trent to exercise their commissioning functions. It takes lead responsibility for strategic commissioning, financial, performance and quality management work to implement Strategic Plans from CCGs’ perspectives.

It leads on setting commissioning intentions / plans, monitoring performance against those and making recommendations about corrections. It will develop common Staffordshire-wide Strategic Commissioning Plans and work with the three Divisional Committees in order to implement them.

All meetings were quorate

The Committee focused upon:

• The development of a strategic commissioning organisation • Development of a lead provider for orthopaedics • Consultation on excluded and restricted procedures • Alignment of IVF Policies • Discharge to Assess • Management of complex cases • Scheme of Reservation and Delegation • EU Exit Plan.

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The North Divisional Committee met five times.

The Committee operates with representation from CCGs and their memberships to jointly plan locally-relevant, transactional implementation items aligned to the Commissioning Plans for their area. The Committee has responsibility for transacting agreed deliverables established by the Joint Strategic Commissioning Committee and taking local ownership of implementing these.

All meetings were quorate.

The Committee focused on:

• Financial position • Performance • Quality, Innovation, Productivity and Prevention (QIPP) • Primary Care Networks • Services: spirometry, falls, eye health • Technology-enabled care (TECs).

UK Corporate Governance Code

NHS Bodies are not required to comply with the UK Code of Corporate Governance. However, we have reported on our Corporate Governance arrangements by drawing upon Good Governance Institute best practice.

Discharge of statutory functions

Arrangements have been put in place by the CCG and developed with extensive expert external legal input, to ensure compliance with all relevant legislation. That legal advice also informed the matters reserved for Membership Body and Governing Body decision and the scheme of delegation.

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

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

Risk management arrangements and effectiveness

The CCG’s approach to risk management was developed in line with best practice and with input from the organisation’s Audit Committee and Internal Auditors. The new approach was scrutinised by Internal Auditors, the CCG’s Audit Committee and Governing Body in the Autumn of 2018.

During 2018/19, the CCG conducted a thorough review of the risk management process across all six CCGs. A Risk Strategy (overview below) was developed and agreed across the six CCGs; and in February 2019 a Board Assurance Framework (BAF) was developed.

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A complex review to align all six CCGs’ Risk Registers has also been conducted and a new electronic risk register has been developed across all six CCGs. Directorate (operational) Risk Registers feed into the Corporate Risk Register where identified risks score over 12. All risks on the Risk Register were aligned within the review to support the new BAF, aligned whilst retaining risks which are local to the area. The Risk Group was launched in March 2019 to ensure triangulation across directorates of all risks was put in place.

Key elements of the new, joint Risk Strategy define the way in which risk (or changes in risk) are identified, evaluated, and controlled across the CCGs to:

• Help staff to prevent or deter risk wherever possible by being aware of risks / issues associated with their role and in taking reasonable measures to minimise these. Where not, to initiate action to stop any practice considered to be unsafe (especially including fraud risk), regardless of seniority / profession of the person undertaking the practice. This enables them and their Directorate to manage operational activities and consider risks potentially arising from these that either directly or indirectly link to strategic objectives; thereby helping them to manage “day job” issues effectively to prevent those becoming formally-identified risks.

• Where such issues are not possible to be mitigated as “business as usual”, the risk is recorded and steps put in place by the nominated Risk Owner to manage all current risks identified.

• A series of control mechanisms work to support and analyse risk. Risk description (assessment), scoring, evaluation and treatment matters are determined by the Risk Owner – involving the Governance Team if required – and then formal risk monitoring and reporting undertaken through the Risk Group and CCG Committee process described later on in this section.

• Risk appetite is determined as part of the risk treatment process – a range of interventions are included within the Risk Strategy to determine whether any risk is Avoided (by not undertaking the activity introducing the risk); Reduced (by implementing the identified mitigating actions to minimise the risk to acceptable levels); Transferred (where feasible to do so); or Accepted then Closed (by making an informed decision that the risk rating is at an acceptable level or that the cost of the risk treatment outweighs the benefit).

In this way we actively support our “Risk Culture” to ensure that risk management is fully embedded in the CCG’s core business activity (including inter-linked areas such as undertaking Equality Impact Assessments with in-built risk assessment checks, or to support all incident reporting to be carried out openly).

The BAF and the Risk Register should work together to identify and monitor threats to the CCG’s strategic goals. The late development of the BAF meant this did not happen early enough in the year. The new BAF is being updated in May 2019 to ensure the Governing Bodies are alerted to risks that impact delivery of the strategic objectives throughout the year.

The Governing Body has received the Risk Register early on the agenda to ensure discussions are informed by risk. There has been one exception in the South where this didn’t happen. All Board reports identify links between their content and items on the Risk Register. At the end of each meeting, the Committee considers whether any new risks have

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been identified and are recommended for addition to the Risk Register. This practice is now being embedded into the work of all of the Governing Body sub-committees.

The Internal Risk Audit Report carried out by PwC during July / August 2018 noted the work that is being undertaken to implementing a single risk management system across all six CCGs, including:

• A Risk Management Strategy, policy and procedures • A Risk Register for all six CCGs, with risks for individual CCGs where relevant • A BAF, tailored for individual CCGs where appropriate, which as noted above was developed at the end of the financial year.

Risk Management training has been delivered by our Internal Auditors to our Senior Leadership Team and to staff involved in identifying, recording, managing and monitoring risks. Following concerns expressed at Governing Bodies and Audit Committees in December that the process needed more oversight and review by officers from directorates, a Risk Group has been set up from March 2019. This meets monthly and reports into the Audit Committee as a sub-group. The membership of the Risk Group comprises of all Executive Directors, or their deputies. The Governance Manager supports the Risk Group and the management of the BAF and Risk Register and will support the Governing Body and its Committees in risk management. Directors are held to account for their risks through the Group. The Group’s purpose is to develop and embed the risk culture as proposed by the Risk Strategy for the CCGs in Staffordshire and Stoke-on-Trent, ensure that the Risk Register is clear, up to date and there is a consistent application of the scoring matrix. The risk group also helps ensure consistency of approach and provides challenge to risk owners that they are taking sufficient and appropriate action.

All CCG staff are expected to risk assess their areas of work and to discuss these with their line managers and Executive Directors. These discussions will determine the actual risk and how this can be managed.

The CCG encourages involvement from public stakeholders in managing risk through the BAF and Risk Register which will be on the agenda for the Governing Bodies held in public and by publishing it on the CCG’s website in the meeting papers. This document will be discussed in Governing Body meetings, thereby presenting an opportunity for public stakeholders to engage in the CCG’s risk management.

Assessment and review of the Directorate and Corporate Risk Registers is undertaken by the relevant lead committee, as indicated on the risk register. The relevant risks are assigned to the relevant committee – e.g. Quality & Safety Committee is responsible for clinical risk; the Divisional Committees are responsible for tactical clinical or non-clinical risks pertinent to their area. The Audit Committee and Governing Body receive regular updates of the Corporate Risk Register, covering all risks scoring over 12, in undertaking their strategic oversight roles.

These meetings are attended by lay members – both statutory and non-statutory. Risk is discussed at the CCG’s Annual General Meeting where the Governance Statement and Annual Reports and Accounts are presented.

Owing to the focus on bringing the Risk Registers together and the delay agreeing an aligned set of strategic objectives the BAF wasn’t developed until February 2019 which has provided limited opportunity for the Governing Body to discuss the impact of risk on delivery of the strategic objectives.

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The PwC Audit reviews of the Corporate Governance and Risk Management processes and a more focused piece on Risk Management has resulting in the following findings:

Corporate Governance and Risk Management

Our report includes two high risk findings which relate to all of the Staffordshire and Stoke- on-Trent CCGs:

• In general, there is a lack of discussion and scrutiny of financial issues. At some meetings where there were papers on finance then no finance staff were present. At others the finance staff were not senior enough to answer members’ questions.

A Staffordshire-wide Finance and Performance Committee should be put in place as soon as possible, to provide the opportunity for focused scrutiny of financial performance and where appropriate finance officers should be in attendance to help explain the current position, financial risks and financial plans.

• Attendance at meetings is mixed. Six of the 13 meetings we observed were not quorate. Executive directors did not attend the first two meetings of the Risk Group: a Group specifically put in place for executive directors to discuss the CCGs’ risks and where the Terms of Reference specify that all Executive Directors are expected to attend, and send a deputy if they are unable to attend.

We also identified two medium risk findings which relate to all the Staffordshire and Stoke- on-Trent CCGs:

• Improvements are required to the level and degree of discussion of risk at Governing Body and committee meetings, including increased clarity as to the extent to which risk management is discussed in each setting.

• The role of the divisional committees is unclear, as they have no power to make decisions.

Risk Management

We reported two findings in our report, both of which are rated as high risk because of the implications for the overall management of risk at the Staffordshire and Stoke-on-Trent CCGs:

• The Governing Bodies have not agreed strategic objectives for the Staffordshire and Stoke-on-Trent CCGs.

• The Board Assurance Framework (BAF) was produced in February 2019 by the Executive Team. Because of the timing of this, there were limited opportunities for members of the Governing Body to review, provide feedback, and challenge the content of the BAF. The Audit Committee accepted the BAF in February 2019, and whilst five of the six Governing Bodies did approve the BAF in March 2019, the East Staffordshire CCG Governing Body did not as there was no public meeting prior to 31 March 2019. Work needs to be done to ensure that all Governing Bodies have agreed the format and structure of the BAF, and to refine the content.

The response to these findings will be addressed through the Integrated Improvement Plan.

Work is now required in 2019/20 to complete the transfer of the Risk Register onto the new Datix system for the six CCGs in Staffordshire and Stoke-on-Trent.

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Capacity to Handle Risk

The CCG Governing Body is responsible for the organisation’s systems for internal control, including risk management. The Accountable Officer is designated with overall responsibility for ensuring the implementation of external assurances covering risk management and reporting to the Governing Body. The Accountable Officer delegates some of these responsibilities to senior officers of the CCGs.

Single Leadership Team The role of the Single Leadership Team covering all CCGs in Staffordshire and Stoke-on- Trent is to have oversight of the Board Assurance Framework and the encompassing Risk Register for risks scoring 12+. Executive Directors are responsible for risks within their designated remit of work.

Audit Committee (held in common) The Audit Committee ensures that effective systems of integrated governance, risk management and internal control are maintained.

The Audit Committee reviews the Risk Register and Board Assurance Framework, and the work of the Risk Group.

The sub-committees of the Governing Bodies are responsible for overseeing the risks relating to their workstreams. The Audit Committee has oversight of all risks.

Accountable Officer The Accountable Officer has overall responsibility to ensure appropriate systems of internal control are in place for all aspects of governance, including financial and risk management as well as plans for dealing with emergencies that may impact on the CCGs.

Day-to-day management of risk management processes is delegated to the Director of Corporate Services, Governance and Communications.

Executive Directors The relevant Executive Director ensures all risks are identified, managed and mitigated for their workstreams and that the Risk Owner effectively carries out their duties. The attribution of risks will be aligned with the program portfolios, where possible and Executive Directors will attend the Risk Group to provide updates when required.

Risk Owners The Risk Owners will ensure that their risks are continuously managed, and the Risk Register is updated on at least a monthly basis or as deemed appropriate for the risk and approval by their Executive Director.

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The Directors are:

Executive Leads Area of Work

Director of Finance Finance, Governance and SIRO

Director of Quality and Safety and Chief Quality, Safety, Safeguarding, Caldicott Nurse Guardian

Director of Corporate Services, Governance Corporate Governance, Human Resources and Communications (HR) and Organisational Development, Communications and Engagement

Director of Primary Care Primary Care and Medicines Management

Director of Strategy, Planning and Performance, Information, Planning and Performance Strategy, as well as formal processes for consultation

Director of Strategic Commissioning and Commissioning and Operations, including Operations the work of Integrated Care and Urgent Care

Risk Assessment

During 2018/19, work commenced on the strategic risks for the Board Assurance Framework across the six CCGs from Staffordshire and Stoke-on-Trent and will be integral to the CCG’s Risk Management Procedures. Prior to August 2018 the CCG operated a single Risk Register; and after this date the Risk Registers for the six CCGs were aligned into one and double-run until the new system was fully implemented. To ensure further scrutiny the formal committees of the Governing Body receive a copy of their Risk Register (scoring 12+) at their bi-monthly meetings held in public.

The CCG can declare that it is currently managing 12 strategic risks on the Risk Register scoring 12+ and which will be carried forward into 2019/20, which includes:

• Six risks scoring 15 (extreme) and above in total, requiring the oversight of the Audit Committee and the Governing Body • Six risks scoring 12 (high), requiring the oversight of the Executive Management Team and the Audit Committee.

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Details of the six extreme scoring risks are as follows:

Risk Description Actions to Mitigate 1. Team capacity to cope with 1. A short-term resolution is being safeguarding process: discussed and is to be formalised. Safeguarding – Mental Capacity Act / Currently the South Safeguarding lead is Deprivation of Liberty Safeguards managing all open cases. (DoLs): The number of DoLs Assessments are likely to increase 2. A Brief on legislative change and following the Supreme Court's decision, current Mental Capacity Act S21a has and there is a risk that the team will not been issued. Challenges including likely be able to review these in a timely timescales have been drafted for sharing manner and ensuring any DoL is with the Executive Team. appropriate.

2. Increased number of nursing homes 1. Safeguarding Team is now fully closing / nursing home regulatory staffed. The Provider Improvement failure: Concerns around a high number Response Team (PIRT) commence in of nursing homes closing together with diction April 2019; the band 7 post is reduced bed numbers for patients back out for recruitment. requiring the service. Bed losses due to Nursing Home Regulatory failure which 2. Safeguarding and Nursing Home could impact on patient flow. Quality Assurance Team continue with phased return and development of one of the full time posts. PIRT interviews have been completed and will now be employed directly via the CCG.

3. There is a risk that the CCGs individually 1. The CCGs, at year-end, continue to or collectively fail to achieve their agreed forecast a deficit of £53m including all control totals through either increased risks. costs (including unplanned costs e.g. Referral to Treatment (RTT) backlog 2. The CCGs are collectively forecasting clearance/additional summer/winter a deficit of c. £53m – an unacceptable pressures) or through lower levels of failure against the control total (CT) Quality Innovation Productivity and (£20.1m) by £32.9m. Within this position, Prevention (QIPP) savings than planned. East Staffordshire, Cannock & Stafford CCGs will achieve the CT with the others forecasting a range of financial failure.

3. The resolution to this position is being constructed both internally and with support from Deloitte in partnership with the Sustainable Transformation Partnership (STP), with the recovery likely to take a minimum of two to three years, including a new Intelligent Fixed Payment System (IFPS) in order to meet guidance highlighting that all CCGs should be in balance by 2022/23, which will be the CCG minimum requirement.

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4. Workforce: GP recruitment and 1. Workforce plans and action plan retention: Failure to stabilise general developed by GP Forward View practice due to national shortage of GPs / Workforce Programme – approved by practice nurses. This shortage also spans NHS England workforce plan, includes health and social care, in particular recruitment and retention, international community nurses and other staff which recruitment, training and development, may impact across the Staffordshire new workforce models, marketing footprint. northern Staffordshire in partnership with the British Medical Journal. Monitored through Primary Care Workforce Group.

2. International recruitment scheme in progress. Task and Finish Group established.

5. The Staffordshire-wide network is made 1. Networks continue to be under threat up of core components, namely: from cyber-attack but new N3/Health and Social Care Network links/hardware in place, coupled with (HSCN) link which gives access to clinical other protective security software has systems, internet links, wide area network increased our cyber security defence. / local network (SSHIS) central links and individual practice links. All of these 2. Following new HSCN links components are at risk of cyber-attack or implementation the area has had a environmental impacts, such as links period of stability in regards to the major being impacted by local building work. incidents that impacted primary care last year. Whilst there have been network outages, these have been specific hardware, electrical and outside infrastructure incidents which were not connected and not possible to stop. 6. Failure to undertake the CCG’s 1. Case for Change, Issues Paper and statutory duties to involve in relation Programme Interdependencies available to the STP: The consequences of not in draft for consideration by Healthcare doing so could be legal challenge Transformation Board (HCTB). resulting in judicial review, Joint Health Overview Scrutiny Committee (JHOSC) 2. Concern that system partners are not referral to Secretary of State or that the working together with an open book Governing Bodies do not have sufficient approach has led to the development of understanding of public acceptability of a system-wide, ten-year plan with the proposals to give conscientious commitment from senior leaders to consideration and make the wrong deliver this. Workforce involvement decision. commenced in February 2019 across system partners. Governing Bodies report now includes narrative risk assessment.

The extreme risks listed above and the high scoring risks can be found within the Governing Body papers on the CCG’s website: https://www.stokeccg.nhs.uk/your-ccg-stoke/board-meetings

The CCG can also confirm that it holds an operational Risk Register and can declare that they are currently monitoring 38 risks in total, of which there is a request to close down one low scoring risk. The remainder are being carried forward into 2019/20. The current risks include:

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• Six risks scoring 15 (extreme) and above, requiring oversight of the Audit Committee and Governing Body • Six risks scoring 12 (high) and above, requiring oversight of the Audit Committee • 26 risks scoring ten or below (moderate to low) requiring oversight by the appropriate committee.

Whilst risks are managed by the Risk Owner and with oversight by their Executive Director and presented to Governing Body and the appropriate committee for assurance, there is further scrutiny by the Risk Group. The Risk Group, which has Director or Deputy Director level representation from all directorates, seeks to identify and share both positive and negative.

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

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

A robust system of internal control was not fully in place for the year ending 31 March 2019, the position has now strengthened with the introduction of the Board Assurance Framework in late 2018/19.

The BAF and review of the Risk Register are included within the Governing Body and Audit Committee Cycle of Business, as appropriate.

The Board Assurance Framework will be refreshed to develop the objectives in 2019/20. This will take place in May 2019.

A substantial piece of work is underway to align 220-plus individual CCG HR, Corporate Governance, Information Governance and other business policies across all six CCGs through the Policy Group which is a sub-committee of the Audit Committee.

Assessment of CCG effectiveness

Capability and Capacity Review In 2018, Deloitte reviewed the capacity and capability of the Finance Function. A number of findings were identified, including the need for additional senior capacity and subsequently the Finance Management structure was modified accordingly. The actions will form a key part of the Integrated Improvement Plan to be monitored by the Turnaround Board and Governing Bodies.

During 2018, the CCG commissioned Mike Attwood (Journeyman Support and Development), an independent OD Practitioner, to develop an OD Plan. NHS England provided funding to the CCG to appoint an OD partner to support the CCG’s journey towards becoming a strategic commissioner, as outlined in the NHS Long Term Plan (January 2019). Following a procurement exercise, Deloitte were appointed to this role. As part of their role, they have undertaken a capacity and capability review of the CCG.

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

Headlines/summary of findings Stoke-on-Trent CCG has aligned the Conflicts of Interest Policy across the six CCGs in Staffordshire and Stoke-on-Trent. They have also reviewed and aligned the templates used to collate the declarations from its staff and membership. The CCG is required to submit quarterly returns to NHS England confirming its compliance with the statutory guidance. The CCG publishes its registers of interest on its website and requests conflict of interest returns on an annual basis as per the statutory guidance.

Our Internal Auditors, PwC, carried out their annual internal audit of conflicts of interest on behalf of the CCG in quarter four of 2018/19.

PwC’s review focused on the revised changes to ensure the CCG continues to have sufficient processes and controls in place to meet the revised requirements. Internal Audit also reviewed the implementation of their prior year findings.

Three medium risks were identified:

• The December 2018 Conflict of Interest Register presented to the Audit Committee identified some gaps (46 members of staff) where declarations had either not been received or updated onto the register 2018/19 year to date • Minutes from two Governing Body meetings contained two incorrect declaration records in the publicly available minutes • There were three sets of Conflicts of Interest policies across the Staffordshire and Stoke-on-Trent CCGs. Given the closer working these should be reviewed and updated into one policy.

The response to these findings will be addressed through the Integrated Improvement Plan (see later section on page 99).

NHS England Conflicts of Interest Training:

• The CCG has taken a proactive approach to encourage staff to complete mandatory training on time, with regular monitoring and reporting throughout the year • Further action is in place in instances where training has not been completed by the required date.

Data Quality The Governing Body agrees the data, information and intelligence brought to its attention and the attention of the membership board and its committees is fully acceptable and fit for purpose.

Information Governance The NHS Information Governance Framework sets the processes and procedures by which the NHS handles information about patients and employees, in particular personal identifiable information. The NHS Information Governance Framework is supported by a Data Security & Protection Toolkit and the annual submission process provides assurances

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to the Clinical Commissioning Group, other organisations and to individuals that personal information is dealt with legally, securely, efficiently and effectively.

The CCG places high importance on ensuring there are robust information governance systems and processes in place protect patient and corporate information. We have established an information governance management framework and have developed information governance processes and procedures in line with the NHS Data Security & Protection Toolkit. All staff undertake annual information governance training and the Staff Information Governance Handbook is regularly updated to ensure staff are aware of their information governance roles and responsibilities.

There are processes in place for reporting and investigating serious incidents. The CCG has information risk assessments and management procedures and a programme will be established to embed an information risk culture throughout the organisation against identified risks.

The Data Protection Act 2018 and General Data Protection Regulation (GDPR) was implemented on 25 May 2018. The legislation introduced greater rights for individuals and the implementation of the accountability principle for organisations to ensure greater assurances relating to data sharing practices and protocols.

The CCG adheres to the legislation and has implemented data protection by design.

• The CCG appointed Paul Winter, Deputy Director of Corporate Services, Governance and Communications as the Data Protection Officer • All projects, processes or services carried out by or on behalf of the CCG, where personal data is or may be processed or access, have a Data Privacy Impact Assessment completed • The CCG publishes Privacy Notices on all CCG websites explaining what data is collected, how data is collected/shared and processed with appropriate legal basis to support processing evidenced • The CCG maintains an Information Asset Register to evidence all information assets held and associated data flows are mapped.

The Data Security & Protection Toolkit is an online self-assessment tool that enables organisations to evidence and publish their compliance against the ten data security and protection assertions.

On 28 March 2019, the CCGs published their Data Security and Protection Toolkit returns, which had been approved for submission by the Senior Information Risk Owner (SIRO) on behalf of the six CCGs from Staffordshire and Stoke-on-Trent.

To support staff a suite of documents was produced, incorporating the Information Governance Handbook, Staff Code of Conduct and Information Governance and Data Security and Protection Policies. Staff are required to read and acknowledge their understanding of these documents to ensure accountability of processes. It is a mandatory requirement for all staff employed by or on behalf of CCGs to undertake and pass Annual Information Governance training.

Personal Data Related Incidents There were three Information Governance personal data related incidents recorded for Stoke-on-Trent CCG between 1 April 2018 and 31 March 2019. The breaches involved:

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• a letter issued to a member of staff with an enclosure, containing a previous member of staff's personal details within it. The staff member was informed of the breach by the Caldicott Guardian. • staff members doing their NVQ had the assessor recording conversations • employee inappropriately accessing records

Two of the breaches were non-reportable, as they were classified as a low risk and one was externally reported.

Freedom of Information (FOI) Requests Following a review of the Freedom of information processes, additional oversight of the FOI service, provided by Midlands and Lancashire Commissioning Support Unit, has been implemented. This has led to an improvement in performance.

Stoke-on-Trent CCG has received 232 FOI requests and in excess of 98% were responded to within 20 working days. There were two breaches in the first six months of the year and zero in the second six months of the year.

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

Third party assurances The CCG commissions its back-office support from Midlands and Lancashire Commissioning Support Unit (MLCSU). Monthly performance reviews are scheduled with the CSU.

MLCSU’s Internal Audit support is provided by Deloitte.

PwC have completed their independent 2018/19 Service Auditor Reports (SARs) and the CCGs have been assured there was no impact on the service provided to CCGs.

The MLCSU’s Service Auditor Report stated “In total at the control level there were 2 exceptions out of the 83 controls tested. This has manifested into 1 exception at the objective level. The exception manifesting into an exception at the Control Objective level is as follows:

• Control Description B.3.1 relating to invoices raised are valid, accurate and processed in a timely manner. One sales order was identified as having been raised incorrectly by the O2C Team, a credit note was raised, and the invoice was re-raised correctly, however the invoice was re-raised outside of the specified timescale.”

Control issues

No material issues requiring reporting beyond the data incidents reported on the previous page and the underlying financial position were identified via the Month 9 Governance Statement return to NHS England.

Stoke-on-Trent CCG commenced the 2018/19 financial year with a planned surplus of £5.8m.

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Owing to a combination of a shortfall in the planned level of savings and additional, unanticipated in-year cost pressures, the CCG was unable to achieve this planned position and is predicting a deficit of £30.07m.

However, finances remain the significant control issue currently facing the CCG, and remedial action has been undertaken through a range of improvement plan activities noted previously in this report.

While it was determined that this issue did not prejudice the achievement of the other organisational priorities or undermined the integrity or reputation of the CCG and/or wider NHS, advice and opinions were sought by both Internal and External Audit and provided to the Audit Committee, including briefings on the financial position by the Chief Finance Officer throughout 2018/19.

At the time of writing the External Audit opinion on the financial statements is expected to be unqualified; therefore, delivery of the standards expected of the Accounting Officer are not deemed to be at risk. Furthermore, the issue has not made it harder for the CCG to resist fraud or other misuse of resources and has not diverted resources from another significant aspect of the business.

As a result of the financial position, Stoke-on-Trent CCG has been placed in special measures. To support the financial recovery the CCG has appointed a Turn-Around Director who is providing additional capacity and capability.

Review of economy, efficiency and effectiveness of the use of resources

Ratings for the ‘Quality of Leadership’ indicator of the CCG Improvement & Assessment Framework 2018/19 were awaited at the time of publication of the report. However, it was strongly expected that the CCG would be rated “inadequate” under the IAF process.

Financial planning and in-year performance monitoring (i.e. details about the CCG’s recovery planning process) are covered within the Performance Report section.

Central management costs are provided within the Financial Performance Targets note within the Accounts section.

In 2018/19, the CCG asked Deloitte to review the capacity and capability of the Finance Team. Deloitte recommended the appointment of additional senior capacity to strengthen the core team. Posts have been recruited to and the appointments were taken up in early April 2019. To bridge the gap, interim appointments were made.

The CCG’s Governing Body, the Joint Finance and Performance Committee, North Divisional Committee, Joint Strategic Commissioning Committee and Audit Committees meeting in common, have been kept fully abreast of the CCG’s financial position, and have provided both support and challenge as would be expected.

The CCG’s QIPP delivery and monitoring function has been reviewed and revised by the Turn-Around Director to ensure there is senior leadership and scrutiny of the processes. A Turn-Around Board (meeting monthly) and QIPP Boards (meeting twice per month) were established in February 2019.

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Delegation of functions

The Key Financial Systems (General Ledger, Accounts Payable, Accounts Receivable and Payroll) are operated by Shared Business Support under contract to MLCSU. These systems undergo a separate regime of Internal Audit assessment which is provided by Deloitte. Their Service Audit Reports are published twice a year, presented to Audit Committee and are reviewed by the CCG’s External Auditors in terms of informing the overall audit opinion. For details on internal delegations, please refer to the CCG’s Constitution (Scheme of Reservation & Delegation): as available on the CCG website: https://www.stokeccg.nhs.uk/stoke-governance/constitution

Counter fraud arrangements

The CCG has an accredited Counter-Fraud Specialist in place to undertake counter-fraud work proportionate to identified risks and this service is provided by PwC. The CCG Audit Committee receives a report against each of the standards for commissioners at least annually, and the Executive Director for Finance and officers work with the Counter-Fraud Specialist to support a proactive work plan to address identified risks.

The Fraud Risk Group (established in 2016/17) continues to meet with representation from directorates in 2018/19. The CCGs adhere to the NHS Protect Standards for Commissioners 2017/18 – Fraud Bribery & Corruptions which outline the action for commissioners on the action they should take to prevent fraud, bribery and corruption and to deal with it should it occur.

We have undertaken the annual Self Review Tool (SRT) against the national commissioner facing Anti-Fraud standards. There are five thematic self-assessment areas covered within these. The majority of areas were met by the CCG and were rated as compliant. Any areas subject to “Amber” or “Red” assessment will have detailed actions set – which will form part of the Integrated Improvement Plan and routinely be monitored through Audit Committee.

The CCG has not had any areas identified or actions recommended to be taken as a result of the NHS Protect quality assurance.

The Executive Director of Finance is proactively and demonstrably responsible for tackling fraud, bribery and corruption.

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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 Stoke-on-Trent CCG’s system of risk management, governance and internal control.

The Head of Internal Audit concluded that:

• There are significant weaknesses and non-compliance in the framework of governance, risk management and control which put the achievement of organisational objectives at risk. • Major improvements are required to improve the adequacy and effectiveness of governance, risk management and control.

Basis of our draft opinion In summary, our draft opinion is based on the following:

• High risk rated weaknesses identified in individual assignments that are significant in aggregate but discrete parts of the system of internal control remain unaffected.

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

Area of Audit Level of Assurance Given

Complex Cases High Risk Procurement Medium Risk Individual Funding Requests Medium Risk Conflicts of Interest Medium Risk Audit Follow-up* Corporate Governance and Risk Management High Risk Finance Low Risk Quality in Primary Care In progress Data Protection Act 2018 Low Risk Delegated Commissioning Low Risk Early Risk Management High Risk * Follow-up reviews are not risk-rated because of the nature of the reviews.

Integrated Improvement Plan

A single Integrated Improvement Plan is being developed to oversee to address the required improvements required by the audit findings in relation to

• the three medium risks identified in the Conflicts of Interest Audit (see COI for detail) • the two high risks and two medium risks identified in Corporate Governance and Risk Management (see Discharge of Statutory Functions) • the two high risk findings from the Risk Management Audit (see Discharge of Statutory Functions)

The single Improvement Plan will also address

• the IAF feedback, which we anticipate, owing to our financial position, will be rated as Inadequate • the findings of the Deloitte Capacity and Capability Review

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The CCG is taking these findings very seriously, the Improvement Plan will be managed by the Turnaround Board on behalf of the Governing Bodies.

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 on their annual audit letter and other reports.

Our Assurance Framework, although completed late in the tear, 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 • if relevant, the Risk / Clinical Governance / Quality Committee • Internal Audit (e.g. Audit Plan activities and ad hoc advisory work) • other explicit review/assurance mechanisms: o Other sub-committees of the Governing Body including the Joint Strategic Commissioning Committee, the Communications, Engagement, Equality and Employment Committee and Remuneration and Terms of Service Committee. o External Audit via their annual audit letter which provides a high level summary of audit work carried out o Weekly executive management team meetings o Local Counter-Fraud Specialist reports to the Audit Committee o NHS Data Security & Protection Toolkit submission o Review of the Risk Register and Board Assurance Framework by the Governing Body, the committees and the Risk Group o Regular review meetings with NHS England o Regular clinical quality review meetings with all main provider organisations o NHS England commissioned Finance Capacity & Capability review by Deloitte.

Conclusion

My review of the effectiveness of the governance, risk management and internal control has confirmed that:

There were weaknesses in the system of internal control during 2018/19 and action is being undertaken to make the required improvements to ensure there is robust system designed to meet the system of internal control designed to meet the organisation’s objectives and that controls are generally being applied consistently.

However, this has been a challenging year for the six CCGs in Staffordshire, as they have operated through a period of immense change whilst transitioning to working more collaboratively, including the move to one staff team and a single leadership team, whilst

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having to continue to meet the statutory requirements as six separate statutory bodies. This has given the CCGs significant governance challenges, with new committee arrangements, including some meetings in common, and other new joint committee arrangements. At the same time, the CCGs have been operating with major financial pressures and working in a health economy where healthcare providers have significant financial and operational challenges.

Based on the work undertaken by a range of assurance providers, the CCG has identified four significant control issues:

1. Risk that the CCG will not deliver its control total submitted as part of the plan to NHS England, leading to non-compliance with its statutory duties as laid out in the Constitution.

The non-delivery of the CCG’s control total is a significant concern. Given the ongoing financial pressures across the economy the CCG has appointed a Turn- Around Director and enhanced the capability and capacity of the Finance Team to support the Programme Management Office and turn-around approach.

2. Risk that the CCG will fail to achieve one or more of the NHS Constitution waiting time targets, leading to NHS England not being assured and the CCG receiving a rating of ‘not assured’. A more detailed explanation of the CCG's performance against the NHS Constitutional targets is available in the Performance Analysis section.

3. The Governing Bodies have not agreed strategic objectives for the Staffordshire and Stoke-on-Trent CCGs.

4. The BAF was only developed in February by the Executive Team. Because of the timing of this, there were limited opportunities for members of the Governing Body to review, provide feedback, and challenge the content of the BAF. Work needs to be done to ensure that all Governing Bodies have agreed the format and structure of the BAF, and to refine the content.

Accepting the control issues identified above I am confident that the organisation has appropriate mechanisms in place to deliver good governance.

Marcus Warnes Accountable Officer

23 May 2019

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Remuneration and Staff Report

Remuneration Report

Remuneration Committee

The CCG has a Remuneration and Terms of Service Committee in Common, which is a sub- committee of the Governing Bodies in Common. The Chair of the Remuneration Committee is the Lay Member for Governance and its members are the Clinical Chairs of each CCG, lay members and Secondary Care consultants. The purpose of the committee is to advise the Governing Bodies about appropriate remuneration and terms of service for the Accountable Officer, Director of Finance and other senior employees, on Very Senior Manager contracts, including:

• All aspects of salary; • Provisions for other benefits, including pensions and cars; • Arrangements for termination of employment and other contractual terms; • Discipline and dismissal of officer members of the Governing Body.

The Director of Corporate Services ,Governance and Communications and the HR lead from the Midlands and Lancashire Commissioning Support Unit, support the meeting with the Chair, the Accountable Officer and the Director of Finance being asked to attend as appropriate.

Title First Surname Position Date of Date of name joining the leaving the committee* committee*

Mr Neil Chambers Chair / Lay Member for Governance (Cannock Chase)

Dr Alison Bradley Clinical Chair of North Staffordshire CCG

Dr Ruth Chambers Clinical Chair of Stoke- December on-Trent CCG 2018

Dr Lorna Clarson Clinical Chair of Stoke- January on-Trent CCG 2018

Mr David Harding Lay Member for Governance (East Staffs)

Mr Paul Gallagher Lay Member for PPI (Cannock Chase)

Lay Member for Quality (SESSP)

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Dr Rachel Gallyot Clinical Chair of East August 2018 Staffs CCG

Dr Paddy Hannigan Clinical Chair or Stafford & Surrounds CCG

Mrs Sue Harper Lay Member PPI (Stafford & Surrounds)

Ms Anne Heckels Lay Member for PPI and Finance and Performance (SESSP)

Mr John Howard Lay Member for Governance (Stoke- on-Trent)

Dr Mo Huda Clinical Chair of Cannock Chase CCG

Mrs Lynne Smith Lay Member for Governance (SESSP)

Mr Neil McFadden Lay Member for Governance (North Staffs)

Mr Simon Mellor Secondary Consultant September (Stoke-on-Trent) 2018

Mr Chris Ragg Lay Member for PPI (East Staffs)

Mr Raj Saha Secondary Care Consultant (East)

Mr Doug Robertson Secondary Care October consultant (Cannock 2018 – Chase, North Staffs, Stoke-on- SESSP, Stafford & Trent Surrounds and Stoke- on-Trent)

Mrs Diana Smith Lay Member (Stafford and Surrounds)

Mrs Jan Toplis Lay Member (Cannock Chase)

* Dates only included if there has been a change in-year

Details of the Remuneration and Terms of Service Committees meeting in Common can be found in the committee section of the Annual Governance Statement in this document.

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Policy on the remuneration of senior managers – subject to audit

Senior Managers are paid under one of three national frameworks:

• The Accountable Officer and the Director of Finance were paid under remuneration guidance for Chief Officers (where the Senior Manager also undertakes the Accountable Officer role) and Chief Finance Officers, published in 2012; • The following posts were paid on the Very Senior Manager pay scale: o Director of Strategy, Planning and Performance o Director of Commissioning and Operations o Director of Nursing and Quality, and Chief Nurse o Director of Corporate Services, Governance and Communications o Director of Primary Care o Managing Director - North o Managing Director – East o Managing Director - South • Agenda for Change – see next paragraph.

Agenda for Change All other staff except medical and dental staff are paid through the Agenda for Change pay structure. Following recommendations from the independent pay review bodies, the NHS Pay Review Body and the Doctors’ and Dentists’ Review Body, doctors, dentists and all NHS staff on Agenda for Change contracts received a variable pay increase in 2018/19, depending on their seniority and their positions on the pay scale.

Lay member remuneration was based on the rate for PCT non-executive directors set by the former Appointments Commission in accordance with national policy.

No senior managers have been paid/will be paid through a performance-related pay mechanism in 2018/19.

Everything relating to the remuneration and terms and conditions of the Accountable Officer, Director of Finance and Very Senior Managers is subject to approval by the Remuneration Committee.

Remuneration of Very Senior Managers – subject to audit

In accordance with DHSC GAM para 3.42 – 3.43, we can confirm there are no Very Senior Managers of the CCG paid more than £150,000 per annum

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Senior manager remuneration (including salary and pension entitlements) – subject to audit

These tables have been completed in accordance with DHSC GAM 2018/19 para 3.44 – 3.48, providing explanatory footnotes as required.

2018 / 2019 (d) (b) (c) (e) (a) Long Term Expense Performance All Pension (f) Salary performance Payments pay and related Total (a to Name and Title Position Start Date End Date (bands pay and (taxable) bonuses benefits e) (bands of bonuses to nearest (bands of (bands of of £5,000) £5,000) (bands of £100** £5000) £2,500) £5000) £000 £ £000 £000 £000 £000 *Marcus Warnes Accountable Officer 145 - 150 0 - 0 0 - 0 0 - 0 87.5 - 90 235 - 240 *Alistair Mulvey Chief Financial Officer 135 - 140 0 - 0 0 - 0 0 - 0 17.5 - 20 155 - 160 Director of Strategy, Planning & 16/08/2018 *Zara Jones 40 - 45 0 - 0 0 - 0 0 - 0 52.5 - 55 95 - 100 Performance Director of Strategy, Planning & 01/07/2018 *Jane Moore 55 - 60 0 - 0 0 - 0 0 - 0 0 - 0 55 - 60 Performance *Heather Johnstone Director of Quality and Safety 110 - 115 0 - 0 0 - 0 0 - 0 57.5 - 60 170 - 175 *Lynn Millar Director of Primary Care 110 - 115 0 - 0 0 - 0 0 - 0 110 - 112.5 225 - 230 Director of Corporate Services, *Sally Young 110 - 115 0 - 0 0 - 0 0 - 0 202.5 - 205 315 - 320 Governance & Communications Director of Strategic Commissioning and *Cheryl Hardisty 115 - 120 0 - 0 0 - 0 0 - 0 0 - 0 115 - 120 Operations ***Jonathan Bletcher Director of Planning & Strategy 95 - 100 0 - 0 0 - 0 0 - 0 0 - 0 95 - 100 ***Tracey Shewan Director of Nursing and Quality 105 - 110 0 - 0 0 - 0 0 - 0 7.5 - 10 110 - 115 ****Ian Baines Director of Organisational Development 31/12/2018 185 - 190 0 - 0 0 - 0 0 - 0 0 - 0 185 - 190 **Fiona Froggatt Chief Operating Officer 45 - 50 0 - 0 0 - 0 0 - 0 0 - 0 45 - 50 **Mark Seaton Managing Director North 105 - 110 0 - 0 0 - 0 0 - 0 80 - 82.5 185 - 190 *Christopher Bird Director of Contracting 25/03/2019 85 - 90 0 - 0 0 - 0 0 - 0 0 - 0 85 - 90 Lorna Clarson Joint Clinical Director/CCG Chair 01/01/2019 45 - 50 0 - 0 0 - 0 0 - 0 20 - 22.5 65 - 70 Ruth Chambers CCG Chair 31/12/2018 25 - 30 0 - 0 0 - 0 0 - 0 0 - 0 25 - 30 **Stephen Fawcett Joint Medical Director 75 - 80 0 - 0 0 - 0 0 - 0 42.5 - 45 120 - 125

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**Waheed Abbasi Clinical Director 45 - 50 0 - 0 0 - 0 0 - 0 5 - 7.5 50 - 55 **Latif Hussain Joint No Exec GP Board Member 10 - 15 0 - 0 0 - 0 0 - 0 0 - 0 10 - 15 John Gilby Clinical Director 45 - 50 0 - 0 0 - 0 0 - 0 0 - 0 45 - 50 John Howard Lay Member for Governance 15 - 20 0 - 0 0 - 0 0 - 0 0 - 0 15 - 20 Margaret Woodhead Lay Member for PPI 10 - 15 0 - 0 0 - 0 0 - 0 0 - 0 10 - 15 Tim Bevington Lay Member 15 - 20 0 - 0 0 - 0 0 - 0 0 - 0 15 - 20 Simon Mellor Secondary Care Specialist 30/09/2018 0 - 5 0 - 0 0 - 0 0 - 0 0 - 0 0 - 5 **Ruth Chambers Clinical Associate 01/05/2018 55 - 60 0 - 0 0 - 0 0 - 0 0 - 0 55 - 60 **Sally Parkin Clinical Director 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 **Note: Taxable expenses and benefits in kind are expressed to the nearest £100. **Column E disclosed the growth of all pension related benefits during the year. It reflects pension related benefits and is sourced from the Greenbury information.

***The figures in the table above for Ian Baines and Fiona Froggatt are inclusive of exit packages transacted in 2018/19.The amounts of those were; 100 – 105 relating to Ian Baines and 10 – 15 relating to Fiona Froggatt.

****For those applicable, dates are included in the above table for those who commenced in role and/or terminated their period of employment within 2018/19.

NHS CC CCG = NHS Cannock Chase CCG NHS ES CCG = NHS East Staffordshire CCG NHS NS CCG = NHS North Staffordshire CCG NHS SESSP CCG = NHS South East Staffordshire & Seisdon Peninsula CCG NHS SAS CCG = NHS Stafford & Surrounds CCG NHS SOT CCG = NHS Stoke-on-Trent CCG

Note 1 - “Unless stated otherwise, the costs of the individuals shown above are 100% attributable to NHS Stoke-on-Trent CCG”

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Note 2 - “NHS Stoke-on-Trent CCG shares a single leadership team with the five other Staffordshire CCGs, with the remuneration of those senior officers being apportioned out on a capitated basis. Under this capitated basis NHS Stoke-on-Trent CCG pays 24.45% of the following individuals costs”

Name NHS CC CCG NHS ES CCG NHS NS CCG NHS SESSP CCG NHS SAS CCG NHS SOT CCG *Marcus Warnes 25 – 30 25 – 30 45 – 50 45 – 50 30 – 35 55 - 60 *Alistair Mulvey 15 - 20 15 - 20 25 - 30 30 - 35 20 - 25 35 - 40 *Zara Jones 10 - 15 10 - 15 15 - 20 15 - 20 10 - 15 20 - 25 *Jane Moore 5 - 10 5 - 10 10 - 15 10 - 15 5 - 10 10 - 15 *Heather Johnstone 20 - 25 20 - 25 30 - 35 30 - 35 20 - 25 40 - 45 *Lynn Millar 25 - 30 25 - 30 40 - 45 40 - 45 25 - 30 55 - 60 *Sally Young 35 - 40 35 - 40 60 - 65 60 - 65 40 - 45 75 - 80 *Cheryl Hardisty 10 - 15 10 - 15 20 - 25 20 - 25 15 - 20 25 - 30 *Christopher Bird 10 - 15 10 - 15 15 - 20 15 - 20 10 - 15 20 - 25

Note 3 - “NHS Stoke-on-Trent CCG shares specific named senior managers with NHS North Staffordshire CCG, with the remuneration of those senior officers being apportioned out on an agreed basis. Under this agreed basis NHS Stoke-on-Trent CCG pays 56.28% of the following individuals costs”

Name NHS CC CCG NHS ES CCG NHS NS CCG NHS SESSP CCG NHS SAS CCG NHS SOT CCG **Mark Seaton 0 - 0 0 - 0 80 - 85 0 - 0 0 - 0 105 - 110 **Stephen Fawcett 0 - 0 0 - 0 50 - 55 0 - 0 0 - 0 65 - 70 **Waheed Abbasi 0 - 0 0 - 0 20 - 25 0 - 0 0 - 0 25 - 30 **Latif Hussain 0 - 0 0 - 0 0 - 5 0 - 0 0 - 0 5 - 10 **Ruth Chambers 0 - 0 0 - 0 25 - 30 0 - 0 0 - 0 30 - 35 **Sally Parkin 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0

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Note 4 - “NHS Stoke-on-Trent CCG has specific senior managers on external secondments to other organisations, with an element of the remuneration of those senior officers being recharged to the host organisation. The residual value of the remuneration is then apportioned out on a capitated basis. Under this capitated basis NHS Stoke-on-Trent CCG pays 24.45% of the following individuals costs”

Name NHS CC CCG NHS ES CCG NHS NS CCG NHS SESSP CCG NHS SAS CCG NHS SOT CCG ***Jonathan Bletcher 10 - 15 10 - 15 15 - 20 15 - 20 10 - 15 20 - 25 ***Tracey Shewan 10 - 15 10 - 15 20 - 25 20 - 25 10 - 15 25 - 30

Note 5 - “NHS Stafford & Surrounds CCG has specific senior managers on external secondments to other organisations, with an element of the remuneration of those senior officers being recharged to the host organisation. The residual value of the remuneration is then apportioned out on a capitated basis. Under this capitated basis NHS Stoke-on-Trent CCG pays 24.45% of the following individuals costs. The exit packages related to the specific individuals have been apportioned out on an agreed basis. Under this agreed basis NHS Stoke-on-Trent CCG pays 0% of those costs”

Name NHS CC CCG NHS ES CCG NHS NS CCG NHS SESSP CCG NHS SAS CCG NHS SOT CCG ****Ian Baines 40 - 45 10 - 15 15 - 20 50 - 55 40 - 45 20 - 25

Note 6 - “NHS North Staffordshire CCG shares specific named senior managers with NHS North Staffordshire CCG, with the remuneration of those senior officers being apportioned out on an agreed basis. Under this agreed basis NHS Stoke-on-Trent CCG pays 56.28% of the following individuals costs. The exit packages related to the specific individuals have been apportioned out on a different agreed basis. Under this agreed basis NHS North Staffordshire CCG pays 60.00% of those costs”

Name NHS CC CCG NHS ES CCG NHS NS CCG NHS SESSP CCG NHS SAS CCG NHS SOT CCG *****Fiona Froggatt 0 - 0 0 - 0 15 - 20 0 - 0 0 - 0 25 - 30

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2017 / 2018 *(Restated for Group) (d) (b) (c) (e) Long Term (a) Expense Performance All Pension (f) performance Salary Payments pay and related Total (a to Name and Title Position pay and (bands of (taxable) bonuses benefits e) (bands bonuses £5,000) to nearest (bands of (bands of of £5,000) (bands of £100** £5000) £2,500) £5000) £000 £ £000 £000 £000 £000 105.0 - Marcus Warnes Accountable Officer 135 - 140 240 - 245 107.5 Alistair Mulvey Chief Financial Officer 125 - 130 47.5 - 50.0 175 - 180 Zara Jones Director of Strategy, Planning & Performance 105 - 110 87.5 - 90.0 195 - 200 Jane Moore Director of Strategy, Planning & Performance 0 - 0 0 - 0 0 - 0 Heather Johnstone Director of Quality and Safety 105 - 110 32.5 - 35.0 140 - 145 Lynn Millar Director of Primary Care 95 - 100 62.5 - 65.0 160 - 165 Director of Corporate Services, Governance & Sally Young* 90 - 95 47.5 - 50.0 140 - 145 Communications Director of Strategic Commissioning and Cheryl Hardisty 105 - 110 0 - 0 105 - 110 Operations Fiona Froggatt Chief Operating Officer 110 - 115 25.0 - 27.5 140 - 145 387.5 - Mark Seaton Managing Director North 90 - 95 250 - 255 390.0 Christopher Bird Director of Contracting 90 - 90 27.5 - 30.0 115 - 120 Lorna Clarson Joint Clinical Director/CCG Chair 20 - 25 42.5 - 45.0 65 - 70 Ruth Chambers CCG Chair 30 - 35 0 - 0 30 - 35 Stephen Fawcett Joint Medical Director 75 - 80 47.5 - 50.0 125 - 130 Waheed Abbasi Clinical Director 45 - 50 32.5 - 35.0 75 - 80 Richard Page Joint No Exec GP Board Member 10 - 15 0 - 0 10 - 15 Latif Hussain Joint No Exec GP Board Member 10 - 15 0 - 0 10 - 15 John Gilby Clinical Director 35 - 40 0 - 0 35 - 40 John Howard Lay Member for Governance 15 - 20 0 - 0 15 - 20

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Margaret Woodhead Lay Member for PPI 10 - 15 0 - 0 10 - 15 Tim Bevington Lay Member 10 - 15 0 - 0 10 - 15 Simon Mellor Secondary Care Specialist 5 - 10 0 - 0 5 - 10 Ruth Chambers Clinical Associate 10 - 15 0 - 0 10 - 15 Sally Parkin** Clinical Director 10 - 15 12.5 - 15.0 25 - 30

*The 2017/18 Salary bands have been restated to those shown in the table above, following a review of actual salary payments made. **The 2017/18 Pension Benefits have been restated to those shown in the table above, following a recalculation of the information provided via the Greenbury system

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Pension benefits as at 31 March 2018 – subject to audit

This table is completed in accordance with DHSC GAM 2018/19 para 3.44 – 3.48, with reference to CCG Annex 2 – Pension Disclosures. Explanatory notes are provided as required.

2018/19

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

Name and Title £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 Marcus Warnes - Accountable Officer 45 - 115 - 5.0 - 7.5 5.0 - 7.5 50 120 764 177 964 21 Alistair Mulvey - Chief Financial Officer 40 - 100 - 0.0 - 2.5 0.0 - 2.5 45 105 656 115 790 20 Zara Jones - Director of Strategy, Planning & Performance 20 - 2.5 - 5.0 0.0 - 2.5 25 45 - 50 228 74 310 6 Jane Moore - Director of Strategy, Planning & Performance (0.0) - 60 - (2.5) 0 - 0 65 0 - 0 840 80 946 8 Heather Johnstone - Director of Quality and Safety 30 - 2.5 - 5.0 2.5 - 5.0 35 70 - 75 467 113 594 16 Lynn Millar - Director of Primary Care 10.0 - 25 - 5.0 - 7.5 12.5 30 60 - 65 277 129 414 17 Sally Young - Director of Corporate Services, Governance & 27.5 - 30 - 95 - Communications 7.5 - 10.0 30.0 35 100 451 266 731 17 Fiona Froggatt - Chief Operating Officer (7.5) - 5 - - (10.0) 0 - 0 10 0 - 0 165 78 93 5

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Mark Seaton - Managing Director North 10.0 - 20 - 2.5 - 5.0 12.5 25 65 - 70 365 133 509 15 Christopher Bird - Director of Contracting 30 - 0.0 - 2.5 0 - 0 35 0 - 0 331 56 397 13 Lorna Clarson - Joint Clinical Director/CCG Chair (2.5) - 15 - 0.0 - 2.5 (5.0) 20 35 - 40 209 45 261 6 Stephen Fawcett - Joint Medical Director 20 - 0.0 - 2.5 5.0 - 7.5 25 60 - 65 386 90 488 6 Waheed Abbasi - Clinical Director (0.0) - 10 - 0.0 - 2.5 (2.5) 15 20 - 25 151 29 185 7

NHS Pensions are using pension data from their systems without adjustment for potential future legal remedy required as a result of the McCloud judgement. (This is a legal case concerning age discrimination over the manner in which UK public service pension schemes introduced a CARE benefit design in 2015 for all but the oldest members who retained a Final Salary design.) Given the considerable uncertainty this means that the benefits and related CETVs presented do not allow for a potential future adjustment arising from the McCloud judgment.

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Cash equivalent transfer values (CETV) – subject to audit

A 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. CETVs are calculated in accordance with the Occupational Pension Schemes (Transfer Values) Regulations 2008.

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

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

Real increase in CETV – subject to audit

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).

Compensation on early retirement or for loss of office – subject to audit

No payments have been made in respect of compensation on early retirement. Payments paid or payable in respect of loss of office are summarised within the notes relating to Exit Packages starting on page 121.

Payments to past members – subject to audit

Payments have been made in relation to exit packages for three past directors of the six Staffordshire and Stoke-on-Trent CCGs, and have been declared within the Remuneration report starting on page 102 and within the Exit Packages starting on page 121.

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Pay multiples – subject to audit

Reporting bodies are required to disclose the relationship between the remuneration of the highest-paid director/Member in their organisation and the median remuneration of the organisation’s workforce.

For the majority of staff, costs are shared across the six Staffordshire and Stoke-on-Trent CCGs in proportion to their Running Cost Allocation. To report the salary band of the highest paid director/member for each individual entity based upon the share of basic salary costs paid by each CCG would result in an abnormally low figure. Therefore, to maximise transparency and to show a true and fair view of the pay multiple across the six Staffordshire and Stoke-on-Trent CCGs, the banded remuneration of the aggregate total salary cost of the highest paid director/member for the six Staffordshire and Stoke-on-Trent CCGs is shown and used as the basis for the pay multiple calculation.

The banded remuneration of the highest paid director/Member for the six Staffordshire and Stoke-on-Trent CCGs in the financial year 2018/19 was £145,000-150,000 (2017/18, £135,000-140,000). This was 3.43 times (2017/18, 3.64) the median remuneration of the workforce, which was £43,041 (2017/18, £37,777).

The increase in highest paid remuneration has arisen due to the restructure that commenced in 2017/18 where directors are now responsible for six CCGs. The increase in median remuneration is also due to the restructure across the six Staffordshire and Stoke- on-Trent CCGs.

In 2018/19, 0 (2017/18, 0) employees received remuneration in excess of the highest-paid director/member. Remuneration ranged from £17,460 to £145,000-£150,000 (2017/18 £7,800 to £135,000-140,000).

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

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Staff Report During the first part of 2018, the CCG undertook a Management of Change process which enabled the joint structure to be implemented across the six CCGs from Staffordshire and Stoke-on-Trent. Following the appointment of the Single Leadership Team, the six CCGs started working more closely together to maximise opportunities to improve experiences and health outcomes for the local people of Staffordshire, to reduce unacceptable health inequalities and improve provider performance.

The next natural step was to formalise these arrangements by implementing a joint structure across the six CCGs to ensure they had the right staff with the right resources and skills in the right place to deliver the collective strategic aims. The process was clear that each CCG would retain its own legal status and would ensure that any decisions would be locally-led, but there would be an emphasis on reducing duplication.

In October 2018, a staff event was held to launch the Organisational Plan for the six CCGs in Staffordshire. Staff were invited to think about the CCGs’ objectives, key behaviours in support of each of the value statements and to define a set of working principles to ensure real and meaningful clinical leadership is achieved.

A further event was held with staff in March 2019, which was a key part of our planned engagement work, to jointly discuss the possible system changes that lie ahead. Staff worked together to look at how the CCGs might form a response to the Long Term Plan’s vision for the future of the NHS. This event was important to see how to focus on where the CCGs are now and what is planned in the short to medium term through a supporting OD programme to be launched in the first quarter of 2019/20.

PwC Commissioning Capability programme was completed by the Accountable Officer and Executive Directors between January and May 2018.

Directors and senior team members have been part of a capability and capacity review programme led by Deloitte, funded by NHS England. The outputs from this piece of work are currently being finalised and it is clear this has identified a number of training needs to deliver the emerging vision for the future. These will be incorporated in the OD programme being developed.

To support the development of this, there are a number of OD interventions currently being planned, including:

• development of a business planning cycle • development programmes for Chairs, Executive Directors and Governing Body members • training for staff on working in the new system • team development (Governing Bodies, Divisions and Divisional Committees) • talent identification and development approach including succession planning • support to the localities in developing the provider alliance model • use of data, business intelligence and population health • resolving the financial allocation issue • a future approach to contracting • training needs identified through staff appraisals.

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The role of the six Governing Bodies is key in ensuring change to the way we work is implemented smoothly and ensures all aspects are considered. There will be a targeted development plan for the Governing Bodies to work through together.

The six Governing Bodies have agreed that Governing Body meetings will be held in common for all six CCGs, with six Governing Body meetings in common held in public and a confidential meeting, alternating with an OD session for six Governing Bodies and a confidential Governing Body meeting in common. The six OD sessions will focus on planned development sessions aligned to the work with Deloitte to support the roll out of new ways of working. The first OD sessions will look at the role of the divisions and the membership in the changes, and agreeing the vision, values and objectives for 2019/20.

The six CCGs in Staffordshire and Stoke-on-Trent have set up a formal Staff Engagement Group, which includes representatives from all directorates and reports directly to the Communications, Engagement, Equality and Employment Committees in common (CEEE). The remit includes looking at OD support, and feedback on a regular basis on key issues. All staff were invited to an event in October entitled ‘Every Connection Counts’, where staff engaged in early learning and successes as the CCGs came together, including how we can work together more effectively, ensuring that ‘every connection counts’ towards building our values and approaches to delivering the best for the people of Staffordshire and Stoke-on- Trent.

The Health and Wellbeing Charter remains as a national charter and continues to assist the CCGs in benchmarking against best practice. In conjunction with the County Council, the CCGs continue to support lunchtime group walking as part of a health initiative for physical activity for staff.

Staff Awards and Achievement of the Month are being reviewed and this is something that will be rolled put in the new financial year across all six CCGs. The commitment to organisational development by the Governing Bodies remains strong and work will progress for 2019/20. The new CEEE Committee will oversee the development of the new OD Plan for the six CCGs.

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Number of senior staff (including managers)

Senior staff analysis by band (based on staffing at 31 March 2019):

Pay Band Headcount Apprentice 0 Band 2 6 Band 3 0 Band 4 7 Band 5 4 Band 6 11 Band 7 12 Band 8 - Range A 8 Band 8 - Range B 6 Band 8 - Range C 5 Band 8 - Range D 2 Very Senior Manager (VSM) 13 Medical Pay scale 9 Governing Body (off payroll)* 2 Total 85 *Governing Body (off payroll) pertains to Governing Body Members without a pay record in the CCG Electronic Staff Record (ESR) system

Staff numbers and costs

Average number of people employed 2018/19

Permanently Other Total employed

Administration and Estates 180 25 205 Medical and Dental 10 10 Nursing, Midwifery and Health Visiting Staff 18 18 Other 3 3 Scientific, Therapeutic and Technical Staff 30 30 Total CCG 241 25 266

The table above shows the aggregate total of average number of people employed across the six Staffordshire and Stoke-on-Trent CCGs.

Stoke-on-Trent CCG’s share of the average number of people employed in 2018/19 was 64.

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Staff composition

Staff analysis by gender (based on staffing at 31 March 2019):

Headcount by % by Gender Gender Staff Grouping Female Male Totals Female Male Governing Body 8 10 18 44.4 55.6 Other Senior Management 8 5 13 61.5 38.5 (Band 8C+) All Other Employees 47 7 54 87 13

Total 63 22 85 74.12 25.88

Trade Union Facility Time

We have two local representatives across the six CCGs in Staffordshire and Stoke-on-Trent. The percentage of facility time is not monitored.

Sickness absence data

Turnover decreased in November and December from 1.76%, to 0.8%, below target of 1%. Between April and December, the sickness absence rate continued to fall as the CCGs moved through the Management of Change process. Calendar days lost due to sickness has fallen from 351 in April to 164 in December, as HR continue to work with line managers to ensure processes were being followed and ensuring staff were supported.

The below table shows the number of sickness days in 2018/19:

Staff sickness absence 2018/19 number FTE Days Available* 56121.96 FTE Days Lost to Sickness Absence* 2001.84 Average Sick Days per FTE 8.01 *figures cover FTE days for all six CCGs in Staffordshire and Stoke-on-Trent)

Staff policies

Stoke-on-Trent CCG is working with the Staff Engagement Group, Union Representatives and the CEEE Committee to align all staff policies across the six CCGs in Staffordshire and Stoke-on-Trent. It is anticipated that the policies will be fully aligned by the end of the first quarter of 2019/20. The aim is to ensure staff from all six CCGs are treated equitably, regardless of which CCG is their employing organisation.

This includes all HR Policies such as flexible and agile working. Any changes to policies will always be accompanied by an Equality Impact Assessment, which includes assessing the impact of any protected characteristic groups. Our mandatory equality and diversity training includes awareness of a range of issues impacting on people with disabilities. We also ensure that any employee who needs training (either because they work with people with disabilities, or because they have acquired an impairment or medical condition) receives the necessary training.

Staff can more easily access HR Policies and documents with the launch of the new intranet, ‘Information and News’, known as IAN.

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Expenditure on consultancy

The table below details expenditure on consultancy for the financial year 1 April 2018 to 31 March 2019.

Consultancy Provision £000 Clarion Call Consulting & Coaching 13 Curtins Consulting Ltd 23 Liaison Vat Consultancy Ltd 26 Meridian Productivity Ltd 23 Oakes Surveys LTD 1 Poole Dick Associates Ltd 6 RPS Group Plc 24 RSM UK Tax & Accounting Ltd 5 Sandy Brown Consultants in Acoustics Noise & Vibration 3 Total 124

Off-payroll engagements

Off-payroll engagements longer than six months For all off-payroll engagements as of 31 March 2019, for more than £245 per day and that last longer than six months:

Number Number of existing engagements as of 31 March 2019 2 Of which, the number that have existed: • For less than one year at the time of reporting • For between one and two years at the time of reporting • For between two and three years at the time of reporting • For between three and four years at the time of reporting 2 • For four or more years at the time of reporting

All existing off-payroll engagements, outlined above, have at some point been subject to a risk-based assessment as to whether assurance is required that the individual is paying the right amount of tax and, where necessary, that assurance has been sought.

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New off-payroll engagements For all new off-payroll engagements, or those that reached six months in duration, between 1 April 2018 and 31 March 2019, for more than £245 per day and that last longer than six months:

Number Number of new engagements, or those that reached six months in duration, between 1 April 2018 and 31 March 2019 0 Of which: • Number assessed as caught by IR35 • Number assessed as not caught by IR35

• Number engaged directly (via PSC contracted to department) and are on the departmental payroll • Number of engagements reassessed for consistency / assurance purposes during the year

Off-payroll board member / senior official engagements For any off-payroll engagements of Board members and/or senior officials with significant financial responsibility, between 1 April 2018 and 31 March 2019.

Number of off-payroll engagements of board members, and/or senior officers 2 with significant financial responsibility, during the financial year. (1) Total no. of individuals on payroll and off-payroll that have been deemed 25 “board members, and/or, senior officials with significant financial responsibility”, during the financial year. This figure should include both on payroll and off-payroll engagements. (2)

Following the Capability and Capacity review conducted by Deloitte into the CCG Finance team, one of the recommendations was to increase the capacity of the senior finance team. Whilst a recruitment process was enacted to appoint three Very Senior Managers, given the urgent requirement to provide additional senior financial expertise to the CCGs, two very senior managers were appointed on an interim basis. The duration of both engagements was between 4 and 5 months at the time of reporting.

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Exit packages, including special (non-contractual) payments

2018/19

Table 1: Exit packages

Exit package Number of Cost of Number of Cost of other Total number Total cost of Number of Cost of cost band compulsory compulsory other departures of exit exit packages departures special (including redundancies redundancies departures agreed packages where special payment any special agreed payments element payment have been included in element) made exit packages WHOLE £s WHOLE £s WHOLE £s WHOLE £s NUMBERS NUMBERS NUMBERS NUMBERS ONLY ONLY ONLY ONLY Less than 1 3,333 0 0 1 3,333 0 0 £10,000 £10,000 - 1 18,888 0 0 1 18,888 0 0 £25,000 £25,001 - 0 0 0 0 0 0 0 0 £50,000 £50,001 - 6 503,730 0 0 6 503,730 0 0 £100,000 £100,001 - 2 261,848 0 0 2 261,848 0 0 £150,000 £150,001 - 0 0 0 0 0 0 0 0 £200,000 >£200,000 0 0 0 0 0 0 0 0 Totals 10 787,799 0 0 10 787,799 0 0

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Redundancy and other departure costs have been paid in accordance with the provisions of the agenda for change terms and conditions or in line with contractual terms and conditions. Exit costs in this note are the full costs of departures agreed in the year. Where the CCG has agreed early retirements, the additional costs are met by the CCG and not by the NHS Pensions Scheme. Ill-health retirement costs are met by the NHS Pensions Scheme and are not included in the table.

This disclosure reports the number and value of exit packages agreed in the year. Note: the expense associated with these departures may have been recognised in part or in full in a previous period.

Redundancy costs relating to former members of Executive Management Teams have been shared equally across the original CCG groupings. Redundancy costs relating to the Management of Change were shared equally across the six Staffordshire and Stoke-on-Trent CCGs. Other redundancy costs were incurred wholly by the employing CCG.

Table 1 shows the aggregate total of Exit Packages agreed in year for the group of six Staffordshire and Stoke-on-Trent CCGs. Stoke-on-Trent CCG's share of costs relating to Exit Packages agreed in 2018/19 was £117,410.

There is a restatement of Exit Packages agreed in year for 2017/18 in relation to three employees. The total amount of restated costs is £152,745. Stoke-on-Trent CCG's share of restated costs relating to Exit Packages agreed in 2017/18 was £31,235.

Stoke-on-Trent CCG's share of the cost for Exit Packages agreed in 2018/19 and restated Exit Packages agreed in 2017/18 was £148,646. This is shown in the accounts as termination benefits costing £140,646 and as utilisation of provisions made in 2017/18 costing £8,000.

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Table 2: Analysis of Other Departures

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

As a single exit package can be made up of several components each of which will be counted separately in this Note, the total number above will not necessarily match the total numbers in Table 1 which will be the number of individuals.

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

**includes any non-contractual severance payment made following judicial mediation and relating to non-contractual payments in lieu of notice.

No non-contractual payments were made to individuals where the payment value was more than 12 months’ of their annual salary.

The Remuneration Report includes disclosure of exit payments payable to individuals named in that Report.

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2017/18 (restated for group)

Table 1: Exit packages

Exit package Number of Cost of Number of Cost of other Total number Total cost of Number of Cost of cost band compulsory compulsory other departures of exit exit packages departures special (including redundancies redundancies departures agreed packages where special payment any special agreed payments element payment have been included in element) made exit packages WHOLE £s WHOLE £s WHOLE £s WHOLE £s NUMBERS NUMBERS NUMBERS NUMBERS ONLY ONLY ONLY ONLY Less than 0 0 0 0 0 0 0 0 £10,000 £10,000 - 2 33,333 0 0 2 33,333 0 0 £25,000 £25,001 - 1 45,829 0 0 1 45,829 0 0 £50,000 £50,001 - 1 93,582 0 0 1 93,582 0 0 £100,000 £100,001 - 0 0 0 0 0 0 0 0 £150,000 £150,001 - 1 160,000 0 0 1 160,000 0 0 £200,000 >£200,000 2 461,872 0 0 2 461,872 0 0 Totals 7 794,617 0 0 7 794,617 0 0

The note below should be read in conjunction with the notes relating to 2018/19.

Table 1 shows the aggregate total of Exit Packages agreed in year for the group of six Staffordshire and Stoke-on-Trent CCGs. Stoke-on-Trent CCG's share of costs relating to Exit Packages agreed in 2017/18 was £31,235.

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Table 2: Analysis of Other Departures

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

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Parliamentary Accountability and Audit Report

Stoke-on-Trent CCG is not required to produce a Parliamentary Accountability and Audit Report.

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

Marcus Warnes Accountable Officer

23 May 2019

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List of acronyms

5YFV Five Year Forward View A&E Accident and Emergency AO Accountable Officer ARP Ambulance Response Programme ASSET Authority’s Adult Specialist Safeguarding Enquiry Team BAF Board Assurance Framework BHFT Burton Hospitals NHS Foundation Trust CAS Clinical Assessment Service CATs Critically Appraised Topics CCG Clinical Commissioning Group CEEE Communication, Engagement, Equality and Employment Committee CDiff / CDifficile Clostridium Difficile CETV Cash equivalent transfer value CKD Chronic Kidney Disease COPD Chronic Obstructive Pulmonary Disease CPAG Clinical Priorities Advisory Group CQC Care Quality Commission CQRM Clinical Quality Review Meetings CQUIN Commissioning for Quality and Innovation D2A Discharge to Assess DCO Designated Clinical Officer DGH The Dudley Group of Hospitals NHS Foundation Trust DHRs Domestic Homicide Reviews DHSC Department of Health and Social Care EBP Evidence-Based Practice Group ED Emergency Department EDS Equality Delivery System EIRA Equality Impact and Risk Assessment EPS Electronic Prescribing Services e-RS e-Referral Service ETTF Estates and Technology Transformation Fund FOI Freedom of Information GDPR General Data Protection Regulations GNBSIs Gram-negative blood stream infections GP General Practitioner GPFV General Practice Forward View GPN General Practice Nurse GRR Glaucoma Referral Refinement Service HCAI Health Care Associated Infections HCTB Healthcare Transformation Board HMCI Her Majesty’s Chief Inspector HR Human Resources IAF Improvement and Assessment Framework IAPT Increased Access to Psychological Therapies IFRS International Financial Reporting Standards IG Information Governance IM&T Information Management and Technology IUC Integrated Urgent Care JSNA Joint Strategic Needs Assessment KPI Key Performance Indicator LCAV Leading Change, Adding Value LEAF Local Equality Advisory Forum LeDeR Learning Disabilities Mortality Review

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LMS Local Maternity System MLCSU Midlands and Lancashire Commissioning Support Unit MPFT Midlands Partnership NHS Foundation Trust MRSA Methicillin-Resistant Staphylococcus Aureus MTP Maternity Transformation Programme MVP Maternity Voices Partnership NMC New Models of Care NSCHT North Staffordshire Combined HealthCare NHS Trust OD Organisational Development Ofsted Office for Standards in Education, Children's Services and Skills PALS Patient Advice and Liaison Service PIRT Provider Improvement and Response Team PLACE Patient Led Assessments of Care Environment PLT Protected Learning Time PPGs Patient Participation Groups PPI Patient and Public Involvement PwC Pricewaterhouse Coopers QIA Quality Impact Assessment QIF Quality Improvement Framework QIPP Quality Innovation Productivity and Prevention QSCC Quality and Safety Committees in Common RCA Root Cause Analysis RTT Referral to Treatment SARs Safeguarding Adult Reviews SARs Service Auditor Reports SEND Special Educational Needs and Disabilities SSASPB Staffordshire and Stoke-on-Trent Adult Safeguarding Partnership Board SSOTP Staffordshire and Stoke-on-Trent Partnership NHS Trust SSSFT South Staffordshire and Shropshire Healthcare NHS Foundation Trust STP Sustainability Transformation Partnership TEC Technology-Enabled Care UCC Urgent Care Centre UEC Urgent and Emergency Care UHDB University Hospital of Derby and Burton NHS Foundation Trust UHNM University Hospitals of North Midlands which runs County Hospital in this area VCSL Virgin Care Services Limited WMAS West Midlands Ambulance Service NHS Trust WTE Whole Time Equivalent

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NHS Stoke on Trent CCG - Annual Accounts 2018-19

CONTENTS Page Number

The Primary Statements:

Statement of Comprehensive Net Expenditure for the year ended 31st March 2019 2 Statement of Financial Position as at 31st March 2019 3 Statement of Changes in Taxpayers' Equity for the year ended 31st March 2019 4 Statement of Cash Flows for the year ended 31st March 2019 5

Notes to the Accounts 1 Accounting policies 6-10 2 Other operating revenue 11 3 Revenue 12 4 Employee benefits and staff numbers 13-15 5 Operating expenses 16 6 Better payment practice code 17 7 Income generation activities 18 8 Operating leases 19 9 Property, plant and equipment 20 10 Trade and other receivables 21 11 Cash and cash equivalents 22 12 Trade and other payables 23 13 Provisions 24 14 Contingencies 25 15 Commitments 25 16 Financial instruments 25-26 17 Operating segments 27 18 Joint arrangements - interests in joint operations 28-29 19 Related party transactions 30 20 Financial performance targets 31 21 Impact of IFRS 32-33 22 Losses and Special Payments 34 NHS Stoke on Trent CCG - Annual Accounts 2018-19

Statement of Comprehensive Net Expenditure for the year ended 31 March 2019

2018-19 2017-18 Note £'000 £'000

Income from sale of goods and services 2 (1,460) (251) Other operating income 2 - (848) Total operating income (1,460) (1,099)

Staff costs 4 3,766 3,525 Purchase of goods and services 5 474,687 432,952 Depreciation and impairment charges 5 50 50 Provision expense 5 30 64 Other Operating Expenditure 5 1,049 142 Total operating expenditure 479,582 436,733

Net Operating Expenditure 478,123 435,634

Finance income - - Finance expense - - Net expenditure for the year 478,123 435,634

Net (Gain)/Loss on Transfer by Absorption - - Total Net Expenditure for the Financial Year 478,123 435,634 Other Comprehensive Expenditure Items which will not be reclassified to net operating costs Net (gain)/loss on revaluation of PPE - - Net (gain)/loss on revaluation of Intangibles - - Net (gain)/loss on revaluation of Financial Assets - - Actuarial (gain)/loss in pension schemes - - Impairments and reversals taken to Revaluation Reserve - - Items that may be reclassified to Net Operating Costs Net gain/loss on revaluation of available for sale financial assets - - Reclassification adjustment on disposal of available for sale financial assets - - Sub total - -

Comprehensive Expenditure for the year 478,123 435,634

2

NHS Stoke on Trent CCG - Annual Accounts 2018-19

Statement of Changes In Taxpayers Equity for the year ended 31 March 2019 Revaluation Other Total General fund reserve reserves reserves £'000 £'000 £'000 £'000 Changes in taxpayers’ equity for 2018-19

Balance at 01 April 2018 (11,535) 0 0 (11,535) Transfer between reserves in respect of assets transferred from closed NHS bodies 0 0 0 0 Impact of applying IFRS 9 to Opening Balances 0 0 Impact of applying IFRS 15 to Opening Balances 0 0 Adjusted NHS Clinical Commissioning Group balance at 31 March 2018 (11,535) 0 0 (11,535) 0 Changes in NHS Clinical Commissioning Group taxpayers’ equity for 2018-19 0 Net operating expenditure for the financial year (478,123) (478,123) 0 Net gain/(loss) on revaluation of property, plant and equipment 0 0 Net gain/(loss) on revaluation of intangible assets 0 0 Net gain/(loss) on revaluation of financial assets 0 0 Total revaluations against revaluation reserve 0 0 0 Net gain (loss) on available for sale financial assets 0 0 0 0 Net gain/(loss) on revaluation of other investments and Financial Assets (excluding available for sale financial assets) 0 0 Net gain (loss) on revaluation of assets held for sale 0 0 0 0 Impairments and reversals 0 0 0 0 Net actuarial gain (loss) on pensions 0 0 0 0 Movements in other reserves 0 0 0 0 Transfers between reserves 0 0 0 0 Release of reserves to the Statement of Comprehensive Net Expenditure 0 0 0 0 Reclassification adjustment on disposal of available for sale financial assets 0 0 0 0 Transfers by absorption to (from) other bodies 0 0 0 0 Reserves eliminated on dissolution 0 0 0 0

Net Recognised NHS Clinical Commissioning Group Expenditure for the Financial Year (478,123) 0 0 (478,123) Net funding 448,843 0 0 448,843 Balance at 31 March 2019 (40,815) 0 0 (40,815)

Revaluation Other Total General fund reserve reserves reserves £'000 £'000 £'000 £'000 Changes in taxpayers’ equity for 2017-18

Balance at 01 April 2017 (13,131) 0 0 (13,131) Transfer of assets and liabilities from closed NHS bodies as a result of the 1 April 2013 transition 0 0 0 0 Adjusted NHS Clinical Commissioning Group balance at 31 March 2018 (13,131) 0 0 (13,131)

Changes in NHS Clinical Commissioning Group taxpayers’ equity for 2017-18 Net operating costs for the financial year (435,634) (435,634)

Net gain/(loss) on revaluation of property, plant and equipment 0 0 0 0 Net gain/(loss) on revaluation of intangible assets 0 0 0 0 Net gain/(loss) on revaluation of financial assets 0 0 0 0 Total revaluations against revaluation reserve 0 0 0 0

Net gain (loss) on available for sale financial assets 0 0 0 0 Net gain (loss) on revaluation of assets held for sale 0 0 0 0 Impairments and reversals 0 0 0 0 Net actuarial gain (loss) on pensions 0 0 0 0 Movements in other reserves 0 0 0 0 Transfers between reserves 0 0 0 0 Release of reserves to the Statement of Comprehensive Net Expenditure 0 0 0 0 Reclassification adjustment on disposal of available for sale financial assets 0 0 0 0 Transfers by absorption to (from) other bodies 0 0 0 0 Reserves eliminated on dissolution 0 0 0 0 Net Recognised NHS Clinical Commissioning Group Expenditure for the Financial Year (435,634) 0 0 (435,634) Net funding 437,229 0 0 437,229 Balance at 31 March 2018 (11,535) 0 0 (11,535)

The notes on pages 6 to 34 form part of this statement

4 NHS Stoke on Trent CCG - Annual Accounts 2018-19

Statement of Cash Flows for the year ended 31 March 2019 2018-19 2017-18 Note £'000 £'000 Cash Flows from Operating Activities Net operating expenditure for the financial year (478,123) (435,634) Depreciation and amortisation 5 50 50 (Increase)/decrease in trade & other receivables 10 5,521 (4,391) Increase/(decrease) in trade & other payables 12 23,527 2,749 Provisions utilised 13 (8) 0 Increase/(decrease) in provisions 13 30 64 Net Cash Inflow (Outflow) from Operating Activities (449,003) (437,162)

Cash Flows from Investing Activities Net Cash Inflow (Outflow) from Investing Activities 0 0

Net Cash Inflow (Outflow) before Financing (449,003) (437,162)

Cash Flows from Financing Activities Grant in Aid Funding Received 448,843 437,229 Net Cash Inflow (Outflow) from Financing Activities 448,843 437,229

Net Increase (Decrease) in Cash & Cash Equivalents 11 (160) 67

Cash & Cash Equivalents at the Beginning of the Financial Year 299 231 Cash & Cash Equivalents (including bank overdrafts) at the End of the Financial Year 139 299

The notes on pages 6 to 34 form part of this statement

5 NHS Stoke on Trent CCG - Annual Accounts 2018-19

Notes to the financial statements

1 Accounting Policies

NHS England has directed that the financial statements of clinical commissioning groups shall meet the accounting requirements of the Group Accounting Manual issued by the Department of Health and Social Care. Consequently, the following financial statements have been prepared in accordance with the Group Accounting Manual 2018-19 issued by the Department of Health and Social Care. The accounting policies contained in the Group Accounting Manual follow International Financial Reporting Standards to the extent that they are meaningful and appropriate to clinical commissioning groups, as determined by HM Treasury, which is advised by the Financial Reporting Advisory Board. Where the Group Accounting Manual permits a choice of accounting policy, the accounting policy which is judged to be most appropriate to the particular circumstances of the clinical commissioning group for the purpose of giving a true and fair view has been selected. The particular policies adopted by the clinical commissioning group are described below. They have been applied consistently in dealing with items considered material in relation to the accounts. 1.1 Going Concern These accounts have been prepared on a going concern basis. 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. Where a clinical commissioning group ceases to exist, it considers whether or not its services will continue to be provided (using the same assets, by another public sector entity) in determining whether to use the concept of going concern for the final set of financial statements. If services will continue to be provided the financial statements are prepared on the going concern basis. With the CCG reporting a deficit in 2018/19 the CCG Governing Body has formally considered the ongoing financial viability of the CCG - and the appropriateness of preparing the year end accounts for 2018/19 on a ‘going concern’ basis. The CCG has referred to the Department of Health Manual of Accounts 2018-19 (page 79), which outlines the following in respect of the going concern assumption: "IAS 1 presentation of financial statements: preparers of financial statements should be aware of the following interpretations of Going Concern for the public sector context.

- For non-trading entities in the public sector, the anticipated continuation of the provision of a service in the future, as evidenced by inclusion of financial provision for that service in published documents, is normally sufficient evidence of going concern. However, a trading entity needs to consider whether it is appropriate to continue to prepare its financial statements on a going concern basis where it is being, or is likely to be, wound up." The following is clear evidence that the CCG meets the requirement highlighted above and as set out in section 4.13 of the Department of Health Manual of Accounts: • Stoke on Trent CCG (the CCG) was established on 1 April 2013 as a separate statutory body; • the CCG has an agreed Constitution which it is operating to for the governance of its activities; • the CCG has been allocated funds from NHS England for 2019/20; and submitted a financial plan to NHS England for 2019/20 which recognises the accumulated deficit position of the CCG; • the CCG is allocated a cash drawdown which is based on the cash requirements of the CCG • the CCG is in the process of producing a medium term financial plan in collaboration with the health economy as a whole in accordance with NHS England requirements – which includes assumed allocations through to 2020/21. Based upon the above, it is therefore concluded that under the Government Financial Reporting Manual (FReM) that the CCG is a going concern for financial reporting purposes – and no additional disclosures are required. 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 of the National Health Service Act 2006, and where the substance of that arrangement is that of a joint operation, the CCG would then recognise:-.

If the clinical commissioning group is in a “jointly controlled operation”, the clinical commissioning group recognises: - It's Assets, including Its share of any Assets held jointly. - It's liabilities, including its share of any liabilities incurred jointly. - It's expenses, including its share of any expenses incurrect jointly. - It's income, including its share of any income arising from the joint operation.

1.4 Operating Segments Income and expenditure are analysed in the Operating Segments note and are reported in line with management information used within the clinical commissioning group. 1.5 Revenue The transition to IFRS 15 has been completed in accordance with paragraph C3 (b) of the Standard, applying the Standard retrospectively recognising the cumulative effects at the date of initial application. In the adoption of IFRS 15 a number of practical expedients offered in the Standard have been employed. These are as follows; • As per paragraph 121 of the Standard the clinical commissioning group will not disclose information regarding performance obligations part of a contract that has an original expected duration of one year or less, • The clinical commissioning group is to similarly not disclose information where revenue is recognised in line with the practical expedient offered in paragraph B16 of the Standard where the right to consideration corresponds directly with value of the performance completed to date. • The FReM has mandated the exercise of the practical expedient offered in C7(a) of the Standard that requires the clinical commissioning group to reflect the aggregate effect of all contracts modified before the date of initial application. Revenue in respect of services provided is recognised when (or as) performance obligations are satisfied by transferring promised services to the customer, and is measured at the amount of the transaction price allocated to that performance obligation. Where income is received for a specific performance obligation that is to be satisfied in the following year, that income is deferred.

Payment terms are standard reflecting cross government principles. The value of the benefit received when the clinical commissioning group accesses funds from the Government’s apprenticeship service are recognised as income in accordance with IAS 20, Accounting for Government Grants. Where these funds are paid directly to an accredited training provider, non- cash income and a corresponding non-cash training expense are recognised, both equal to the cost of the training funded.

6 NHS Stoke on Trent CCG - Annual Accounts 2018-19

Notes to the financial statements

1.6 Employee Benefits 1.6.1 Short-term Employee Benefits Salaries, wages and employment-related payments, including payments arising from the apprenticeship levy, are recognised in the period in which the service is received from employees, including bonuses earned but not yet taken. The cost of leave earned but not taken by employees at the end of the period is recognised in the financial statements to the extent that employees are permitted to carry forward leave into the following period.

1.6.2 Retirement Benefit Costs Past and present employees are covered by the provisions of the NHS Pensions Schemes. These schemes are unfunded, defined benefit schemes that cover NHS employers, General Practices and other bodies allowed under the direction of the Secretary of State in England and Wales. The schemes are not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities. Therefore, the schemes are accounted for as though they were defined contribution schemes: the cost to the clinical commissioning group of participating in a scheme is taken as equal to the contributions payable to the scheme for the accounting period.

For early retirements other than those due to ill health the additional pension liabilities are not funded by the scheme. The full amount of the liability for the additional costs is charged to expenditure at the time the clinical commissioning group commits itself to the retirement, regardless of the method of payment. The schemes are subject to a full actuarial valuation every four years and an accounting valuation every year. Local Government Pensions There are no employees in NHS Stoke on Trent CCG covered by the Local Governament Superannuation Scheme.

1.7 Other Expenses Other operating expenses are recognised when, and to the extent that, the goods or services have been received. They are measured at the fair value of the consideration payable. 1.8 Grants Payable Where grant funding is not intended to be directly related to activity undertaken by a grant recipient in a specific period, the clinical commissioning group recognises the expenditure in the period in which the grant is paid. All other grants are accounted for on an accruals basis. 1.9 Property, Plant & Equipment 1.9.1 Recognition Property, plant and equipment is capitalised if: · It is held for use in delivering services or for administrative purposes; · It is probable that future economic benefits will flow to, or service potential will be supplied to the clinical commissioning group; · It is expected to be used for more than one financial year; · The cost of the item can be measured reliably; and, · The item has a cost of at least £5,000; or, · Collectively, a number of items have a cost of at least £5,000 and individually have a cost of more than £250, where the assets are functionally interdependent, they had broadly simultaneous purchase dates, are anticipated to have simultaneous disposal dates and are under single managerial control; or,

· Items form part of the initial equipping and setting-up cost of a new building, ward or unit, irrespective of their individual or collective cost. Where a large asset, for example a building, includes a number of components with significantly different asset lives, the components are treated as separate assets and depreciated over their own useful economic lives. 1.9.2 Measurement All property, plant and equipment is measured initially at cost, representing the cost directly attributable to acquiring or constructing the asset and bringing it to the location and condition necessary for it to be capable of operating in the manner intended by management. Assets that are held for their service potential and are in use are measured subsequently at their current value in existing use. Assets that were most recently held for their service potential but are surplus are measured at fair value where there are no restrictions preventing access to the market at the reporting date Revaluations are performed with sufficient regularity to ensure that carrying amounts are not materially different from those that would be determined at the end of the reporting period. Current values in existing use are determined as follows: · Land and non-specialised buildings – market value for existing use; and, · Specialised buildings – depreciated replacement cost.

Properties in the course of construction for service or administration purposes are carried at cost, less any impairment loss. Cost includes professional fees but not borrowing costs, which are recognised as expenses immediately, as allowed by IAS 23 for assets held at fair value. Assets are re-valued and depreciation commences when they are brought into use. IT equipment, transport equipment, furniture and fittings, and plant and machinery that are held for operational use are valued at depreciated historic cost where these assets have short useful economic lives or low values or both, as this is not considered to be materially different from current value in existing use. An increase arising on revaluation is taken to the revaluation reserve except when it reverses an impairment for the same asset previously recognised in expenditure, in which case it is credited to expenditure to the extent of the decrease previously charged there. A revaluation decrease that does not result from a loss of economic value or service potential is recognised as an impairment charged to the revaluation reserve to the extent that there is a balance on the reserve for the asset and, thereafter, to expenditure. Impairment losses that arise from a clear consumption of economic benefit are taken to expenditure. Gains and losses recognised in the revaluation reserve are reported as other comprehensive income in the Statement of Comprehensive Net Expenditure. 1.9.3 Subsequent Expenditure Where subsequent expenditure enhances an asset beyond its original specification, the directly attributable cost is capitalised. Where subsequent expenditure restores the asset to its original specification, the expenditure is capitalised and any existing carrying value of the item replaced is written- out and charged to operating expenses.

7 NHS Stoke on Trent CCG - Annual Accounts 2018-19

Notes to the financial statements

1.10 Leases Leases are classified as finance leases when substantially all the risks and rewards of ownership are transferred to the lessee. All other leases are classified as operating leases. 1.10.1 The Clinical Commissioning Group as Lessee Property, plant and equipment held under finance leases are initially recognised, at the inception of the lease, at fair value or, if lower, at the present value of the minimum lease payments, with a matching liability for the lease obligation to the lessor. Lease payments are apportioned between finance charges and reduction of the lease obligation so as to achieve a constant rate on interest on the remaining balance of the liability. Finance charges are recognised in calculating the clinical commissioning group’s surplus/deficit. Operating lease payments are recognised as an expense on a straight-line basis over the lease term. Lease incentives are recognised initially as a liability and subsequently as a reduction of rentals on a straight-line basis over the lease term. Contingent rentals are recognised as an expense in the period in which they are incurred. Where a lease is for land and buildings, the land and building components are separated and individually assessed as to whether they are operating or finance leases. 1.11 Cash & Cash Equivalents Cash is cash in hand and deposits with any financial institution repayable without penalty on notice of not more than 24 hours. Cash equivalents are investments that mature in 3 months or less from the date of acquisition and that are readily convertible to known amounts of cash with insignificant risk of change in value. In the Statement of Cash Flows, cash and cash equivalents are shown net of bank overdrafts that are repayable on demand and that form an integral part of the clinical commissioning group’s cash management. 1.12 Provisions Provisions are recognised when the clinical commissioning group has a present legal or constructive obligation as a result of a past event, it is probable that the clinical commissioning group will be required to settle the obligation, and a reliable estimate can be made of the amount of the obligation. The amount recognised as a provision is the best estimate of the expenditure required to settle the obligation at the end of the reporting period, taking into account the risks and uncertainties. Where a provision is measured using the cash flows estimated to settle the obligation, its carrying amount is the present value of those cash flows using HM Treasury’s discount rate as follows: Early retirement provisions are discounted using HM Treasury’s pension discount rate of positive 0.29% (2017-18: positive 0.10%) in real terms. All general provisions are subject to four separate discount rates according to the expected timing of cashflows from the Statement of Financial Position date: • A nominal short-term rate of 0.76% (2017-18: negative 2.42% in real terms) for inflation adjusted expected cash flows up to and including 5 years from Statement of Financial Position date. • A nominal medium-term rate of 1.14% (2017-18: negative 1.85% in real terms) for inflation adjusted expected cash flows over 5 years up to and including 10 years from the Statement of Financial Position date. • A nominal long-term rate of 1.99% (2017-18: negative 1.56% in real terms) for inflation adjusted expected cash flows over 10 years and up to and including 40 years from the Statement of Financial Position date. • A nominal very long-term rate of 1.99% (2017-18: negative 1.56% in real terms) for inflation adjusted expected cash flows exceeding 40 years from the Statement of Financial Position date. All 2018-19 percentages are expressed in nominal terms with 2017-18 being the last financial year that HM Treasury provided real general provision discount rates.

When some or all of the economic benefits required to settle a provision are expected to be recovered from a third party, the receivable is recognised as an asset if it is virtually certain that reimbursements will be received and the amount of the receivable can be measured reliably.

A restructuring provision is recognised when the clinical commissioning group has developed a detailed formal plan for the restructuring and has raised a valid expectation in those affected that it will carry out the restructuring by starting to implement the plan or announcing its main features to those affected by it. The measurement of a restructuring provision includes only the direct expenditures arising from the restructuring, which are those amounts that are both necessarily entailed by the restructuring and not associated with on-going activities of the entity. 1.13 Clinical Negligence Costs NHS Resolution operates a risk pooling scheme under which the clinical commissioning group pays an annual contribution to NHS Resolution, which in return settles all clinical negligence claims. The contribution is charged to expenditure. Although NHS Resolution is administratively responsible for all clinical negligence cases, the legal liability remains with clinical commissioning group. 1.14 Non-clinical Risk Pooling The clinical commissioning group participates in the Property Expenses Scheme and the Liabilities to Third Parties Scheme. Both are risk pooling schemes under which the clinical commissioning group pays an annual contribution to the NHS Resolution and, in return, receives assistance with the costs of claims arising. The annual membership contributions, and any excesses payable in respect of particular claims are charged to operating expenses as and when they become due.

1.15 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 group contribute annually to a pooled fund, which is used to settle the claims. 1.16 Contingent liabilities and contingent assets A contingent liability is a possible obligation that arises from past events and whose existence will be confirmed only by the occurrence or non- occurrence of one or more uncertain future events not wholly within the control of the clinical commissioning group, or a present obligation that is not recognised because it is not probable that a payment will be required to settle the obligation or the amount of the obligation cannot be measured sufficiently reliably. A contingent liability is disclosed unless the possibility of a payment is remote. A contingent asset is a possible asset that arises from past events and whose existence will be confirmed by the occurrence or non-occurrence of one or more uncertain future events not wholly within the control of the clinical commissioning group. A contingent asset is disclosed where an inflow of economic benefits is probable. Where the time value of money is material, contingent liabilities and contingent assets are disclosed at their present value.

8 NHS Stoke on Trent CCG - Annual Accounts 2018-19

Notes to the financial statements

1.17 Financial Assets Financial assets are recognised when the clinical commissioning group becomes party to the financial instrument contract or, in the case of trade receivables, when the goods or services have been delivered. Financial assets are derecognised when the contractual rights have expired or the asset has been transferred. Financial assets are classified into the following categories: · Financial assets at amortised cost; · Financial assets at fair value through other comprehensive income and ; · Financial assets at fair value through profit and loss. The classification is determined by the cash flow and business model characteristics of the financial assets, as set out in IFRS 9, and is determined at the time of initial recognition. 1.17.1 Financial Assets at Amortised cost Financial assets measured at amortised cost are those held within a business model whose objective is achieved by collecting contractual cash flows and where the cash flows are solely payments of principal and interest. This includes most trade receivables and other simple debt instruments. After initial recognition these financial assets are measured at amortised cost using the effective interest method less any impairment. The effective interest rate is the rate that exactly discounts estimated future cash receipts through the life of the financial asset to the gross carrying amount of the financial asset. 1.17.2 Financial assets at fair value through other comprehensive income Financial assets held at fair value through other comprehensive income are those held within a business model whose objective is achieved by both collecting contractual cash flows and selling financial assets and where the cash flows are solely payments of principal and interest. 1.17.3 Financial assets at fair value through profit and loss Financial assets measure at fair value through profit and loss are those that are not otherwise measured at amortised cost or fair value through other comprehensive income. This includes derivatives and financial assets acquired principally for the purpose of selling in the short term. 1.17.4 Impairment For all financial assets measured at amortised cost or at fair value through other comprehensive income (except equity instruments designated at fair value through other comprehensive income), lease receivables and contract assets, the clinical commissioning group recognises a loss allowance representing the expected credit losses on the financial asset. The clinical commissioning group adopts the simplified approach to impairment in accordance with IFRS 9, and measures the loss allowance for trade receivables, lease receivables and contract assets at an amount equal to lifetime expected credit losses. For other financial assets, the loss allowance is measured at an amount equal to lifetime expected credit losses if the credit risk on the financial instrument has increased significantly since initial recognition (stage 2) and otherwise at an amount equal to 12 month expected credit losses (stage 1). HM Treasury has ruled that central government bodies may not recognise stage 1 or stage 2 impairments against other government departments, their executive agencies, the Bank of England, Exchequer Funds and Exchequer Funds assets where repayment is ensured by primary legislation. The clinical commissioning group therefore does not recognise loss allowances for stage 1 or stage 2 impairments against these bodies. Additionally DHSC provides a guarantee of last resort against the debts of its arm's lengths bodies and NHS bodies and the clinical commissioning group does not recognise allowances for stage 1 or stage 2 impairments against these bodies. For financial assets that have become credit impaired since initial recognition (stage 3), expected credit losses at the reporting date are measured as the difference between the asset's gross carrying amount and the present value of the estimated future cash flows discounted at the financial asset's original effective interest rate. Any adjustment is recognised in profit or loss as an impairment gain or loss.

1.18 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. 1.18.1 Financial Guarantee Contract Liabilities Financial guarantee contract liabilities are subsequently measured at the higher of: · The premium received (or imputed) for entering into the guarantee less cumulative amortisation; and, · The amount of the obligation under the contract, as determined in accordance with IAS 37: Provisions, Contingent Liabilities and Contingent Assets. 1.18.2 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. 1.19 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. 1.20 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).

9 NHS Stoke on Trent CCG - Annual Accounts 2018-19

Notes to the financial statements

1.21 Critical accounting judgements and key sources of estimation uncertainty In the application of the clinical commissioning group's accounting policies, management is required to make various judgements, estimates and assumptions 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 fuure periods if the revisions affects both current and future periods.

1.21.1 Critical accounting judgements in applying accounting policies The following are the judgements, apart from those involving estimations (see below) that management has made in the process of applying NHS Stoke on Trent's accounting policies, and that have the most significant effect on the amounts recognised in the financial statements.

Due to the varied nature of Better Care Fund arrangements the CCG has had to exercise its judgement in deciding the extent to which funds are pooled, and the nature of the pooling. For each element of the funds, the control has been assessed as one of the following:

- A lead commissioner arrangement where the parties to the funds have granted full control to one party, who then selects the providers, can vary the contracts unilaterally, holds those providers to account, and is subject to greater risk than the other members., In these circumstances the CCG only records the transactions with the Local Authority, who in turn records the transactions with the provider/ in its accounts.

- A joint arrangement - where all the members have joint control although one party, the host, acts as an agent for the others, but where the decisions regarding the relevant actibities are unanimous and any member can veto any agreement, all members bear the risks equally (in line with the S75 Agreement).

- An arrangement whereby the CCG operates under its own authority and at its sole discretion, making its own relevant decisions, placing its own contracts, bearing its own risk, unmodified by the activities of the pooled budget, its host or other members. In these circumstances the CCG records its own transactions with the provider of those services, in the same way as it would for any other expenditure.

The NHS Stoke on ~Trent CCG's judgement in relation to this policy is set out in Pooled Budget Note 19 in these Accounts. The following are assumptions about the future and other major sources of estimation uncertainty that have a significant risk of resulting in a material adjustment to the carrying amounts of assets and liabilities within the next financial year.

1.21.2 Sources of estimation uncertainty The following are assumptions about the future and other major sources of estimation uncertainty that have a significant risk of resulting in a material adjustment to the carrying amounts of assets and liabilities within the next financial year.

Alongside other Staffordshire Clinical Commissioning Groups, NHS Stoke on Trent Clinical Commissioning Group has entered into an Expert Determination process with University Hospitals of North Midlands concerning contractual challenges covering both 2017/18 and 2018/19 financial years the result of which is anticipated to be received prior to the Final Accounts submission. Although the Clinical Commissioning Group has provided for the most likely outcome within it’s 2018/19 accounts the result of the determination could result in a material adjustment being required to the financial position as stated within the draft accounts submission.

In addition, there are three accounting estimates which are considered to be significant, These are the Prescribing accrual, Contract Outturn accruals, and Partially Completed Spells which is calculated by the Provider.

1.22 Gifts Gifts are items that are voluntarily donated, with no preconditions and without the expectation of any return. Gifts include all transactions economically equivalent to free and unremunerated transfers, such as the loan of an asset for its expected useful life, and the sale or lease of assets at below market value.

1.23 Accounting Standards That Have Been Issued But Have Not Yet Been Adopted The DHSC GAM does not require the following IFRS Standards and Interpretations to be applied in 2018-19. These Standards are still subject to HM Treasury FReM adoption, with IFRS 16 being for implementation in 2019-20, and the government implementation date for IFRS 17 still subject to HM Treasury consideration. ● IFRS 16 Leases – Application required for accounting periods beginning on or after 1 January 2019, but not yet adopted by the FReM: early adoption is not therefore permitted. ● IFRS 17 Insurance Contracts – Application required for accounting periods beginning on or after 1 January 2021, but not yet adopted by the FReM: early adoption is not therefore permitted. ● IFRIC 23 Uncertainty over Income Tax Treatments – Application required for accounting periods beginning on or after 1 January 2019.

10 NHS Stoke on Trent CCG - Annual Accounts 2018-19

2 Other Operating Revenue 2018-19 2017-18 Total Total £'000 £'000

Income from sale of goods and services (contracts) Education, training and research 20 20 Non-patient care services to other bodies 196 231 Patient transport services - - Prescription fees and charges - - Dental fees and charges - - Income generation - - Other Contract income 1,243 - Recoveries in respect of employee benefits - - Total Income from sale of goods and services 1,460 251

Other operating income Rental revenue from finance leases - - Rental revenue from operating leases - - Charitable and other contributions to revenue expenditure: NHS - - Charitable and other contributions to revenue expenditure: non-NHS - - Receipt of donations (capital/cash) - - Receipt of Government grants for capital acquisitions - - Continuing Health Care risk pool contributions - - Non cash apprenticeship training grants revenue - - Other non contract revenue - 848 Total Other operating income - 848

Total Operating Income 1,460 1,099

Other revenue includes £0.408m for Prescribing Flu ( 2017 18 £0.420m).

Revenue in this notes does not include cash received from the Department of Health, which is drawn down directly into the bank account of the Clinical Commissioning Group and credited to the General Fund.

11 NHS Stoke on Trent CCG - Annual Accounts 2018-19

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

Non-patient care Recoveries in Education, training Other Contract services to other respect of employee and research income bodies benefits £'000 £'000 £'000 £'000 Source of Revenue NHS 20 - 928 - Non NHS - 196 315 - Total 20 196 1,243 -

Non-patient care Recoveries in Education, training Other Contract services to other respect of employee and research income bodies benefits £'000 £'000 £'000 £'000 Timing of Revenue Point in time 20 196 1,243 - Over time - - - - Total 20 196 1,243 -

12 NHS Stoke on Trent CCG - Annual Accounts 2018-19

4. Employee benefits and staff numbers

4.1.1 Employee benefits Total 2018-19

Permanent Employees Other Total £'000 £'000 £'000 Employee Benefits Salaries and wages 2,709 262 2,971 Social security costs 305 - 305 Employer Contributions to NHS Pension scheme 350 - 350 Other pension costs - - - Apprenticeship Levy - - - Other post-employment benefits - - - Other employment benefits - - - Termination benefits 141 - 141 Gross employee benefits expenditure 3,504 262 3,766

Less recoveries in respect of employee benefits (note 4.1.2) - - - Total - Net admin employee benefits including capitalised costs 3,504 262 3,766

Less: Employee costs capitalised - - - Net employee benefits excluding capitalised costs 3,504 262 3,766

4.1.1 Employee benefits Total 2017-18

Permanent Employees Other Total £'000 £'000 £'000 Employee Benefits Salaries and wages 2,806 34 2,841 Social security costs 301 1 302 Employer Contributions to NHS Pension scheme 382 - 382 Other pension costs - - - Apprenticeship Levy - - - Other post-employment benefits - - - Other employment benefits - - - Termination benefits - - - Gross employee benefits expenditure 3,489 36 3,525

Less recoveries in respect of employee benefits (note 4.1.2) - - - Total - Net admin employee benefits including capitalised costs 3,489 36 3,525

Less: Employee costs capitalised - - - Net employee benefits excluding capitalised costs 3,489 36 3,525

4.1.2 Recoveries in respect of employee benefits The CCG had no recoveries in respect of employee benefits in 2018-19 (nil 2017 18)

13 NHS Stoke on Trent CCG - Annual Accounts 2018-19

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

Total 61.30 2.70 64.00 70.00 1.00 71.00

None of the above were engaged in capital projects

4.3 Exit packages agreed in the financial year

2018-19 2018-19 2018-19 Compulsory redundancies Other agreed departures Total Number £ Number £ Number £ Less than £10,000 1 3,333 - - 1 3,333 £10,001 to £25,000 1 18,888 - - 1 18,888 £25,001 to £50,000 ------£50,001 to £100,000 6 503,730 - - 6 503,730 £100,001 to £150,000 2 261,848 - - 2 261,848 £150,001 to £200,000 ------Over £200,001 ------Total 10 787,799 - - 10 787,799

2017-18 2017-18 2017-18 Compulsory redundancies Other agreed departures Total Number £ Number £ Number £ Less than £10,000 ------£10,001 to £25,000 2 33,333 - - 2 33,333 £25,001 to £50,000 1 45,829 - - 1 45,829 £50,001 to £100,000 1 93,582 - - 1 93,582 £100,001 to £150,000 ------£150,001 to £200,000 1 160,000 - - 1 160,000 Over £200,001 2 461,872 - - 2 461,872 Total 7 794,616 - - 7 794,616

The tables in this note show the aggregate total of Exit Packages agreed in year for the group of six Staffordshire CCGs. Stoke-on-Trent CCG's share of costs relating to Exit Packages agreed in 2018-19 was £117,410, and the share of costs relating to Exit Packages agreed in 2017-18 was £31,235. Redundancy costs have been paid in accordance with the provisions of the Agenda for Change Scheme or in line with contractual terms and conditions. Exit costs are accounted for in accordance with relevant accounting standards and at the latest in full in the year of departure.

14 NHS Stoke on Trent CCG - Annual Accounts 2018-19

4.4 Pension costs

Past and present employees are covered by the provisions of the two NHS Pension Schemes. Details of the benefits payable and rules of the Schemes can be found on the NHS Pensions website at www.nhsbsa.nhs.uk/pensions.

These schemes are unfunded, defined benefit schemes that cover NHS employers, General Practices and other bodies allowed under the direction of the Secretary of State in England and Wales. The schemes are not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities.

Therefore, the schemes are accounted for as though they were defined contribution schemes: the cost to the clinical commissioning group of participating in a scheme is taken as equal to the contributions payable to the scheme for the accounting period.

The schemes are subject to a full actuarial valuation every four years and an accounting valuation every year.

4.4.1 Accounting valuation

A valuation of scheme liability is carried out annually by the scheme actuary (currently the Government Actuary’s Department) as at the end of the reporting period. This utilises an actuarial assessment for the previous accounting period in conjunction with updated membership and financial data for the current reporting period, and is accepted as providing suitably robust figures for financial reporting purposes. The valuation of the scheme liability as at 31 March 2019, is based on valuation data as 31 March 2018, updated to 31 March 2019 with summary global member and accounting data. In undertaking this actuarial assessment, the methodology prescribed in IAS 19, relevant FReM interpretations, and the discount rate prescribed by HM Treasury have also been used.

The latest assessment of the liabilities of the scheme is contained in the report of the scheme actuary, which forms part of the annual NHS Pension Scheme Accounts. These accounts can be viewed on the NHS Pensions website and are published annually. Copies can also be obtained from The Stationery Office.

4.4.2 Full actuarial (funding) valuation

The purpose of this valuation is to assess the level of liability in respect of the benefits due under the schemes (taking into account recent demographic experience), and to recommend contribution rates payable by employees and employers.

The 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 2018-19, employers’ contributions of £343,789 were payable to the NHS Pensions Scheme (2017-18: £381,771) 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.

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5. Operating expenses 2018-19 2017-18 Total Total £'000 £'000

Purchase of goods and services Services from other CCGs and NHS England 2,994 3,341 Services from foundation trusts 61,085 16,873 Services from other NHS trusts 220,925 239,817 Provider Sustainability Fund (Sustainability Transformation Fund 1718) - - Services from Other WGA bodies - - Purchase of healthcare from non-NHS bodies 75,243 77,044 Purchase of social care 10,026 1,741 General Dental services and personal dental services - - Prescribing costs 50,093 50,343 Pharmaceutical services - - General Ophthalmic services 188 (0) GPMS/APMS and PCTMS 44,725 42,069 Supplies and services – clinical 4 - Supplies and services – general 5,129 761 Consultancy services 160 30 Establishment 721 343 Transport 1,917 38 Premises 831 131 Audit fees 54 54 Other non statutory audit expenditure · Internal audit services 42 40 · Other services 16 - Other professional fees 205 189 Legal fees 36 128 Education, training and conferences 293 11 Funding to group bodies - - CHC Risk Pool contributions - - Total Purchase of goods and services 474,687 432,952

Depreciation and impairment charges Depreciation 50 50 Amortisation - - Impairments and reversals of property, plant and equipment - - Impairments and reversals of intangible assets - - Impairments and reversals of financial assets · Assets carried at amortised cost - - · Assets carried at cost - - · Available for sale financial assets - - Impairments and reversals of non-current assets held for sale - - Impairments and reversals of investment properties - - Total Depreciation and impairment charges 50 50

Provision expense Change in discount rate - - Provisions 30 64 Total Provision expense 30 64

Other Operating Expenditure Chair and Non Executive Members 104 77 Grants to Other bodies - - Clinical negligence - - Research and development (excluding staff costs) 20 65 Expected credit loss on receivables 924 - Expected credit loss on other financial assets (stage 1 and 2 only) - - Inventories written down - - Inventories consumed - - Non cash apprenticeship training grants - - Other expenditure - - Total Other Operating Expenditure 1,049 142

Total operating expenditure 475,816 433,207

16 NHS Stoke on Trent CCG - Annual Accounts 2018-19

6.1 Better Payment Practice Code

Measure of compliance 2018-19 2018-19 2017-18 2017-18 Number £'000 Number £'000 Non-NHS Payables Total Non-NHS Trade invoices paid in the Year 16,353 92,849 17,579 129,128 Total Non-NHS Trade Invoices paid within target 15,773 78,476 17,204 123,458 Percentage of Non-NHS Trade invoices paid within target 96.45% 84.52% 97.87% 95.61%

NHS Payables Total NHS Trade Invoices Paid in the Year 3,208 278,215 3,099 264,634 Total NHS Trade Invoices Paid within target 3,093 277,049 3,044 263,501 Percentage of NHS Trade Invoices paid within target 96.42% 99.58% 98.23% 99.57%

This note reports compliance with the better payment practice code in respect of invoices received from both NHS and Non NHS trade creditors. The target is to pay all trade creditors within 30 calendar days of receipt of goods or a valid invoice unless other payment terms have been agreed. The measure of compliance is that at least 95% of invoices are paid within target unless these are disputed by the CCG.

6.2 The Late Payment of Commercial Debts (Interest) Act 1998 2018-19 2017-18 £'000 £'000

Amounts included in finance costs from claims made under this legislation - - Compensation paid to cover debt recovery costs under this legislation - - Total - -

17 NHS Stoke on Trent CCG - Annual Accounts 2018-19

7 Income Generation Activities

The Clinical Commissioning Group undertook income generation activities with an aim of achieveing profit, which was then used in commissioning healthcare services. None of these activities had a full cost which exceeded £1m or was otherwise material.

Income generation activity relates primarily to the ongoing development of the Telehealth scheme in relation to membership fees received from other organisations.

18 NHS Stoke on Trent CCG - Annual Accounts 2018-19

8. Operating Leases

8.1 As lessee 8.1.1 Payments recognised as an Expense 2018-19 2017-18 Land Buildings Other Total Buildings Other Total £'000 £'000 £'000 £'000 £'000 £'000 £'000 Payments recognised as an expense Minimum lease payments - 348 1 349 94 1 95 Contingent rents ------Sub-lease payments ------Total - 348 1 349 94 1 95

The six Staffordshire CCGs came under a single leadership arrangment for 2018 19. As a result the Operating lease costs of buildings across the six Staffordshire CCGs are now shared on a capitation basis.

Other lease payments relate to expenditure on photocopiers.

8.1.2 Future minimum lease payments 2018-19 2017 18 Land Buildings Other Total Buildings Other Total £'000 £'000 £'000 £'000 £'000 £'000 £'000 Payable: No later than one year - 79 - 79 165 - 165 Between one and five years - 318 - 318 660 - 660 After five years - 180 - 180 495 - 495 Total - 577 - 577 1,320 - 1,320

Future Minimum Lease payments are now shared across the six Staffordshire CCGs on a capitation basis. As such the costs for 2018 19 are lower than 2017 18 for each CCG.

Whilst our arrangements with Staffordshire County Council fall within the definition of operating leases, rental charge for future years has not yet been agreed . Consequently this note does not include the minimum lease payments in respect of the specific agreement with Staffordshire County Council.

19 NHS Stoke on Trent CCG - Annual Accounts 2018-19

9 Property, plant and equipment

Information 2018-19 technology Total £'000 £'000 Cost or valuation at 01 April 2018 248 248

Additions purchased - - Cost/Valuation at 31 March 2019 248 248

Depreciation 01 April 2018 50 50

Charged during the year 50 50 Depreciation at 31 March 2019 99 99

Net Book Value at 31 March 2019 149 149

Purchased 149 149 Total at 31 March 2019 149 149

Asset financing:

Owned 149 149

Total at 31 March 2019 149 149

Revaluation Reserve Balance for Property, Plant & Equipment

The CCG holds no Revaluation Reserve balance for Property,Plant and Equipment in 2018 19 (nil 2017 18)

9.1 Economic lives Minimum Life Maximum Life (years) (Years)

Information technology 2 10

20 NHS Stoke on Trent CCG - Annual Accounts 2018-19

10.1 Trade and other receivables Current Non-current Current Non-current 2018-19 2018-19 2017-18 2017-18 £'000 £'000 £'000 £'000

NHS receivables: Revenue 3,539 - 3,412 - NHS receivables: Capital - - - - NHS prepayments 1,605 - 1,619 - NHS accrued income 1,937 - 7,846 - NHS Contract Receivable not yet invoiced/non-invoice - - - - NHS Non Contract trade receivable (i.e pass through funding) - - - - NHS Contract Assets - - - - Non-NHS and Other WGA receivables: Revenue 440 - 479 - Non-NHS and Other WGA receivables: Capital - - - - Non-NHS and Other WGA prepayments 28 - 37 - Non-NHS and Other WGA Contractaccrued incomeReceivable not yet 1,642 - 429 - invoiced/non-invoice - - - - Non-NHS and Other WGA Non Contract trade receivable (i.e pass through funding) - - - - Non-NHS Contract Assets - - - - Expected credit loss allowance-receivables (924) - - - VAT 42 - 9 - Private finance initiative and other public private partnership arrangement prepayments and accrued income - - - - Interest receivables - - - - Finance lease receivables - - - - Operating lease receivables - - - - Other receivables and accruals - - (2) - Total Trade & other receivables 8,309 - 13,829 -

Total current and non current 8,309 13,829

The great majority of trade is with NHS bodies. AS NHS bodies are funded by Government, no credit scoring of them is considered necessary.

10.2 Receivables past their due date but not impaired 2018-19 2018-19 2017-18 2017-18 DHSC Group Non DHSC DHSC Group Non DHSC Bodies Group Bodies Bodies Group Bodies £'000 £'000 £'000 £'000 By up to three months 1,044 157 471 196 By three to six months 504 - 67 133 By more than six months 501 115 1,117 128 Total 2,049 272 1,655 457

10.3 Impact of Application of IFRS 9 on financial assets at 1 April 2018

Trade and other Trade and other Trade and other Other Cash and cash receivables - receivables - receivables - financial Total equivalents other DHSC NHSE bodies external assets group bodies

£000s £000s £000s £000s £000s Classification under IAS 39 as at 31st March 2018 Financial Assets held at Amortised cost 299 5,645 5,613 908 (2) 12,463 Total at 31st March 2018 299 5,645 5,613 908 (2) 12,463

Classification under IFRS 9 as at 1st April 2018 Financial Assts designated to FVTPL ------Financial Assets mandated to FVTPL ------Financial Assets measured at amortised cost 299 5,645 5,613 908 (2) 12,463 Financial Assets measured at FVOCI ------Total at 1st April 2018 299 5,645 5,613 908 (2) 12,463

Changes due to change in measurement attribute ------Other changes ------Change in carrying amount ------

Financial Assets in note 10.3 excludes prepayments, VAT and includes cash balances. The CCG had no movement in loss allowances due to application of IFRS9.

21 NHS Stoke on Trent CCG - Annual Accounts 2018-19

11 Cash and cash equivalents

2018-19 2017-18 £'000 £'000 Balance at 01 April 2018 299 231 Net change in year (160) 67 Balance at 31 March 2019 139 299

Made up of: Cash with the Government Banking Service 139 298 Cash with Commercial banks - - Cash in hand 0 0 Current investments - - Cash and cash equivalents as in statement of financial position 139 299

Bank overdraft: Government Banking Service - - Bank overdraft: Commercial banks - - Total bank overdrafts - -

Balance at 31 March 2019 139 299

22 NHS Stoke on Trent CCG - Annual Accounts 2018-19

Current Non-current Current Non-current 12 Trade and other payables 2018-19 2018-19 2017-18 2017-18 £'000 £'000 £'000 £'000

Interest payable - - - - NHS payables: Revenue 7,908 - 5,385 - NHS payables: Capital - - - - NHS accruals 9,150 - (761) - NHS deferred income - - - - NHS Contract Liabilities - - - - Non-NHS and Other WGA payables: Revenue 14,436 - 8,252 - Non-NHS and Other WGA payables: Capital - - - - Non-NHS and Other WGA accruals 16,765 - 11,198 - Non-NHS and Other WGA deferred income - - - - Non-NHS Contract Liabilities - - - - Social security costs 41 - 46 - VAT - - - - Tax 36 - 38 - Payments received on account - - - - Other payables and accruals 989 - 1,641 - Total Trade & Other Payables 49,326 - 25,798 -

Total current and non-current 49,326 25,798

Other payables include £0.234m outstanding pension contributions at 31 March 2019 (£0.314m 31 March 2018)

12.1 Impact of Application of IFRS 9 on financial liabilities at 1 April 2018 Trade and Trade and Trade and Other Other Total other payables other payables other payables borrowings financial - NHSE bodies - other DHSC - external (including liabilities group bodies finance lease obligations) £000s £000s £000s £000s £000s £000s Classification under IAS 39 as at 31st March 2018 Financial Liabilities held at Amortised cost 2,301 2,323 21,090 - - 25,714 Total at 31st March 2018 2,301 2,323 21,090 - - 25,714

Classification under IFRS 9 as at 1st April 2018 Financial Liabilities measured at amortised cost ------Total at 1st April 2018 ------

Changes due to change in measurement attribute 2,301 2,323 21,090 - - 25,714 Other changes ------Change in carrying amount 2,301 2,323 21,090 - - 25,714

23 NHS Stoke on Trent CCG - Annual Accounts 2018-19

13 Provisions Current Non-current Current Non-current 2018-19 2018-19 2017-18 2017-18 £'000 £'000 £'000 £'000 Restructuring - - 64 - Redundancy 86 - - - Total 86 - 64 -

Total current and non-current 86 - 64 -

Restructuring Redundancy Total £'000 £'000 £'000

Balance at 01 April 2018 64 - 64 - Arising during the year - 86 86 Utilised during the year (8) - (8) Reversed unused (56) - (56) Balance at 31 March 2019 - 86 86 - Expected timing of cash flows: - Within one year - 86 86 Between one and five years - - - After five years - - - Balance at 31 March 2019 - 86 86

NHS Stoke on Trent CCG held a formal Management of Change process during 2017-18 As a result two Executives were unsuccessful. Redundancy payments were made in 2018 19 and the unutilised provision reversed as unused.

The new redundancy provision has been calculated based upon the enactment of a management of change programme which has yet to be fully completed. The provision has been made in 2018-19 as the decision as to the make up of the organisational structure and consequential reduction in head count has been made in this financial year.

24 NHS Stoke on Trent CCG - Annual Accounts 2017 - 18

14 Contingencies NHS Stoke on Trent Clinical Commissioning Group had no contingency assets or liabilities as at 31st March 2019.

15 Commitments 15.1 Capital commitments There are no contracted capital commitments as at 31st March 2019 not otherwise included in these financial statements.

15.2 Other financial commitments NHS Stoke on Trent Clinical Commissioning Group and consolidated group had no non cancellable contracts (which are not leases, PFI contracts or other service concession arrangements) as at 31st March 2019.

16 Financial instruments

16.1 Financial risk management

Financial reporting standard IFRS 7 requires disclosure of the role that financial instruments have had during the period in creating or changing the risks a body faces in undertaking its activities.

Because NHS clinical commissioning group is financed through parliamentary funding, it is not exposed to the degree of financial risk faced by business entities. Also, financial instruments play a much more limited role in creating or changing risk than would be typical of listed companies, to which the financial reporting standards mainly apply. The clinical commissioning group has limited powers to borrow or invest surplus funds and financial assets and liabilities are generated by day-to-day operational activities rather than being held to change the risks facing the clinical commissioning group in undertaking its activities.

Treasury management operations are carried out by the finance department, within parameters defined formally within the NHS clinical commissioning group standing financial instructions and policies agreed by the Governing Body. Treasury activity is subject to review by the NHS clinical commissioning group and internal auditors.

16.1.1 Currency risk The NHS clinical commissioning group is principally a domestic organisation with the great majority of transactions, assets and liabilities being in the UK and sterling based. The NHS clinical commissioning group has no overseas operations. The NHS clinical commissioning group and therefore has low exposure to currency rate fluctuations.

16.1.2 Interest rate risk

The clinical commissioning group borrows from government for capital expenditure, subject to affordability as confirmed by NHS England. The borrowings are for 1 to 25 years, in line with the life of the associated assets, and interest is charged at the National Loans Fund rate, fixed for the life of the loan. The clinical commissioning group therefore has low exposure to interest rate fluctuations.

16.1.3 Credit risk

Because the majority of the NHS clinical commissioning group and revenue comes parliamentary funding, NHS clinical commissioning group has low exposure to credit risk. The maximum exposures as at the end of the financial year are in receivables from customers, as disclosed in the trade and other receivables note.

16.1.4 Liquidity risk

NHS clinical commissioning group is required to operate within revenue and capital resource limits, which are financed from resources voted annually by Parliament. The NHS clinical commissioning group draws down cash to cover expenditure, as the need arises. The NHS clinical commissioning group is not, therefore, exposed to significant liquidity risks.

25 NHS Stoke on Trent CCG - Annual Accounts 2018-19

16.1.5 Financial instruments contd

16.1.6 Financial assets

Financial Assets measured at amortised cost Total 2018-19 2018-19 £'000 £'000

Loans receivable with group bodies - - Loans receivable with external bodies - - Trade and other receivables with NHSE bodies 3,228 3,228 Trade and other receivables with other DHSC group bodies 3,890 3,890 Trade and other receivables with external bodies 440 440 Other financial assets - - Cash and cash equivalents 139 139 Total at 31 March 2019 7,697 7,697

16.1.7 Financial liabilities

Financial Liabilities measured at amortised cost Total 2018-19 2018-19 £'000 £'000

Loans with group bodies - - Loans with external bodies - - Trade and other payables with NHSE bodies 3,455 3,455 Trade and other payables with other DHSC group bodies 22,043 22,043 Trade and other payables with external bodies 22,761 22,761 Other financial liabilities 989 989 Private Finance Initiative and finance lease obligations - - Total at 31 March 2019 49,248 49,248

26 NHS Stoke on Trent CCG - Annual Accounts 2018-19

17 Operating segments

Gross Income Net expenditure Total assets Total liabilities Net assets 2018-19 expenditure £'000 £'000 £'000 £'000 £'000 £'000 Commissioning of Healthcare 479,582 (1,460) 478,123 8,597 (49,412) (40,815) Total 479,582 (1,460) 478,123 8,597 (49,412) (40,815)

Gross Income Net expenditure Total assets Total liabilities Net assets 2017-18 expenditure £'000 £'000 £'000 £'000 £'000 £'000 Commissioning of Healthcare 436,733 (1,099) 435,634 14,327 (25,862) (11,535) Total 436,733 (1,099) 435,634 14,327 (25,862) (11,535)

The CCG considers it has only one Operating segment - Commissioning of Healthcare.

27 NHS Stoke on Trent CCG - Annual Accounts 2018-19

18 Joint Arrangements - interests in joint operations

The BCF was implemented under the Care Act which requires CCGs to establish joint arrangements to operate pooled budgets (under S75 of the NHS Act 2006). The BCF is a key catalyst for the Health and Social Care, and working with other partners, to establish a complementary approach to whole systems working that builds upon approaches and infrastructures that are already part of the Staffordshire and Stoke-on-Trent landscape. BCF affords the opportunity to develop shared positions, to adopt agreed objectives, and to drive changes that are systems wide. Stoke on Trent Clinical Commissioning Group and Stoke on Trent City Council in 2016/2017 entered into a Section 75 Framework Agreement which included a range of schemes, and due to the complexity of the local systems differing levels of contributions were made. Judgements were made regarding the way in which the various elements of the fund were pooled. The agreed approach was that the majority of funding was attributed in a virtual pool with funding transferred to the Local Authority commissioned on a lead basis. Other elements of the pooling remained under CCG authority. Overall the CCG’s contribution under these pooling arrangements amounted to £21.966m. The table below details the scheme contributions and the arrangements for each scheme.

CCG resources within the S75 framework agreement

CCG Contribution to each Scheme in 2018-19 Scheme Area Category Pooling Assessment £000

Resources transferred by CCG to Staffordshire County Council who act as principal. CCG accounts for its Protection of Adult Social Care Social Care Section 256 Funds Transfer transactions with council. 8,579

Resources transferred by CCG to Staffordshire County Council who act as principal. CCG accounts for its Carers Breaks Mental Health Carers transactions with council. 138 8,717

Dementia.Frailty/Complex Needs Resources controlled and expended by (MPFT contract) Mental Health Frail Elderly the CCG 1,316

Resources controlled and expended by Hospices Other End of Life the CCG 1,801

Intermediate Care/Step Down Resources controlled and expended by Beds/Reablement Community Health Frail Elderly the CCG 5,095

Admission Avoidance/Discharge to Resources controlled and expended by Assess Mental Health Other - Mental health/wellbeing the CCG 2,561

Resources controlled and expended by Continuing Healthcare (dementia) Community Health Frail Elderly the CCG 2,476 13,249 21,966

Governance and reporting arrangements in respect of the delivery of the Better Care Fund Plan was undertaken by the Health and Wellbeing Board (as established in terms of the Social Care Act 2012).

NHS Stoke on Trent CCG did not have any debtor or creditor balances relating to the BCF with the Lead Authority as at 31 March 2019

28 NHS Stoke on Trent CCG - Annual Accounts 2018-19

18.1 Pooled budgets 2017 - 18 Comparator

The NHS Clinical Commissioning Group shares of the income and expenditure handled by the pooled budget in the financial year were:

2017-18 2016-17 2017-18 2016-17 £'000 £'000 Income 0 0 Expenditure -20918 -32233

The BCF was implemented under the Care Act which requires CCGs to establish joint arrangements to operate pooled budgets (under S75 of the NHS Act 2006). The BCF is a key catalyst for the Health and Social Care, and working with other partners, to establish a complementary approach to whole systems working that builds upon approaches and infrastructures that are already part of the Staffordshire and Stoke-on-Trent landscape. BCF affords the opportunity to develop shared positions, to adopt agreed objectives, and to drive changes that are systems wide. Stoke on Trent Clinical Commissioning Group and Stoke on Trent City Council in 2016/2017 entered into a Section 75 Framework Agreement which included a range of schemes, and due to the complexity of the local systems differing levels of contributions were made. Judgements were made regarding the way in which the various elements of the fund were pooled. The agreed approach was that the majority of funding was attributed in a virtual pool with funding transferred to the Local Authority commissioned on a lead basis. Other elements of the pooling remained under CCG authority. Overall the CCG’s contribution under these pooling arrangements amounted to £20.918m. The table below details the scheme contributions and the arrangements for each scheme.

CCG resources within the S75 framework agreement Scheme Area Category Pooling Assessment £000's

Ensuring sustainability of adult Social Care Social Care Support to Live at Home Local Authority - Lead 7352 Enhanced Primary and Community Care Social Care Integrated Care Planning Local Authority - Lead 780 Enhanced Primary and Community Care Social Care Carers Services Local Authority - Lead 127 High Impact Change Model for Admission Avoidance / Discharge to Assess Social Care Managing Transfer of Care Local Authority - Lead 1327 Sub total Local Authority 9586

Admission Avoidance/Discharge to Assess Commmunity Health Home First/Discharge to Assess CCG Authority 4152

Enhanced Primary and Community Care Commmunity Health Reablement/Rehabilitation Services CCG Authority 1316 Admission Avoidance/Discharge to Assess Mental Health Other - Mental Health/Wellbeing CCG Authority 1938 Enhanced Primary and Community Care Continuing Care Other - Mental Health/Wellbeing CCG authority 1963 Home First/Discharge to Assess, Admission Avoidance/Discharge to Assess Social Care Voluntary Sector CCG authority 105 Admission Avoidance/Discharge to Assess Social Care Home First/Discharge to Assess CCG authority 1742 Admission Avoidance/Discharge to Assess Community Health Home First/Discharge to Assess CCG authority 116 Sub total CCG 11332

Total of Funds in the BCF Pool 20918

Governance and reporting arrangements in respect of the delivery of the Better Care Fund Plan was undertaken by the Health and Wellbeing Board (as established in terms of the Social Care Act 2012).

Stoke on Trent CCG has a small number of registered patients, resident in Staffordshire, and therefore contributes to the Staffordshire BCF. The value of this for 2016 17 is £0.160m.

The contributions from the CCG form part of total expenditure for the Better Care Fund in Stoke on Trent of £31.278m. This includes spending of £2.601m in respect of the Disabilities Facilties Grant, and £7.759m on the Improved Better Care Fund.

NHS Stoke on Trent CCG did not have any debtor or creditor balances relating to the BCF with the Lead Authority as at 31 March 2018

29 NHS Stoke on Trent CCG - Annual Accounts 2018-19

19 Related party transactions

Details of related party transactions with individuals are as follows:

Receipts Amounts Amounts from owed to due from Payments to Related Related Related Related Party Party Party Party £'000 £'000 £'000 £'000 Moorcroft Medical Centre 1602 0 0 0 North Staffordshire GP Federation 2640 4 8 0 Brook Medical Centre 2040 0 0 0

Dr Steve Fawcett, CCG Clinical Director and Joint Medical Director from 1.1.17, is a GP Partner and Prinicpal at Moorcroft Medical Centre & Moss Green Surgery. The practice is a member of the North Staffordshire GP Federation.

Dr, John Gilby CCG Clinical Director, is a GP Partner at Brook Medical Centre. The practice is a member of the NS GP Federation. NHS Stoke on Trent CCG has operated a joint Management structure with the five other Staffordshire CCGS as listed below* from11th December 2017. The shared Board posts as detailed in the Renumeration report are equally shared between each CCG.

The Department of Health is the parent department to the CCG. During the year the clinical commissioning group has had a significant number of material transactions with other public sector entities. The main entities with which the CCG has transacted are shown below.

University Hospital of North Midlands NHS Trust Staffordshire and Stoke on Trent Partnership Trust North Staffordshire Combined Healthcare NHS Trust West Midlands Ambulance Service NHS Foundation Trust NHS Midlands and Lancashire CSU NHS England NHS Property Services NHS North Staffordshire CCG* NHS South East Staffs and Seisdon CCG* NHS Cannock Chase CCG* NHS East Staffordshire CCG NHS Stafford and Surrounds CCG*

In addition, the Clinical Commissioning Group has had a number of material transactions with other government departments and other central and local government bodies. Most of these transactions have been with Staffordshire County Council, Stoke on Trent City Council and HM Revenue & Customs.

The NHS Business Services Authority is also a Related Party as it operates the NHS Pension scheme for CCG employees.

30 NHS Stoke on Trent CCG - Annual Accounts 2018-19

20 Financial performance targets

NHS Clinical Commissioning Group have a number of financial duties under the NHS Act 2006 (as amended). NHS Clinical Commissioning Group performance against those duties was as follows:

2018-19 2018-19 2017-18 2017-18 Duty Duty Section Target Performance Achieved Target Performance Achieved £'000 £'000 £'000 £'000

The CCG overspent it's 2018/19 223H(1) Expenditure not to exceed income 450,037 479,582 No revenue resource allocation and 437,328 436,733 revenue income by £29,546k Yes

The CCG did not incur any any Capital resource use does not exceed the capital expenditure on matters 223I(2) amount specified in Directions 0 0 N/A specified in Directions 0 0 N/A

The CCG overspent it's 2018/19 Revenue resource use does not exceed revenue resource allocation by 223I(3) the amount specified in Directions 448,577 478,123 No £29,546k 436,229 435,634 Yes

Capital resource use on specified The CCG did not incur any any matter(s) does not exceed the amount capital expenditure on matters 223J(1) specified in Directions 0 0 N/A specified in Directions 0 0 N/A

Revenue resource use on specified The CCG did not incur any revenue matter(s) does not exceed the amount expenditure on matters specified in 223J(2) specified in Directions 0 0 N/A Directions 0 0 N/A

Revenue administration resource use The CCG underspent the does not exceed the amount specified in administration resource use specified 223J(3) Directions 5,995 5,616 Yes in Directions by £379k 5,986 5,152 Yes

The clinical commissioning group has therefore failed it's duty to operate within it's identified revenue resource, resulting in an in-year deficit of £29,546k. As a result, the clinical commissioning group's external auditors sent a report on 28th May 2019 to the Secretary of State for Health under Section 30 of the Local Audit and Accountability Act 2014.

As per the Allocations Directions in 2018/19 the maximum resource target will be calculated as being the in year allocation.

The deficit position has arisen from overspends across all areas of the commissioning group's responsibility, ie Secondary Care, Primary Care including prescribing and Continuing Healthcare.

223J(2) Revenue Resource use on specified matter (s) 2017/18 Target has been restated from £38,640 to 0 to remove the Delegated Co Commissioning Budget as it is contained within 223H(1) and 223I(3)

31 NHS Stoke on Trent CCG - Annual Accounts 2018-19

21 Effect of application of IFRS 15 on current year closing balances

21.1 Statement of Comprehensive Net Expenditure 2018-19 Total Transitional IFRS 2018-19 pre application Change equivalent (ie 2017-18 IFRS requirements)

£'000 £'000 £'000

Income from sale of goods and services (contracts) (1,460) - (1,460) Other operating income - - - Total operating income (1,460) - (1,460)

Total operating expenditure 479,582 479,582

Net Operating Expenditure 478,123 - 478,123

Finance income - - Finance expense - - Net (gain)/loss on transfers by absorption - - Net expenditure for the year 478,123 - 478,123

21.2 Statement of Financial Position 2018-19 Total Transitional IFRS 2018-19 pre application Change equivalent (ie 2017-18 IFRS requirements)

£'000 £'000 £'000 Non Current Assets Non current trade and other receivables - - - Other non-current assets 149 - 149 Total Non Current Assets 149 - 149

Current Assets Trade and other receivables 8,309 - 8,309 Other current assets - - - Inventories, assets held for sale, cash and financial assets 139 - 139 Total Current Assets 8,448 - 8,448

Total Assets 8,597 - 8,597

Current Liabilities Trade and other payables (49,326) - (49,326) Provisions (86) - (86) Other liabilities - - - Net Current Assets/Liabilities (49,412) - (49,412) Non Current Assets plus/less net Current Assets/Liabilities (40,815) - (40,815)

Non Current Liabilities Other payables - - - Other non-current liabilities - - - Total Non Current Liabilities - - -

Total Assets less Liabilities (40,815) - (40,815)

Taxpayers' Equity and other reserves General Fund (40,815) - (40,815) Other taxpayers equity - - - Total Equity (40,815) - (40,815)

32 NHS Stoke on Trent CCG - Annual Accounts 2018-19

21 Effect of application of IFRS 15 on current year closing balances

21.3 Statement of Cash Flows 2018-19 Total Transitional IFRS 2018-19 pre application Change equivalent (ie 2017-18 IFRS requirements)

£'000 £'000 £'000 Net Cash Flow from Operating Activities Net operating cost (478,123) - (478,123) (Increase)/decrease in trade and other receivables 5,521 - 5,521 Increase/(decrease) in trade payables 23,527 - 23,527 Other cash flow from operating activity 72 - 72 Net cash outflow from operating activities (449,003) - (449,003)

Cash Flows from Investing Activities - - - Cash Flows from Financing Activities 448,843 - 448,843

Net increase/(decrease) in cash and cash equivalents in the (160) - (160) period before adjustment for receipts and payments to the Consolidated Fund Cash and cash equivalents at the beginning of the period 299 - 299 Cash and cash equivalents at the end of the period 139 - 139

21.4 Statement of Changes in Taxpayers equity - General 2018-19 Total Transitional IFRS 2018-19 pre application Fund Change equivalent (ie 2017-18 IFRS requirements)

£'000 £'000 £'000 Opening Balance adjusted for PPAs (11,535) - (11,535) Impact of applying IFRS 15 to the opening balances - - - Total net expenditure for the year (478,123) - (478,123) Other movements - - - Net Funding 448,843 - 448,843 Closing balance (40,815) - (40,815)

SoCTE Total (40,815)

33 NHS Stoke on Trent CCG - Annual Accounts 2018-19

22. Losses and special payments

The CCG recorded no losses or special payments in 2018-19 (nil 2017-18)

34