Annual Report and Accounts 2017/18

Annual Report and Accounts

2017/18

May 2018 Contents

1. Foreword from Joint Accountable Officer for Surrey Heartlands CCGs and Clinical Chair 6 2. Performance Overview 8 2.1. Introduction 8 2.2. Our population and characteristics 9 2.3. Our member practices 10 2.4. Purpose and activities of the CCG 10 2.4.1 Vision, mission and values 11 2.4.2 CCG structure 12 2.4.3 Managing conflicts of interest 12 2.5. Surrey Heartlands Health and Care Partnership 13 2.6. Key issues and/or risks that could affect the CCG’s delivery of its objectives 15 2.7. Explanation of going concern basis 15 2.8. Performance overview 16 2.8.1. A summary of our year 16 2.8.2. Children and young people 19 2.8.3. Mental healthcare for adults 20 2.8.4. Supporting people with learning disabilities 20 2.8.5. Young carers 21 2.8.6. Safeguarding adults and children 21 2.8.7. Urgent and emergency care 21 2.8.8. NHS Continuing healthcare 22 2.8.9. Medicines management 24 2.8.10. Cancer care 25 2.8.11. Improving stroke care 26 2.8.12 Primary care 27 2.8.13 Planned care 28 2.8.14 Urgent care and integration 29 2.9. Performance analysis - finance 30 2.9.1. Introduction 30 2.9.2. Financial summary 30 2.9.3. Financial expenditure and Statement of Financial Position 30 2.10. Performance analysis - sustainable development 35 2.10.1. Introduction 35 2.10.2. Modelled Carbon Footprint 35 2.10.3. Policies (Sustainable Management Development Plan) 35

2.10.4. Contracts (and how we work with others to ensure sustainability is met) 36 2.10.5. Rural proofing 36 2.10.6. Summary of performance 36 2.10.7. Future strategy 37 2.11. Performance analysis - improving quality 38 2.11.1. How the CCG monitors and improves quality of services 38 2.11.2. Performance against national schemes and indicators 40 2.11.3. Better Care Fund metrics 41 2.11.4. NHS Outcomes Framework and Indicators 41 2.11.5. NHS Constitution Standards 46 2.12. Engaging people and communities 50 2.12.1. Introduction 50 2.12.2. How we engaged and involved local communities and partners in 2017/18 50 2.12.3 Structure and resources 50 2.12.4. Partnership working 51 2.12.5. Key engagement activity 52 2.12.6. Involving people in their own health and care 55 2.12.7 Looking ahead 55 2.12.8. Responding to FOIs 56 2.12.9 Principles for Remedy - How the CCG manages complaints 56 2.13. Reducing health inequalities 58 2.13.1. Introduction 58 2.13.2. Equality analyses 58 2.13.3. Equality objectives 58 2.14. Health and Wellbeing Strategy . 59 2.14.1. Introduction 59 2.14.2. Improving children's health and wellbeing 59 2.14.3. Improving older adults' health and wellbeing 60 2.14.4. Promoting emotional wellbeing and mental health 62 2.14.5. Developing a preventative approach 63 2.14.6. Safeguarding the population 65 3. Corporate Governance Report 67 3.1. Members’ Report 67 3.1.1. Introduction 67 3.1.2. Council of Members – members and performance 67 3.1.3. Governing Body – members and performance 67

3.1.4. Registers of Interest 68 3.1.5. Governing Body Committee Framework 69 3.1.6. Audit Committee – role of committee and members 69 3.1.7. Quality Committee – role of committee and members 70 3.1.8. Finance and Performance Committee – role of committee and members 70 3.1.9. Remuneration Committee – role of committee and members 71 3.1.10. Collaborative working 71 3.1.11. Personal Data related incidents 72 3.1.12. Statement of Disclosure to Auditors 73 3.1.13. Modern Slavery Act 73 3.2. Statement of Accountable Officer’s Responsibilities 74 3.3. Governance Statement 76 3.3.1. Introduction and context 76 3.3.2. Scope of responsibility 76 3.3.3. Governance arrangements and effectiveness 76 3.3.4. UK Corporate Governance Code 77 3.3.5. Discharge of Statutory Functions 78 3.3.6. Risk management arrangements and effectiveness 78 3.3.7. Capacity to handle risk 79 3.3.8. Risk assessment 79 3.3.9. Assurance sources - Internal Control Framework 80 3.3.10. Assurance sources - Annual audit of conflicts of interest management 80 3.3.11. Assurance sources - data quality 81 3.3.12. Assurance sources - information governance 81 3.3.13. Assurance sources - Business Critical Models 81 3.3.14. Other sources of assurance – third party assurances 84 3.3.15. Control issues 84 3.3.16. Review of economy, efficiency and effectiveness of the use of resources 84 3.3.17. Delegation of functions 84 3.3.18. Counter fraud arrangements 85 3.3.19. Head of Internal Audit Opinion 85 3.3.20. Review of the effectiveness of governance, risk management and internal control 91 3.3.21. Conclusion 91 3.4. Remuneration Report 92 3.4.1. Introduction 92 3.4.2. Remuneration Committee - Members and Performance 92

3.4.3. Policy on the remuneration of senior managers 92 3.4.4. Remuneration of Very Senior Managers 92 3.4.5. Pension benefits 96 3.4.6. Compensation on early retirement or for loss of office 97 3.4.7. Payments to past members (directors) 97 3.4.8. Pay multiples (Fair pay disclosure) 98 3.5. Staff Report 99 3.5.1. Introduction 99 3.5.2. Number of senior managers 99 3.5.3. Staff numbers and costs 100 3.5.4. Staff composition . 100 3.5.5. Sickness absence data 103 3.5.6. Staff policies 104 3.5.7. Expenditure on consultancy 105 3.5.8. Off-payroll engagements 105 3.5.9. Exit packages, including special (non-contractual) payments 108 3.5.10. Recruitment 108 3.5.11. Equal opportunities for our workforce 109 3.5.12. Staff engagement and consultation 110 3.6. Parliamentary Accountability Audit Report 111 4. Audit opinion on CCG’s financial statements 112 5. Financial statements 116 5.1 Statement of Comprehensive Net Expenditure 116 5.2 Statement of Financial Position as at 31 March 2018 117 5.3 Statement of Changes in Taxpayers’ Equity for year ending 31 March 2018 118 5.4 Statement of Cash Flow for year ending 31 March 2018 119 5.5 Notes to the financial statements 120

1. Foreword from Joint Accountable Officer and Clinical Chair

It has been a busy twelve months for us as a Clinical Commissioning Group and during that time we have seen some really exciting developments, as well as a number of changes.

Following a number of changes in the CCG’s executive management team, we both took up our roles at Surrey Downs during the year. This has given the organisation continuity in its leadership and it has also helped facilitate closer working across Guildford and Waverley, North West Surrey and Surrey Downs CCGs, and across the wider Surrey Heartlands Health and Care Partnership.

To further strengthen these arrangements, in November our new Joint Executive Team took up their posts. This includes a number of posts that are shared across the three organisations and signalled the start of a much more collaborative way of working across the three organisations. This closer working offers many benefits in terms of efficiency and working smarter, where we can share our resources and reduce duplication. However, the local focus remains crucial and each organisation will continue to operate as a statutory organisation, at a very local level, to commission healthcare services that are tailored to the needs of local populations and local communities.

Through our coming together as the Surrey Heartlands Health and Care Partnership, which covers a population of around 850,000 people across the areas covered by the three CCGs, we can work together, with local healthcare organisations, to address some of the bigger challenges we face as a system. This will compliment and support the work happening at a local level and help us deliver improvements at scale, across a wider geography, bringing together commissioners and healthcare providers to work as one team to deliver the improvements needed to make the local health economy work more effectively.

As a commissioning group, a key focus for us is looking for ways to improve care for local people and over the past twelve months we have introduced a range of new initiatives and services that have made a real difference. For example, we have introduced a new community dermatology service for people with skin problems that is helping to detect and diagnose problems much earlier, in GP practices. In the past, these patients would have been referred on for a hospital appointment so this new service, which has recently won a Health Service Journal Award for its use of new technology, is helping patients to be seen more quickly, leading to more rapid detection of skin cancer.

This year we have continued to work with High Street optometrists to offer a wider range of eye care services in the community and we have launched a new community glaucoma monitoring service, which means people with cataracts who are now in a stable condition can be monitored and supported by a local community team.

Given our ageing population, and that long-term health conditions are much more common as we get older, supporting our older and frail members of the community is another important area we are continuing to invest in. Across our three localities there are a range of innovative and pioneering services that are now operating to help provide personalised, wrap-around care to these individuals, and we continue to support the development and expansion of these services, which are playing an important role in supporting patients in their own homes and helping to avoid unnecessary hospital admissions. We have also recently announced the launch of our new adult community contract from October 2018, which sees the coming together of Epsom and St Helier University Hospitals NHS Trust, CSH Surrey and our three GP federations through a new partnership that will deliver more integrated care to our local population, which is another really positive development.

As well as delivering improvements, we also work closely with local organisations to monitor the quality of care people are receiving to make sure it is meeting the quality standards we would want to see for local people. Broadly, local organisations have performed well and we have seen improvements in a number of areas including dementia diagnosis and how quickly people with suspected cancer are being seen. We have

6 also had some areas where performance has been below the standards we would expect and you can read more about this, and the action we have taken, in our performance overview from page 16.

Quality of care and how services are performing is our main priority but as a public organisation we also work hard to manage our financial performance and meet our financial requirements. Against a challenging financial position, at the end of 2017/18 we achieved efficiency savings of £11.8m, without compromising on care. This was a really good achievement and was as a result of the hard work and commitment of our CCG team and member practices, supported by our wider partners. This builds on the £15.5million of savings we achieved last year and we have already focused our attention to 2018/19 and developing a robust programme of initiatives that will release further savings by working more efficiently and delivering more care closer to home. As a wider system, the main challenges we continue to face are in relation to the increasing demand for healthcare, and our ageing population, and using the resources we have to provide effective healthcare that meets these needs, whilst also operating within our resource allocation. Longer-term we are clear that our focus needs to be on delivering transformation, where re-designed and improved care pathways improve care and health outcomes and also result in efficiency savings that can be reinvested into frontline services. This will mean working in a new and different way with our partners and it has been encouraging to see the energy and enthusiasm our partners have shown so far in developing our shared ambitions and a real willingness to work together to achieve the improvements in care we want to see for local people.

Our plans for devolution, which will see the Surrey Heartlands Health and Care Partnership taking on a broader range of commissioning responsibilities, are fundamental to our plans and will mean we get more say in how some services are commissioned at a local level. This year, for the first time, we will also be working to one shared budget across Surrey Heartlands, which will mean collaboration and co-operation at a scale that we have not seen before. This removes the divide between commissioning and provider organisations and will give us the opportunity to work together to provide care for patients as one system, which is a really exciting development.

It’s been recognised that we’re making good progress and earlier in the year we were really pleased to hear that we had been selected to become part of a national Integrated Care System development programme, led by NHS England. We’re one of just ten areas in the country that’s leading the way in terms of new ways of working and over the next year we both look forward to working with our member practices, partners and local people to start to make our ambitious plans a reality as we drive forward the improvements in care we are committed to delivering.

We hope you find this report a helpful summary of our year, and our plans for the next twelve months, and we look forward to continuing to work with you, and for you, in 2018/19.

Matthew Tait Dr Russell Hills Joint Accountable Officer Clinical Chair

2. Performance Report

2.1 Introduction 2.1.1 About us

Clinical Commissioning Groups (or CCGs), were set up in April 2013 following a series of changes across the NHS. They took on some of the work previously done by primary care trusts. Our main job is to plan and buy healthcare services for a population of over 305,000 people who live in the local area.

In terms of geography, we cover Mole Valley, Epsom and Ewell, Banstead and the east side of Elmbridge and surrounding villages, so we buy healthcare for everyone living in this area (see map).

We are a membership organisation, which means we are made up of the GP practices in our area. During 2017/18 we had 31 member practices. This number will change in 2018/19 when Riverbank Surgery merges with Dorking Medical Practice but the timing for this change is still being confirmed.

We work across three localities (or local health economies). These are:

Epsom (which covers Epsom, Ewell, Leatherhead, Fetcham, Bookham, Ashtead, Cobham, Stoneleigh, Worcester Park and neighbouring villages). Epsom Hospital is in this locality.

Dorking (which covers Dorking, Capel, Newdigate, Beare Green, Brockham and surrounding villages). East Surrey Hospital in Redhill is the closest acute hospital for most of this area.

East Elmbridge (which covers Esher, Molesey, Thames Ditton, Oxshott and surrounding areas. Kingston Hospital is the closest acute hospital for most patients in this locality.

We receive money from central government to spend on local healthcare services for local people and in 2017/18 we had a budget of over £367.5 million. We used this to buy healthcare from local hospitals, community services, social care, ambulance services, mental health care and many other services for local people.

Based on the funding we receive, `when we share this between our population, this equates to around £1,200 for everyone living in our area.

There are six NHS clinical commissioning groups in Surrey and some CCGs lead on areas of commissioning on behalf of the others. At Surrey Downs we lead on NHS Continuing Healthcare for the whole of Surrey and we also lead on Individual Funding Requests and medicines management for some areas. You can read more about our joint commissioning arrangements on page 71.

2.1.2 Commissioning responsibilities Our CCG doesn’t commission core primary care services from GP practices as we have not yet taken on delegated commissioning arrangements, like some other CCGs. We don’t commission core services from pharmacies, optometrists or dental practices either – this is done by NHS England. Some specialist care is done by a separate part of the NHS known as NHS Specialised Services. These specialist services range from specialist kidney and mental health services to treatment for rare cancers.

Working with Guildford and Waverley and North West Surrey CCGs, hospital trusts, other healthcare organisations and Surrey County Council, we are now part of what is known as the Surrey Heartlands Health and Care Partnership. Through this exciting new venture we are planning to take on additional commissioning responsibilities through a devolution arrangement. You can read more about this, and the Surrey Heartlands Health and Care Partnership, on page 13.

2.2 Our population and characteristics 2.2.1 Local health needs Although our population is generally healthy when compared nationally, there are still particular communities and areas of deprivation where people are more likely to have poor health.

Half the population of Surrey Downs is of working age, however 20% of residents are over 65 years and more at risk of developing chronic diseases, meaning the demand for health and social care services is expected to rise over the next ten years. Commissioners are working together with social care services and community health providers to ensure that this population has the support they need to live a healthy life in their own homes for as long as possible, and to prevent avoidable hospital admissions through more preventative care and supporting those who are at greatest risk of admission.

The Surrey Downs population is mostly white British, however, there are also some minority groups in the population who may experience poorer health as a result of health inequalities. One of the largest ethnic groups in Surrey is the Gypsy Roma and Travellers (GRT) group, who have worse health outcomes than any other disadvantaged group. They are more likely to experience the death of a child, have higher rates of anxiety and depression and high rates of undiagnosed hypertension.

There are also 4,352 dwellings classed as ‘cold hazards’ due to poor insulation and poor energy efficiency, mainly in rural areas. Living in a cold home increases the risk of emergency admissions to hospital, increases healthcare costs and contributes to excess winter deaths. Developing long-term preventative plans through our Strategic Resilience Partnerships is helping to address this.

Surrey Downs is estimated to have 1,465 people aged 18 – 64 years with a serious personal care disability and this is projected to increase by 9% in the next ten years. In addition, 4,031 adults aged 16 – 64 years are estimated to have a learning disability, which will increase to 4,200 by 2025. Learning disability in adults aged 65 years and over is predicted to increase from 1,203 in 2015 to 1,457 in 2025, an increase of 21%. Both these factors have implications for service planning.

The most prevalent conditions for Surrey Downs currently identified in general practice, are depression, obesity, Chronic Obstructive Pulmonary Disease (COPD) and asthma. Although the prevalence of depression is lower in Surrey Downs when compared nationally, we know it is under-diagnosed. Depression is significantly more likely in people with long-term conditions or in those who are socially isolated. Embedding social prescribing into prevention plans can help to reduce the risk of social isolation and the associated health risks.

Another health issue for our population is rising levels of obesity in both children and adults. The National Child Measurement Programme found that there are 16.2% of 4 - 5 year olds and 23.9% of 10 - 11 year olds in Surrey Downs with excess weight (classified as overweight or obese). Children with excess weight tend to grow into obese adults and increase their risk of diabetes and cardiovascular disease.

Smoking increases the risk of COPD, an under-diagnosed condition for Surrey Downs and one with high associated costs. Stopping smoking is the most effective way of preventing COPD.

Whilst smoking levels are relatively low, there are a number of local authority wards, linked to deprivation (including Preston and Court wards) with high levels of smoking, which increases the risk of COPD and other health problems.

We also know there are some conditions which may not be diagnosed and in Surrey Downs hypertension (a risk factor for cardiovascular disease and stroke, the main causes of premature mortality) and dementia are key areas to focus on. For example, estimates suggest that of the number of people expected to have dementia in Surrey Downs, over 51% of these remain undiagnosed.

Finally, we know that uptake for immunisations (including childhood immunisations and the seasonal flu jab) are below other areas and we also know we have a higher prevalence of skin cancer which we are working to address, with partners.

To address some of these areas we are looking at prevention and we are working on a range of work relating to this, which you can read more about on page 63.

2.3 Our member practices As a GP-led organisation, our member practices are at the heart of the CCG and they play an active role in developing our plans and priorities and also in our decision-making processes.

Our Clinical Cabinet, which brings together our GP Clinical Directors for specific areas (such as mental health, children’s and maternity, integration and prescribing), public health and members of our Joint Executive Team, advises the CCG on clinical issues and pathways and ensures GPs and other clinicians are at the centre of our plans to drive forward improvements in care. Our Clinical Directors also feed directly into the redesign of care pathways, making sure their clinical experience and knowledge is shaping the design of new and improved patient pathways.

Our practices also come together through our Council of Members, where all thirty-one of our member practices are represented. Under our CCG Constitution the membership will be asked to vote on decisions that would require a change to the Constitution and during 2017/18 we invited practices to vote on the issue of delegated commissioning. Whilst there was support from the majority of practices, we needed 75% of the membership to support this change, which we did not quite achieve. In view of this, we have continued with the current arrangements, where NHS England remain responsible for the commissioning of core GP services.

During 2017/18 we have had four GPs as members of the Governing Body and our Clinical Chair also visits individual practices at least once a year to hear about local issues and update members on CCG developments.

We also actively engage with our Local Medical Committee, which represents GPs in Surrey, on issues relating to primary care services and the implementation of local and national initiatives such as delivery of the NHS GP Forward View.

2.4 Purpose and activities of the CCG Now in our fourth year of operation, we have firmly established ourselves as an innovative organisation that has patient care as our top priority.

The activities of the CCG are underpinned by our corporate objectives. For 2017/18 these were:

 Take responsibility, with other partners in the footprint, for developing the Surrey Heartlands Health and Care Partnership within the framework of locally devolved responsibilities; and ensure that this contributes significantly to the creation of a sustainable health economy with improved outcomes and quality  With partner CCGs, develop the CCG's capacity for the commissioning and delivery of primary care in 2017-18, ensuring that this is consistent with broader commissioning development in areas such as integration.

 Ensure that the CCG's Organisational Development programmes support localities, clinical leaders, staff and the Governing Body to work locally and across Surrey Heartlands on the successful delivery of both strategic objectives and ‘business as usual’.  Deliver our financial plan and CCG control total, based largely on a successful transformational QIPP programme

The objectives provide a framework for the Governing Body Assurance Framework, against which risks and opportunities that may have an impact on delivery are identified and assessed. Each corporate objective is assigned to a director lead, responsible for overseeing the goals and deliverables and identifying any risks which may impact on delivery. The Governing Body regularly reviews the Governing Body Assurance Framework to seek assurance on progress and how any risks are being mitigated or managed.

Following the appointment of our Joint Executive Team, we continue to identify opportunities for closer working across the three Surrey Heartlands CCGs. We also continue to actively engage with partners through the Surrey Heartlands Health and Care Partnership to realise our shared ambitions.

2.4.1 Vision, mission and values

We want to ensure the NHS in Surrey Downs offers healthcare that meets the needs of local people, gives patients the best chance of the best outcome when they are ill and helps individuals to stay healthy and live healthy lives.

We will achieve this by putting local doctors and other healthcare professionals in charge of decisions about how NHS services should be organised, always taking into account the views of patients, the public and other partner organisations (such as charities and voluntary organisations).

The NHS has a limited pot of money to spend so we will live within our means. This means we have to work out what services are most important to our local population’s health needs and how we can ‘do more for less’ to make sure we are getting the best value for money.

Our mission is to improve the health and wellbeing of our population

Our vision is to achieve this by:

 working together  improving experiences  always doing better  using what we have to provide the best quality care  addressing inequality

We have also a number of values that underpin how we work as an organisation.

2.4.2 CCG structure The CCG is led by a Governing Body, which is made up of local doctors, nurses, lay members, members of our Joint Executive Team and local authority and public health representatives. Together the Governing Body are responsible for our overall strategy and for decision-making. They are supported by a Joint Executive Team, shared across the three CCGs, and other committees, who are responsible for specific areas of work, with delegated authority.

We also have a Council of Members, which brings together a lead GP from each of our member practices. The Council of Members shapes our vision, strategy and our commissioning plans and sets our CCG Constitution, which governs how we work as an organisation.

Following the retirement of Dr Palta and the closure of Auriol Surgery at the end of April 2017, the CCG is now made up of 31 GP practices.

You can read more about our Governing Body and committee structure in our Corporate Governance Report.

2.4.3 Managing conflicts of interest Everyone who contributes to the work of the CCG brings with them a range of outside interests and connections. It is important, in the public interest, these are recognised and, in some cases, actively managed. We treat all interests in the same way, regardless of whether they are at GP practice level, involve a member of the Governing Body, or relate to an individual member of staff.

As an organisation we want to be open and transparent. We expect any interests to be well managed, in line with our policies relating to conflicts of interest. These state that the CCG “recognises that a conflict of interest, or perceived conflict of interest, in its role as a commissioner of healthcare services is a key risk that requires careful management and handling whether this is a direct or indirect conflict, pecuniary or otherwise.”

As part of our robust policy we:  Maintain appropriate registers of interests, including for our Governing Body, staff and our member practices and in 2017/18 we have invested in a new online system to support this  Publish these registers on our website and prior to Governing Body meetings  Require the prompt declaration of interests by members, practices and employees and ensures that these interests are entered into the relevant register  Make arrangements for managing conflicts and potential conflicts of interest and review our policies in light of guidance from NHS England and Monitor in relation to conflicts of interest.  Have an identified Conflicts of Interest Guardian (the Chair of our Audit Committee) who provides advice and guidance on this area

2.5 Surrey Heartlands Health and Care Partnership Local health and care organisations – Guildford and Waverley CCG, North West Surrey CCG, Surrey Downs CCG, Surrey County Council, acute hospitals, the ambulance trust, local GPs, community services and the mental health trust - all share an ambition to integrate health and care services for the local population in Surrey.

Collectively, these organisations have come together as the Surrey Heartlands Health and Care Partnership to create a new sector-wide model of integrated care. This partnership will work together to deliver national priorities focusing on:  service and clinical pathway improvements  the delivery of outstanding quality services for local people

 improvements in productivity and efficiency to ensure systems remain viable in the long-term

Our five-year Sustainability and Transformation Plan describes how we intend to meet these challenges collectively.

Surrey Heartlands serves a population of 850,000 people, across nine boroughs with a combined health budget of over £1 billion and a combined social care and public health budget of £328 million.

Our partnership includes:  3 CCGs working through eight GP-led localities  92 GP practices (from 1 April 2018)  4 acute hospital sites

 11 community hospital sites  1 mental health provider operating from 4 in-patient sites and delivering community  services from 22 sites  1 community health services provider  1 upper tier local authority (Surrey County Council) operating adult and children’s social services and public health

 9 district and borough councils

Our progress so far Over the past year we have made significant progress in a number of areas. This has included:  Securing additional investment to improve care in several priority areas (‘Better births’, diabetes, cancer and psychiatric liaison in A&E)  Redirecting local system funding to support our priority areas (including managing winter pressures)  Developing plans for devolution1, which would see the partnership taking on greater commissioning responsibilities  Being rated as an ‘advanced’ partnership and becoming part of wave 1 of a new Integrated Care System development programme (a more evolved partnership) – we are one of 10 partnerships nationally to have been selected

Our devolution agreement All commissioning responsibilities for the Surrey Heartlands population, subject to agreement with the relevant national bodies, could come under the scope of our new devolution agreement beginning in April 2018 (and in shadow form during the 2017/18 financial year).

This ground-breaking plan means funding (for both health and social care) historically held at regional and national level could be devolved locally. This would give us more control in how this funding is used, meaning we can address the specific needs of our population. It would also give us an opportunity to further join up health and social care services.

The details are still being confirmed but devolution could include the following aspects of health and care:  All current commissioning responsibilities of the CCGs, starting with services where we already commission on a wider footprint such as children’s, mental health and learning disabilities.  Social care and public health commissioning responsibilities  Other commissioning responsibilities devolved or delegated to Surrey Heartlands from national bodies such as NHS England, as agreed. You can read more about the benefits of devolution at www.surreyheartlands.uk/devolution

Becoming an Integrated Care System Surrey Heartlands has been invited to be part of an Integrated Care System development programme. Integrated Care Systems build on local Sustainability and Transformation Partnerships and go a step further, with the aim of creating integrated health systems at a local level. This would see commissioners, providers and local authorities taking on clear, collective responsibility for local resources and the population’s health. Find out more at www.surreyheartlands.uk.

1 www.surreyheartlands.uk/devolution

2.6 Key issues and/or risks that could affect the CCG’s delivery of its objectives Key issues and risks that could affect our ability to deliver our corporate objectives (as set out in section 2.4) have been carefully considered, communicated and cascaded within the organisation, where the relevant committees have discussed and sought assurances on plans to minimise or mitigate these risks, where possible. The Governing Body has reviewed these issues and risks and the CCG’s Corporate Risk profile is a standing agenda item at Governing Body meetings.

However, it is recognised that the top rated risks on the Governing Body Assurance Framework may require management over longer timescales beyond any given financial year, and that there are wider factors beyond the scope of the CCG’s control which influence the likelihood and impact of those risks.

There has been continued discussion throughout the year of the following top rated risks, with assurances given that all mitigations within the scope of the CCG’s control have been applied to minimise their impact on the delivery of the CCG’s objectives:  achieving financial balance, which is a statutory duty

 delivering a challenging Service Transformation Programme  keeping within a reduced running cost allocation

The Governing Body Assurance Framework for the CCG, and associated risks as of 31 March 2018, are detailed in the Annual Governance Statement, see section 3.3.8 below.

2.7 Explanation of going concern basis Public sector bodies are described as a ‘going concern’, where the continuation of the provision of a service is expected to continue into the future. The CCG accounts have been prepared on this basis (despite the issue of a report to the Secretary of State for Health under Section 30 of the Local Audit and Accountability Act 2014).

The Directors of the CCG are required to make an assessment of the CCG as a ‘going concern’ and have used the following evidence to validate this classification:  The CCG has been operating since 1 April 2013 as a statutory body with an agreed Governance Framework and an Operational plan.  The CCG has been allocated funds from NHS England for the financial year 2018/19.  The CCG submitted detailed financial plans for 2018/19 to NHS England in March 2018.  The CCG has an Operational Plan in place.

2.8 Performance Overview

2.8.1 Introduction

This section summarises how we are performing as an organisation and how we are improving care. It describes some of our achievements and key developments that occurred during the year, having listened to staff, stakeholders and patients.

2.8.1.2 A summary of our year

The following section of this report summarises some of our achievements and some key developments that occurred during the year.

April Positive 360 degree stakeholder feedback As part of our NHS England assurance process, every year we invite some of our key partners (including member practices, local healthcare providers, Healthwatch, patient representatives, MPs and councillors) to give us feedback on how they feel we engage, involve, share information and generally work with them.

When we received our detailed feedback report in April, it showed improvement on our 2016 feedback across almost all areas. We were also rated in the top CCGs nationally for some areas including how engaged key partners feel, how confident partners feel in our clinical leadership and how informed key stakeholders feel about our plans and priorities. We use the feedback to address areas of improvement and we will compare the findings with the feedback we receive from the 2018 survey.

May

Celebrating our staff We held our annual staff awards ceremony, which recognises the contribution made by our staff and especially those that go the extra mile to provide patient-centred care or just deliver a great service. The ceremony included recognition for the service redesign work that has taken place this year which has resulted in improvements in care for our local population.

June

New Joint Accountable Officer appointed Matthew Tait took up the new role of Joint Accountable Officer across Guildford and Waverley, North West Surrey and Surrey Downs CCGs. The appointment signalled the start of closer working across the three organisations and greater collaboration through the Surrey Heartlands Health and Care Partnership.

Matthew joined us from Bedfordshire CCG, where he was Accountable Officer. He has held a number of leadership roles in the NHS and was previously Interim Chief Officer across the three East Berkshire CCGs. Prior to that Matthew was an Area Director for NHS England Thames Valley.

July

Epsom and St Helier 2020-2030 Following on from their estates review, which highlighted some issues around the condition of both hospitals, Epsom and St Helier University Hospitals NHS Trust began a further period of engagement. This was an opportunity for the trust to share the outcome of the review and their current thinking, and to seek the views of local people and stakeholders on next steps. As part of this conversation, the trust asked for views on the possible co-location of some specialist acute services (inpatient paediatrics, major A&E, births and complex emergency surgery) onto one site at Epsom, St Helier or at Sutton, located with the Royal Marsden. The feedback from this engagement is being used to inform the development of a Strategic Outline Case to make a case for funding.

We continue to work with the trust and Sutton and Merton CCGs (which also commission services from the trust) on next steps as part of the Epsom and St Helier acute sustainability programme. For more information see the trust’s website.

August

New Clinical Chair We welcomed Dr Russell Hills as our new Clinical Chair. Russell is a GP and Partner at the Integrated Care Partnership and works as a GP at Fitznells Manor Surgery in Ewell. He has been a GP member of the CCG’s Governing Body since April 2015, where his responsibilities have included acting as GP lead for Equality and Diversity and being an active member of the Finance and Performance Committee and Remuneration and Nominations Committee. Dr Russell Hills took up his new post on 1 August 2017 following the departure of Dr Claire Fuller, who moved on to become Senior Responsible Officer for the Surrey Heartlands Health and Care Partnership.

September

Shortlisted for two national HSJ awards We found out that we had been shortlisted for two Health Service Journal awards. The CCG’s innovative Tele- dermoscopy referral platform, which provides real-time communication between GPs and dermatology specialists to provide faster, more accurate, skin abnormality diagnoses, was shortlisted in the Improving Care with Technology category. Former Clinical Chair, Dr Claire Fuller, was also shortlisted for Clinical Leader of the Year for her leadership of the CCG through a challenging period of change, and her development of the Clinical Academy, part of the Surrey Heartlands Health and Care Partnership.

In November we attended the awards ceremony in London and celebrated a double win, taking both awards.

October

Stay warm, stay well October saw the launch of the national ‘stay well this winter’ campaign so locally we led work to raise awareness of the seasonal flu programme for people who are in the clinical at risk groups and who are eligible to have the vaccine. This included community engagement, roadshows in town centres and a media campaign that encouraged over 65s, people with long-term health conditions, carers and parents of young children to take part in the programme and reduce the risk of getting flu. We are still collecting data on the uptake of the flu vaccination programme in 2017/18 but early results suggest an increase in uptake in some priority groups, compared with previous years.

November

Appointments to Joint Executive Team To reflect closer working across the three CCGs, our new Joint Executive Team took up their posts, some of which are shared across the three organisations and across our Governing Bodies. You can read more about our joint leadership team on our website at www.surreydownsccg.nhs.uk.

December

Outcome of delegated commissioning vote We invited our member practices to vote on whether they would support the CCG taking on responsibility for the commissioning of core GP services from NHS England (known as delegated commissioning). Of the 29 practices that voted, 22 voted to move to delegated commissioning arrangements and seven practices voted to retain the current arrangements. As an organisation we would only pursue this change with the support of our member practices, and this is also a requirement of our CCG Constitution, which requires that we achieve the support of 75% of all practices. Following the outcome of the vote we continue to work closely with, and support our member practices, working alongside NHS England, but the commissioning of core primary care services remains with NHS England.

January Engaging on our joint commissioning intentions Reflecting the closer working happening across the three CCGs, Surrey County Council and the wider Surrey Heartlands area, we published our draft joint health and social care commissioning intentions for 2018/19. The commissioning intentions summarise our health and social care plans and priorities and sets out how we will commission, or buy, care that meets the needs of the Surrey Heartlands population. As part of our engagement we asked local people and partners to give their views on our draft plans and we will use this feedback to inform our next steps and our final plans for 2018/19.

February

Welcome to our new MD We welcomed Colin Thompson as our new substantive Managing Director (MD) at Surrey Downs CCG, who took over from our Interim Managing Director, Donna Derby. Colin’s career in healthcare spans a wide range of provider and commissioner-led organisations and he joins us from Luton Clinical Commissioning Group, where he was Accountable Officer.

Adult community contract awarded Following a robust, competitive, procurement process, we also announced that a partnership of local organisations, led by Epsom and St Helier University Hospitals NHS Trust, were awarded the three year contract to provide adult community services from 1 October 2018.The contract will be held by Epsom and St Helier University Hospitals NHS Trust, which will work with a number of local organisations through a partnership arrangement, which will be known as the Integrated Dorking, Epsom and East Elmbridge Alliance (IDEEA).

This partnership will bring together Epsom and St Helier University Hospitals NHS Trust, CSH Surrey and the three GP federations that operate in the Surrey Downs area (GP Health Partners in the Epsom, Leatherhead and Ewell area, Dorking Healthcare for Dorking practices and Surrey Medical Network for practices in the East Elmbridge area). The new service has been designed to support integration and will include closer

18 working between the different members of the partnership, leading to a service that will be more personalised, and more joined up for patients, with local partners working together to provide the best care.

March

Extended access to primary care During winter we worked with GP practices to commission extra GP appointments, making it even easier for people to see their GP. We continued this in the run up to Easter, and the bank holidays, which is always a busy time for the health system and over the Easter weekend there were over 200 extra GP appointments available for people living in Surrey Downs.

We also continued our campaign to raise awareness of the different sources of information and health advice, including NHS111 and the role of local pharmacists, to help people know which service to access when.

2.8.2 Children and young people

Children’s Community Health Service This has been a year of change as the new children’s community health service, procured in 2016/17, began delivery across Surrey in April 2017 under an innovative single contract. As agreed in the 201/17 procurement, Surrey Downs Children’s services were delivered by CSH (Surrey) for 2017/18, as part of an existing contract and these services have now been successfully transitioned to Children and Family Health Surrey from 1 April 2018.

Key areas of difference in the new service offered by Children and Family Health Surrey (CFHS) will:

 Ensure children and young people (CYP) are at the centre of the care they receive  Keep parents and carers involved in the care of their children

 Provide timely and effective support through a single referral route, connecting families to the right team first time  Establish one set of records, which can be seen by the whole healthcare so parents and carers only have to tell their story once  Ensure physical and emotional wellbeing experts work together to better support family physical and emotional wellbeing Children and Family Health Surrey has improved access and communication for children and young people using innovative technologies with examples including:

 One Stop – a centralised referral and triage service for Surrey's specialist children’s community services

 Chat Health – a confidential text-based advice service to communicate with secondary school students who find it difficult to discuss personal and sensitive subjects particularly in a school setting

 I Want Great Care – capturing service user feedback to increase user feedback and opportunities to influence service development

2.8.3 Mental healthcare for adults During 2017/18 the CCG has actively supported improvements to services for people experiencing mental health issues. We work with other CCGs in Surrey to commission more efficient systems that increase value for money and improve our residents’ mental health.

Our key achievements this year include:  In April 2017 the Epsom Safe Haven was recommissioned on an ongoing basis, as it has met its original aims. As well as being regarded as a valuable resource by service users, it is also considered a crucial element of the mental health crisis care pathway. Following its success, Safe Havens for young people are now being set up across the county, including in Epsom and Guildford.

 Continuing to raise awareness of our Improving Access to Psychological Therapies service, which offers support to people experiencing depression, anxiety and other common mental health problems. In 2018 we will also be working with partners to link the IAPT programme to some long-term condition pathways as many of these individuals may also need support with their mental health and wellbeing.

2.8.4 Supporting people with learning disabilities Highlights and improvements we have made this year in relation to services and support for people with learning disabilities includes:  An increase in the number of GP Annual Health Checks and Health Action Plans at Transition for Young People aged 14 years plus being carried out.  Timely completion of adult and young people’s care, education (young people only) and treatment reviews, working jointly with education, social care and NHS England, to ensure that people at risk of placement breakdown or have an inpatient mental health admission have a robust treatment plan and care package to meet their complex health, education and social care needs.  Implementation of the multi-agency Adult Intensive Support Service. The team provides specialist support when people are in crisis either in their own home, family home, supported living or residential services. By providing rapid responses the team can deliver urgent person-centred care. As a result there has been a reduction in the numbers of people being admitted to inpatient beds as well as faster recovery times.  Joint working with Surrey social care and partner agencies has seen further development of the Positive Behavioural Support (PBS) network. This year, we have: o developed a training network of PBS Coaches o held a PBS Festival in September 2017, placing people into unusual learning environments to stimulate new thinking o secured funding to deliver PBS training o worked with Health Education Kent Surrey and Sussex, Skills for Care and Skills for Health to map development of the Transforming Care Agenda o initiated a skills audit with all Adult Social Care teams to form the basis of recruitment, training and development plans  We continue to work with partners to improve the experience and support provided for people with learning disabilities through the Transforming care Programme. This is a national programme which is focusing on improving health and care services so that more people can live in the community, with the right support, and close to home. The programme is delivered locally through a partnership of health, social care, districts and boroughs and other statutory and voluntary agencies and through a number of work streams.

 Another development this year has been the roll out of the Learning Disabilities Mortality Review (LeDeR) programme across Surrey. A key part of this programme is to support local areas to review the deaths of people with learning disabilities, aged 4 years and older. It also aims to support improvements in the quality of health and social care service delivery for people with learning disabilities and help to reduce health inequalities and premature death. There are a number of staff from organisations who have received specific training and have carried out a number of reviews locally. We are planning to roll out the training further over 2018/19 so that we can increase reviews and share the learning from these both locally and nationally.

2.8.5 Young carers

To raise awareness of the needs of young carers, the NHS Young Carers Pledge2 and our new hospital young carers’ information leaflets were launched at the Royal Surrey County Hospital and Ashford & St Peter’s Hospitals during Young Carer Awareness Day in January 2018.

Additionally Surrey Young Carers held a national event at the Royal Academy of Dramatic Arts to launch their young carers play ‘People Like Us’3. We are now planning a young carers’ forum to build on the legacy of this play. To find out about adult carers, please refer to the Health and Wellbeing section of this report from page 59.

2.8.6 Safeguarding adults and children The CCG has led and supported work on multi-agency safeguarding and has met its commissioner responsibilities towards safeguarding children and adults, and for looked after children.

Throughout the year, the Safeguarding Team has:  worked with NHS England, NHS Digital and Surrey County Council to support the successful implementation of CP-IS, a system that supports information sharing between health and social care staff to help better protect society’s most vulnerable children

 developed approaches to ensure their work is underpinned by the voice of the service user  facilitated an event to ensure the key findings of the National Care Leavers Project influence the future commissioning of services for both children and adults locally

 worked with partners to implement ‘signs of safety’ within health. ‘Signs of safety’ is an innovative strengths-based, safety-organised approach to safeguarding work.

2.8.7 Urgent and emergency care Improving urgent and emergency care is one of the NHS’s key priorities in the Five Year Forward View (FYFV). A core element is to commission an integrated urgent care service to provide the right clinical advice, treatment and care closer to a patient’s home; reducing both unnecessary hospital attendances and admissions.

Strategic and performance governance for urgent care is overseen by Local Accident and Emergency Delivery Boards (LAEDB). As a CCG we play an active role in the Local A&E Delivery Boards for Epsom Hospital, East Surrey Hospital and Kingston Hospital to reflect our patient flows into these three main acute hospitals. This includes monitoring local performance, supporting collaboration across the system and gaining assurance of the processes and plans providers have put in place to deliver integrated urgent and emergency

2 www.youngcarersstuff.org.uk 3 https://www.actionforcarers.org.uk/news/article/film-launch-young-carers-awareness-day/

21 care.

Highlights from this year are summarised on the following pages.

Robust planning for the winter months Over the past 12 months the CCG has led the operational coordination of the urgent care system in Surrey Downs, including the system winter planning. The CCG has worked with local providers to look at the data from previous months to develop and implement a range of initiatives to support local systems over the winter period. These initiatives included:

 Additional primary care provision in our GP practices, with additional resource for out-of-hours services  Additional Rapid Response and home-based rehabilitation care  Step down / step up beds in care homes  Access to consultant advice so GPs can seek advice prior to making a referral  GPs in A&E to triage and treat patients who can more appropriately be seen by primary care professionals  A care home line that allows staff to speak directly to a GP for advice out-of-hours and reduce hospital admissions

2.8.8 NHS Continuing Healthcare NHS continuing healthcare is a package of on-going care that is arranged and funded solely by the NHS. It is designed to support individuals aged 18 or over who are found to have a primary health need which has arisen as a result of disability, accident or illness.

The national framework for NHS continuing healthcare and NHS funded nursing care sets out the principles and how eligibility is determined. The frameworks ensure that those assessing and delivering NHS continuing healthcare, do so fairly, considering the same criteria in the same way.

More information about NHS continuing healthcare and NHS funded healthcare is available on the NHS England website at www.england.nhs.uk/healthcare/.

In Surrey, the continuing healthcare service is hosted by Surrey Downs CCG on behalf of the other five Surrey CCGs (Guildford and Waverley, North West Surrey, North East Hampshire and Farnham - Farnham patients only- Surrey Heath and East Surrey CCGs).

All referrals for continuing healthcare are carefully considered against the national criteria. This process involves assessing the individual’s healthcare needs and working with healthcare providers, people involved in their care and family members to get all the information we need to fully understand the type of care and support that an individual needs. This information is then considered against the national criteria to determine if an individual is eligible for a continuing healthcare package of care.

If someone is receiving continuing healthcare, in line with national guidance, the team review their health needs at least every twelve months, sooner if their needs change, to see if anything has changed, and to make sure they are getting the right care and support.

Performance against key standards NHS England monitors performance against a number of different areas. Two key indicators that we are measured against include:

 Where there has been a positive checklist for CHC eligibility, the CCG must make the CHC eligibility decision within 28 days from the receipt of the checklist in at least 80% of cases  Less than 15 % of all CHC assessments should take place in an acute hospital setting

As a county, our performance in both areas is currently below these targets so improving this position remains a key priority for us, working closely with social care, acute hospital and other partners who may also be involved in an individual’s care.

Carefully considering needs against the national framework If a client, carer or family member is not satisfied with the outcome of an assessment, the continuing healthcare team support them and let them know how they can make an appeal. In some cases these appeals get referred to NHS England.

Of the appeals that have been passed to NHS England over the last 18 months, the original decision has been upheld in all cases. This demonstrates our commitment to ensuring we operate in line with the national framework and shows we have robust decision-making processes in place to make sure clients’ needs are carefully considered against the national criteria.

Ongoing service development The team are committed to ongoing service improvement and following a workshop in January 2018 involving CHC staff, this work has been focusing on delivering improvements in the following areas:  Use of technology and improving communication  Training and education across systems  Discharge to assess pathways (and how we can ensure assessments happen in a timely way)  Integration and further opportunities for closer working with social care and other partner organisations  Contractual efficiencies (through value for money and the negotiation of packages of care)

In addition, the service is being supported by NHS England through a national improvement programme. This includes specific work on the following areas:

Working with partners: The national team is facilitating workshops that support closer working with partners, helping us to work through some of the issues, as well as the opportunities to improve care, particularly in relation to closer working with social care.

Discharge to assess pathways: There are a number of examples of good practice relating to discharge to assess care pathways and we have been identifying, and exploring, these so we can learn from the areas where this is working well and apply this learning locally. These discussions are progressing well and plans for devolution through the Surrey Heartlands Health and Care Partnership present a further opportunity to work more closely with Surrey County Council and social care colleagues.

Real time monitoring: This involves the use of technology to provide real-time data that is displayed on screens for staff and a placement status portal to aid the allocation of placements. This is another area of best practice we continue to explore locally.

Workforce initiatives The availability of specialist nurses with the expertise to carry out assessments is an issue nationally and locally and we are currently involved with several projects that will help address this:  The Continuing Healthcare team is currently working with NHS England to pilot apprentice ‘Associate Practitioners’ who will have specialist training in CHC assessment, whilst working towards a foundation degree.

 The team is also working with the University of Surrey to provide placements for Student Nurses and post graduate specialist programmes, which will raise the profile of CHC as a specialism and as a

career pathway.

 A review is also underway to ensure we continue to have the right staff, with the right skills to undertake the increasing number of referrals we are seeing, is also underway

Deprivation of Liberty Safeguards The Deprivation of Liberty Safeguards (DoLS) were introduced in 2009 as an amendment to the Mental Capacity Act. Given the nature of continuing healthcare, we are currently reviewing our processes in this area to ensure we are actively identifying any individuals that may need to be considered under these safeguards and that the appropriate steps are being taken in line with the legislation. As part of this work the team are also continuing staff awareness and training in relation to this area.

Governance arrangements The performance of, and assurance in relation to, the continuing healthcare service is provided through a joint CHC Programme Board, which includes membership from all six CCGs, Surrey County Council and other partners. This is in addition to the monitoring and assurance which happens through individual CCG committees and the assurance provided at a Governing Body level. Following the development of the Surrey Heartlands Health and Care Partnership and other STPs in other parts of the county, the membership and Terms of Reference of the Programme Board are currently being reviewed. This will ensure that they fully reflect local system changes and it will also strengthen the governance framework that supports the service.

2.8.9 Medicines management

The CCG hosts a medicines management team that works across a number of different clinical commissioning groups.

The team works closely with local practices, the Local Pharmaceutical Committee and prescribing networks to provide guidance on prescribing issues and other projects relating to pharmacy services. This includes working with providers (including care homes) to ensure regular medicine reviews are taking place, projects promoting improvements in the safe and cost-effective use of medicines, and continued work to reduce the volume of medicines that are wasted.

A key focus during 2017/18 has been to support prescribers to develop a structured approach to medication review with a particular focus on high risk medicines and complex patients. In addition, practices have been encouraged to report incidents relating to medicines so that information and learning can be shared across the CCG and processes put in place to mitigate any identified risks.

During the year the CCG also raised awareness of two national consultations, led by NHS England, on the prescribing of over-the-counter and low cost medicines and whether certain products should continue to be available on prescription.

The Pharmaceutical Commissioning Team provides expert advice and support to four CCGs, ensuring good medicines optimisation in services commissioned by the CCGs from providers to meet the needs of patients. Activities this year include:

 Managing the introduction of new drugs through presentation of robust evidence reviews and development of cost-effective treatment pathways e.g. inflammatory bowel disease and psoriasis

 Providing contract documentation to ensure providers of NHS services comply with local policies and have systems in place for managing medicines

 Independent review and presentation of individual funding requests

 Co-ordinating three clinical networks of providers and commissioners to inform cost-effective recommendations to CCGs  Containing costs of high cost drugs through invoice validation and agreement of arrangements to facilitate implementation of best value biosimilar medicines.

2.8.9.1 Clinical pharmacists in General Practice scheme In July 2017 NHS England announced that GP Health Partners, the GP federation that brings together 19 GP practices covering the Epsom locality, had been successful in their bid to become part of a national scheme that will see pharmacists working in local GP surgeries, helping with patients’ routine medication and treatment.

As a result, from summer 2018 clinical pharmacists will work as part of the general practice team by providing expertise on day-to-day medicine issues and consultations with patients directly. This includes providing extra help to manage patients’ long-term conditions, such as helping to manage a patient’s high blood pressure earlier and more effectively and advice for patients on taking multiple medications. This delivers quicker access to clinical advice for patients and allows GPs to spend time with patients who have more complex needs.

2.8.10 Cancer care

Improving cancer care In line with the NHS England Cancer Five Year Forward View, our local focus as a CCG during 2017/18 has been on early detection and screening, risk stratified follow up pathways, and living with and beyond cancer.

Early detection and screening We have worked more closely over the past year with our member practices, public health and NHS England to promote uptake of national screening programmes through primary care. We have seen improvements in screening for breast and bowel cancer, and will continue to drive this forward in 2018/19. To help achieve this, we applied for, and received transformational funding, as part of the Surrey and Sussex Cancer Alliance to roll our FiT testing (a quicker and more convenient way for patients to be screened for bowl cancer) for low risk symptomatic patients, who would not normally meet the criteria for invitation to screening, which will launch in November 2018. This programme will be assisted by the launch of the new FiT test to the wider public by public health in January 2019.

Uptake for cervical cancer screening in Surrey Downs was lower than the national average during 2017/18 and we have continued to engage with practices on ways to improve uptake. One of the outcomes of this has been a decision to offer individuals an opportunity to self-test, within their own homes, and post samples off for screening. We will be supporting public health with the launch of HPV self-testing in March 2019.

We have also worked with primary care colleagues to develop a lung health check pilot, which will see a mobile unit providing spirometry tests within the community, and GPs targeting patients within primary care who are at greater risk of developing lung cancer, including those who smoke. We are hoping to launch this service in 2018/19.

Risk stratification In 2017 we launched a new prostate pathway, where post-treatment cancer patients, who were stable, could have their care transferred from a hospital to primary care setting. By providing GPs with access to a Macmillan specialist, this has enabled patients to receive care closer to home, without having to travel in and out of a hospital setting for follow up appointments. We will continue to monitor progress in this area through

2018/19, but have already been received feedback, especially in relation to the psychological benefit this is having on patients.

We have also been awarded transformational funding to set up a vague symptoms clinic, for patients who don’t necessarily meet the two week rule criteria. By providing these patients with access to diagnostic tests, we will be able to get them on the appropriate treatment pathway sooner, and stop the cycle of repeat presentation between primary care and A&E. The service will launch in December 2018.

We will continue to develop other pathways for the transfer of stable patients to primary care in 2018/19, including pathways for breast and colorectal cancer.

Living with and beyond We now have a Macmillan prostate cancer specialist to complete holistic needs assessments with patients, within a primary care setting. This includes all aspects of patient care on the pathway, such as support with signs and symptoms, psychological and emotional wellbeing, psychosexual wellbeing, and finances. Our Macmillan nurse facilitator has also worked with practices to develop a cancer care template, which can be used by GPs to reassess the needs of all cancer patients. This provides a great psychological benefit for patients and also means that they can be signposted to additional services, that may not have been appropriate during a previous stage of care.

We will also be working throughout 2018/19 to look at improving cancer care across the whole of the Surrey Heartlands Health and Care Partnership, and are excited about new ways of joint working as part of the cancer care clinical pathway.

2.8.11 Improving stroke care

Principles for improving stroke services in hospital and in the community were developed following a review of stroke care that took place prior to 2017/18. These included:

 establishing sustainable hyper-acute stroke units across Surrey;  ensuring that everyone has six month and annual reviews after discharge from hospital; and  ensuring better links and more integration between services such as health and social care and hospital and community services.

Following this review it was agreed that implementing the South East Coast Stroke Services Specification across Surrey would deliver the required improvement, enhancing stroke care across the county. Given that each local health economy and local hospitals, all operate in a slightly different way, rather than apply a ‘one size fits all’ approach, it became clear that local health systems would need to work together in find a solution that met the specification and required standards of care and was also feasible, safe, affordable and met local needs.

For the Surrey Downs area, this has involved working with Epsom and St Helier University Hospitals NHS Trust, Surrey and Sussex Healthcare NHS Trust, CSH Surrey, Epsom Health and Care and other local providers.

A separate review process is now underway in Sussex and given our patient flows into East Surrey Hospital, we need to align these two pieces of work and find a solution that works for both Surrey Downs and Sussex patients. In the interim, we have made some improvements to existing services while this work is undertaken and longer term we remain committed to improving stroke care for our patients, working with partners to identify the right solution.

Guildford and Waverley and North West Surrey CCGs led a public consultation on a range of proposals to improve stroke care in west Surrey in 2017/18 and these changes have subsequently been implemented.

A Surrey Stroke Oversight Group of providers and commissioners was established in October 2017 to mobilise the new model of care in west Surrey and progress work relating to the Surrey Downs area and east Surrey. This group will particularly address the following items in the NHS Outcomes Framework for which the CCG performed below cluster and England levels in 2017/18:

 people with stroke who are discharged from hospital with a joint health and social care plan

 people who have a follow-up assessment between 4 and 8 months after initial admission for stroke

The Surrey Stroke Oversight Group will continue to meet in 2018/19 to continue to oversee the delivery of stroke care across the three CCGs.

2.8.12 Primary care

We continue to work with our three localities and our member practices to support a range of initiatives in primary care that are helping to make it even easier for people to get the care they need at their local GP surgery. These initiatives include:

 Offering extended GP access – In line with the NHS’ plans as part of the GP Five Year Forward View, this year we have worked with our GP federations to offer extended access to GP services. This has meant extra GP appointments for local people, including during evenings and at weekends in some areas, making it even easier for people to see their GP. Over the Easter period alone, our practices provided more than 200 extra appointments so people could get the help they needed locally. During 2018/19 we will continue to work with practices to make appointments available from 8.00am to 8.00pm during the week and extended access at the weekends from October 2018, in line with NHS England’s requirements. This will include pre-bookable routine appointments and urgent appointments and will be provided via hubs across the three localities.  Providing more services, closer to home – through our Primary Care Standards we commission extra GP services that mean local people can benefit from a wider range of clinics and support in the community, at local GP practices. In the past patients may have travelled to a hospital for these clinics and other services so it’s more convenient for patients and means hospitals can focus on providing care for patients with more complex health needs.  Enhancing primary care IT systems – We continue to work with practices to enhance their IT systems, integrating systems where possible so patients experience more joined-up care. In 2017/18 we also supported a national NHS England campaign to increase awareness, and use of GP Online services. If patients register for this service with their practice, this enables them to book appointments online and order repeat prescriptions 24/7, making it easier and more convenient for them.  Delegated primary care commissioning arrangements – We will continue to engage member practices on the issue of delegated commissioning, which would mean the CCG becoming responsible for the commissioning of core primary care services (currently done by NHS England). If, following a vote of our member practices, this change is supported, we will submit an application to NHS England to request this change.

2.8.13 Planned care

Diabetes This year the Surrey Heartlands CCGs were awarded two-years funding totalling £1,623,823 to transform diabetes care in Surrey. The ambition of the Surrey Diabetes Collaborative is to develop high quality services for people with diabetes, particularly across primary care and preventative interventions. There were three aspects of delivery agreed by each CCG to support the Diabetes Transformation Bid:  Improving the uptake of structured education  Improving the achievement of the NICE recommended treatment targets for HbA1c (blood glucose), cholesterol and blood pressure  Reduce the length of stay for in-patients with diabetes through provision of Diabetes Inpatient Specialist Nurses

The CCG has put plans in place to support delivery of all three of these ambitions to improve diabetes care.  Structured education – The CCG supported practices to increase referrals for patients diagnosed with type 2 diabetes to the Desmond type 2 structured education course. The CCG has also invested in training further course educators to deliver the additional sessions, particularly expanding the weekend and evening course offering. This additional capacity will triple the number of places available to patients, enable non-newly diagnosed patients to be referred, and enable delivery of education to Surrey prisoners with diabetes.  NICE three treatment targets – The three Surrey Heartlands CCGs have created a standardised diabetes offer for patients through a GP Locally Commissioned Service (LCS). This LCS will support improvements in quality outcomes for patients and will launch in 2018/19.  Prevention – The CCG launched the National Diabetes Prevention Programme in May 2017 and there have been over 1,400 referrals to date. This programme identifies those who have a high risk of developing diabetes and refers them on to a course that supports people to understand and change key behaviours, reducing their risk of developing the condition. Feedback so far has been extremely positive with weight loss reductions, reductions in blood sugar levels, greater understanding and clarity and other wellbeing benefits.

Musculoskeletal (MSK) care

The CCG is working across Surrey Heartlands to share resources and best practice in the identification and treatment of musculoskeletal disease. A shared website resource is being created to provide educational materials for patients and healthcare professionals, to support individuals to make informed choices about their healthcare. Further work is being done to identify tools that can support GPs in their consultations with patients. This will enable GPs to make decisions together on the options available to the patient to best manage their condition.

Cardiovascular disease

The CCG, with partners in Surrey Heartlands, is working to deliver transformational change in cardiovascular workstreams. The partnership has identified four key priority areas:  Chest Pain  Hypertension  Atrial Fibrillation

 Heart Failure

The CCG is developing new pathways supported by current best practice to assist the effective management of patients with cardiovascular disease. The CCG is also developing a model that upskills community and consultant pharmacists to deliver rapid screening and help patients with undiagnosed and uncontrolled hypertension ensuring they understand and successfully manage their condition.

Community dermatology pathway Through our new community dermatology service, people with skin lesions and potentially malignant moles and tumours are now being seen much more quickly, and closer to home.

The service means GPs can now send referrals and images directly to qualified clinicians who are able to respond quickly to help GPs develop management plans for patients within primary care, helping patients to be seen more quickly and reducing unnecessary referrals into secondary care.

The service, which is delivered by Communitas Clinics, has been rolled out across 19 practices in Surrey Downs with approximately 76 referrals being made per month, above the projected figures. Key successes include improved diagnoses and outcomes, reduced wait times and cost savings by treating patients in the community. Of the total number of Teledermoscopy referrals, 10% have been escalated to an urgent suspected cancer pathway in less time than it would have taken had they been routinely referred.

Following Teledermoscopy advice, 65% of patients were successfully managed in primary care who would otherwise have been referred to secondary care. This represents an NHS saving for each patient and, with current waits to see a secondary care consultant averaging at three-four months, it allows GPs to be able to manage their own patients quickly and within primary care.

2.8.14 Urgent care and integration

Community hubs expanded to support frail patients Community hub services across our three localities continue to provide wrap-around care to frail older people and in July 2017 we expanded the East Elmbridge hub service to include social care and reablement support so patients could benefit from a more joined up service.

The hub services first launched in December 2015 and involve multi-disciplinary team of GPs, nurses and support staff (including social care) working together to provide healthcare that focuses on frail older people with long-term conditions. These can range from dementia to chest infections and heart failure and as a result these people are at a high risk of hospital admission due to a potential exacerbation of their condition, or a crisis. These patients usually have acute, complex health and social care needs so whilst they are not usually sick enough to be in hospital, they need intensive support for a short period of time.

This further investment meant that staff from Surrey County Council, together with colleagues from Surrey Medical Network and CSH Surrey, are now providing additional, personalised care to local older residents at home or in the community wherever possible.

2.9 Performance analysis – finance 2.9.1 Introduction

This section of our performance report summarises our financial performance during the year.

2.9.2 Financial summary – our financial performance in 2017/18 We ended the 2017/18 financial year having achieved Quality, Innovation, Prevention and Productivity (QIPP) savings of £11.8m, which was 65% of our target. Combined with the cumulative delivery over the last two years, the CCG has now delivered over £37m of efficiency savings over a three year period. We have achieved this by redesigning and improving, patient pathways and through working smarter, without compromising patient care or reducing quality.

2.9.3 Financial expenditure

Statement of Financial Position Overview

2017/18 Outturn and cumulative position The CCG received net funding of £367.5million (£361.1m for healthcare, and £6.4m for running costs). This is made up of our in year allocation of £333.6m plus our historic deficit of £33.9m.

The CCG spent £382.2m in 2017/18, which means in its statutory accounts it reported an in-year deficit position at the end of 2017/18 of £14.7m (the £367.5million net funding, less the actual expenditure of £382.2m). The reported outturn included:  the release of a £1.8m reserve that all CCGs were instructed to hold against national system cost pressures. In the event, the national position across the provider sector has been such that NHS England has been unable to allow the CCG’s 0.5% reserve to be spent. Therefore, the CCG has released its 0.5% reserve to the bottom line, resulting in an additional surplus for the year of £1.8m; and;

 the return of £0.4m of ‘Category M’ prescribing savings which had been held back centrally by NHS England during the course of the year.

Excluding the benefit of these two one-off releases, which were not anticipated in the CCG’s original plan, the CCG’s in year deficit figure was £16.9m.

The CCG’s cumulative deficit position at the end of 17/18 is £48.6m (the accumulated deficit of £33.9m plus the £14.7m in year deficit).

Expenditure during 2017/18 in detail The £382.2m compares to a total expenditure of £364.9m in 2016/17, an increase of £17.3m or 4.7%. The main reasons for the year on year increase is the acute area of spend which has increased by around £9m. In addition, mental health and primary care spend have each increased by approximately £3m respectively.

The breakdown of spend by programme together with prior year comparators is shown in the pie chart on the following page.

2017/18 expenditure, with 2016/17 Prior Year comparisons Acute - £225.9m (PY £217.2m) 6.2% 1.6% 0.7% 6.2% Primary Care - £50.4m (PY £47.4m) 6.3% Mental Health - £25.5m (PY £23.0m) 6.7% Other - 24.0m (PY £17.8m)

CHC - £23.9m (PY £23.7m)

13.2% Community - £23.6m (PY £27.6m)

59.1% Running Costs - £6.2m (PY £6.4m)

Learning Difficulties - £2.7m (PY £1.8m)

. Acute (£225.9m or 59% of annual spend)

The acute area, which accounts for 59% of total expenditure is supplied by NHS Foundation Trusts, NHS Trusts and independent providers and are secured through annually negotiated contracts between the CCG and the provider. The CCG’s largest provider is Epsom & St Helier NHS Trust which (including both the main acute and renal site and smaller orthopaedic site) accounted for £111m of the CCG’s spend in 2017/18.

. Community (£23.6m or 6% of annual spend)

Community spend is split across a number of smaller providers but the main provider is CSH Surrey, which delivers community services on behalf of the CCG through a longer term, block contract. Last year the spend on community included the cost of the estate for community services (£4.1m) but this year the spend (£3.9m) has moved to ‘Other’.

. Mental health (£25.5m or 7% of annual spend)

The majority (over 75%) of mental health expenditure is with Surrey and Borders NHS Partnership Trust which is agreed through an annual block contract with the Trust. As well as this block contract, the CCG also commissions and funds Improved Access to Psychological Therapies (IAPT) which accounted for £1.4m of expenditure in 2017/18.

. Learning Difficulties (£2.7m or 1% of annual spend)

The majority of learning difficulty expenditure is with Surrey and Borders Partnership NHS Foundation Trust which is agreed through an annual block contract with the Trust.

. Primary care (£50.4m or 13% of annual spend)

The majority (£40m) of the primary care expenditure relates to the cost of prescriptions, with the remainder being spent on local enhanced services with our GPs, out of hours services and primary care IT. Core GP services are commissioned and funded directly by NHS England.

. Continuing healthcare (£23.9m or 6% of annual spend)

Continuing healthcare (CHC) payments are payments for the living costs (primarily nursing or care home costs) as well as the associated nursing care costs for people whose health needs qualify them for continuing healthcare payments. The CCG administers CHC payments on behalf of all the CCGs in Surrey totalling close to £100m. The £23.9m is the element of CHC payments that relates to Surrey Downs only.

. Other (£24.0m or 6% of annual spend)

£3.9m relates to community estate which was accounted for in Community last year. The Better Care Fund (BCF), which is a pooled budget held by Surrey County Council designed to protect adult social care accounts for £16.6m of the CCG expenditure across a number of programme areas. £10m is accounted for through this area which relates to the Surrey County Council schemes. The remainder relates to areas such as patient transport and the CCG’s investments in community medical teams and community hubs.

Financial duties As a statutory organisation there are six main financial duties we are required to meet. Below are the details and how we have performed against them during 2017/18:

 Our expenditure should not exceed our income: for 2017/18 the CCG reported an in year deficit of £14.8m (cumulative £48.7m), so this requirement was not met.

 Our capital resource use should not exceed our notified limit: for 2017/18 the CCG had capital resource of £109K and the CCG did not exceed this limit, therefore, this requirement was met.

 Revenue resource use should not exceed our notified limit: for 2017/18 the CCG reported an in year deficit of £14.8m (cumulative £48.7m), so this requirement was not met.

 Capital resource use on specified matters should not exceed the notified limit: for 2017/18 the CCG had capital resource of £109K and the CCG did not exceed this limit therefore this requirement was met.

 Revenue resource use on specified matters should not exceed our notified limit: for 2017/18 the CCG had no spend on specified matters, so this requirement was met.

 Revenue administration resource use should not exceed our notified limit: for 2017/18 the CCG had revenue resource of £6.4m for administrative spend which was not exceeded so the CCG met this target.

Other financial requirements In addition to the six statutory duties above, CCGs are expected to meet the requirements of the Better Payments Practice Code which requires payment of 95% of invoices within 30 calendar days of receipt of goods or a valid invoice. During 2017/18 the CCG achieved 96% of trade payables within the timescale.

Quality, Innovation, Prevention and Productivity (QIPP) The Quality, Innovation, Prevention and Productivity programme (also known as QIPP) is a large scale programme developed by the Department of Health to drive forward improvements in NHS care.

For 2017/18 the CCG’s QIPP target totalled £18.2m (5% of the CCGs recurrent resource allocation) of which £11.8m was backed by identified QIPP schemes. The remaining £6.4m of the target had no schemes identified against it.

In total the CCG achieved 100% of the identified QIPP which equated to 65% of the overall £18.2m target of QIPP savings in 2017/18.

Our QIPP target for each area (labelled ‘plan’) is shown below against our actual end of year position.

Looking forward to 2018/19 The CCG’s financial position continues to be challenging. From 2018/19 onwards Surrey Downs CCG will operate to a combined control total with its partner CCGs in the Surrey Heartlands Health and Care Partnership. In aggregate, the control total for 2018/19 across the three CCGs is a deficit of £12m and NHS England will monitor the financial performance of the three CCGs in aggregate. The alignment and closer working across the CCGs as well as the provider sector in the Heartlands footprint should ensure a consistency of service and quality across Surrey as well as allow for any system economies and efficiencies to be leveraged at scale.

Key issues and risks As an organisation there are a number of issues and risks that could affect the CCG, and our ability to meet our objectives, and these are explained in our Governance Statement on page 76.

Matthew Tait Joint Accountable Officer 25 May 2018

2.10 Performance analysis – sustainable development

2.10.1 Introduction As an NHS organisation that spends public funds, we have an obligation to work in a way that has a positive effect on the communities we commission healthcare services for; spending money well and considering the social and environmental impacts is enshrined in the Public Services (Social Value) Act (2012). This includes the influence of the organisation on sustainability, which has become increasingly important as the impact of people’s lifestyles and business choices continues to change.

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 in the immediate and longer term, even in the context of the rising cost of natural resources.

Providers are asked to establish a social contribution that creates a ‘whole business’ approach to sustainability, with policies and systems that enable the implementation of initiatives that reduce the impact on the environment.

For example, we include community provision in any procurement undertaken, to assist in balancing the different needs against an awareness of the environmental, social and economic limitations. Staff car sharing is also encouraged and venues are accessible to all groups.

2.10.2 Modelled carbon footprint The CCG is committed to reducing its Carbon Footprint[4] by working closely with our landlord and suppliers to improve utilisation and functionality in all areas of the business and day-to-day operations. This year we have increased the use of digital and mobile technology through increased use of audio and video conferencing facilities to reduce staff travel and lessen the impact on the environment. Our IT service provider changed at the end of 2017; remote working capabilities (which enables staff to work from home thus reducing travel impact on the environment) have been extended as well as the ability to work in our neighbouring CCG offices.

As an organisation we promote active travel to our staff. Due to the office’s central location in Leatherhead, close to the train station, staff are able to easily commute to the office. By encouraging different behaviours we can help to improve local air quality, health and wellbeing.

2.10.3 Policies (Sustainable Management Development Plan) The CCG is not able to implement a Sustainable Management Development Plan (SMDP) as we occupy a multi-tenanted office environment building. Some service contracts associated with this building are managed by the Landlord’s Managing Agents and others we pro-actively manage directly (e.g. confidential waste recycling, cleaning, franking, photocopying, drinking water dispensers). Staff make use of paper, plastic and aluminium recycling bins in the office.

We work with the Managing Agents to ensure improvements in terms of waste, utility and water consumption and all other areas of building management in line with their ISO14001 Environmental Management System. We also meet regularly and these discussions include considering how we can improve sustainability.

[4] Greenhouse gas emissions associated with consumption

Starting in 2016 the continuing healthcare team’s migration to electronic records has substantially reduced printed file records and therefore cut the need for paper for printing.

2.10.4 Contracts (and how we work with others to ensure sustainability is met) The CCG aims to work with partners who are dedicated to sustainable development and this is explored during any procurement processes. Service providers commissioned by the CCG which hold an NHS Standard Contract are bound under Service Condition 185 to perform and operate in a sustainable manner by:  Taking all reasonable steps to minimise adverse impacts on the environment.  Maintaining a Sustainable Development plan in line with NHS Sustainable Development Guidance. Any progress on climate change adaptation, mitigation and sustainable development, including performance against carbon reduction management plans and an annual summary of that progress, must be reported to the co-ordinating commissioner.

 Giving due regard to the impact of their expenditure on the community over and above the direct purchase of goods and services as envisaged by the Public Services (Social Value) Act 2012. Where appropriate we procure from smaller business to provide services where they meet the service specification requirements.

We use the services of NHS Supply Chain to purchase all our stationery supplies, office equipment and general supplies ensuring value for money. The NHS Supply Chain has sustainable strategies and practices which are integral to their procurement and operations.

2.10.5. Rural proofing The geographical area covered by the CCG is notable for its urban/rural mix with a number of larger towns surrounded by much smaller, rural communities. All service developments and policies undergo equality analysis, to assess impact on different equality groups. Geographical location is included as an additional consideration for analysis. This is to ensure due consideration is given to rural communities and access to services when making decisions about commissioned services and policies.

2.10.6 Summary of performance

Our landlords have not been able to provide detailed and robust data in relation to utility usage and this is an area we will be working with them on closely in 2018/19 so we can better understand current performance and where improvements can be made.

We receive regular recycling reports from the Landlord’s Managing Agents so that we can monitor recycling volumes for the building and work with the other tenants to further increase our sustainability.

Technology Following the implementation of a Boardpad system, which gives access to meeting papers through handheld devices we have seen a significant reduction in the volume of printing in the office. This has reduced spend considerably and has also offered benefits in terms of a reduction in staff time spent on administrative duties such as printing and collating papers.

5 Conditions which the provider must abide by in accordance with the Fundamental Standards of Care and the Service Specifications

2.10.7 Future strategy The CCG is committed to improving the environmental impact of our activities by working with our staff, NHS support departments and third parties. Our future strategy to maintain and improve the sustainability of our activities includes:  Absorbing organisational growth by enabling more staff to work flexibly and enhancing our ‘hot desk’ booking schedule. These will result in the carbon footprint of the building not increasing, thereby reducing the need to take on additional space and keep use of carbon-emitting transport at a steady level.  Continuing to review our use of technology to move to a more digital approach, by promoting use of tablets and laptops, thereby reducing printing and the need for secure disposal of committee papers.  The CCG has moved into a joint management arrangement with the other CCGs within Surrey Heartlands. This opportunity will present a number of options to further our sustainability including the availability of more offices to reduce staff travel as well as the digital options that the partnership is exploring.

2.11 Performance analysis – improving quality As an organisation, first and foremost our job is to improve the health of local people and make sure their healthcare needs are being met. We want people to have a good experience and receive safe, effective, high quality care – and we have a statutory duty to meet in relation to this. Taking this into account, our focus on quality is a key priority for us.

2.11.1 How the CCG monitors and improves quality of services

When we agree our contracts with local healthcare providers (such as ambulance services, hospital trusts, community services and independent providers) we start by setting out the services we want to commission and the quality standards we expect them to meet. These standards are based on clinical evidence, best practice, clinical effectiveness and nationally set quality standards.

There are some core standards that every NHS organisation must achieve. This includes targets relating to many planned procedures and operations (such as hip and knee operations) being done within 18 weeks after a GP referral, ambulance response times and making sure people who attend A&E are seen quickly. There are also some quality and performance targets we set locally with the healthcare organisations we buy services from. These are based on local performance and take into account local patient feedback.

We receive information from hospital, community and ambulance trusts and other healthcare providers on a daily, weekly and monthly basis on how services are performing. We carefully analyse this to understand how services are performing and whether there are any issues that may affect the quality of care our patients are receiving. We also listen to the feedback we receive directly from patients, carers and their families about their experiences of local healthcare. This could be as an informal query or formal complaint, by letter, phone call or during a conversation with a patient or carer during a planned visit to a particular service area. We also receive feedback from our GPs and member practices and people also have the opportunity to raise any issues or concerns with us at our regular Governing Body meetings, held in public.

We also meet on a regular basis with Healthwatch Surrey who will discuss with us the themes of any feedback they may have received through their work with the public. We are always grateful for feedback and if issues are highlighted, we work with local partners to make sure these are resolved as quickly as possible.

Where performance is below what we would expect, we take action, working with the organisation to ensure this improves. If key standards are not being met, this means patients are not receiving the quality of care we would expect. It also means we are not getting the level of service we have paid for so it’s also about ensuring value for money and making the best use of public money.

In most cases, there are simple steps that can be taken and performance quickly improves but we can also enforce improvements contractually, for example, requiring the provider to develop a Service Improvement Plan if issues are identified that are not being addressed in the way they should be. We meet with organisations regularly through Clinical Quality Review Meetings. These are an opportunity to discuss any issues in relation to quality and performance and agree any action that may be required. We also work in partnership with other commissioners and regulators such as NHS Improvement and the Care Quality Commission to ensure that we have a joined up approach to our quality improvement work with our providers.

Areas of focus for the Quality Committee during 2017/18 included:  Assurance relating to the quality and safety of care provided to our patients, with a particular focus on the South East Coast Ambulance Service NHS Foundation Trust, where we have worked with commissioners and the trust to seek assurance and monitor progress against their quality improvement plan

 Working with Surrey and Borders Partnership NHS Foundation Trust in relation to mental health services (specifically in relation to Child and Adolescent Mental Health Services and the Improving Access to Psychological Therapies programme)

 A focus on children’s services, working with other Surrey CCGs and local partners

 Working with Epsom and St Helier University Hospitals NHS Trust following Care Quality Commission inspections to ensure the necessary improvements are being made.

 Monitoring performance against key quality indicators, with a focus on areas where our performance may be below the standards we would want, and expect, for our patients.

 Care homes, with a particular focus on the experience of residents. There are a number of projects in place that support this. These include quality assurance improvement work that has been carried out across the local health and care system and the new Quality Care Home initiative. Within this we also have projects underway to improve awareness of hydration and nutrition in care homes. The hydration project in particular has been very well received by care homes locally and there have been a number of improvements seen in the incidence of falls and other associated patient harm as a result.

 We also share learning through clinical harm reviews. The CCG takes the safety and experience of our patients very seriously and as a consequence, if we become aware of any problems within a service such as long delays, we will undertake a process to review individual patient cases to ascertain whether there has been any harm as a result. We expect our providers to work within the principles of “being open” and to involve individuals and their family if appropriate in any investigation, keeping them informed at every stage of the process, ensuring that the right treatment and care is being delivered. In addition, any learning about the systems and processes that have contributed to any harm will be shared to prevent similar occurrences.

 A focus on stroke services and the work of the stroke networks in improving care across the whole pathway, which is monitored through the Sentinel Stroke National Audit Programme. You can read more about this on page 26.

The CCG has also worked with our providers on a number of quality improvement schemes, including work as part of the national Commissioning for Quality and Innovation (CQUIN) programme and Quality Premium. Under the CQUIN programme, a proportion of a healthcare providers' income is conditional on them demonstrating improvements in quality and innovation in specific areas of patient care.

During 2017/18, the national CQUIN programme focussed on the following key areas of clinical practice:  Reducing the impact of serious infections  Improving physical healthcare to reduce mortality in people with Serious Mental Illness  Improving services for people with mental health needs who present at Accident and Emergency  Transitions out of Children and Young People’s Mental Health Services  Offering advice and guidance  NHS E-referrals  Supporting Proactive and safe discharge  Preventing ill health through risky behaviours alcohol and tobacco use  Improving the assessment of wounds  Personalised care and support planning  Ambulance conveyance

 NHS 111 referrals

The CCG worked with other commissioners to ensure that we worked in a co-ordinated way to improve practice in these areas.

In addition we worked with our providers to improve staff health and wellbeing as evidence shows that improvements in this area leads to higher levels of staff engagement, better staff retention, and better clinical outcomes for patients.

There are a number of areas where we have seen evidence of good partnership working across our providers to improve care for patients. One of these areas is supporting proactive and safe discharge where acute and community providers have worked with our colleagues in social services to improve the experience of discharge from hospital, ensuring that it is more timely and that communication with patients is clearer. This work has also been supported by the Surrey Heartlands Safe Discharge and Transfer workstream which has supported the sharing of good practice across all providers and developed innovative ways of discharging patient’s home safely.

Other areas of improvement include in the assessment of wounds, where our community provider has developed a local assessment tool that can be used consistently across the area and has improved the care that is offered to our patients.

During 2018/19 we will be continuing to work with our providers to make further improvements in these areas and also in other important areas such as infection prevention and control.

Quality of care is monitored through a range of national schemes and indicators, available for the public to view on My NHS. NHS England launched My NHS in 2014 with the intention of making information about the quality of NHS healthcare services available to all and to improve accountability, in line with the NHS England CCG Improvement and Assessment Framework 2017/18.

Through our CCG website we promote My NHS as a way of helping people feel more informed about their healthcare and their options under patient choice.

2.11.2 Performance against national schemes and indicators

Quality is monitored through a range of national schemes and indicators, available for the public to view on My NHS6. NHS England launched My NHS in 2014 with the intention of making information about the quality of NHS health care services available to all and to improve accountability, in line with the NHS England CCG Improvement and Assessment Framework 2017/187. The indicators are drawn from a wide range of data sets that are routinely available for NHS organisations e.g. the NHS Outcomes Framework and the NHS Constitution, as described in section X. They are presented for the public in four categories: Better Care, Better Health, Sustainability and Well-led. The following sections report on:  Better Care Fund metrics

 NHS Outcomes Framework

 NHS Constitutional Standards Contractual incentives, for example Commissioning for Quality and Innovation (CQUIN) schemes, are used to enable improvements in local services, to share and continually improve how care is delivered.

6 www.nhs.uk/Service-Search/Performance/Search 7 www.england.nhs.uk/commissioning/ccg-assess

2.11.3 Better Care Fund metrics The Better Care Fund (BCF) is a programme spanning the NHS and local government which seeks to join up health and care services to allow people to manage their own health and wellbeing, and live independently in their communities for as long as possible.

The Better Care Fund provides a single pooled budget to integrate health and social care budgets. It aims to incentivise NHS and local authorities to work closer together, placing wellbeing at the centre of health and care services, providing alternatives to unplanned hospital admission.

Detailed monitoring allows the CCG and its partners in the Better Care Fund work streams to target their quality improvement expertise where it is needed.

Table 1: CCG Performance for Better Care Fund 2017/18

Indicator Q1 Q2 Q3 Q4

[Non-elective admissions]

Total non-elective admissions in to hospital (general and acute), 2,466 2,414 2,526 all-age, per 100,000 population 2,481

[Reablement]

Proportion of older people (65 and over) who were still at home

91 days after discharge from hospital into reablement/ 75.1% 72.5% 70.3% 67.9% rehabilitation services (Countywide data)

[Delayed Transfers of Care]

Delayed days from hospital per 100,000 population (aged 18+) 897.2 994.8 839 597 (Surrey)

The 2017/18 BCF schemes have supported a range of programmes including the following:  Targeted support such as telehealth, equipment and other services for home adaptations  A 24/7 Psychiatric Liaison Service in the acute trust to support those in crisis and to provide additional support in the community.

2.11.4 NHS Outcomes Framework and Indicators The NHS Outcomes Framework (NHS OF) indicators provide national level accountability for the outcomes that the NHS delivers; they drive transparency, quality improvement and outcome measurement throughout the NHS.

Figure 1: The NHS Outcomes Framework

Domain 1

•Prevent people from dying prematurely

Domain 2

•Enhance quality of life for people with long-term conditions

Domain 3

•Help people to recover from episodes of ill health or following injury

Domain 4

•Ensure people have a positive experience of care

Domain 5

•Treat and care for people in a safe environment and protect them from avoidable harm

Located beneath each of the five broad ambitions or domains, shown in Figure 1, are a number of measureable objectives or indicators all aimed at improving health and reducing health inequalities. This data makes our services transparent; this in turn enables comparison between different services and therefore stimulates improvements to be made. The CCG and NHS England monitor these indicators in full partnership with our providers to drive forward improvements on a continual basis.

How are we performing? The table below summarises the CCG’s performance against the NHS Outcomes Framework indicators and how this compares with performance nationally.

Table 2: CCG performance against NHS Outcomes Framework 2017/18 Key Description Significantly better Significantly worse Non significantly better Non significantly worse Non significantly worse Non significantly better No change Direction of arrow = whether CCG is above or below the national average Colour of arrow = indicates whether performance is better or worse than the national average

Most Metric Comparison Metric Value Cluster England recent ID to England data

NHS Outcomes Framework Data Source – Domain 1 Potential Years of Life Lost amenable to 1.1 1553 1742 1869 2014 healthcare - female Potential Years of Life Lost amenable to 1.1 2150 1921 2266 2014 healthcare - male 1.2 Under 75 Mortality from CVD 42.4 52.3 64.0 2015 Myocardial infarction, stroke and stage 5 1.4 82.5 91.7 100 2015/16 kidney disease in people with diabetes Mortality within 30 days of hospital admission 1.5 1.15 1.0 1.04 2016/17 for stroke 1.6 Under 75 Mortality from respiratory disease 20.3 23.1 29.4 2015 1.7 Under 75 Mortality from liver disease 10.1 12.8 16.1 2015 Emergency admissions for alcohol related 2016-2017 1.8 20.3 20.6 27.7 liver disease (Oct-Sept) 1.9 Under 75 Mortality for Cancer 106 112 120 2015 Diagnosed 1.10 One Year survival from all cancers combined 75.3 70.9 70.4 2015 One year survival from breast, lung and Diagnosed 1.11 71.7 69.6 69.3 colorectal cancers 2011 2017/18 1.14 Maternal smoking at delivery 4.9 8.49 10.75 Q3 2014/15 1.15 Breast feeding prevalence at 6-8 weeks 52.2 50.3 47.3 Q3 1.17 Record of stage of cancer at diagnosis 72.5 77.7 79.6 2015 Percentage of cancers detected at stage 1 1.18 50.4 52.1 52.4 2015 and 2 Record of lung cancer stage at decision to 1.19 88.2 91.6 92.5 2015 treat 2013 to 1.20 Mortality from breast cancer in females 34.6 35.0 34.3 2015 All-cause mortality - 12 months following a Apr 2013 1.21 first emergency admission to hospital for 99.3 97.2 100 to March heart failure in people aged 16 and over 2016 2016-2017 1.22 Hip fracture - incidence 433 401 430 (Oct to Sept) 1.25 Neonatal mortality and stillbirths 5.1 6.09 7.00 2015 1.26 Low birth weight full-term babies 1.9 2.37 2.8 2015 NHS Outcomes Framework Data Source – Domain 2 Health related quality of life for people with 2.1 0.80 0.77 0.74 2016/17 long term conditions % of patients with long term conditions who 2.2 61.2 62.7 64.0 2016/17 feel supported to manage their condition People with diabetes diagnosed less than a 2.5 70.8 77.8 77.2 2014/15 year referred to structured education

Most Metric Comparison Metric Value Cluster England recent ID to England data

2016-2017 Unplanned hospitalisation for chronic ACS 2.6 576 657 812 (Oct to conditions Sept) 2016-2017 Unplanned hospitalisation for asthma, 2.7 269 242 299 (Oct to diabetes and epilepsy in under 19s Sept) 2.8 Complications associated with diabetes 74.1 86.3 100 2015/16 Access to community mental health services 2.9 by people from Black and Minority ethnicity 1283 1633 2201 2014/15 (BME) groups Access to psychological therapies services 2.10 by people from Black and Minority ethnicity 886 1026 1312 2015/16 (BME) groups Percentage of referrals to IAPT services 2015 (Jan 2.11.a which indicated a reliable recovery following 45.9 46.1 43.5 to Dec) completion of treatment Percentage of referrals to IAPT services 2015 (Jan 2.11.b which indicated a reliable improvement 70.3 64.1 61.8 to Dec) following completion of treatment Percentage of referrals to IAPT services 2.11.c which indicated a reliable deterioration 4.40 5.56 6.2 2015 following completion of treatment Health-related quality of life for carers , aged 2.15 0.81 0.81 0.8 2016/17 18 and above Health-related quality of life for people with 2.16 0.59 0.56 0.52 2016/17 long-term mental health conditions NHS Outcomes Framework Data Source – Domain 3 Emergency admissions for acute conditions 2016-2017 3.1 that should not usually require hospital 1,182 1153 1331 (Oct-Sept) admission Emergency readmissions within 30 days of 3.2 11.5 11.5 11.9 2011/12 discharge from hospital Elective Hip replacement (Primary) 3.3 0.44 0.44 0.44 2015/16 procedures (PROMS) Elective Knee replacement (Primary) 3.3 0.29 0.31 0.32 2015/16 procedures (PROMS) 3.3 Elective groin hernia procedures (PROMS) 0.11 0.1 0.09 2015/16 2016-17 Emergency admission for children with lower 3.4 477 419 453 (Oct to respiratory tract infections Sept) People who have had a stroke who are 3.5 admitted to an acute stroke unit within 4 55.1 56.8 58.7 2016/17 hours of arrival to hospital People who have had an acute stroke who 3.6 7.9 13.18 11.5 2016/17 receive thrombolysis People with stroke who are discharged from 3.7 hospital with a joint health and social care 100 90.9 90.5 2016/17 plan

Most Metric Comparison Metric Value Cluster England recent ID to England data

People who have a follow-up assessment 3.8 between 4 and 8 months after initial 40.1 23.82 31.6 2016/17 admission for stroke People who have had an acute stroke who 3.9 spend 90% or more of their stay on a stroke 73.4 83.5 84.3 2016/17 unit Hip fracture: proportion of patients 3.10.i recovering to their previous levels of 32.1 38.9 37.4 2015 mobility/walking ability at 30 days Hip fracture: proportion of patients recovering 3.10.ii to their previous levels of mobility/walking 69.3 65.7 63.9 2016 ability at 120 days 3.11 Hip fracture: collaborative orthogeriatric care 99.7 98.0 96.4 2016 3.12 Hip fracture: timely surgery 90.6 75.8 72 2016 Hip fracture: multifactorial falls risk 3.13 100 99.1 98.6 2016 assessment 2016-2017 3.14 Alcohol-specific hospital admissions 70.2 70.4 109.3 (Oct to Sept) Emergency alcohol-specific readmission to 2014-17 3.15 any hospital within 30 days of discharge 113.1 104.4 100 (Oct to following an alcohol-specific admission Sept) Unplanned readmissions to mental health 2014/15 services within 30 days of a mental health 3.16 82.3 92.3 100 (Oct to inpatient discharge in people aged 17 and Sept) over Percentage of adults in contact with 2017 3.17 secondary mental health services in 7.00 7.83 6.00 (Sept) employment

Hip fracture: care process composite 3.18 85.8 67.7 62.7 2016 indicator

NHS Outcomes Framework Data Source – Domain 4 Patient experience of GP out-of-hours 4.1 61.6 64.6 68.6 2014/15 services 4.2 Patient experience of hospital care 76.4 76.7 77 2015/16 Responsiveness to Inpatients' personal 4.5 69.3 69.2 69.2 2015/16 needs NHS Outcomes Framework Data Source – Domain 5 Incidence of healthcare-associated infection - April 2017 5.3 5 7.3 6.41 MRSA to Feb 18 Incidence of healthcare-associated infection - April 2017 5.4 93 92.4 105.8 C.difficile to Feb 18 **An issue has been identified in the production of this indicator. As a result, this indicator has been removed pending a methodological review.

2.11.5 NHS Constitution Standards The NHS Constitution standards fall within the patient safety, clinical effectiveness or experience domains of the NHS Outcomes Framework or they relate to the access and flow of patients into a particular healthcare service.

Table 3 shows the CCG’s performance against the NHS Constitution Standards at CCG level for the first three quarters of the 2017/18 financial years. Performance is risk rated, Red-Amber-Green (RAG) according to thresholds.

Table 3: NHS Constitution Standards verses CCG performance, Quarter 1 to Quarter 4 2017/18

National Year to Performance Metrics Apr-Jun Jul-Sep Oct-Dec Jan-Mar Target date

RTT Incomplete Patients (RTT within 18 weeks) 92.0% 92.7% 91.9% 91.5% 89.8% 91.8% Number of Patients Waiting More Than 52 Weeks 0 15 7 6 13 41

Diagnostic Waiting Times (Within 6 weeks) 99.0% 99.4% 99.4% 99.2% 99.1% 99.3%

Mixed Sex Accommodation (MSA) 0 1 1 1 48 51*

Cancer Waits: 2 Week Rule (Urgent GP Referral) 93.0% 95.4% 95.9% 96.2% 96.5% 96.0% Cancer Waits: 2 Week Wait (Exhibited Non- Cancer Breast Symptoms) 93.0% 94.3% 95.4% 95.7% 94.2% 94.8% Cancer Waits: 31 Days to First Treatment 96.0% 97.9% 98.2% 95.9% 98.0% 97.5% Cancer Waits: 31 Days to subsequent Treatment (Drugs) 98.0% 99.3% 100.0% 100.0% 100.0% 99.8% Cancer Waits: 31 Days to subsequent Treatment (Radiotherapy) 94.0% 92.1% 95.8% 93.7% 93.9% 94.0% Cancer Waits: 31 Days to subsequent Treatment (Surgery) 94.0% 96.7% 92.9% 93.7% 96.7% 95.2% Cancer Waits: 62 Days from Screening service referral 90.0% 95.8% 92.5% 89.8% 95.3% 93.3% Cancer Waits: 62 Days from Urgent GP referrals 85.0% 88.2% 87.4% 78.4% 84.8% 84.8%

MRSA Bacteraemia (All cases) In month 0 2 1 1 1 5 C difficile Infections (All cases) In month 82 32 25 28 14 99

* The National Emergency Pressures Panel (NEPP) meeting. NEPP have agreed that CCGs should temporarily suspend sanctions for mixed sex accommodation breaches.

Standards breaching national targets There were seven measures rated red that have breached the national targets set beyond the lower threshold limits for 2017/18. Explanation and actions for these measures are shown below.

Number of patients waiting more than 52 weeks for consultant-led pathways

 For the full 2017/18 financial year, forty-one patients waited more than 52 weeks for their first consultant-led appointment. The breaches occurred mainly at one provider and the CCG has worked with providers to establish why this has happened for each patient and, where necessary, ensure mitigating actions are taken to prevent reoccurrence including demand and capacity model and a planned performance trajectory.

Diagnostic waiting time (within 6 weeks)

 In 2017/18 (Q1-Q4), Surrey Downs CCG has been performing consistently above the 99% target, achieving 99.4% in Quarter 1, 99.4% in Quarter 2, 99.2% in Quarter 3 and 99.1% in Quarter 4. The final year to date performance was 99.3%.

Mixed sex accommodation

 In the first 9 months of 17/18 there were 3 mixed sex accommodation breaches for Surrey Downs CCG patients. However; in the final quarter there was a sharp rise in the number of breaches which meant that the number of breaches totalled 51 for the year. The increase coincided with sustained NHS emergency pressures over the winter period and the direction from the NHS National Emergency Pressures Panel that CCGs should temporarily suspend sanctions for mixed sex accommodation breaches.

Cancer Waits: 62 Days from Urgent GP referrals

 In 2017/18 (Q1-Q4) Surrey Downs achieved a performance of 81.1% which fell below the national target of 85%. Surrey Downs CCG has been meeting regularly with the trust to develop and support improvement plan. The CCG is also working with providers to model demand and capacity to ensure that there is the appropriate resources available to manage waiting times.

MRSA bacteraemia

 In 2017/18 (Q1-Q4), there was 5 CCG assigned cases of MRSA for Surrey Downs CCG. Surrey Downs CCG is carrying out the scoping of the Infection Control requirement to support the three CCGs with Surrey Heartlands and develop a supporting business case.

Clostridium Dificille

 Clostridium difficile infection (CDI) remains an unpleasant, and potentially severe or fatal, infection that occurs mainly in elderly and other vulnerable patient groups, especially those who have been exposed to antibiotic treatment. Both commissioners and providers are set annual objectives for the number of infections that might be expected to occur with an ambition to reduce that through improved prescribing and infection prevention and control practices. During 20 17/18, the CCG was set an objective of no more than 76 cases in the year. At the end of the year, there were 99 cases reported across Surrey Downs.

All cases are reviewed by clinicians, any potential lapses in care are identified and learning from this shared. A lapse in care would be indicated by evidence that the a provider did not follow policies and procedures in line with local guidance, that reflect national guidance and standards and this might include failure to isolate a patient with symptoms, poor hand hygiene practice or antimicrobial prescribing that does not meet agreed guidelines. To improve the scrutiny of this very important area of patient care the CCG is planning to increase the resource that is available to focus on this, working across the three CCGs. The Quality Committee will continue to monitor this area closely.

Areas for improvement Improvement and Assessment Framework (IAF) indicators identify where Surrey Downs CCG was an outlier nationally at the time of the 2016/17 assessment (in the worst quartile in England as at 30 June 2017). These areas are listed in the table below:

England England Ranking Area Indicator Ranking Identified Actions (Jun-17 (Nov-17 IAF) IAF)

• Implementation of the collaborative CHC Personal strategy (2017-2019). Better Health 164/209 200/207 ↓ Health Budgets • CHC PBB specialist lead is collaborating with CCG’s End of Life Care team.

• Surrey Heartlands Dementia Strategy (2017-2021) development.

• Local action plan completed for 2017/2018 to drive improvement for the SD population Dementia and put the strategy into action. Better post- 185/209 182/207 ᴏ • Integration with other services, such as Care diagnostic IAPT. support • Investment in Mental Health Practitioners (Psychiatric Nurses) in the community Hubs.

• Working to improve dementia diagnosis.

Management Better of Long Indicator • The CCG is no longer an outlier against 17/209 Care Term replaced new measure (indicator 106a). Conditions

Surrey Downs CCG new areas requiring improvement for 2018/19 Additional IAF indicators where Surrey Downs CCG has slipped into the worst performing quartile since the 2016/17 assessment are listed in the table below:

Area Indicator Period CCG Peers England

Utilisation of the NHS e- Sustainability 2017 06 29.3% ↓ 6/11 170/207 referrals service

Progress against workforce Leadership 2016 0.16 ᴏ 9/11 163/207 race equality standard

IAPT Access NEW Better Care 2017 06 3.2% ↓ 11/11 186/207 INDICATOR 1718

% CHC assessments in Better Care 17-18 Q1 53.3% ᴏ 6/11 172/207 acute hospital

 e-RS Utilisation: We expect to meet the national requirement by September 2018 and work is underway to achieve this, with a plan in place to roll this out service by service. However, a risk around non-compliance has been escalated due to one trust not yet updating their Directory of Service on e-RS. The timetable currently extends beyond the soft close date of 31 July, with the main focus on general referrals before rolling out to include urgent 2 week cancer referrals.

 Progress against the Workforce Race Equality Standard (WRES): In March 2017 we introduced a new programme called ‘Be the change’ which aimed to increase awareness of equality and diversity issues across the organisation. The programme comprised of an internal awareness campaign with information added into staff induction, eye-catching posters that focused on the needs of different protected characteristic groups and regular updates at team brief sessions.

 Improving Access to Psychological Therapies (IAPT): Performance across Surrey Heartlands for IAPT in terms of recovery and waiting times is good, with key performance indications reached during most of 2017/2018. Access (number of people who commence a course of treatment) remains a challenge for providers. Interventions in progress to improve access rates are based on co-location with GPs and integration with long-term conditions and this work is underway.

 Percentage of Continuing healthcare assessments taking place in an acute hospital: A broad range of initiatives are in place across Surrey Heartlands, including CHC Clinical Coordinators, roll- out of Discharge to Assess, and training with the CHC team to emphasise the importance of 28 day performance to improve performance in this area.

2.12 Performance analysis – engaging people and communities

2.12.1 Introduction

Good healthcare is important to everyone, so making sure local people are involved in planning and delivering NHS services across Surrey Downs is something we take very seriously. Delivering health services shaped by the people who use them ensures patients are well-informed and involved in their care. It also means people experience better services, which meet their needs. We call this patient and public engagement. Under the NHS Act 2006 patient and public engagement is also a legal duty which should inform our thinking and underpin our decisions when planning local healthcare.

This section of this report sets out our commitment to patient and public engagement and summarises how we have met our legal duties in this area over the past twelve months.

2.12.2 How we engaged and involved local people, local communities and partners in 2017/18 As a CCG we have adopted some key principles to ensure we engage and involve local people in the right way and in line with best practice in this area. These principles include the following:

 Patient and public engagement is the responsibility of everyone who works for the CCG – not just one person, or one team  Feedback received will be considered and taken into account when making decisions about how health services are planned and delivered  Information will be made available in large print, Braille or another language on request  Engagement and opportunities to participate will take place at different times of the day and locations to meet the engagement needs of local people (eg those who work during the day)  Meeting rooms will be accessible for people with physical impairments (ie contain a hearing loop and be located close to public transport).  We will use a range of methods to communicate and engage, tailored by audience  We will deliver information and messages which are clear, simple and consistent  We will identify the people we need to reach by mapping key groups and engaging with local communities  We will evaluate our work so we can improve how we engage in the future

Further information about how we engage and involve local people is available in our full Communications and Engagement Strategy, which is available on our website.

2.12.3 Structure and resources Our patient and public engagement work is supported and delivered in different ways and at different levels locally. These include:  We have a Governing Body Lay Member for Patient and Public Engagement to ensure engagement and patient involvement is championed at the highest level and to seek assurance on how we engage  We set up Patient Advisory Groups to support our work around developing new care pathways and new services so people can share their views and experiences and help us design new services  We invite patient representatives to join our programme boards and our procurement programmes (where we are planning to buy a new service) to give their input and help shape our plans#  We have set up a Participation Action Network to bring together representatives from the local voluntary sector and representation from the protected characteristic groups under the Equality Act.

The PAN works with us to develop our plans and it engages with others on our behalf (please see ‘Partnership working’ section below)  We hold Governing Body meetings in public, where local people can hear about our plans and priorities and ask questions  We also have an Annual General Meeting, held in public, every year to inform and engage local residents  We engage with local Patient Participation Groups, which most GP practices have  We invite local people and service users to give their views at events and through surveys and public consultations. We also monitor feedback provided through other surveys including the Friends and Family test, which asks people whether they would recommend a service to others  We hold roadshows and other events where we talk to local people about our plans and seek their views on specific projects  We have a website which contains information about the CCG and lets people know how they can get involved  We seek the views of some stakeholders through an annual 360 degree survey which also captures the views of community and patient groups. We use the feedback to improve how we work and how we can engage.  We have a communications and engagement team at Surrey Downs CCG and during 2018 we will be moving to an integrated team across the three Surrey Heartlands CCGs  We have a Patient and Public Engagement Manager that works closely with the voluntary sector and undertakes outreach work  We have an Improving Care Together e-newsletter, which we send to around 1,000 people who have joined our mailing list to keep them updated on our work  We also actively use social media channels to raise awareness of public health issues, seek views and share opportunities to get involved

In addition, working with colleagues through the Surrey Heartlands Health and Care Partnership our residents are also involved in a wider citizen engagement programme. This involves both quantitative and qualitative research methods where people are asked their views on health and social care issues. We then use this feedback to inform our planning, which feeds directly into the work of the partnership and its clinical workstreams.

2.12.4 Partnership working We are committed to working in partnership to improve health outcomes and we do this across the range of services we design and deliver.

Our ‘Quality in Care Homes’ project supports and monitors improvements in health and the quality of care provided in care homes for over 65 year olds. In 2017/18 our ‘Quality in Care Homes’ team worked with 37 care homes individually by providing staff with training, recommendations and signposting to other services. The project also engages with a larger group of care homes through regular Care Home Forums and quarterly newsletters. The Care Home Forums provide a platform for sharing of best practice between care homes as well as group training sessions and useful updates on relevant local and national health information. The ‘Quality in Care Homes’ team also works closely with a wide range of interest groups to deliver this service including Surrey County Council and South East Coast Ambulance Service.

We continue to work closely with Healthwatch Surrey and we meet with them regularly to hear the feedback they are receiving from people about local healthcare services so we understand where there are issues and take the appropriate action, working with providers. This feedback can include information about the length of time people are waiting for treatment, their experiences and the service they have received and access to GPs and other services. Healthwatch Surrey also carry out their own research into specific areas (recently this

51 has included work on discharge processes from hospital and safe havens) and we use these reports and the recommendations to inform our plans.

During the year we also participated in the Brighter Futures Forum, supporting the Gypsy, Roma and Traveller community and the Annual General Meeting of the Surrey Coalition of Disabled People. These forums were used to inform and engage Gypsy representatives and local residents about our work.

We are also an active member of the Surrey Health and Well Being Board and its related sub groups. During 2017/18 we worked with partners on a range of areas including delivering a Surrey-wide media and radio campaign to help with winter pressures and raise awareness of where to seek help if people did feel unwell. We also worked together to deliver a joint awareness campaign in relation to the seasonal flu programme, which included making people aware of the clinical at risk groups and those who were eligible to have a flu vaccine. This included targeted engagement aimed at parents of 2-4 year olds to increase awareness, and uptake of the vaccine, for this group. Based on the data received to date we have seen an increase in uptake among this group, which may have been partly as a result of our engagement work.

During the year we also strengthened our links with The Surrey Minority Forum and Outline Surrey (a Lesbian, Gay, Bi-Sexual and Transgender support group). Speakers from both organisations participated in information events held for CCG project leads to help us develop a better understanding of these communities.

As a core member of the Surrey Heartlands Health and Care Partnership, we have also actively worked with partners on joint engagement activities and supported the Surrey Heartlands Stakeholder Reference Group, which involves local people and stakeholders in this work.

Participation Action Network PAN is our forum for representatives from local equality, voluntary and community groups co-hosted with Surrey County Council that meets quarterly. Members include Surrey Young Carers, the Mary Frances Trust, representatives from the Gypsy Roma Traveller Network, local foodbanks, Sunnybank Trust, local PPGs, Age Concern and Healthwatch Surrey.

During 2017/18 we held three meetings of our Participation Action Network (PAN). These took place in July 2017, September 2017 and February 2018.

In July 2017 PAN members contributed feedback which shaped our End of Life Care Strategy (eg this specifically included feedback in relation to the need to involve youth services and the need for further training and awareness that is also available to the voluntary sector). In September 2017 PAN members identified communities at higher risk of mental ill health and the need for flexible mental health services which the CCG also agreed to explore. In February 2018 PAN members provided feedback on our 2018 Joint Commissioning Intentions, particularly in relation to the need for inter-agency co-ordination and closer working with the voluntary sector. This feedback was shared with project leads and a commissioner response will be shared with all groups that took part in the engagement, to let them know what we are doing in response to their comments.

2.12.5 Key engagement activity

During 2017/18 we supported a number of larger pieces of work relating to engagement. These are summarised below.  Adult community services procurement As part of our work to deliver a new Adult Community Service we organised a series of engagement

events to encourage people to give their views on how they would like to receive adult community services in the future. This included community roadshows in town centres and attending local groups. Feedback was also invited through an online survey, which was completed by 51 people. Feedback from this engagement such as the need to support people with a long term illness was incorporated into the final designs for the new service.

 Winter and seasonal flu campaign Delivered with the Surrey Heartlands Health and Care Partnership and partners of the Surrey Health and Well-being Board, the aim of this engagement was to support the NHS during the winter period, encourage residents to seek advice at the most appropriate place and raise awareness of the flu vaccine for people in the ‘at risk’ groups (eg children aged 2-4, people over 65 years, people with long-term health conditions and carers). We also wanted to understand why people were not having the vaccine in the first place and what if any further information they would find helpful.

Direct engagement including one-to-one contact was undertaken with users of the Epsom Food Bank to reach the homeless, a local carers forum, nursery school parents and day centres to reach frail, older people. During this outreach work which also involved four community roadshows we engaged 466 people across ten locations including Dorking, Leatherhead, Molesey, Epsom, Banstead, Thames Ditton and Cobham.

The feedback and insights obtained from this engagement shaped our winter Facebook advertising campaign which followed. This targeted parents with a video about the flu nasal spray to encourage uptake among this group. This week-long campaign resulted in almost 300 click-throughs to the Healthy Surrey website for further information and reached 15,307 people. The biggest take-up was among women aged 25-34 which aligned well with our campaign objectives.

 Wheelchair services review In February 2018 we led a workshop with wheelchair users, carers, their families and other partners to co-design a new wheelchair service. This workshop captured what worked well in the current service, what didn’t work well and the vision for a new service. This feedback has shaped the service specification and contract for the new service and has informed key elements of the design of the new service, particularly in relation to integration, waiting times and repair times and staff training. The feedback will also be used to shape questions for bidders who wish to deliver the new service as part of a procurement process. Two wheelchair users currently sit on the Programme Board to provide invaluable insight and bring a service-user perspective to the discussions.

 Joint commissioning intentions for 2018/19 For the first time, the CCG worked with its Surrey Heartlands commissioning partners (North West Surrey and Surrey Downs CCGs and Surrey County Council) to engage the public on their commissioning intentions for 2018/19. As part of this engagement, we had several objectives:

 To raise awareness of our draft plans and priorities for 2018/19 among key stakeholders and local communities.

 To raise awareness of the opportunity for local people and partners to give their feedback on our plans.

 To encourage people to comment on our draft plans and priorities through an online survey or through face-to-face engagement.

 To engage key partners and stakeholders through direct communications to encourage them to comment on our draft plans and priorities.

 To maximise engagement opportunities with partners and the voluntary sector through face-to-face engagement to seek more detailed, qualitative feedback on our plans.

A summary document and a survey were widely promoted and CCG staff visited a range of community, faith and voluntary groups to discuss the plans and seek feedback. Over 700 key stakeholders, including councillors, MPs, faith groups, local councils, hospices, healthcare providers, patient participation groups and voluntary and community sector organisations were contacted. 150 people gave their views on the many different aspects of the draft joint commissioning intentions. An engagement report was included in the final commissioning intentions document (part 5) with a commitment from the three Governing Bodies to include the commissioner response in the 2018/19 Operating Plan to enable a greater understanding of their intentions and to incorporate public and patient views into the commissioning cycle. There was a wealth of learning and the CCGs, with Surrey County Council, have committed to reviewing and refining how they engage patients and the public in 2018/19.

 End of Life Care Strategy “There is a need to have In 2017 our End of Life Care Strategy was co-produced with, available and promote and by, people with experience of caring for those with a alternatives to A&E such as terminal illness, hospices and voluntary organisations. Our walk-in centres or urgent care Participation Action Network also provided feedback on this centres to help ensure that strategy. As a result of the feedback we received the strategy A&E is protected from non- was changed to include a wider range of voluntary groups and urgent requests.” greater focus on preventing people from being admitted to hospital in the last 12 months of life.

 Patient feedback Our Quality Team monitors patient feedback gathered by the community, mental health and hospital services we commission on a regular basis to ensure this is acted on. We also respond directly to enquiries we receive through our Patient Experience Service and issues that are raised with us as

“There needs to be a serious commitment to improving knowledge, awareness and understanding of CHC, health and social care needs and Personal Health Budgets. Guidance and protocols are needed that staff can follow to ensure good practice and avoid frequent reassessments. We also need more signposting.”

complaints, We use the feedback and learning from these areas to improve services and address any issues.

 Annual General Meeting (AGM) We held our Annual General Meeting on 29 September 2017 and we used this opportunity to update local people and partners on our achievements during the past year and share our plans for the future.

 Wider engagement During 2017 we supported the Epsom and St Helier University Hospital 2020-2030 progamme by attending community groups to engage local people in the broader conversation about the acute sustainability programme and how services could be provided in future. Further work continues in 2018 and we continue to play an active role in this to ensure local people are fully engaged in the next steps.

We also captured patient and public feedback on a new combined NHS 111 and GP Out-of-Hours service. This involved a multi-agency event, a public roadshow at Ashley Shopping Centre in Epsom and surveys and leaflets distributed to all our GP practices.

Finally, we promoted national consultations such as prescribing over the counter medicines through a range of communication channels such as social media, the media and through our website and newsletters.

2.12.6 Involving people in their own health and care This year we supported our patients to better manage their well-being through GP-led referrals to services run by our district and borough councils. These schemes cover Banstead, Elmbridge, Mole Valley and Epsom and Ewell. The schemes, which vary slightly by area, include well-being advisers, health coaching and community support provided by the voluntary sector and local councils. Most referrals were for weight management, social isolation and mental health support. An evaluation of the scheme in Mole Valley and Banstead showed patients needed fewer GP appointments following take-up of support.

We also continue to offer Personal Health Budgets to support more personalised care. Last year 60 residents across Surrey Downs benefited from a personal health budget to support their health and wellbeing needs. We will continue to develop this further and offer personal health budgets to clients who would benefit from more tailored support.

Over the last year we also supported people living with diabetes and those at risk of developing diabetes through organised education programmes delivered across Surrey Downs. These sessions focussed on lifestyle, exercise and diet. The number of places available for people at risk of diabetes was increased and both programmes will run again next year.

2.12.7 Looking ahead Moving forward our aim is to harness the wider change process in place as an opportunity for joint working to ensure patient engagement and participation has real impact, which is both captured, and celebrated. This process has already started and following a workshop with Lay Members for patient engagement and teams from across the three CCGs we are already looking at how we can share best practice, align our resources and deliver a common approach to engagement across the three organisations. We will also be working together to take forward the next steps around NHS England’s new patient and community engagement indicator and the areas for improvement this identified.

A wide programme of patient focus group worked is planned to shape and drive the design and development of new musculo-skeletal, urology and gynaecology services in 2018/19. This year we also plan to develop our Out of Hospital Strategy which will focus on preventing ill health and hospital admissions. Once again, this strategy will be co-designed with service users, social care partners and community groups to ensure it is patient-focussed.

There is a real understanding of the importance of patient and public engagement within the CCG, demonstrated by some of the co-design and partnership working summarised above. Moving forwards, our

55 aim is to build on this positive commitment to patient and public voice over the next year through increasing our engagement with seldom heard groups, partnership-working with Healthwatch Surrey and increasing overall levels of participation.

Finally, as a core member of the Surrey Heartlands Health and Care Partnership, driving forward local transformation, we will continue to ensure this programme of work meets the needs of patients and service users through our communications and engagement activity.

We would like to thank everyone who took time to share their views about local health services with us during 2017/18. Your feedback has been invaluable and will help us to better meet the health needs of the communities we serve.

2.12.8 Responding to FOIs The CCG is open to scrutiny by members of the public through Freedom of Information Act 2000 requests (FOIs) and is classified as a public authority under the Act.

During 2017/18 the CCG received 255 FOI requests. Of these, 222 requests (87%) were responded to within the statutory deadline of 20 working days. One internal review was requested during 2017/18. The outcome concluded that the CCG’s decision to not disclose the information requested was correct and the time taken to process the request was reasonable. During 2017/18 no applicants requested an external review by the Information Commissioner’s Office (ICO).

2.12.9 Principles for Remedy – how the CCG manages complaints The CCG is committed to the principles for remedy as set out by the Parliamentary and Health Services Ombudsman:  Getting it right

 Being customer focused  Being open and accountable  Acting fairly and proportionately  Putting things right  Seeking continuous improvement

Complaints are handled according to the CCG’s Complaints Policy. There is a dedicated page on the CCG’s website that explains how complaints are handled in the NHS and directs potential complainants to the right organisation first time in order to improve their experience. When complaints are received, written acknowledgement is sent within three working days; complainants will be contacted by phone to request additional information if required to enable the complaint to be handled effectively. Complainants are given contact details so that they can speak to a member of the patient experience service, should they wish.

Complaints are managed as part of the CCG’s quality team, which means the key themes of feedback we receive through the patient experience service or as a complaint can be investigated and directly addressed with providers through quality and contracting discussions.

During 2017/18 there were 69 complaints received by the CCG, an increase of 33% on the previous year. Of the 69 complaints received, 58 were related to Continuing Healthcare (CHC), compared to 41 CHC complaints in 2016/17. This increase reflects the higher volume of referrals the CHC team has received for

CHC funding or Funded Nursing Care during 2017/18.

The CCG directly responded to these complaints, either as a CCG or as the coordinator of responses, working with other providers to ensure these individuals received a detailed response. The main themes were around process and outcomes of continuing healthcare assessments, care pathways, delayed hospital discharges and communication.

Patient experience and complaints reports are submitted to the CCG’s Quality Committee on a regular basis to ensure any themes or issues can be discussed by clinicians and Governing Body members and addressed quickly.

Examples of improvements following investigations into complaints that the CCG received included:  Improved communication processes with patients pre and post admission, especially where patients are going to have an operation  Strengthened staff training, particularly in relation to safeguarding, pain management and communication  Strengthened processes in relation to information governance and personal information

The CCG has a standard to resolve all complaints regarding its own commissioning, including collaborative commissioning, within 25 working days, but this may depend on how the complainant wishes to address the complaint and its complexity. When taking a coordinating role i.e. when the CCG writes a single response on behalf of two or more organisations involved, this can also take longer than 25 working days. Where we were unable to respond within twenty-five days, we kept individuals fully updated on progress and they were able to make contact with a member of the Patient Experience Service team if required.

This year there have been five cases passed to the Parliamentary and Health Services Ombudsman and we have worked closely with the Ombudsman’s office to provide any information needed.

2.13 Performance analysis – reducing health inequalities 2.13.1 Introduction

As an organisation we are committed to ensuring equality, diversity and inclusion are actively considered through our day-to-day business and every year we publish an Equality, Diversity and Inclusion Report, which outlines our commitment to this area and summarises the progress we have made during the year against our action plan.

2.13.2 Equality analyses We consider equalities as part of our work, particularly in relation to any service-redesign projects or if we are proposing changes to a care pathway. This involves carrying out an equality impact assessment so we can fully understand the impact of a proposed change. Every project manager is required to undertake this analysis as part of their role as part of the development of business cases and alongside quality and privacy impact assessments. This ensures that consideration is given to equality as required by legislation.

During 2017/18 we carried out equality impact assessments in relation to the following projects:  Procurement of adult community health services  Introduction of a new Teledermoscopy (community dermatology) service  Proposed changes to the management of Inflammatory Bowel Disease (IBD)  Introduction of an integrated falls service  Review of adult hearing services  Developments relating to community hub services

2.13.3. Equality objectives The CCG is required to publish its equality objectives on an annual basis and we do this as part of our Annual Equality, Diversity and Inclusion report. These objectives support the CCG’s vision to improve access and outcomes for patients and communities that experience disadvantage for whatever reason.

Following the appointment of a joint Accountable Officer and a joint leadership team across Guildford and Waverley, North West Surrey and Surrey Downs CCGs the three organisations are increasingly working together to align function, priorities, policies, procedures and governance arrangements. This closer working forms part of the Surrey Heartlands Health and Care Partnership, which also includes some local providers.

This opportunity for closer working will naturally lead to a common approach across the three CCGs that will ensure that our equality duties are being fully met and that best practice approaches are being adopted. It will also facilitate the sharing of good practice to the benefit of all three organisations. Closely related to this change will be the advancement of the clinical and enabling workstreams that are the priorities of Surrey Heartlands, which will all require a standardised approach to equality and diversity.

Recommendations for 2018 1. Review current equality and diversity processes, plans and priorities across the three CCGs and align these to achieve an approach that measures impact, shares outcomes, learning and best practice and ensures a consistent approach across the three organisations 2. Work with wider Surrey Heartlands partners to ensure a common equality framework is applied to projects and plans that are being delivered through the clinical and enabling workstreams

3. Continue to develop the current programme of equality awareness training across the three CCGs, taking advantage of the strengths that come from working in collaboration.

These are broad recommendations that will need to be further refined, once closer working arrangements are in place across the three CCGs from the beginning of April 2018.

2.14. Health and Wellbeing Strategy

2.14.1. Introduction The CCG is an active member of Surrey’s Health and Wellbeing Board. The Board is the place for the NHS, Public Health, children’s and adult social care, local councillors, voluntary, community and faith sector and service user representatives to work together to improve the health and wellbeing of the people of Surrey. The Board sets direction and makes sure that direction is translated into activity, supporting each partner organisation. The Health and Wellbeing Board has a statutory duty under the Health and Social Care Act 2012 to jointly produce a Health and Wellbeing Strategy. This strategy helps with the planning of a joined-up approach to addressing factors determining local health needs and sets out to improve health and social care outcomes, identifying a number of priorities that are shared across the organisations. This section of the annual report explains how the CCG has supported the five priorities within the Health and Wellbeing Strategy.

2.14.2. Improving children's health and wellbeing Key outcomes identified by the Health and Wellbeing Strategy are:  Children have a healthy weight  Children with special educational needs and disabilities (SEND) have their educational, health and care needs assessed and met

 The health outcomes for looked after children and care leavers improve

During 2017/18, the CCGs across Surrey developed a set of Surrey-wide commissioning intentions aimed at improving the health outcomes of Surrey’s children and young people. They reflect local and national strategic priorities and directives including Sustainable Transformation Partnerships, local maternity systems, CAMHS Transformation and the reconfiguration of Surrey’s Early Help offer. The intentions sit alongside the County Council’s ‘Child First’ approach, which outlines the organisational priorities for 2017-2020. They are also incorporated in the priorities for Surrey’s Health and Wellbeing Board. The county-wide Children’s Community Health Service, procured during 2016, was mobilised from April 2017. The provider of this contract, Children and Family Health (CFH) Surrey8, has improved access and communication for children and young people through ‘One Stop’, the new centralised referral and triage service for Surrey's specialist children’s community services. In addition, robust processes have been implemented to ensure that children who are looked after by Surrey undergo their statutory health assessments whether they are placed in-county or out-of-county. CFH Surrey provides a single looked after children medical and nursing service for all Surrey children. The Whole System Local Transformation Plan for Surrey’s Child and Adolescent Mental Health Service was updated in 2017. The plan reports on progress made over the past two years against key priorities including crisis care services, the community eating disorders service, youth justice, early intervention in psychosis and challenging stigma and promoting wellbeing, together with our plans to make further improvements in order to meet Surrey’s identified needs. This work is under-pinned by priorities given to us by children and young

8 Children and Family Health Surrey is an alliance between CSH Surrey, First Community Health and Surrey and Borders Partnership NHS Foundation Trust. Their trading name is Children and Family Health Surrey.

59 people and their families, with services also being shaped by their views and Surrey County Council’s Joint Strategic Needs Assessment. Children and young people themselves provided an Executive Summary setting out what differences this work is starting to have on the lives of children, young people and their families experiencing mental health issues.

2.14.3. Improving older adults' health and wellbeing Key outcomes identified by the Health and Wellbeing Strategy are:  Older adults stay healthier and independent for longer  Surrey is dementia friendly  Carers are identified and supported  People at the end of their life can choose where they die Key outcomes identified by the Health and Wellbeing Strategy are:  Older adults stay healthier and independent for longer  Surrey is dementia friendly  Carers are identified and supported  People at the end of their life can choose where they die

Supporting the frail and elderly through community hubs As a CCG we have supported the continued development of the three community hubs, which operate in each of our localities. These bring together a multi-disciplinary team to work more proactively to support our frail and elderly population. The hubs involves partners from local health and social care organisations and are helping to prevent avoidable hospital admissions by supporting older people in the community and in their own homes.

We have also supported the development of the Epsom Health and Care partnership’s @home service, which delivers care in a more integrated way for frail and older people.

Surrey is dementia-friendly A key achievement this year was the development and publication of the Surrey Heartlands and East Surrey Dementia Strategy. This was a great example of collaboration across the system that built on the experiences of people with dementias and their carers. The core model underpinning the strategy was the ‘Living Well’ approach. This was developed by NHS England and we have adapted it to suit local needs. The next phase is to implement the strategy over the coming years using the approaches being developed within Surrey Heartlands. As a CCG we continue to work with our member practices to improve the dementia diagnosis rate in order to achieve the national target of 67.6%. This rate is important for our population, as it provides access to the vital support they and their carers need.

Carers are identified and supported Surrey Heartlands has been selected by NHS England as one of four national exemplar areas in a project to demonstrate how the system-wide approach can be a medium for improving identification and support for carers9.

9 The need to identify and support carers is flagged in the NHS Constitution and a range of national policy documents from NHS England, including Commitment to Carers. These have been encapsulated locally in our Surrey Carers Memorandum of Understanding “Together for Carers”.

Our vision is to ensure ‘carers’ are embedded across our health and social care system, making carers everyone’s business. We have done this by implementing the Surrey Carers Memorandum of Understanding (MOU) ‘Together for Carers’ with each NHS provider developing their own carers’ action plan based on the eight principles of the Carers’ MOU. We continue to promote the identification of carers in general practice. Surrey Heartlands CCGs currently have 17,450 adult carers registered across GP practices. 43% are achieving the 2% target. Table 4: Number of adult carers registered in GP practices across Surrey Heartlands CCGs

Guildford & North West Surrey Waverley CCG Surrey CCG Downs CCG

Number of registered 4,750 7,300 5,400 adult carers

Number (%) of practices 14 (66%) 18 (44%) 9 (29%) achieving 2% target

Our award-winning Surrey Carers’ Prescription, which provides a ‘one-stop shop’ secure referral mechanism for health professionals continues to grow, with 4,075 prescriptions discharged in the year to date (Q1 - Q3) delivering 8,509 service requests. Within health, our GP Carers’ Prescriptions have grown by 44% on last year figures.

This year saw the launch of two new initiatives to support carers:  A new adult carers’ support service hosted by Action for Carers Surrey. The new service provides a holistic assessment for carers’ needs and a tailored carers’ support plan. Across Surrey 7,178 adult carers have been supported year to date.

 A hospital carers’ support service. This was originally piloted at Royal Surrey County Hospital. Services have now opened in Ashford & St Peter’s Hospital’s, Epsom General Hospital, East Surrey Hospital and Frimley Park Hospital10.

As part of the work of the Surrey Carers and NHS Providers network we have now recruited over 200 health carer champions. The Royal Surrey County Hospital took the opportunity of Dementia Awareness week in May 2017 to relaunch their commitment to Johns Campaign11 with Virgin Care following suit at a Carers’ Tea in November 2017.

As part of our ongoing commitment to promote the better awareness of our services to the black and minority ethnic community, a partnership event was held with the Surrey Muslim Association in November 2017. 92 members of the community attended the event which was hosted by 3 Imams and included a presentation on the Islamic perspective of caring.

Our armed forces carers’ support is now well established and was cited at the international carers’ conference held in Adelaide in October 2017. NHS England has awarded funding to develop an armed forces young carers film.

We continue to provide regular staff carer awareness training with over 4,000 staff receiving training to date. Additionally we now have 16 organisations across Surrey registered with Employers for Carers service providing carer friendly employment practice

10 Number of Carers identified in Hospital Setting (Year to date) Surrey Heartlands Partnership – 497, RSCH – 318, Epsom General -167, ASPH – 12 11 http://johnscampaign.org.uk/

Our Partnership Manager for Carers has been co-opted to sit on two NICE committees developing guidance around adults in the last year of life and support for adult carers.

Improving end of life care The national framework, ‘Ambitions for Palliative and End of Life Care’, sets out a vision to improve end of life care. With our partners, our focus in 2017/18 has been on delivering our action plan to achieve the framework. Significant progress has been made in year, and we have been working with local partners, including hospices, to develop an End of Life Care Strategy, that focuses on 6 key areas:

 Early identification  Staff training and education  Care that is co-ordinated  Services that are accessible and meet local needs  Enhancing new technology to improve communication  Bereavement support

Place of death has become a key indicator of the quality of end of life care underpinned by the conviction that most people would prefer to die at home and this is a key area we are focusing on.

Another quality indicator for end of life care is the percentage of people who have three or more emergency hospital admissions during the last ninety days of life. It is not good for people at the end of life to be admitted into hospital a number of times through an emergency route. This would suggest their symptom management is not well controlled.

The graph below shows the current position for Surrey Downs CCG and we continue to work with partners, including care homes, to further reduce the number of emergency admissions which occur at end of life.

Chart 1: Percentage of people who have three or more emergency hospital admissions during the last 90 days of life

2.14.4. Promoting emotional wellbeing and mental health Key outcomes identified by the Health and Wellbeing Strategy are:  The gap in life expectancy for people with serious mental illness narrows  Children, young people and families have good emotional wellbeing and mental health

 The provision of perinatal mental health services improves

 There is a reduction in the death rate from suicide  People with mental health needs live independently wherever possible

Child and Adolescent Mental Health Service The Surrey Child and Adolescent Mental Health Whole System Local Transformation Plan (LTP) was updated in 2017. We have, and are continuing to develop a number of new and existing services, as set out in the Local Transformation Plan.

Key highlights this year are:  The Community Eating Disorder Service now accepts self-referral from children and young people or their families and anyone presenting with a suspected eating disorder will be offered an assessment.100% of children and young people are being assessed within 15 days of referral whilst a 60% reduction in admissions to inpatient care (tier 4) has been maintained despite the number of referrals to the service increasing by 30% in 2017, made possible by the enhanced level of early intervention that is now provided in the community.

 A Children and Young Person’s Haven (CYP Haven) opened in Guildford in May 2017 following co- design with children and young people to develop a model that would enable them to get support at an early stage, avoiding the need for more intensive medical support. It has already seen over 150 children and young people, many of whom said that without the Haven they would have attended A&E. We have provided funding this year for all five acute hospitals in Surrey to have in place Paediatric Psychiatric Liaison. Each trust has been able to recruit two additional nurses to provide additional support on their paediatric wards for children and young people presenting to A&E with mental health and learning disability (LD) behavioural issues, including those linked to learning disabilities. Additional training for ward staff has also been provided.

The CAMHs Youth Advisors (CYA) have worked specifically with the acute trusts to help ensure that the CYP and parent/carer related outcome measures reflect the needs of CYP. This new service also links with the existing CAMHs Crisis Support Service and the Adult Psychiatric Liaison Services in each of the five hospitals.

2.14.5. Developing a preventative approach Key outcomes identified by the Health and Wellbeing Strategy are:  The gap in healthy life expectancy across Surrey narrows  People (children, young people and adults) with multiple needs have better health outcomes

 People eat and drink healthily, are physically active and stop smoking  People travel actively, air quality in Surrey is improved and health is embedded in planning  People with learning disabilities live independently locally wherever possible

The vision of Surrey’s Health and Wellbeing Board is: “Through mutual trust, strong leadership, and shared values, we will improve the health and wellbeing of Surrey people”.

Innovative communications and engagement are essential to the delivery of this vision. The CCG supports the Prevention workstream of the Surrey Heartlands Health and Care Partnership and has contributed to the newly-launched Tobacco Control Strategy. All programmes incorporate equality impact assessments to maximise impact amongst the most vulnerable groups, to help in narrowing health life expectancy. A new Programme Management approach has been introduced this year to ensure impacts are routinely assessed.

A collaborative summer campaign was adopted to raise awareness of the importance of keeping safe and well during summer months, particularly for the vulnerable groups; older people and the very young. The summer campaign, delivered through the Surrey Health and Wellbeing Being Board’s communications group, aligned with many of the Surrey-wide initiatives and priorities under an umbrella heading – Stay safe and well this summer. The campaign, promoted widely using a variety of communication mechanisms had three key areas of focus:

 Hydration – targeting vulnerable groups, such as over 65s and their carers  Skin cancer prevention – endorsing the Cover Up Mate campaign

 Safe Day Out – covering water safety, food safety, bites, and allergies. Through the communications group the CCG also supported a co-ordinated Surrey-wide Stay Well This Winter campaign from October until March, with a focus on flu vaccination take-up, particularly for vulnerable groups. Messaging was centred on preparing for winter, stocking up on medications, keeping warm and keeping well and choosing the most appropriate service. This campaign included funding from the Surrey Heartlands Health and Care Partnership, which was used to deliver a radio and social media campaign, which reinforced these key messages.

At a local level the CCG has a proactive approach to sharing health messages and health promotion, where we raise awareness on a wide range of issues through our website, social media, the media, staff communications and many other channels. In the last year the CCG has supported communications relating to a wide range of areas including:

 Smoking cessation – including Stoptober  Mental health and wellbeing – including promotion of safe havens and Improving Access to Psychological Therapies (IAPT) services  Know your numbers – Blood pressure checks  Keep Antibiotics Working  Wheel of Wellbeing – emotional wellness  Breastfeeding support services  NHS111 and the service it offers  Pharmacy advice (linked to the national pharmacy campaign)  Patient choice

 Sexual health  Extended GP access  Stay well this winter  Change for Life  Cancer awareness

 Carers support

 Stroke – FAST  Organ and blood donation

2.14.6. Safeguarding the population

Key outcomes indicated by the Health and Wellbeing Strategy are:  Children, young people and adults are safe and healthy in Surrey  There is a reduction in the number of people experiencing domestic abuse and repeat incidents of domestic abuse  There is a reduction in the number of people experiencing sexual abuse, including child sexual exploitation, rape and assault  There is a reduction in the number of children experiencing abuse and neglect

Guildford and Waverley CCG host Surrey-wide Safeguarding Adult and Children services on behalf of all CCGs in Surrey, including key posts for Safeguarding Children, Safeguarding Adults, the Child Death Overview Process and Looked After Children (LAC).

Effective governance and accountability arrangements are in place to meet all safeguarding statutory duties. This includes providing regular reports, updates and exception reports to the Quality and Clinical Governance Committee and an annual safeguarding report to the Governing Body; submitting quarterly Safeguarding Self- Assessments to provide assurance of its arrangements.

The CCG makes a significant contribution to the work of the Surrey Safeguarding Children’s Board, the Surrey Safeguarding Adult’s Board and the Corporate Parent’s Board. The CCG coordinates and drives safeguarding improvements across the health system, chairing system-wide health groups with safeguarding leads from across a range of providers. The work plans for these groups focus upon the key priorities for children and adults and these plans are reviewed and reported to the safeguarding and corporate parenting boards. The priorities of NHS England, Surrey Safeguarding Children’s Board and Surrey Safeguarding Adult’s Board include:  Domestic abuse  Child Sexual Exploitation  Looked after Children  Early Help  Modern day slavery  Prevent

 Independent Inquiry into Child Sexual Abuse  Female Genital Mutilation  Mental Capacity Act and Deprivation of Liberties

A safeguarding audit and assurance programme is in place with our providers. All CCG contracts for commissioned services contain a requirement to report against a set of safeguarding children and adult safeguarding standards. Systems are in place to share the data provided to monitor and challenge actions

65 such as training compliance and progress against the outcomes of serious incidents and reviews to ensure learning has been embedded.

The county-wide designated and named Lead GPs have provided ongoing leadership and support to the CCG in its duty to make improvements in the quality of primary care.

The CCG has worked with Surrey County Council and Surrey Police to continue to develop and improve the Multi-Agency Safeguarding Hub (MASH), the single point of contact for reporting concerns about the safety of a child, young person or adult. It aims to improve the safeguarding response for children and adults at risk of abuse or neglect through better information sharing and high-quality and timely responses.

Matthew Tait Joint Accountable Officer 25 May 2018

3. Corporate Governance Report 3.1 Members Report 3.1.1 Introduction Clinical commissioning groups are membership organisations that are made up of local GP practices. Our 31 member GP practices are responsible for agreeing the CCG’s governance arrangements as set out in our Constitution, and for delegating commissioning responsibilities to CCG leaders, including members of its Governing Body. The Members Report includes information about the membership and performance of the Council of Members, Governing Body and other Governing Body committees.

The CCG requires declarations of interest from Members for inclusion on the Register of Interests; a link to the register(s) is included in this section. The Joint Accountable Officer’s statement of Accountable Officer’s responsibility is also included.

3.1.2 Council of Members – members and performance

The composition and responsibilities of the Council of Members is described in the CCG’s Constitution, which is available on our website. The Council of Members comprises 31 Commissioning Leads, one from each of the 31 Surrey Downs practices.

During 2017/18 there were 4 meetings of the Council of Members, held on the following dates: 29 June 2017 21 September 2017 23 November 2017 22 February 2018

During the year the Council of Members discussed a range of areas including:  CCG performance and finances  Delegated commissioning  Closer working with partner organisations  Primary care and locality developments  Developments across Surrey Heartlands Health and Care Partnership and plans for devolution  Proposed changes to the CCG Constitution and governance arrangements  360 degree stakeholder feedback

3.1.3 Governing Body – members and performance The membership of, and Terms of Reference for, the CCG’s Governing Body are described in our CCG Constitution.

During 2017/18 there were 6 Governing Body meetings held in public. Minutes and papers for these meetings are available on the CCG website.

The membership of the Governing Body during the year was as follows: Member Position Dr Claire Fuller (left June 2017) Clinical Chair Dr Russell Hills (became Clinical Chair in August Clinical Chair/ GP Member 2017 and prior to that was a GP Member) Matthew Tait (joined June 2017) Joint Accountable Officer Peter Collis Deputy Chair and Lay Member for Governance Dr Andrew Sharpe GP Member and Caldicott Guardian Dr Elena Cochrane (left March 2018) GP Member Dr Louise Keene GP Member Dr Hannah Graham GP Member Eileen Clark Chief Nurse Jonathan Perkins Lay Member for Governance Jacky Oliver Lay Member for Patient and Public Engagement Gill Edelman (left August 2017) Lay Member for Patient and Public Engagement Debbie Stubberfield Independent Nurse on the Governing Body Tony Kelly Secondary Care Doctor Andrew Demetriades (left November 2017) Interim Managing Director Donna Derby (November-February 2018) Interim Managing Director Colin Thompson (joined February 2018) Managing Director Matthew Knight (left May 2017) Chief Finance Officer Dan Brown (left November 2017) Interim Chief Finance Officer Karen McDowell (joined November 2017) Chief Finance Officer Elaine Newton (joined November 2017) Executive Director for Communications and Corporate Affairs Sumona Chatterjee (joined November 2017) Executive Director of Strategic Commissioning Clare Stone Executive Director of Quality Ruth Hutchinson Public health representative and Deputy Director of Public Health at Surrey County Council Yvonne Rees (left June 2017) Local authority representative Jason Russell (joined November 2017) Local authority representative

3.1.4 Register of Interests The CCG embraces the principles of transparent and open decision making and has welcomed the focus on strengthening arrangements for managing conflicts of interest across the NHS following publication of NHS England’s revised statutory guidance for CCGs in February 2017. The CCG’s Standards of Business Conduct and Conflict of Interest Policy (including receipt of gifts and hospitality, commercial sponsorship and joint working with the pharmaceuticals’ industry) has been aligned with this guidance.

The CCG has:  Aligned its Conflict of Interest Policy with the February 2017 guidance  Processes in place to regularly refresh registers of interests  Delivered a series of training and awareness sessions

The CCG’s corporate registers are published on the CCG’s website and can be viewed online at http://www.surreydownsccg.nhs.uk/about-us/governance/

3.1.5 Governing Body Committee Framework The National Health Service Act 2006 (as amended), at paragraph 14L(2)(b) states:  The main function of the Governing Body is to ensure that the group has made appropriate arrangements for ensuring that it complies with such generally accepted principles of good governance as are relevant to it. The effectiveness and success of the CCG is the collective responsibility of the Council of Members (as the Membership Body) and the Governing Body, supported by a committee governance structure. The following Governing Body committees have met consistently throughout the year:

 Audit Committee  Quality Committee  Finance and Performance Committee  Remunerations and Nominations Committee

3.1.6 Audit Committee – role of committee and members This committee critically reviews the CCG’s reporting and internal control principles, monitors financial governance and ensures the CCG has an effective system of integrated checks and balances on its activities. It also covers risk management, provides an effective internal audit function and oversees arrangements for counter fraud.

The membership of this committee during 2017/18 was as follows:

Member Position Peter Collis Lay Member for Governance (Chair) Jonathan Perkins Lay Member for Governance Dr Andrew Sharpe GP Member

A number of other CCG officers attending during the year. This included the Joint Accountable Officer, Clinical Chair, Independent Nurse on the Governing Body, Chief Finance Officer, Managing Director and colleagues from our internal and external audit.

3.1.7 Quality Committee – role of committee and members This committee plays an important role in monitoring and seeking assurance on quality of care, patient experience and patient safety. It looks at clinical quality, clinical governance, safeguarding and quality

69 improvements across our main healthcare providers and works with providers to drive forward quality improvements for the Surrey Downs population. The membership of this committee during 2017/18 was as follows:

Member Position Debbie Stubberfield Independent Nurse on the Governing Body (Co-Chair) Eileen Clark Chief Nurse Dr Tony Kelly Secondary Care Doctor on the Governing Body (Co-Chair) Dr Elena Cochrane GP member Dr Louise Keene GP member Gill Edelman (left August 2017) Lay Member for Patient and Public Engagement Jacky Oliver Lay Member for Patient and Public Engagement

A number of other CCG colleagues, including members of our quality and engagement teams also attended meetings during the year.

This committee has one sub-committee which is responsible for reviewing patient safety incidents.

3.1.8 Finance and Performance Committee – role of committee and members This committee oversees the CCG’s performance, both in terms of how we are performing against key quality standards and how we are performing financially.

The membership of this committee during 2017/18 was as follows:

Member Position Jonathan Perkins Lay Member for Governance (Chair) Peter Collis Lay Member for Governance Dr Claire Fuller (left June 2017) Clinical Chair Dr Russell Hills Clinical Chair Donna Derby (joined November 2017) Interim Managing Director Andrew Demetriades (left November 2017) Interim Managing Director Colin Thompson Managing Director for Surrey Downs Hannah Graham GP Member Eileen Clark Chief Nurse Matthew Tait (joined June 2017) Joint Accountable Officer Matthew Knight (left May 2017) Chief Finance Officer Dan Brown (left November 2017) Acting Chief Finance Officer

Karen McDowell (joined November 2017) Chief Finance Officer

A number of other CCG colleagues, including members of our Programme Management Office, quality, finance and other teams, also attended meetings during the year.

3.1.9 Remuneration and Nominations Committee – role of committee and members This committee makes recommendations on the remuneration (pay) and conditions of service of staff and other general HR matters. It also advises on contractual arrangements for Governing Body members and senior employees and oversees the appointment and election of Governing Body members (including succession planning, terms of office, performance and review processes).

The membership of this committee during 2017/18 was as follows:

Member Position Peter Collis Lay Member for Governance (Chair) Jonathan Perkins Lay Member for Governance Dr Russell Hills GP Member and Clinical Chair (from August 2017)

A number of other CCG colleagues, including our Managing Director, Joint Accountable Officer and members of our finance team also attended some meetings during the year.

3.1.10 Collaborative working The CCG has signed up to collaborative arrangements with Surrey CCGs. The areas where we take a joined up approach to buying health services, hosted by a single CCG on behalf of the others, are shown in table 5. Where CCGs work collaboratively it increases consistency in quality for patients and enables risk to be shared, the transfer of skills and best practice and the securing of commissioning support. It also provides arrangements that are responsive, flexible, resilient and sustainable in meeting local needs. Over the past year the CCG has worked with Surrey CCGs and led on the provision of a number of services across Surrey, as detailed below: Table 5: Collaborative Commissioning in Surrey

Description Host/lead commissioner

Surrey-wide CCGs Integrated Safeguarding Team NHS Guildford and Waverley CCG Children’s Community Health Services NHS Guildford and Waverley CCG Children’s and Adolescents Mental Health Services NHS Guildford and Waverley CCG leads on (CAMHS) Specialist CAMHS whilst Surrey County Council leads on the Targeted CAMHS via a section 75 agreement with Surrey CCGs Adult Learning Disabilities services NHS Guildford and Waverley CCG Adult Mental Health Services, including the main NHS Guildford and Waverley CCG for Surrey contract with Surrey & Borders Partnership NHS Heartlands and East Surrey CCGs only Foundation Trust, IAPT services (Surrey wide) and voluntary sector contracts (Heartlands and East Surrey CCGs)

Wheelchair Services NHS North West Surrey CCG Emergency Ambulance Services, NHS 111, Patient NHS North West Surrey CCG Transport Services NHS continuing health care and NHS funded NHS Surrey Downs CCG Nursing care services across Surrey Individual Funding Requests NHS Surrey Downs CCG for all Surrey CCGs Medicines management NHS Surrey Downs CCG for East Surrey, Surrey Downs and Surrey Heath only. We also host pharmaceutical commissioning only for Guildford and Waverley CCG. Accreditation and Annual Appraisal of General NHS Surrey Heath CCG Practitioners with a Special Interest

3.1.11 Personal data related incidents

Incident reporting The CCG has in place robust IG incident reporting and management procedures, which reflect the requirements of the ‘Checklist Guidance for Reporting, Managing and Investigating Information Governance and Cyber Security Serious Incidents Requiring Investigation’ issued by the Health & Social Care Information Centre (now known as NHS Digital). In accordance with the requirements of this mandatory guidance, the table below provides statutory disclosures relating to IG, personal data, and cyber security incidents occurring during the financial year. Table 6: Summary of Serious Incidents requiring investigation involving personal data as reported to the Information Commissioner’s Office during 20/17/18

Date of Nature of Nature of data Number of data Notification steps incident incident involved subjects potentially (month) affected

31 Information Paper files containing 22 Reported on StEIS March 2017 Governance details of applications Notification to ICO Breach (meeting and assessments and Duty of Candour SI Criteria) associated correspondence relating to Continuing Healthcare funding

Further action on information risk Review of Policies Additional staff training carried out Additional audits of process scheduled throughout the year Sharing of identified learning to other areas

3.1.12 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.

3.1.13 Modern Slavery Act

Surrey Downs CCG fully supports the Government’s objectives to eradicate modern slavery and human trafficking but does not meet the requirements for producing an annual Slavery and Human Trafficking Statement as set out in the Modern Slavery Act 2015.

3.2 Statement of Accountable Officer’s Responsibilities 3.2.1 Introduction

The National Health Service Act 2006 (as amended) (the NHS Act 2006) states that each Clinical Commissioning Group (CCG) shall have an Accountable Officer and that Officer shall be appointed by the NHS Commissioning Board (NHS England). NHS England has appointed Matthew Tait to be the Accountable Officer of NHS Surrey Downs CCG.

The responsibilities of an Accountable Officer are set out under the NHS Act 2006, 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 CCG and enable them to ensure that the accounts comply with the requirements of the Accounts Direction; • Such internal control as they determine is necessary to enable the preparation of financial statements that are free from material misstatement, whether due to fraud or error; • Safeguarding the CCGs 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 NHS Act 2006 and with a view to securing continuous improvement in the quality of services (in accordance with Section14R of the NHS Act 2006; and • Ensuring that the CCG complies with its financial duties under Sections 223H to 223J of the NHS Act 2006.

Under the NHS Act 2006, NHS England has directed each CCG to prepare for each financial year financial statements in the form and on the basis set out in the Accounts Direction. The financial statements are prepared on an accruals basis and must give a true and fair view of the state of affairs of the CCG and of its net expenditure, changes in taxpayers’ equity and cash flows for the financial year.

In preparing the financial statements, the Accountable Officer is required to comply with the requirements of the Group Accounting Manual issued by the Department of Health and in particular to:

• Observe the Accounts Direction issued by NHS England, including the relevant accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis; • Make judgements and estimates on a reasonable basis; • State whether applicable accounting standards as set out in the Group Accounting Manual issued by the Department of Health have been followed, and disclose and explain any material departures in the financial statements; • Assess the CCGs ability to continue as a going concern, disclosing, as applicable, matters related to going concern; and • Use the going concern basis of accounting unless they have been informed by the relevant national body of the intention to dissolve the CCG without the transfer of its services to another public sector entity.

To the best of my knowledge and belief, and subject to the disclosure set out below, I have properly discharged the responsibilities set out under the NHS Act 2006, Managing Public Money and in my Clinical Commissioning Group Accountable Officer Appointment Letter.

The CCG deficit has been reported by the external auditors under Section 30(b) of The Local Audit and Accountability Act 2014.

I also confirm that:

 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; and

 The annual report and accounts as a whole is fair, balanced and understandable and that I take personal responsibility for the annual report and accounts and the judgments required for determining that it is fair, balanced and understandable.

Matthew Tait 25 May 2018 Joint Accountable Officer NHS Surrey Downs Clinical Commissioning Group

3.3 Governance Statement 3.3.1 Introduction and context NHS Surrey Downs CCG is a body corporate established by NHS England on 1 April 2013 under the National Health Service Act 2006 (as amended).

The clinical commissioning group’s statutory functions are set out under the National Health Service Act 2006 (as amended). The CCG’s general function is arranging the provision of services for persons for the purposes of the health service in England. The CCG is, 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 2017, the clinical commissioning group was still subject to directions from NHS England (issued on 15th August 2015 under Section 14Z21 of the National Health Service Act 2006 as amended). These directions were formally lifted in August 2017. Details of the Directions can be found in the CCG’s annual report for 2016-17, on the CCG’s website.

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

For the first part of 2017/18 the CCG had an Interim Chief Officer, Dr Claire Fuller, who was the Accountable Officer for the CCG. As I was not in post as the Accountable Officer for the whole of the year in question, I have taken the advice of the Governing Body and its committees (particularly the Audit Committee), of NHS England, and of individual officers of the CCG in preparing this Governance Statement and providing assurance on governance matters for the whole of the year in question.

I am responsible for ensuring that the clinical commissioning group is administered prudently and economically and that resources are applied efficiently and effectively, safeguarding financial propriety and regularity. I also have responsibility for reviewing the effectiveness of the system of internal control within the clinical commissioning group as set out in this Governance Statement.

3.3.3 Governance arrangements 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 having the following constitutional governance arrangements in place:  The CCG has a Council of Members that meets regularly and ensures that the 31 member practices determine the overall strategic direction of the organisation, its expectations of how safe and effective care will be commissioned, and how its other functions will be discharged. The member practices delegate the majority of the functions relating to the running of the group to the Governing Body, with the membership having significant engagement and involvement at a more local level through its three localities (Epsom, East Elmbridge and Dorking respectively). The Council of Members met 4 times in 2017/18. Locality meetings were held monthly.

 The Governing Body, which is made up of local GPs, executive officers, external clinicians, local authority and public health representative and lay members, met eleven times during the year (six times formally in public) to scrutinise how the CCG was delivering the broad strategies and plans agreed with the membership.  The Governing Body is structured in such a way as to separate out the responsibilities for assurance, delivery and clinical challenge, so as to ensure that there is a proper balance and scrutiny in place. Every Committee has a local GP on it, and these clinicians take no part in the CCG’s Clinical Cabinet.

 The Governing Body during 2017-18 was composed of 19 members. In addition to meeting as a body, the CCG discharged its functions through a number of committees as follows: a Quality Committee; a Finance and Performance Committee; an Audit Committee; and a Remuneration and Nominations Committee. The Quality Committee has a patient safety sub-committee.  Full details of the membership of the Governing Body and its committees, is given in the Members’ Report  All the above committees have undertaken an assessment of their own effectiveness. This assessment broadly confirms that the structures in place are fit for purpose whilst highlighting some areas of organisational development to be addressed in 2018/19.  A significant development during 2017-18 was the collaboration between the CCG and other neighbouring CCGs (North West Surrey and Guildford and Waverley) in the area known as “Surrey Heartlands” and the programme of joint organisational development undertaken to support this. This included the introduction of a single Joint Executive Team, shared management arrangements, and the development of collaborative governance as a move towards “in common” working arrangements.

3.3.4 UK Corporate Governance Code The CCG is not required to comply with the UK Corporate Governance Code. However, we have reported on our corporate governance arrangements by drawing upon best practice available, including those aspects of the UK Corporate Governance Code we consider to be relevant to the CCG. Specifically:

 Leadership. The CCG accepts that one of the key roles for the Governing Body includes establishing the culture, values and ethics of the organisation. It is important that the Governing Body sets the correct ‘tone from the top’.  Division of responsibilities. The revised governance arrangements are designed to enshrine the principles in the code that there should be a clear division of responsibilities between the role of the Governing Body and the executive’s responsibility for the running of the organisation’s business, allowing a healthy balance between constructive challenge and contribution to the development of an agreed strategy and its delivery.  Accountability. In line with the code’s emphasis on accountability, the CCG has developed and continues to develop better information on the quality and cost of commissioned services, and improved systems for assessing risk to the delivery of its objectives and its operations. These include enhanced performance reports and more descriptive and accessible risk profiles.  Relationships with stakeholders. The CCG has put in place significantly improved internal relationships (for instance between the member practices, the Governing Body and the Executive) and has enshrined these in new structures that give clinical stakeholders more ownership of the delivery of safe and effective care.  Organisational development. At ‘board’ level and down through the organisation there is a renewed emphasis on ensuring that the CCG has an appropriate balance of skills, experience, independence and knowledge to enable it to discharge its respective duties and responsibilities effectively.

This is one of the key drivers for putting in place shared executive and collaborative governance arrangements across the three Surrey Heartlands CCGs as it will ensure the best use of scarce management resources.

As a statutory NHS organisation the CCG does not have a requirement to demonstrate that it is a “going concern” but the work undertaken to ensure strong governance and achievement of the long-term financial sustainability do reflect this approach, and provides assurance that the CCG can continue to operate as a viable entity within the framework of public sector finances.

3.3.5 Discharge of Statutory Functions In light of recommendations of the 2013 Harris Review, the clinical commissioning group has reviewed (as part of the introduction of shared management arrangements with neighbouring CCGs) 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 clinical commissioning group’s statutory duties.

The Committees in Common approach, gives further evidence of the primary importance which we give, along with our partner CCGs, to ensure good governance and open, transparent decision making processes. This mechanism supported the governance underpinning the development of the Surrey Heartlands Sustainability and Transformation Plan.

Health and Safety The CCG has undertaken all Health and Safety risk assessments and is compliant with legislation.

Emergency Preparedness, Resilience and Response (EPRR) The CCG is compliant with emergency preparedness and civil contingency requirements and able to meet its obligations as a Category 2 responder.

3.3.6 Risk management – arrangements and effectiveness

The CCG has a Risk Management Strategy and Policy that was refreshed and agreed by the Governing Body in January 2018 and is embedded in our normal management processes and structures and organisational culture. This strategy and policy was agreed with the other CCGs in Surrey Heartlands and reflects the delegation of responsibility within the new executive arrangements.

The CCG has a statement of risk appetite which sets out the broad risk tolerances of the organisation but also gives specific guidance to managers on how to score risk. The Strategy uses a common scoring matrix for assessing the likelihood and impact of risk which is then either Treated, Tolerated, Transferred or Terminated (the Four T methodology).

This approach complies with best practice, NHS Litigation Authority and National Patient Safety guidance and Department of Health requirements. It has also been assessed as fit for purpose by internal audit.

With all CCG processes, and in particular projects involving service change, risks around quality, equality and

78 privacy impact are assessed using the same risk scoring matrix to determine whether the impact is likely to be Positive, Negative or Neutral.

The CCG is also advised on risk by engagement with the public and clinicians on changes to services, including open questions at the start of each CCG Governing Body meeting in public. It is possible for any member of the public to raise an issue and its associated risks directly with the governing body in this forum.

3.3.7 Risk management – capacity to handle risk Risks can be identified at any level of the organisation but are managed by senior staff and all risks have an executive owner who is ultimately accountable for them. The CCG’s incident reporting system (Datix) specifically highlights the need to identify risks for the CCG’s risk register where appropriate, and staff are encouraged to be open and honest when reporting incidents and risks.

The CCG’s committees may also recommend new entries on the CCG’s risk register where appropriate.

The Assurance Framework (which describes and manages the risks to the CCG’s principal objectives) and the Risk Register (which describes and manages more operational risk) are both updated fully for each public Governing Body and also more regularly as new risks are identified.

During the course of the year the majority of staff at Executive, Senior and middle grade level attended training sessions on the revised risk management strategy and its use within the organisation. Risk management is also covered as part of the governance module of the induction programme for new staff. The CCG also provided training and support to staff as part of the ongoing development of the “Datix” system for management of risk, incidents, Freedom of Information and complaints.

3.3.8 Risk management – risk assessment The CCG’s risk strategy requires anyone charged with managing a risk to identify the key controls and mitigating actions that will reduce the score to agreed and specific tolerance levels. The majority of risks the CCG manages are intrinsic to its operations and only rarely capable of elimination.  Risk is prevented by the early use of impact assessments (as described above), and by proactive work in specific areas. For instance the CCG commissions a counter fraud service to work with staff to ensure high standards of business conduct and the early identification of any risk of fraud  The CCG’s risk profile has been relatively consistent across the year in question, with a focus on achieving the Governing Body’s principal objectives as set out in the Assurance Framework.  The first principal objective was financial sustainability. Risks were initially high but reduced during the year as the CCG achieved a substantial proportion of its QIPP targets and agreed other mitigations with regulators. The underlying issues with financial sustainability were however made clear to the member practices and the Governing Body and are a focus of 2018/19 planning and delivery, working collaboratively across the Surrey Heartlands footprint.  The second area of focus in the Assurance Framework was the development of local collaborative arrangements, specifically developing the Sustainability and Transformation Partnership and contributing to the Surrey devolution agenda. The CCG managed this risk in year by developing the joint arrangements between CCGs; taking an active role in developing the Surrey Heartlands Partnership; and supporting shadow local devolution arrangements for Surrey. It also continued to collaborate with Surrey County Council and other partners through the Health and Wellbeing Board, statutory partnerships for safeguarding and crime and disorder, and other mechanisms.  The third area was to develop the CCG's capacity for the commissioning and delivery of primary care in 2017-18, ensuring that this is consistent with broader commissioning development in areas such as

integration. Surrey Downs member practices did not wish to take on delegated commissioning but did work closely across Surrey Heartlands to deliver the GP Forward View and develop primary care locally in line with the integration agenda.

 The final area was to ensure that the CCG's Organisational Development programmes supported localities, clinical leaders, staff and the Governing Body to work locally and across the STP on the successful delivery of both strategic objectives and Business As Usual. This was achieved principally through the implementation of shared management and governance arrangements as set out above.

3.3.9 Assurance sources – Internal Control Framework A system of internal control is the set of processes and procedures in place in the clinical commissioning group to ensure it delivers its policies, aims and objectives. It is designed to identify and prioritise the risks, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically.

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

The CCG uses an industry standard matrix when rating risks which considers the impact of each risk. Each rating is presented as a mitigated score based upon consideration of the controls in place. Actions are recommended to reduce the risk rating. The CCG operates an integrated approach wherein the Governing Body Assurance Framework identifies risks to the CCG’s principal objectives and the Risk Register takes a broader and more operational view of risk. The key threshold which identifies risks as significant or red is a score of 15 or higher. Managers are expected to enhance controls and put in place mitigating actions to bring risk down to the agreed level as set out in the statement of risk appetite. The internal control framework is also dependent on having the required policies and procedures in place to give the Governing Body and staff clarity of expectations against which assurance can be measured.

3.3.10 Assurance sources - Annual audit of conflicts of interest management The revised statutory guidance on managing conflicts of interest for CCGs (published February 2017) requires CCGs to undertake an annual internal audit of conflicts of interest management. To support CCGs to undertake this task, NHS England has published a template audit framework.

The CCG conducted an audit of its arrangements for managing conflict of interest in February and March 2018. This audit provided reasonable assurance but demonstrated a number of areas for improvement in the CCGs controls and administration of conflicts of interest. The CCG agreed a range of actions in the following areas:  Updating of relevant policies  Gap analysis of guidance  Revisions to the gifts and hospitality register  Routine checks of the ABPI database  Medicines management compliance  Levels of declarations  Legacy information management  Updating of the procurement register  GP practice declarations  New starter declarations  Processes for completing online training by 31st May  Validation of data on MES Declare

 Website information regarding breaches  Review of learning outcomes in audit documentation

3.3.11 Assurance sources – data quality The CCG buys commissioning support from NHS North East London Commissioning Support Unit. This includes a business intelligence and performance function which monitors how local providers and the CCG itself are performing against key performance indicators. This information is reported to the Executive and Governing Body on a regular basis. The CCG seeks to continuously improve the timeliness and quality of data to support strategic and operational decision making and individual information issues are reviewed in the relevant committee. During 2017-18 the Finance and Performance Committee played a key role in assessing the quality of information it was receiving.

Information on the CCGs performance was provided regularly to the Council of Members, The Governing Body and to individual committees. Information was also reviewed in the CCG’s Clinical Cabinet.

3.3.12 Assurance sources – information governance The NHS Information Governance Framework sets the processes and procedures by which the NHS handles information about patients and employees, in particular personal identifiable information. The NHS Information Governance Framework is supported by an information governance toolkit and the annual submission process provides assurances to the clinical commissioning group, other organisations and to individuals that personal information is dealt with legally, securely, efficiently and effectively.

The CCG submitted a compliant Information Governance Toolkit return in March 2018 and the internal audit of the CCG’s arrangements gave reasonable assurance.

We place high importance on ensuring there are robust information governance systems and processes in place to help protect patient and corporate information. We have established an information governance management framework and have developed information governance processes and procedures in line with the information governance toolkit. We have ensured all staff undertake annual information governance training and have implemented a staff information governance handbook to ensure staff are aware of their information governance roles and responsibilities.

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

3.3.13 Assurance sources – business critical models The CCG undertakes a number of business critical processes in order to deliver its commissioning functions. The way in which these are managed and assured is set out below.

The CCG is aware that modelling future trends and risk is a difficult process and seeks to undertake these processes rigorously.

The table on the following pages identifies the key processes and models used, along with sources of assurance and scrutiny.

Business critical Model Assurance Timescales process

Population planning and Joint Strategic Needs Public Health Team Five year planning and need Assessment data quality assurance annual reviews - statistical and stakeholder data on demographic trends and epidemiological expectations.

Five year plan Developed based on Reviewed by Area Five year planning and the JSNA, guidance Team of NHS annual reviews from NICE and other England. Signed off by bodies on emerging CCG Governing Body health technologies, and views from stakeholders

Annual planning Annual planning Monitored monthly Core activity from guidance with local by Finance and September to March interpretation; Performance development through Committee, signed localities and off by Governing committees Body

Financial Aligned to QIPP Reviewed by Area Core activity, monthly planning programmes in annual Team of NHS (including plan England; monitored by financial Finance and recovery) Performance Committee. Signed off

by CCG Governing Body Financial Finance modeling Monitored monthly One year and five reporting and extrapolated from by Finance and year, tracked monthly monitoring SBS, SUS, SLAM, Performance Committee, reported Prescribing and other to Governing Body data. RightCare opportunity tracked & monitored.

Programme Structure Programme Monitored by Weekly and monthly management Management Office Programme Delivery (PMO) with written Board (PDB) and procedures Finance and Performance Committee

Business critical Model Assurance Timescales process

Business case / Project Based on standard Reviewed by the Request specific but Initiation Document templates developed PDB , Executive normally monthly development by the Service Team and Clinical Redesign team Cabinet

Quality and Monthly reports using CSU validated. Data Monthly reporting Performance accredited data limitations transparent. reporting sources validated by Monitored by Quality CSU Committee.

Procurement Strictly controlled Executive Committee Bespoke according to processes undertaken review procurements each tender but in with the legal and monthly. All tenders accordance with OJEU technical support of and contract awards requirements where NHS South CSU recorded using necessary and local procurement team. accredited systems. procurement policy

Human resources Formally detailed Reviewed by EMT and Weekly in EMT, policies and procedures; Remuneration and quarterly in business systems e.g. Nominations Remuneration and payroll, HR records and Committee Nominations Committee training provided by CSU

Emergency Planning, Formally detailed Overseen by Audit Quarterly Resilience and Response policies and procedures Committee and EMT (EPRR) and externally assured by NHS England

Clinical services Governed by Overseen by Quality Monthly monitoring operational policies and Committee and in the business continuity case of CHC, by the plans (IFR, RSS, CHC CHC programme and Medicines Board Management)

3.3.14 Assurance sources – third party assurances Where the CCG relies on third party providers, these are subject to audit requirements that are reported to the CCG’s Audit Committee. These include Shared Business Services (SBS), CSU Information technology, information governance and business intelligence.

3.3.15 Control issues The CCG’s major control issue during 2017/18 was financial recovery and the CCG addressing the issues outlined in the remaining Direction issued by NHS England (which was met in June 2017 following the appointment of Matthew Tait our Joint Accountable Officer).

The Finance and Performance Committee met monthly to ensure that there were effective controls in place to maintain Business As Usual and to achieve the required levels of QIPP that would support this work.

The CCG also commissioned extensive developmental programmes to ensure that leadership by Governing Body members, Clinical Leads, and Senior Management was fit for purpose.

In overall terms these issues did not impact on achievement of the CCG’s standards of delivery or undermine the security of its normal business systems. They have not impacted materially on the accounts other than through the management of the CCG’s deficit position as agreed with NHS England.

3.3.16 Review – economy, efficiency, effectiveness, use of resources Sixty per cent of the CCG’s spend is on acute care and the CCG uses national tariffs and benchmarks local tariffs to ensure that it is not paying more than economic rates for services. Changes of contracts are rigorously appraised to ensure value for money and a number of changes have been made to improve value for money. Local Enhanced Service arrangements (known locally as Primary Care Standards) have also been rigorously appraised and benchmarked to increase volume and quality of specification whilst reducing spend. We also use formal procurement processes for spend outside of national tariffs.

As part of its work on financial recovery and wider transformation the CCG has developed its Programme Management Office and used the Right Care Programme and other benchmarking to pursue the opportunities identified for more effective and economical commissioning; this is linked to the CCG’s QIPP programme where there are a number of areas of elective care where national benchmarking indicates that care could be commissioned more effectively.

The restructured executive management arrangements for the CCG which are being implemented jointly with the other Surrey Heartlands CCGs are specifically geared towards creating a stronger connection between strategy, integration of care and efficiency. The Clinical Cabinet advises the executive on proposals for service change to ensure that opportunities are prioritised and maximised. The CCG’s performance is overseen by the Finance and Performance Committee. QIPP schemes were reviewed positively by internal audit who also audited key financial systems. The CCG stayed within its management cost targets for the year. The CCG is also subject to Ratings for the Quality of Leadership indicator of the CCG Improvement and Assessment Framework 2017/18, the outcome of which will be published by NHS England in summer 2018.

3.3.17 Review – delegation of functions The CCG seeks to maximise QIPP opportunity across all its activities including areas where activities are delegated to other organisations (for instance in respect of hosting of services by other CCGs). The Surrey CCG collaborative seeks to maximise QIPP opportunity collectively in these areas of Surrey and oversees the relevant delegation chains relating to them. We also work with other commissioners (specifically in relation to

84 non-local acute and mental health trusts) where we can achieve greater efficiencies by working together. In some high risk areas the CCG has sought a more direct role with host commissioners (for instance in some poorly performing trusts and / or trusts where costs are above benchmarked expectation).

Delegated functions are subject to audit and these audits are shared with the CCG routinely.

3.3.18 Review – counter fraud arrangements

The CCG places a strong emphasis on preventing and countering fraud and purchases accredited counter fraud services from its Internal Auditors. The service liaises closely with NHS Protect and local bodies to appropriately share and gather intelligence on potential fraud and related risks.

The service provided training to CCG staff during the year and in particular to key functions such as Continuing Health Care and the finance team where risks of fraud, particularly amongst suppliers, are more likely to be identified.

The Audit Committee received reports on fraud related risks at the majority of its meetings and the counter fraud service supported the CCG with reporting on Standards for Commissioners. Counter fraud work was increasingly proactive during the year and in addition to training there were staff bulletins and material displayed within the CCG buildings. Counter Fraud is also identified at the CCG’s induction as a key area of governance for all staff.

The Audit Committee was given a specific presentation on cyber related fraud and subsequently commissioned the service to undertake a review of its processes and vulnerabilities. The Chief Finance Officer as the Executive lead works closely with the Audit Committee chair and the counter fraud team.

3.3.19 Head of Internal Audit Opinion Following completion of the planned audit work for the financial year for the CCG, the Head of Internal Audit issued an independent and objective opinion on the adequacy and effectiveness of the clinical commissioning group’s system of risk management, governance and internal control. The Head of Internal Audit Report can be found on the following pages.

Internal Audit Annual Report

Introduction

This is the 2017/18 Annual Report by TIAA on the internal control environment at NHS Surrey Downs Clinical Commissioning Group. The annual internal audit report summaries the outcomes of the reviews we have carried out on the organisation’s framework of governance, risk management and control. This report is designed to assist the Governing Body in making its annual governance statement.

Head of Internal Audit’s Annual Opinion

The overall Head of Internal Audit Opinion for 2017/18 is “Reasonable Assurance” (see Annex A for detail). I am satisfied that sufficient internal audit work has been undertaken to allow me to draw a reasonable conclusion as to the adequacy and effectiveness of NHS Surrey Downs Clinical Commissioning Group's risk management, control and governance processes. In my opinion, despite the CCG’s inability to deliver their planned financial control total, NHS Surrey Downs Clinical Commissioning Group has adequate and effective management, control and governance processes to manage the achievement of its objectives.

Internal Audit Planned Coverage and Output

The 2017/18 Annual Audit Plan approved by the Audit Committee was for 122 days of internal audit coverage in the year. During the year the following change to the Audit Plan was approved by the Audit Committee:

 An audit of Locality Hubs-Contract Management and Monitoring Review was requested by the CCG. This was an additional audit which was not originally included in the Internal Audit Plan for 2017/18. As agreed this was funded from the 6 days originally earmarked for STP Governance and 6 days from the contingency budget. The formal year-end Annual Opinion statement is set out in Annex A. All the planned work has been carried out and the reports have been issued (see Annex B for details). Other than the additional review above which was funded from the existing plan, there was no further work carried out which was in addition to the work set out in the Annual Audit Plan.

Assurance TIAA carried out 9 reviews (excluding the two non-assurance audits), which were designed to ascertain the extent to which the internal controls in the system are adequate to ensure that activities and procedures are operating to achieve NHS Surrey Downs Clinical Commissioning Group’s objectives. For each assurance review an assessment of the combined effectiveness of the controls in mitigating the key control risks was provided. Details of these are provided in Annex B, and a summary is set out below.

Assurance Assessments Number of Reviews Previous Year

Substantial Assurance 0 0

Reasonable Assurance 9 7

Limited Assurance 0 2

No Assurance 0 0

The areas on which the assurance assessments have been provided can only provide reasonable and not absolute assurance against misstatement or loss and their effectiveness is reduced if the internal audit recommendations made during the year have not been fully implemented.

We made the following total number of recommendations on our audit work carried out in 2017/18.

Urgent Important Routine

0 16 50

Audit summary

Control weaknesses: There were no areas reviewed by internal audit where it was assessed that the effectiveness of some of the internal control arrangements provided ‘limited' or 'no assurance’.

Recommendations made: We have analysed our findings/recommendations by risk area and these are summarised below.

Risk Area Urgent Important Routine

Directed 0 4 15

Compliance 0 10 23

Operational 0 2 12

Reputational 0 0 0

Operational Effectiveness Opportunities: One of the roles of internal audit is to add value and during the financial year we provided advice on opportunities to enhance the operational effectiveness of the areas reviewed and the number of these opportunities is summarised below.

Operational

Independence and Objectivity of Internal Audit

There were no limitations or restrictions placed on the internal audit service which impaired either the independence or objectivity of the service provided.

Performance and Quality Assurance

The following Performance Targets were used to measure the performance of internal audit in delivering the Annual Plan.

Performance Measure Target Attained

Completion of Planned Audits 100% 100%

Audits Completed in Time Allocation 100% 100% Final report issued within 10 working days of 100% receipt of responses 100% Compliance with Public Sector Internal Audit 100% 100% Standards

Ongoing quality assurance work was carried out throughout the year, and we continue to comply with ISO 9001 standards. An independent external review was carried out in 2016 of our compliance with Public Sector Internal Audit Standards (PSIAS) which met the requirement for an independent 5 year review. The outcome confirmed full compliance with all the standards. Our work also complies with the IIA-UK Professional Standards.

Release of Report

The table below sets out the history of this Annual Report.

th Date Report issued: 17 April 2018

Annex A

Head of Internal Audit Opinion (HoIA) on the Effectiveness of the System of Internal Control for the Year Ended 31 March 2018

The purpose of my annual HoIA Opinion is to contribute to the assurances available to the Accountable Officer and the Governing Body which underpin the Governing Body’s own assessment of the effectiveness of the organisation’s system of internal control. This Opinion will in turn assist the Governing Body in the completion of its Annual Governance Statement (AGS).

The Finance Report to the March 2018 Governing Body meeting states that at Month 11‘The CCG is forecasting a deficit of £16.9m (original plan was £10.5m deficit). Month 11 (28th February 2018) the CCG reported a deficit of £16.9m against the planned deficit of £9.6m resulting in a £7.3m adverse variance. The forecast has been amended to reflect net risks of £6.4m and is currently £16.9m. All current risks outside of the forecast position are fully mitigated’.

Our opinion on the organisation’s system of internal control has taken this factor into account. My opinion is set out as follows:

1. Overall opinion;

2. Basis for the opinion; and

3. Commentary.

1. My overall opinion is that, despite the CCG’s inability to deliver their planned financial control total, Reasonable assurance can be given that there is a generally sound system of internal control, designed to meet the organisation’s objectives, and that controls are generally being applied consistently. However, some weakness in the design and/or inconsistent application of controls, put the achievement of particular objectives at risk.

2. The basis for forming my opinion is as follows:

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

ii. An assessment of the range of individual opinions arising from risk-based audit assignments, contained within internal audit risk-based plans that have been reported throughout the year. This assessment has taken account of the relative materiality of these areas and management’s progress in respect of addressing control weaknesses.

Additional areas of work that may support the opinion will be determined locally but are not required for NHS England or Department of Health purposes e.g. any reliance that is being placed upon Third Party Assurances.

3. Commentary – see Annex B for a summary of completed internal audit work.

Annex B

Actual against planned Internal Audit Work 2017/18

System Status Planned Actual Assurance Comments days days Assessment

Patient, Public and Practice Final 7 7 Reasonable Engagement

Service Transformation/QIPP Final 12 12 Reasonable Review

Assurance Framework and Risk Final 7 7 Reasonable Management

Review of HR Workforce – Final 9 9 Reasonable Recruitment Controls

Contract Management and Monitoring – Provider Services Final 10 10 Reasonable (NHS and non NHS)

Continuing Healthcare Final 9 9 Reasonable

Critical Financial Assurance Final 10 10 Reasonable

Personal Health Budgets (Adults) No assurance level assigned as Final 5 5 – Follow up review this was a follow up review

IG Toolkit v14.1 – Part 1: Status No assurance level as this was an Final Update Report operational review 8 8

IG Toolkit Review v-Phase 2 Draft Reasonable

Follow Up Completed 5 5 N/A

NHS England Mandatory Review Draft of Conflicts of interest 8 8 Reasonable report arrangements

Locality Hubs-Contract No assurance Management and Monitoring level will be Fieldwork Review 12 11 assigned as this completed is an operational review

Developing the Internal Audit Completed 2 2 N/A Annual Plan

Annual Report and Head of Completed 3 3 N/A Internal Audit Opinion

Management, Quality Assurance Completed 10 10 N/A and Support

Benchmarking and VFM reviews Several Reports shared with Completed 2 2 N/A the CCG and Audit Committee

Contingency c/fwd to 3 0 18/19

Total 122 118 days

3.3.20 Review – effectiveness of governance, risk management and internal control

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

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

I have been advised on the implications of the result of this review by:  The Governing Body  The Audit Committee

 The Quality Committee  Internal audit  Other explicit review/assurance mechanisms.

Specific actions include:  An annual review and approval of the risk management strategy  The Governing Body and Audit Committee reviewing the risk register and assurance framework at every meeting, with additional reviews by other principal committees where appropriate.

 Continuous review of the system of internal controls by the Audit Committee  Review of policies by the Governing Body and all the principal committees; in particular a review of the core policy suite by the internal auditors with actions agreed by the Audit Committee.

 Recommendations and actions from the Remuneration and Nominations committee to more effectively engage staff in understanding policies and the system of internal controls.

3.3.21 Conclusion During the year the CCG made good progress, including the removal of Directions by NHS England. The CCG’s major control issue during 2017/18 was financial recovery and the CCG addressing the issues outlined in the remaining Direction issued by NHS England.

Matthew Tait Joint Accountable Officer 25 May 2018

3.4 Remuneration Report 3.4.1 Introduction Remuneration for Governing Body members is determined in the light of advice from the Remuneration and Nominations Committee, taking into account national guidance on pay rates, any independent evaluation of the post and national and market rates. All other managers are covered by terms and conditions set out in the national NHS Agenda for Change arrangements.

Individual staff performance is assessed as part of our staff appraisal process, where staff receive objective setting and annual reviews with their managers. In line with national guidance and the Agenda for Change programme, staff progress through an incremental pay scale if their performance during the year has been in line with agreed targets and objectives.

3.4.2 Remuneration and Nominations Committee – members and performance Our Remuneration and Nominations Committee has overseen and advised on remuneration issues during 2017/18, ensuring any changes in national guidance or best practice are taken into account.

In 2017/18 the membership of the Remuneration and Nominations Committee was:  Peter Collis, Lay Member for Governance (Committee Chair)  Jonathan Perkins, Lay Member for Governance  Dr Russell Hills, Clinical Chair

A number of other CCG officers, including the Interim Chief Finance Officer also attended this committee during the year.

The tables on the following pages set out the following information:

 Salaries and allowances of members of the CCG’s Governing Body  Pension benefits  Cost of other compensation schemes including exit packages

3.4.3 Policy on the remuneration of senior managers Remuneration for Governing Body members is determined on the basis of reports to the Remuneration and Nominations Committee, taking into account national guidance on pay rates, any independent evaluation of the post and national and market rates. All other managers are covered by terms and conditions set out in the national NHS Agenda for Change arrangements.

3.4.4 Remuneration of Very Senior Managers

For Very Senior Managers (VSM), reference is made using national and regional published guidance for VSMs, as well as local and regional benchmarking in order to set the remuneration of those employed on VSM terms and conditions.

Performance objectives are agreed for all Managers and Staff on NHS Agenda for Change pay. The NHS Terms and Conditions Handbook and pay scales define the process for annual and performance related

92 uplifts. For the Joint Accountable Officer and other members of the Executive, local performance objectives are set using an aligned Performance and Appraisal system similarly to that referenced in VSM guidance.

On Agenda for Change pay, notice periods are between one and three months for all staff up to Band 7 and three months for Band 8a and above. For Executives, the notice period is three months with the exception of the Joint Accountable Officer and the Chief Finance Officer (six months).

The employing CCG is seeking further clarification from NHS Business Services Authority in relation to pension information that has been received.

Remuneration Report

Note 1- Matthew Tait's role as Joint Accountable Officer is hosted by Surrey Downs CCG on behalf of Guildford and Waverly CCG and North West Surrey CCG equally, with Surrey Downs CCG retaining a 33.3% share.

Note 2- The services of these individuals were provided by an interim provider company and the disclosed costs include irrecoverable value added tax

Note 3 - These posts are shared across the Surrey Heartlands Collaborative, for which Surrey Downs are responsible for 33.3%. Sumona Chatterjee and Clare Stone are hosted by North West Surrey CCG. Elaine Newton and Karen McDowell are hosted by Guildford and Waverley CCG. 94

2017/18 2016/17 (a) (b) (c) (d) (e) (f) (a) (b) (c) (d) (e) (f) Long-term Performance Long-term Performance Expense Expense Performance All pension Salaries and Allowances - Governing Body and Lay Members pay and Performance All pension related Total (a-e) pay and Total (a-e) Salary (bands of Payment Salary (bands of Payment pay and related benefits bonuses pay and benefits (Bands of (Bands of bonuses (Bands of £5,000) (Taxable) to £5,000) (Taxable) to bonuses (Bands of (Bands of bonuses (Bands £2,500) £5000) (Bands of £5000) nearest £100 nearest £100 (Bands of £2,500) £5,000) of £5,000) £5,000) £5,000) Name Position From To £000 £00 £000 £000 £000 £000 £000 £00 £000 £000 £000 £000 GP Member (5 days per month) 01/04/2017 31/07/2017 Russell Hills 50-55 - 10-12.5 60-65 25-30 25-30 Clinical Chair (2.5 days per w eek) 01/08/2017 31/03/2018 Debbie Stubberfield Independent Nurse on the Governing Body (2 sessions per month) 01/04/2017 31/03/2018 5-10 1 5-10 5-10 5-10 Dr Andrew Sharpe GP Member (5 sessions per month) 01/04/2017 31/03/2018 10-15 10-15 40-45 40-45 Dr Elena Cochrane GP Member (5 sessions per month) 01/05/2017 31/03/2018 15-20 15-20 Dr Hannah Graham GP Member (5 sessions per month) 01/04/2017 31/03/2018 10-15 10-15 15-20 15-20 Dr Louise Keene GP Member (5 sessions per month) 01/04/2017 31/03/2018 15-20 15-20 15-20 15-20 Dr Tony Kelly Secondary Care Doctor (5 sessions per month) 01/04/2017 31/03/2018 15-20 15-20 15-20 15-20 Gill Edelman Lay Member for Patient and Public Engagement (2 days per month) 01/04/2017 31/07/2017 0-5 0-5 5-10 5-10 Jacky Oliver Lay Member for Patient and Public Engagement (3 days per month) 01/04/2017 31/03/2018 10-15 1 10-15 10-15 10-15 Jason Russell Local Authority representative nominated by Surrey County Council (Non Voting) 01/11/2017 31/03/2018 Nil Nil Yvonne Rees Local Authority representative nominated by Surrey County Council (Non Voting) 01/04/2017 30/06/2017 Nil Nil Nil Nil Jonathan Perkins Lay Member for Governance (4 days per month) 01/04/2017 31/03/2018 20-25 20-25 15-20 15-20 Peter Collis Lay Member for Governance and Deputy Chair (4 days per month) 01/04/2017 31/03/2018 15-20 15-20 15-20 15-20 Ruth Hutchinson Public Health Representative (Non Voting) 01/04/2017 31/03/2018 Nil Nil Nil Nil Dr Suzanne Moore Epsom Locality GP Member (Left role 2016/17) Nil Nil 70-75 70-75 Dr Tim Powell Governing Body GP (Left role 2016/17) Nil Nil 10-15 172.5-175 180-185 Dr Hazim Taki East Elmbridge Locality GP Member (Left 2016/17) Nil Nil 0-5 0-5 Dr Ibrahim Wali Epsom Locality GP Member (Left 2015/16) Nil Nil 0-5 0-5 Dr Kate Laws Epsom Locality GP Member and Deputy Chair for GP Commissioning (Left 2016/17) Nil Nil 15-20 15-20

(a) (b) (c) (d) (e) (f) Performance Long-term Expense pay and Performance All pension related Total (a-e) Salaries and Allowances - Full cost of shared staff Salary (bands of Payment bonuses pay and benefits (Bands of (Bands of £5,000) (Taxable) to (Bands of bonuses (Bands £2,500) £5000) nearest £100 £5,000) of £5,000) Name Position From To £000 £00 £000 £000 £000 £000 Debbie Stubberfield Note 4 Independent Nurse on the Governing Body 01/04/2017 31/03/2018 10-15 1 10-15 Matthew Tait Note 5 Joint Accountable Officer 05/06/2017 31/03/2018 115-120 26 0 120-125 Elaine Newton Executive Director of Communications and Corporate Affairs (Non Voting) 01/11/2017 31/03/2018 45-50 45-47.5 95-100 Karen McDowell Chief Finance Officer 01/11/2017 31/03/2018 50-55 15-17.5 70-75 Clare Stone Executive Director for Quality (Non Voting) 01/11/2017 31/03/2018 45-50 1 75-77.5 125-130 Sumona Chatterjee Executive Director of Strategic Commissioning Development (Non Voting) 01/11/2017 31/03/2018 45-50 0 22.5-25 70-75

Note 4 - 2 sessions per month are recharged to East Surrey CCG Note 5 - Expenses include the taxable element of the lease car

3.4.5 Pension benefits

Real Real Total Lump sum Cash Real Cash Employer’s increase in increase accrued at age 60 Equivalent increase Equivalent contribution pension at in pension pension at related to Transfer in Cash Transfer to age 60 lump sum age 60 at accrued Value at 1 Equivalent Value at stakeholder Pensions (bands of at age 60 31 March pension at April 2017 Transfer 31 March pension £2,500) (bands of 2018 31 March value 2018 £2,500) (bands of 2018 £5,000) (bands of £5,000)

Name Position £000 £000 £000 £000 £000 £000 £000 £00 Russell Hills GP Member & Clinical Chair 0-2.5 0-5 10 10 N/A James Blythe Director of Commissioning 2.5-5 15-20 90 30 121 N/A Matthew Knight Chief Finance Officer 0-2.5 5-10 75 12 88 N/A Acting Director of Clinical Performance Eileen Clark and Delivery & Chief Nurse (Non Voting) 2.5-5 12.5-15 30-35 95-100 592 130 728 N/A Matthew Tait Note 6 Joint Accountable Officer 30-35 75-80 568 522 N/A Dan Brown Acting Chief Finance Officer 0-2.5 5-10 41 16 57 N/A Claire Fuller Acting Chief Officer & Clinical Chair 2.5-5 0-2.5 20-25 45-50 324 40 368 N/A Colin Thompson Managing Director 2.5-5 5-7.5 30-35 80-85 455 97 557 N/A

Note 6- It is not possible to represent the real increase in pension as information in current year is part year only and the calculation returns a negative figure

Cash equivalent transfer values

A cash equivalent transfer value (CETV) is the actuarially assessed capital value of the pension scheme benefits accrued by a member at a particular point in time. The benefits valued are the member’s accrued benefits and any contingent spouse’s (or other allowable beneficiary’s) pension payable from the scheme.

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

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

Real increase in CETV

This reflects the increase in CETV effectively funded by the employer. It does not include the increase in accrued pension due to inflation, contributions paid by the employee (including the value of any benefits transferred from another scheme or arrangement) and uses common market valuation factors for the start and end period.

3.4.6 Compensation on early retirement or for loss of office The CCG has not made any payments for compensation of early retirement or loss of office (paid or receivable).

3.4.7 Payments to past members (directors)

Performance Long-term Expense pay and Performance All pension related Total (a-e) Salary (bands of Payment bonuses pay and benefits (Bands of (Bands of Payment to Past Directors £5,000) (Taxable) to (Bands of bonuses (Bands £2500) £5000) nearest £100 £5,000) of £5,000) Name Position From To £000 £00 £000 £000 £000 £000 Andrew Demetriades Epsom St Hellier Stroke Programme Director Note 8 01/11/2017 31/03/2018 115-120 - - - - 115-120 Dan Brown Deputy Chief Finance Officer 01/11/2017 31/03/2018 40-45 - - - 7.5-10 50-55 Donna Derby Programme Director of Transformation 01/03/2018 31/03/2018 10-15 - - - - 10-15 Senior Responsible Officer for the Surrey Heartlands STP Note 9 01/08/2017 31/03/2018 70-75 5 - - - 70-75 Claire Fuller Coaching Session to Clinical Chair (1 Session per w eek) Note 10 01/08/2017 12/01/2018 5-10 1 - - - 5-10

Note 8- Andrew Demetriades role as Stroke Programme Director is hosted by Surrey Dow ns CCG how ever, 50% of his costs are shared w ith Wandsw orth CCG w ho host the costs for the South West London Sustainability and Transformation Partnership (STP) costs. This is because Epsom and St Helier Hospital is Surrey Dow ns CCGs Main Acute Provider, but the hospital itself falls under the footprint of South West London STP. Note 9- Claire Fuller's role as Senior Responsible Officer for Surrey Heartlands Sustainability and Transformation Partnership is Hosted by Surrey Dow ns CCG, but is then recharged 100% to Guildford and Waverly CCG, as they host the funding of all Sustainability and Transformation Partnership related costs. Note 10- Claire Fuller continued to provide Russell Hills (Clinical Chair) w ith support and coaching equating to 1 session per w eek.

3.4.8 Pay multiples (fair pay disclosure) Reporting bodies are required to disclose the relationship between the remuneration of the highest-paid director/Member in their organisation and the median remuneration of the organisation’s workforce.

The banded remuneration of the highest paid director in NHS Surrey Downs CCG in the financial year 2017/18 was £155,000 to £160,000 for the period between 18/04/17 and 31/10/17 (2016/17, £285,000 to £290,000). Both posts were interim managers and include the cost of unrecoverable VAT. The ratio calculation uses the annualised figure and is shown in the table below. This was 6.9 times (2016/17, 8.1) the median remuneration of the workforce, which was £35,000 to £40,000 (2016/17, £35,000 to £40,000).

2017/18 2016/17 Band of Highest Paid Director's Total Remuneration (annualised) 255-260 285 - 290 Median Total Remuneration of the Staff 37,259 35,674 Ratio 6.91 8.10 In 2017/18, no (2016/17, 0) employees received remuneration in excess of the highest-paid director. Remuneration ranged from £15,000 to £20,000 (2016/17, £15,000 to £20,000) to £170,000 to £175,000 (2016/17 £250,000 to £255,000).

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.

These figures take into account the new shared executive team arrangements across the three CCGs in the Surrey Heartlands footprint (Guildford and Waverley CCG, Surrey Downs CCG and North West Surrey CCG). A Joint Accountable Officer was appointed in June 2017, replacing the role of Chief Officer. In November 2017, a Joint Executive Team was also appointed across the three organisations. The costs for this team are shared across the three partner organisations and each CCG is reporting on its agreed share of the costs.

3.5 Staff Report 3.5.1 Introduction Our staff report provides information relating to our CCG employees. As an organisation, we directly employ 195 members of staff. This includes the Surrey-wide continuing healthcare team (which we host on behalf of the other CCGs and equates to around half of our total CCG workforce) and the medicines management and Individual Funding Request Teams, which we also host on behalf of some other CCGs. This number does not include our Governing Body members, GP Clinical Directors, Clinical leads, locality leads or agency staff, who are not employed staff.

We do work with a number of agency and specialist staff as and when we need them. This gives us more flexibility in how we manage our workforce and it also helps to keep our costs down by only bringing in specialists when we need them for specific projects.

We also buy some additional support services (including IT support) from the South, Central and West NHS Commissioning Support Unit. In many cases these staff are based with us so we engage with them in the same way as we would with directly employed staff.

We continue to promote the development of a capable, competent and skilled workforce that is focussed on delivery, whilst embracing opportunities to develop and progress chosen career pathways. Recruitment has been effective, with a broad range of applications for the posts that we advertise.

The extent to which the composition of the workforce has changed is described in section 3.5.4 and the CCG will use this information to ensure recruitment processes are equitable and non-biased.

To reflect closer working across the three Surrey Heartlands CCGs, during 2017/18 we have undertaken a change programme to align resources and facilitate closer working across functions and organisations.

This report sets out where changes have been made over the last year.

3.5.2 Number of senior managers The CCG currently has 61 senior managers at Band 8a and above. Table 7: Number of senior staff (8a and above by band and by occupational code 2017/18)

Band Occupational Code Band Band Band VSM Band 9 Band 8a Total 8d 8c 8b Senior manager G0A central functions 2 3 1 8 2 1 17 Senior manager G0D clinical support 1 2 3 0 0 0 6 Manager central G1A functions 0 0 0 0 2 11 13 Clerical & G2A administrative central 0 0 0 0 0 0 0 functions N6H Community Nurse 0 0 0 0 1 3 4

S0P Manager pharmacy 0 0 0 0 6 0 6

S2P Scientist pharmacy 0 0 0 0 0 15 15

TOTAL 3 5 4 8 11 30 61

3.5.3 Staff numbers and costs. The total headcount for the CCG as of 31 March 2018 is 195, equating to a Whole Time Equivalent (WTE) of 175.19. Of the 195 staff, 180 are permanent and 15 are on fixed term contracts. The CCG has no other contract types of employment.

As of 31 March 2018, the CCG was engaging 26 Agency Workers, on terms that comply with NHS price caps for agency staff working in the NHS, in terms of time and cost.

The CCG also engages with six additional Governing Body members, 3 Locality Chairs, 8 clinical leads, 3 Lay Members, and 7 bank members of staff. Staff costs are available in Note 4 to the Annual Accounts (section 4.5).

3.5.4 Staff composition 2017/18 When the breakdown of the CCG workforce is compared with the population of Surrey Downs, the CCG is attracting a workforce that is reflective of the local population (drawn from the 2011 census).

The increase in data capture and analysis of it in relation to the composition of our workforce and our local geographical profile is helpful in ensuring the CCG has no inherent bias in its recruitment and selection policy framework. Through planned recruitment, selection and retention training for managers in 2018/19, we will continue to encourage managers to be aware of our responsibilities as an employer under the Equality Act.

Specific data relating to these areas and protected characteristic groups under the Equality Act are summarised below.

Gender The gender profile for year ending 2017/18 is 82% female and 18% male employees. Compared with 2016/17 there has been no change in relation to gender.

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Age In 2017/18 16 – 35 year olds accounted for 27% of the CCG workforce. Currently 49% of the CCG workforce is aged 46 and above, with the age group of 46 – 50 years being the CCG’s highest workforce group by age, totalling 21%.

Sexual orientation For those employees that have disclosed their sexual orientation, 79% have stated that they are heterosexual, which is an increase of 5% since 2016/17. 8% of the CCG’s workforce do not wish to disclose their sexual orientation and 12% remain as undefined. The undefined data has reduced by 6% since 2016/17.

Disability Of the total CCG workforce, 4% of staff have disclosed a disability. This has decreased by 2% since 2016/17. 82% of the workforce has stated that they do not have a disability and the remainder of the workforce have either stated they do not wish to disclose or have not declared this information.

Religion 48% of CCG employees have stated their religion as Christian, 17% of the CCG workforce remains as undefined and 9% do not wish to disclose. 12% of the workforce are atheists. 8% of the CCGs workforce are Hinduism, Islamic, Judaism, Sikhism, Buddhism or Jainism (an increase of 1% in these groups since 2016/17).

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Marriage 58% of CCG employees have stated that they are married, a decrease of 1% from 2016/17. 28% of the CCG workforce are single, with 7% divorced, 2% legally separated, 1% are in a civil partnership and 1% widowed. 4% of the CCG workforce has not disclosed this information.

Ethnicity 75% of employees represent white British, white Irish, white English or white other. Of the remaining staff 8% are Asian, Asian British – Indian and any other Asian background, and 8% are Black Nigerian, Black British – African/Caribbean/any other, 3% are mixed white and black Caribbean or any other mixed background, 1% are Filipino and 8% of the CCG workforce have not disclosed their ethnic origin.

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In accordance with reporting requirements, the number of persons of each sex at the end of the financial year was as follows: Table 8: CCG workforce by gender and role profile 2017/18 Male Female 8 7 On the Governing Body 0 0 Other senior managers who are grade VSM 35 160 Employees of the CCG

3.5.5 Sickness absence data Note 4.3 to the Annual Accounts (section 4.5) details the sickness absence of CCG staff during 2017/18. The Sickness absence estimates are calculated from statistics published by the Health and Social Care Information Centre (HSCIC), using data drawn for January 2016 to December 2016 from the ESR national data warehouse. The figures have been converted to the Cabinet Office measurement base by applying a factor of 225/365 to convert from calendar days to working days lost.

There have been no early retirements or retirements on the basis of ill-health during 2017/18. The CCG has local mechanisms, and a recording process, to monitor sickness absence on a monthly basis to enable the CCG to call to action and support staff; recognising trends and any concerns with staff welfare throughout the year. The actions the CCG has taken to manage staff sickness both short and long-term includes:

 A sickness absence reporting line allows all staff to speak directly to the HR department to report sickness. This allows information to be recorded centrally and reported on to identify trends and issues. This has recorded the loss of 1708 working days in total across the CCG due to sickness. This equates to an average of 2.8% time lost due to sickness absence in the reporting year, based on an average WTE of 166.93. There were 303 periods of sickness absence reported; the average absence duration was 8.39 days. This is monitored against a national NHS reduced rate sickness target of 3.5%.

 A return to work process which all staff must complete, with their managers, when they return to work from a period of sickness. This involves managers undertaking a return to work interview with employees following each period of unplanned absence, regardless of the length of the absence and ideally on the employee’s first day of return to work. This should enable the manager to have a greater understanding of an individual’s health and wellbeing, and assist with identifying adjustments in the workplace that would prevent further absences from occurring. The reporting of absences is well controlled.

 The CCG has a Service Level Agreement (SLA) for Occupational Health Services in place. This service is provided by Epsom and St Helier University Hospitals NHS Trust. As part of this agreement in 2017/18 staff were offered a seasonal flu vaccine to help prevent the spread of flu, particularly for community-based staff and members of our NHS continuing healthcare team who meet with clients and their families and visit hospitals and care homes. Under the SLA with occupational health, CCG staff also have access to self-referrals for occupational health and counselling services. This allows staff to access services for both personal and work related cases which can be take place

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independently.

 The CCG has undergone an organisational change programme over the 2017/18 financial year with alignment of Guildford and Waverley CCG, North West Surrey CCG and Surrey Downs CCG to form the Surrey Heartlands CCGs. Staff were provided with support through the resultant changes with an organisational development programme consisting of a number of workshops including resilience, emotional intelligence, leadership and one to one coaching to achieve the optimum outcomes for staff, teams and the organisation.  We have a Staff Forum, which includes representation from each team and as part of the change programme this year we have also established a Joint Staff Partnership Forum which covers across the three CCGs with representation from the local forums. Staff have also supported us with our communications and engagement with staff in relation to the change programme and closer working across the three CCGs.  Each year we carry out a staff survey to seek the views of our staff on a range of issues, including how they feel about the CCG as a place to work. Once we have analysed the results of our latest survey, we will work with our Staff Forum to develop an action plan to address areas for improvement.

 We have also recently introduced a programme to support wellbeing in the workplace. This has included a new singing group, yoga sessions, badminton groups in the local sports clubs and other social events.

3.5.6 Staff policies All staff policies incorporate our Equality Statement that sets out how its processes and systems support the organisation in being an ‘Equal Opportunities Employer’ as well as being legally compliant.

Throughout the development of the policies and processes cited, we have:  Given due regard to the need to eliminate discrimination, harassment and victimisation, to advance equality of opportunity, and to foster good relations between people who have a shared relevant protected characteristic (as cited under the Equality Act 2010) and those who do not share it;

 Given regard to the need to reduce inequalities between patients in access to, and outcomes from, healthcare services and in securing that services are provided in an integrated way where this might reduce health inequalities.

Members of staff, volunteers or members of the public may request assistance with our policies if they have particular needs and in these cases we will work with these individuals to provide any support or information needed.

During the year we introduced one new policy, which was the Disclosure and Barring Service and Policy Procedure.

We are also working with the other two Surrey Heartlands CCGs to review and align our policies, where there would be benefits in doing so.

Whistleblowing Policy The whistleblowing policy is available to staff and is available on the CCG website at www.surreydownsccg.nhs.uk

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Recruitment and Selection Policy Through the Recruitment and Selection Policy, managers are aware that the CCG gives equal consideration to job applicants and employees who are disabled. Candidates who meet the minimum criteria for the post will be automatically short listed and invited for interview. In addition to recruitment training received, HR offers guidance to managers on a case-by-case basis to ensure a fair and equal selection process, with reasonable adjustments made where indicated. From a total of 649 applications, 4.9% of applicants classed themselves as disabled.

Health and Wellbeing Policy We are committed to supporting our staff and doing all we can to promote health and wellbeing in the workplace and over the past year we have introduced a number of new initiatives that support this, as previously mentioned. This has included a new singing group, on site yoga classes and other sports clubs and events.

The CGG works in partnership with its Occupational Health provider to ensure that any reasonable steps and adjustments in the workplace can be made to support an employee’s health condition. The CCG has proactively manged individual cases to ensure staff feel supported and valued and are retained within the organisation.

3.5.7 Expenditure on consultancy Total spend on Consultancy costs is disclosed in Note 5 to the Annual Accounts (section 4.5). This was £277k in 2017/18 (£391k in 2016/17). These costs related to a number of areas including specialist advice for procurement programmes, HR advice to support our change programme and specialist services relating to service redesign.

All existing off-payroll engagements are detailed in section 3.5.8 and have been subject to a risk-based assessment on whether assurance is required that the individual is paying the right amount of tax. Where this has been required, the appropriate assurances have been sought.

The CCG has not appointed, engaged or terminated any appointment of special advisors during the reporting period.

3.5.8 Off payroll engagements During 2017/18 the CCG has put in place a robust framework of controls to manage off-payroll workers, to ensure compliance with public sector regulations and with Her Majesty’s Revenue and Customs (HMRC) statutory changes, particularly with regards to IR35, effective from April 2017.

The CCG has a process in place to proactively manage off-Payroll engagements, for those where the spend is more than £245 per day and that lasted for more than six months. Tables 9-11 detail the CCG’s activity of engaging off-payroll workers.

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Table 9: Off-payroll engagements as at 31 March 2018, for more than £245 per day and that last longer than six months

Number

Number of existing engagements as of 31 March 2018 21

Of which, the number that have existed:

for less than one year at the time of reporting 7

for between one and two years at the time of reporting 11

for between 2 and 3 years at the time of reporting

for between 3 and 4 years at the time of reporting 1

for 4 or more years at the time of reporting 2

Table 10: New off-payroll engagements between 01 April 2017 and 31 March 2018, for more than £245 per day and that last longer than six months

Number

No. of new engagements, or those that reached six months in duration, between 1 April 44 2017 and 31 March 2018

Of which:

No. assessed as caught by IR35 20

No. assessed as not caught by IR35 24

No. engaged directly (via PSC contracted to department) and are on the departmental 3 payroll No. of engagements reassessed for consistency / assurance purposes during the year. 0

Table 11 - Off- payroll board member/senior official engagements

For all off-payroll engagements of board members, and /or senior officials with significant financial responsibility, between April 2017 and 31 March 2018:

Number of off-payroll engagements of board members, and/or senior officers with 2 significant financial responsibility, during the year.

Number of individuals that have been deemed "board members, and or senior officers with significant responsibility" during the financial year. This figure includes both off- 24 payroll and on-payroll engagements.

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201 6-17 Total Admin Programme Employee benefits and staff numbers

2017- Employee benefits 18 Total Admin Programme

Permanent Permanent Permanent Total Employees Other Total Employees Other Total Employees Other £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 Employee Benefits Salaries and wages 8,806 6,549 2,257 2,804 1,792 1,012 6,002 4,757 1,245 Social security costs 714 714 0 206 206 0 508 508 0 Employer contributions to the NHS Pension Scheme 821 821 0 208 208 0 613 613 0 Apprenticeship Levy 21 21 0 8 8 0 12 12 0 Gross employee benefits expenditure 10,362 8,105 2,257 3,226 2,214 1,012 7,136 5,891 1,245

2016- Employee benefits 17 Total Admin Programme

Permanent Permanent Permanent Total Employees Other Total Employees Other Total Employees Other £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 Employee Benefits Salaries and wages 9,350 5,995 3,355 3,524 1,596 1,928 5,826 4,399 1,427 Social security costs 635 635 0 195 195 0 440 440 0 Employer contributions to the NHS Pension Scheme 738 738 0 209 209 0 529 529 0 Gross employee benefits expenditure 10,723 7,368 3,355 3,929 2,000 1,928 6,795 5,368 1,427

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3.5.9 Exit packages There have been no exit costs during 2017/18 and the CCG has not agreed any early or ill health retirements during the year. The CCG has not issued any redundancy departure costs in 2017/18 and it has not agreed any early retirements in this reporting year.

3.5.10 Recruitment Over the past year the CCG has continued to recruit to its substantive establishment, with all vacancies being advertised through the NHS Jobs website, as standard practice. For the 77 vacancies advertised in 2017/18, we received 43,095 views and subsequently 649 applications. 39 of these vacancies were successfully filled. Training for managers is being planned to equip them further with workforce planning, management of non- employed resources, analysis of recruitment/workforce activity and the recruitment and selection processes during 2018/19. We have also promoted the CCG as an employer at recruitment events and some of our specialist teams (such as the NHS Continuing Healthcare Team), where we are trying to attract more specialist staff with specific clinical skills staff into the workforce.

As part of our recruitment process our recruitment team and the recruiting manager work closely together to identify the most appropriate method of recruitment. For example, where we are advertising lay member roles we would also widely advertise these through our networks and community channels, as well as through social media and our website.

During 2018/19 we aim to provide recruitment opportunities that:  raise awareness, highlight good practice, break down the barriers that both employers and potential employees may face, and create a culture that welcomes people with learning disabilities

 support the opportunities for work experience and employment of people with learning disabilities in the NHS; one of the key priorities in the Five Year Forward View

 attract a diverse range of applicants to the CCG’s recruitment campaigns by advertising on a broader scale than the NHS Jobs website and working in partnership with organisations that support protected characteristic groups into employment.

 make use of initiatives such as ‘Fuller Working Lives: a framework for action’ and ‘Age Positive’.

Diversity dimensions of CCG applicants Gender and ethnicity We continue to attract a balance of applications across genders and ethnicity. From a total of 649 applications, we received 242 (37.29% of total applications received) of applications from men, 404 (62.25% of total applications received) from women and 3 undisclosed.

From the total applications received 71 (32% of total applications received) were of an ethnic minority

108 background, a decrease of 12% since 2016/17.

Age The highest age range for applicants during 2017/18 came from 25 - 29, a total of 105 applications (16.18% of total applications received), The next age-range of most applicants received (being 14.48%) was from 30 – 34 year olds.

Religion Of the 649 applicants, 53%, were of Christian faith, 24.50% of total applications received are from other religions (including Buddhism, Hinduism, Islam, Jainism, Judaism and Sikhism), with 62 of the applicant being atheists and 84 applicants did not disclose.

Sexual Orientation 573 (88.29% of total applications received) applicants were heterosexual, 2.62% being non-heterosexual 9.09% was undisclosed.

3.5.11 Equal opportunities for our workforce We are committed to equal opportunities for all employees and our employment practices, policies and procedures ensure we meet our responsibilities. We firmly believe in equality in the workplace and in protecting our staff from harassment and discrimination and all our employment policies reflect our equality commitment (to ensure that no employee receives less favourable treatment on the protected characteristics of age, disability, gender, gender reassignment, sexual orientation, marriage and civil partnership, race, religion or belief). The CCG also promotes its Whistleblowing Policy and raises awareness, through nationally disseminated campaigns, local training and staff awareness sessions, to ensure staff are informed about the support available to them should they need to raise a matter of concern, and if so, how to do so.

We also believe diversity is something to be celebrated. We recognise everyone is different and equally value the contribution every individual makes to our organisation.

As an organisation, we are committed to tackling discrimination, promoting equality and diversity and protecting human rights. These principles are at the heart of the NHS - they underpin the NHS Constitution and we believe all our staff have a role to play.

We have an Equality and Diversity Strategy, which sets out how we will meet our legal duties in this area and we have also developed an action plan, which summarises the key areas we want to focus on in 2017/18. Our published Annual Equality Report for 2017/18 summarises the progress we made during the year and how we have complied as an Equal Opportunities Employer.

Meeting the needs of any staff, or potential staff, with disabilities and ensuring they are treated equally is part of our duty under the Disability Discrimination Act and this year we have worked with staff to raise awareness about equality issues and the need to consider our protected characteristic groups in how we work, both

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We will continue to ensure that our reporting and governance arrangements embed equality, diversity and human rights throughout the organisation and we will promote the same through our primary care localities development and other partnership working.

For more information about our commitment to equality, diversity and inclusion in the workplace see our Equality Report.

3.5.12 Staff engagement and consultation We know how important it is that our staff know, and understand, ‘the bigger picture’ and what we are trying to achieve together as an organisation, so we do our best to take them with us on the journey. We keep them updated on what’s been happening at our face-to-face Team Brief sessions, which happen every other week. They are led by our Managing Director and include a welcome to any new faces, an update on the business headlines, a project lead talking about their area of work and any other news we want to share. These sessions are informal and are an opportunity for staff to ask questions and share any news they may have with the rest of the organisation. After each Team Brief we circulate an email to all staff with the headlines for anyone who missed it.

Following the appointment of our Joint Accountable Officer, we have also recently launched a new monthly briefing where Matthew Tait updates staff on the latest developments and the work happening across the Surrey Heartlands Health and Care Partnership.

We also engage with our staff and colleagues through:  Regular team meetings – teams have regular meetings to help focus and prioritise workloads. These are also an opportunity for staff to hear about what’s happening in other parts of the CCG.  Staff appraisal processes – as part of our commitment to learning and development every member of staff has a ‘performance setting’ meeting, a mid year review and an end of year review meeting with their manager. This is an opportunity to talk through how staff are doing against their work programme and to discuss their training and development needs.  Through staff surveys – we do a survey every year, which is really helpful in telling us how staff are feeling about their job and working for the CCG. Every year we analyse all the feedback we receive and use it to develop an action plan to address key areas and make improvements for our staff.

 Via our Staff Forum - which meets regularly and is an opportunity for us to engage with a smaller group of staff on a regular basis and to seek their views and input on issues as they arise.

In accordance with legislative rights, we have an Organisational Change Policy which ensures that where staff consultation is required, these processes are inclusive to all staff, with information shared, and views obtained, in a timely manner.

During 2017/18 the CCG has been part of a joint organisation change programme. This has focused on developing closer working arrangements across the three CCGs and aligning staff and functions to support the new Joint Executive Management Team, which operates across the three CCGs. Staff who have been affected by proposed change have been consulted and a Joint Staff Partnership Forum has supported communications and engagement with staff as part of this process.

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3.6 Parliamentary Accountability Audit Report 3.6.1 Introduction NHS Surrey Downs CCG is not required to produce a Parliamentary Accountability and Audit Report. Disclosures on remote contingent liabilities, losses and special payments, gifts, and fees and charges are included as notes in the Financial Statements of this report from page 120. An audit certificate and report is also included in this Annual Report with the financial statements.

Matthew Tait Joint Accountable Officer 25 May 2018

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4. Audit Opinion on CCG’s financial accounts

INDEPENDENT AUDITOR’S REPORT TO THE MEMBERS OF THE GOVERNING BODY OF NHS SURREY DOWNS CLINICAL COMMISSIONING GROUP

REPORT ON THE AUDIT OF THE FINANCIAL STATEMENTS

Opinion

We have audited the financial statements of NHS Surrey Downs Clinical Commissioning Group (“the CCG”) for the year ended 31 March 2018 which comprise the Statement of Comprehensive Net Expenditure, Statement of Financial Position, Statement of Changes in Taxpayers Equity and Statement of Cash Flows, and the related notes, including the accounting policies in note one.

In our opinion the financial statements:

 give a true and fair view of the state of the CCG’s affairs as at 31 March 2018 and of its income and expenditure for the year then ended; and

 have been properly prepared in accordance with the accounting policies directed by the NHS Commissioning Board with the consent of the Secretary of State as being relevant to CCGs in England and included in the Department of Health Group Accounting Manual 2017/18.

Basis for opinion We conducted our audit in accordance with International Standards on Auditing (UK) (“ISAs (UK)”) and applicable law. Our responsibilities are described below. We have fulfilled our ethical responsibilities under, and are independent of the Trust in accordance with, UK ethical requirements including the FRC Ethical Standard. We believe that the audit evidence we have obtained is a sufficient and appropriate basis for our opinion.

Going concern We are required to report to you if we have concluded that the use of the going concern basis of accounting is inappropriate or there is an undisclosed material uncertainty that may cast significant doubt over the use of that basis for a period of at least twelve months from the date of approval of the financial statements. We have nothing to report in these respects.

Other information in the Annual Report The Accountable Officer is responsible for the other information presented in the Annual Report together with the financial statements. Our opinion on the financial statements does not cover the other information and, accordingly, we do not express an audit opinion or, except as explicitly stated below, any form of assurance conclusion thereon.

Our responsibility is to read the other information and, in doing so, consider whether, based on our financial statements audit work, the information therein is materially misstated or inconsistent with the financial statements or our audit knowledge. Based solely on that work we have not identified material misstatements in the other information. In our opinion the other information included in the Annual Report for the financial year is consistent with the financial statements.

Annual Governance Statement We are required to report to you if the Annual Governance Statement does not comply with guidance issued by the NHS Commissioning Board. We have nothing to report in this respect.

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Remuneration and Staff Report In our opinion the parts of the Remuneration and Staff Report subject to audit have been properly prepared in accordance with the Department of Health Group Accounting Manual 2017/18.

Accountable Officer’s responsibilities As explained more fully in the statement set out on page 74, the Accountable Officer is responsible for: the preparation of financial statements that give a true and fair view; such internal control as they determine is necessary to enable the preparation of financial statements that are free from material misstatement, whether due to fraud or error; assessing the CCGs ability to continue as a going concern, disclosing, as applicable, matters related to going concern; and using the going concern basis of accounting unless they have been informed by the relevant national body of the intention to dissolve the CCG without the transfer of its services to another public sector entity.

Auditor’s responsibilities Our objectives are to obtain reasonable assurance about whether the financial statements as a whole are free from material misstatement, whether due to fraud or error, and to issue our opinion in an auditor’s report. Reasonable assurance is a high level of assurance, but does not guarantee that an audit conducted in accordance with ISAs (UK) will always detect a material misstatement when it exists. Misstatements can arise from fraud or error and are considered material if, individually or in aggregate, they could reasonably be expected to influence the economic decisions of users taken on the basis of the financial statements.

A fuller description of our responsibilities is provided on the FRC’s website at www.frc.org.uk/auditorsresponsibilities

REPORT ON OTHER LEGAL AND REGULATORY MATTERS Qualified opinion on regularity

We are required to report on the following matters under Section 25(1) of the Local Audit and Accountability Act 2014. Except for the matters outlined in the basis for qualified opinion on regularity paragraph below, in our opinion, in all material respects, the expenditure and income recorded in the financial statements have been applied to the purposes intended by Parliament and the financial transactions conform to the authorities which govern them.

Basis for qualified opinion on regularity

The CCG reported a deficit of £14.7 million for the year ended 31 March 2018 thereby breaching its duty under the National Health Service Act 2006, as amended by paragraph 223I of Section 27 of the Health and Social Care Act 2012, to break even on its commissioning budget.

Report on the CCG’s arrangements for securing economy, efficiency and effectiveness in its use of resources

Under the Code of Audit Practice we are required to report to you if the CCG has not made proper arrangements for securing economy, efficiency and effectiveness in its use of resources.

Qualified conclusion

Except for the matters outlined in the basis for qualified conclusion paragraph below we are satisfied that in all significant respects NHS Surrey Downs CCG put in place proper arrangements for securing economy, efficiency and effectiveness in the use of resources for the year ended 31 March 2018.

Basis for qualified conclusion The CCG reported a deficit of £14.7 million for the year ended 31 March 2018. The CCG’s cumulative deficit as at 31 March 2018 totalled £48.6 million. The CCG has not yet succeeded in addressing its underlying deficit and is forecasting a further deficit of £7.6 million for 2018/19.

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This evidences challenges in proper arrangements for planning finances effectively to support the sustainable delivery of strategic priorities and maintain statutory functions.

Respective responsibilities in respect of our review of arrangements for securing economy, efficiency and effectiveness in the use of resources As explained more fully in the statement set out on page 74, the Accountable Officer is responsible for ensuring that the CCG exercises its functions effectively, efficiently and economically. We are required under section 21(1)(c) of the Local Audit and Accountability Act 2014 to be satisfied that the CCG has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources. We are not required to consider, nor have we considered, whether all aspects of the CCGs arrangements for securing economy, efficiency and effectiveness in the use of resources are operating effectively. We have undertaken our review in accordance with the Code of Audit Practice, having regard to the specified criterion issued by the Comptroller and Auditor General (C&AG) in November 2017, as to whether the CCG had proper arrangements to ensure it took properly informed decisions and deployed resources to achieve planned and sustainable outcomes for taxpayers and local people. We planned our work in accordance with the Code of Audit Practice and related guidance. Based on our risk assessment, we undertook such work as we considered necessary.

Statutory reporting matters

We are required by Schedule 2 to the Code of Audit Practice issued by the Comptroller and Auditor General (‘the Code of Audit Practice’) to report to you if:

 we refer a matter to the Secretary of State under section 30 of the Local Audit and Accountability Act 2014 because we have reason to believe that the CCG, or an officer of the CCG, is about to make, or has made, a decision which involves or would involve the body incurring unlawful expenditure, or is about to take, or has begun to take a course of action which, if followed to its conclusion, would be unlawful and likely to cause a loss or deficiency; or

 we issue a report in the public interest under section 24 of the Local Audit and Accountability Act 2014; or

 we make a written recommendation to the CCG under section 24 of the Local Audit and Accountability Act 2014.

On 3 May 2018 we referred a matter to the Secretary of State under section 30b of the Act in relation to NHS Surrey Downs Clinical Commissioning Group breaching its revenue resource limit for the year ended 31 March 2018.

We have nothing else to report in these respects.

THE PURPOSE OF OUR AUDIT WORK AND TO WHOM WE OWE OUR RESPONSIBILITIES This report is made solely to the Members of the Governing Body of NHS Surrey Downs CCG, as a body, in accordance with Part 5 of the Local Audit and Accountability Act 2014. Our audit work has been undertaken so that we might state to the Members of the Governing Body of the CCG, as a body, those matters we are required to state to them in an auditor’s report and for no other purpose. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the Members of the Governing Body, as a body, for our audit work, for this report or for the opinions we have formed.

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CERTIFICATE OF COMPLETION OF THE AUDIT We certify that we have completed the audit of the accounts of NHS Surrey Downs CCG in accordance with the requirements of the Local Audit and Accountability Act 2014 and the Code of Audit Practice.

Neil Hewitson 25 May 2018 for and on behalf of KPMG LLP, Statutory Auditor Chartered Accountants 15 Canada Square London E14 5GL

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5. Financial Statements 5.1. Statement of Comprehensive Net Expenditure

Statement of Comprehensive Net Expenditure for the year ended 31 March 2018

2017-18 2016-17 Note £'000 £'000

Income from sale of goods and services 2 (7,708) (8,032) Other operating income 2 (383) (493) Total operating income (8,091) (8,525)

Staff costs 4 10,362 10,723 Purchase of goods and services 5 378,842 362,805 Depreciation and impairment charges 5 35 11 Provision expense 5 79 93 Other Operating Expenditure 5 999 (256) Total operating expenditure 390,317 373,376

Total Net Expenditure for the year 382,226 364,851

Comprehensive Expenditure for the year ended 31 March 2018 382,226 364,851

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5.2 Statement of Financial Position as at 31 March 2018

2017-18 2016-17 Note £'000 £'000 Non -current assets: Property, plant and equipment 8 289 216 Total non-current assets 289 216

Current assets: Trade and other receivables 9 2,754 2,881 Cash and cash equivalents 10 55 50 Total current assets 2,809 2,931

Total current assets 2,809 2,931

Total assets 3,098 3,147

Current liabilities Trade and other payables 11 (45,636) (38,609) Provisions 12 (312) (196) Total current liabilities (45,948) (38,805)

Non -Current Assets plus/less Net Current Assets/Liabilities (42,850) (35,658) Non-current liabilities Provisions 12 (39) (174) Total non-current liabilities (39) (174)

Assets less Liabilities (42,889) (35,832) Financed by Taxpayers’ Equity General fund (42,889) (35,832) Total taxpayers' equity: (42,889) (35,832)

The notes from page 120 form part of this statement. The financial statements from pages 116 were approv ed by the Audit Committee on 25 May 2018 under delegated authority from the Governing Body, with the approval of its membership, and signed by Joint Accountable Officer, Matthew Tait.

Matthew Tait, Accountable Officer 25 May 2018 Karen McDowell, Chief Finance Officer 25 May 2018 117

5.3 Statement of Changes in Taxpayers’ Equity for the year ended 31 March 2018

General Total fund reserves £'000 £'000 Changes in taxpayers’ equity for 2017-18

Balance at 01 April 2017 (35,832) (35,832)

Changes in NHS Clinical Commissioning Group taxpayers’ equity for 2017 -18 Net operating expenditure for the financial year (382,226) (382,226)

Net Recognised NHS Clinical Commissioning Group Expenditure for the Financial Year (382,226) (382,226)

Net funding 375,170 375,170

Balance at 31 March 2018 (7,056) (7,056)

General Total fund reserves £'000 £'000 Changes in taxpayers’ equity for 2016-17

Balance at 01 April 2016 (41,197) (41,197)

Changes in NHS Clinical Commissioning Group taxpayers’ equity for 2016 -17 Net operating costs for the financial year (364,851) (364,851)

Net Recognised NHS Clinical Commissioning Group Expenditure for the Financial Year (364,851) (364,851)

Net funding 370,216 370,216

Balance at 31 March 2017 5,365 5,365

The notes from page 120 form part of this statement

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5.4 Statement of Cash Flows for the year ended 31 March 2018

2017-18 2016-17 Note £'000 £'000 Cash Flows from Operating Activities Net operating expenditure for the financial year (382,226) (364,851) Depreciation and amortisation 5 35 11 (Increase)/decrease in trade & other receivables 9 127 1,174 Increase/(decrease) in trade & other payables 11 7,029 (6,374) Provisions utilised 12 (100) (77) Increase/(decrease) in provisions 12 79 93 Net Cash Inflow (Outflow) from Operating Activities (375,056) (370,024)

Cash Flows from Investing Activities (Payments) for property, plant and equipment (109) (193) Net Cash Inflow (Outflow) from Investing Activities (109) (193)

Net Cash Inflow (Outflow) before Financing (375,165) (370,217)

Cash Flows from Financing Activities Grant in Aid Funding Received 375,170 370,216 Net Cash Inflow (Outflow) from Financing Activities 375,170 370,216

Net Increase (Decrease) in Cash & Cash Equivalents 10 5 (1)

Cash & Cash Equivalents at the Beginning of the Financial Year 50 51

Cash & Cash Equivalents (including bank overdrafts) at the End of the Financial Year 55 50

The notes from page 120 form part of this statement.

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5.5 Notes to the Financial Statements

1 Accounting policies NHS England has directed that the financial statements of clinical commissioning groups shall meet the accounting requirements of the Group Accounting Manual issued by the Department of Health and Social Care. Consequently, the following financial statements have been prepared in accordance with the Group Accounting Manual 2017-18 issued by the Department of Health and Social Care. The accounting policies contained in the Group Accounting Manual follow International Financial Reporting Standards to the extent that they are meaningful and appropriate to clinical commissioning groups, as determined by HM Treasury, which is advised by the Financial Reporting Advisory Board. Where the Group Accounting Manual permits a choice of accounting policy, the accounting policy which is judged to be most appropriate to the particular circumstances of NHS Surrey Downs Clinical Commissioning Group (Surrey Downs CCG or SDCCG) for the purpose of giving a true and fair view has been selected. The particular policies adopted by SDCCG are described below. They have been applied consistently in dealing with items considered material in relation to the accounts.

1.1 Going concern These accounts have been prepared on the going concern basis.

Public sector bodies are assumed to be going concerns where the continuation of the provision of a service in the future is anticipated, as evidenced by inclusion of financial provision for that service in published documents. Whilst SDCCG reported a deficit in 2017/18 and is carrying forward an historic deficit from previous years, the deficit reported since 2015/16 has been in line with NHSE expectations. SDCCG considers the going concern criteria to be met, given it continues to operate in accordance with NHSE guidance and it anticipates continuing to fund service provision throughout 2018/19. SDCCG has submitted detailed financial plans to NHSE for 2018/19, and whilst these plans are pending formal approval, SDCCG has been allocated cash funding from NHSE for 2018/19, and, as such, has adequate financial resource to continue operations in year.

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 Surrey Downs CCG has entered into three pooled budget arrangement under Section 75 of the National Health Service Act 2006. Surrey Downs CCG accounts for its share of the assets, liabilities, income and expenditure arising from the activities of the pooled budget, identified in accordance with the pooled budget agreement. If Surrey Downs CCG is in a “jointly controlled operation”, it recognises: · The assets SDCCG controls; · The liabilities SDCCG incurs; · The expenses SDCCG incurs; and · SDCCG’s share of the income from the pooled budget activities. 120

If Surrey Downs CCG is involved in a “jointly controlled assets” arrangement, in addition to the above, the CCG recognises: · SDCCG’s share of the jointly controlled assets (classified according to the nature of the assets); · SDCCG’s share of any liabilities incurred jointly; and · SDCCG’s share of the expenses jointly incurred. In 2017/18 SDCCG has entered into three pooled budget arrangements in respect of: · Better Care Fund (BCF); · Community Equipment Store (CES); and · Child and Adolescent Mental Health. Further details of each arrangement are contained in Note 17, Pooled Budgets.

1.4 Accounting for Continuing Healthcare (CHC)

Surrey Downs CCG hosts Continuing Healthcare (CHC) on behalf of a collaborative of Surrey CCGs (Guildford and Waverley CCG, North West Surrey CCG, North East Hants and Farnham CCG, Surrey Heath CCG and East Surrey CCG). As host commissioner, SDCCG administers the CHC service on behalf of the other CCGs in the collaborative, and both the costs of administration and the costs of healthcare are split amongst the collaborative members under a 'risk share' arrangement which is documented in the CHC collaborative agreement.

Expenditure on CHC healthcare costs is recorded 'net' in the SDCCG SOCNE statement, that is, SDCCG does not show healthcare provision costs re-allocated to other collaborative members under the risk share agreement as income, nor does it show the associated healthcare cost as expenditure: the two are matched off against each other to give the net cost to SDCCG only. (See Note 21, Continuing Healthcare) Conversely, receivables and payables on SDCCG's SOFP are shown 'gross' i.e. at their value to the collaborative, not just SDCCG. This SOFP presentation is consistent with the principle that SDCCG is the contracting body with the healthcare provider and SDCCG has the legal responsibility for any amount owing and, as such, contractually the receivable or payable belongs in the first instance to SDCCG.

1.5 Critical accounting judgements and key sources of estimation uncertainty

In the application of SDCCG’s accounting policies, management is required to make judgements, estimates and assumptions about the carrying amounts of assets and liabilities that are not readily apparent from other sources. The estimates and associated assumptions are based on historical experience and other factors that are considered to be relevant. Actual results may differ from those estimates and the estimates and underlying assumptions are continually reviewed. Revisions to accounting estimates are recognised in the period in which the estimate is revised if the revision affects only that period or in the period of the revision and future periods if the revision affects both current and future periods.

1.5.1 Critical Judgements in Applying Accounting Policies

The following are the critical judgements, apart from those involving estimations (see below) that management has made in the process of applying SDCCG’s accounting policies that have the most significant effect on the amounts recognised in the financial statements:

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Accruals Various methods are used for calculating different types of accruals. They include: · Trend analysis · Supplier statements · Expert judgment of Senior Managers · Formulaic approach based on historic cost information · Client database information

Provisions A provision is recognised when SDCCG has a legal or constructive obligation as a result of past events and it is probable that an outflow of economic benefits will be required to settle an obligation. In addition to widely used estimation techniques, judgement is required when determining the probable outflow of economic benefits. Any estimates have been made in line with IAS 37: Provisions, Contingent Liabilities and Contingent Assets.

Better Care Fund SDCCG and Surrey County Council (SCC) jointly run a pooled budget under section 75 of the NHS Act 2006 for the Better Care Fund for which SCC is the lead commissioner. The financial statements include gross income and expenditure in relation to this pooled budget (see note 17, Pooled budgets) for further details.

Continuing Healthcare Detailed in note 1.4 above.

Provision for Impairment of Receivables SDCCG provides against non-NHS debt where the debt is older than 3 months. 0% - NHS debt 100% - over 1 year 50% - Over 6 months less than 1 year 25% - Over 3 months and less than 6 months

1.5.2 Key sources of estimation uncertainty The following are the key estimations that management has made in the process of applying SDCCG accounting policies that have the most significant effect on the amounts recognised in the financial statements:

Current assets Included in the receivables balance are a number of prepayments and accrued income. These may inevitably require an element of estimation. Where estimates have been applied, SDCCG has adhered to guidance stipulated in the NHS Group Accounting Manual.

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Current liabilities Payables include a number of NHS and non-NHS accruals which will require an element of judgement. Where applicable, SDCCG adheres to guidance set out in the NHS Group Accounting Manual and relevant financial standards.

Prescribing accrual Prescribing information is sent to SDCCG by the relevant prescribing authorities and is two months behind the current month. Each month including year end, SDCCG has to estimate the year to date expenditure based on the last set of available data. At the year end, SDCCG will be estimating prescribing expenditure based on 10 months data, but with information about profiling and extrapolated trends.

Non-contract activity Non-contract activity, tends, by the nature of the activity, to be invoiced late. SDCCG has made an estimate of the likely uninvoiced value of the NCAs and accrued for them.

Clinical work in progress

This relates to clinical work being carried out by the providers which is in progress at year-end. SDCCG, through discussion with providers, has made a judgement to whether the work in progress should be included in the accounts, based upon materiality. The work in progress is calculated based upon cost of treatment, the number of patients being treated, and the proportion of days in progress against average length of treatment.

1.6 Revenue Revenue in respect of services provided is recognised when, and to the extent that, performance occurs, and is measured at the fair value of the consideration receivable. Where income is received for a specific activity that is to be delivered in the following year, that income is deferred.

1.7 Employee benefits 1.7.1 Short-term employee benefits Salaries, wages and employment-related payments are recognised in the period in which the service is received from employees, including bonuses earned but not yet taken. Where the cost of leave earned but not taken by employees at the end of the period is material it is recognised in the financial statements to the extent that employees are permitted to carry forward leave into the following period.

1.7.2 Retirement benefit costs Past and present employees are covered by the provisions of the NHS Pensions Scheme. The scheme is an unfunded, defined benefit scheme that covers NHS employers, General Practices and other bodies, allowed under the direction of the Secretary of State, in England and Wales. The scheme is not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities. Therefore, the scheme is accounted for as if it were a defined contribution scheme: the cost to SDCCG of participating in the scheme is taken as equal to the contributions payable to the scheme for the accounting period.

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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 SDCCG commits itself to the retirement, regardless of the method of payment.

1.8 Other expenses

Other operating expenses are recognised when, and to the extent that, the goods or services have been received. They are measured at the fair value of the consideration payable.

Expenses and liabilities in respect of grants are recognised when SDCCG has a present legal or constructive obligation, which occurs when all of the conditions attached to the payment have been met.

1.9 Property, plant and equipment

1.9.1 Recognition

Property, plant and equipment is capitalised if:

a) 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 SDCCG; · 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 b) 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 c) 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 Valuation

All property, plant and equipment are measured initially at cost, representing the cost directly attributable to acquiring or constructing the asset and bringing it to the location and condition necessary for it to be capable of operating in the manner intended by management. All assets are measured subsequently at valuation.

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Fixtures and equipment are carried at depreciated historic cost as this is not considered to be materially different from current value in existing use.

1.10 Depreciation, amortisation and impairments Depreciation is charged to write off the costs or valuation of property, plant and equipment, less any residual value, over their estimated useful lives, in a manner that reflects the consumption of economic benefits or service potential of the assets. The estimated useful life of an asset is the period over which SDCCG expects to obtain economic benefits or service potential from the asset. This is specific to SDCCG and may be shorter than the physical life of the asset itself. Estimated useful lives and residual values are reviewed each year end, with the effect of any changes recognised on a prospective basis. At each reporting period end, SDCCG checks whether there is any indication that any of its tangible non-current assets have suffered an impairment loss. If there is indication of an impairment loss, the recoverable amount of the asset is estimated to determine whether there has been a loss and, if so, its amount.

1.11 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.

1.11.1 NHS Surrey Downs CCG (SDCCG) as Lessee 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.

1.12 Cash and 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.

1.13 Provisions

Provisions are recognised when Surrey Downs CCG has a present legal or constructive obligation as a result of a past event, it is probable that SDCCG 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, where material, its carrying amount is the present value of those cash flows using HM Treasury’s discount rate as follows: · Timing of cash flows (0 to 5 years inclusive): Minus 2.42% (previously: minus 2.70%) · Timing of cash flows (6 to 10 years inclusive): Minus 1.85% (previously: minus 1.95%) · Timing of cash flows (over 10 years): Minus 1.56% (previously: minus 0.80%) 125

1.14 Clinical negligence costs

NHS Resolution operates a risk pooling scheme under which SDCCG 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 SDCCG.

1.15 Non-clinical risk pooling

SDCCG participates in the Property Expenses Scheme and the Liabilities to Third Parties Scheme. Both are risk pooling schemes under which SDCCG pays an annual contribution to NHS Resolution and, in return, receives assistance with the costs of claims arising. The annual membership contributions, and any excesses payable in respect of particular claims are charged to operating expenses as and when they become due.

1.16 Continuing healthcare risk pooling

In 2014-15 a risk pool scheme was introduced by NHS England for continuing healthcare claims, for claim periods prior to 31 March 2013. Under the scheme clinical commissioning groups contributed annually to a national pooled fund, which continues to be used to settle the claims. No payment has been made into the pool by SDCCG this year.

1.17 Contingencies A contingent liability is a possible obligation that arises from past events and whose existence will be confirmed only by the occurrence or non- occurrence of one or more uncertain future events not wholly within the control of SDCCG, 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 SDCCG. A contingent asset is disclosed where an inflow of economic benefits is probable.

Where the time value of money is material, contingencies are disclosed at their present value.

1.18 Financial assets Financial assets are recognised when SDCCG becomes party to the financial instrument contract or, in the case of trade receivables, when the goods or services have been delivered. Financial assets are derecognised when the contractual rights have expired or the asset has been transferred. Financial assets are classified into the following categories: · Financial assets at fair value through profit and loss; · Held to maturity investments; · Available for sale financial assets; and · Loans and receivables. 126

The classification depends on the nature and purpose of the financial assets and is determined at the time of initial recognition.

1.18.1 Loans and receivables

Loans and receivables are non-derivative financial assets with fixed or determinable payments which are not quoted in an active market. After initial recognition, they are measured at amortised cost using the effective interest method, less any impairment. Interest is recognised using the effective interest method.

Fair value is determined by reference to quoted market prices where possible, otherwise by valuation techniques. The effective interest rate is the rate that exactly discounts estimated future cash receipts through the expected life of the financial asset, to the initial fair value of the financial asset.

At the end of the reporting period, SDCCG assesses whether any financial assets, other than those held at ‘fair value through profit and loss’ are impaired. Financial assets are impaired and impairment losses recognised if there is objective evidence of impairment as a result of one or more events which occurred after the initial recognition of the asset and which has an impact on the estimated future cash flows of the asset. For financial assets carried at amortised cost, the amount of the impairment loss is measured as the difference between the asset’s carrying amount and the present value of the revised future cash flows discounted at the asset’s original effective interest rate. The loss is recognised in expenditure and the carrying amount of the asset is reduced through a provision for impairment of receivables.

If, in a subsequent period, the amount of the impairment loss decreases and the decrease can be related objectively to an event occurring after the impairment was recognised, the previously recognised impairment loss is reversed through expenditure to the extent that the carrying amount of the receivable at the date of the impairment is reversed does not exceed what the amortised cost would have been had the impairment not been recognised.

1.19 Financial Liabilities

Financial liabilities are recognised on the statement of financial position when SDCCG 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.

1.20 Value Added Tax

Most of the activities of SDCCG 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.

1.21 Losses and 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. 127

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 SDCCG not been bearing its own risks (with insurance premiums then being included as normal revenue expenditure).

1.22 Accounting Standards That Have Been Issued But Have Not Yet Been Adopted

The DHSC Group accounting manual does not require the following Standards and Interpretations to be applied in 2017-18. These standards are still subject to FREM adoption and early adoption is not therefore permitted.

· IFRS 9: Financial Instruments ( application from 1 January 2018) · IFRS 14: Regulatory Deferral Accounts ( not applicable to DH groups bodies) · IFRS 15: Revenue for Contract with Customers (application from 1 January 2018) · IFRS 16: Leases (application from 1 January 2019) · IFRS 17: Insurance Contracts (application from 1 January 2021) · IFRIC 22: Foreign Currency Transactions and Advance Consideration (application from 1 January 2018) · IFRIC 23: Uncertainty over Income Tax Treatments (application from 1 January 2019)

The application of the Standards as revised would not have a material impact on the accounts for 2017-18, were they applied in that year.

2 Other Operating Revenue 2017-18 2017-18 2017-18 2016-17 Total Admin Programme Total

£'000 £'000 £'000 £'000

Education, training and research 62 7 55 40 Non-patient care services to other bodies 7,646 5 7,641 7,992 Other revenue 383 79 304 494 Total other operating revenue 8,091 91 8,000 8,525

Non-patient care services to other bodies includes the hosting charge for Continuing Healthcare, Medicines Management and IFR of £4.5m. It also includes income from Public Health for Health Visitors and School Nursing, £2.6m, and NHS England for Children's immunisations, £0.6m, which is passed on directly to Central Surrey Health, our Community Provider.

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3 Revenue 2017-18 2017-18 2017-18 2016-17 Total Admin Programme Total £'000 £'000 £'000 £'000 From rendering of services 8,091 91 8,000 8,525 Total 8,091 91 8,000 8,525

4. Employee benefits and staff numbers

4.1.1 Employee benefits 2017-18 Total

Permanent Total Employees Other £'000 £'000 £'000 Employee Benefits Salaries and wages 8,806 6,549 2,257 Social security costs 714 714 0 Employer Contributions to NHS Pension scheme 821 821 0 Apprenticeship Levy 21 21 0 Gross employee benefits expenditure 10,362 8,105 2,257

4.1.1 Employee benefits 2016-17 Total

Permanent Total Employees Other £'000 £'000 £'000 Employee Benefits Salaries and wages 9,350 5,995 3,355 Social security costs 635 635 0 Employer Contributions to NHS Pension scheme 738 738 0 Gross employee benefits expenditure 10,723 7,368 3,355

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4.2 Average number of people employed 2017-18 2016 -17 Permanently Total employed Other Total Number Number Number Number

Total 205 170 35 207

Of the above: Number of whole time equivalent people engaged on capital projects 0 0 0 0

4.3 Exit packages agreed in the financial year

There have been no exit packages paid or agreed during 2017/18 or 2016/ 17.

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.

Both are unfunded defined benefit schemes that cover NHS employers, GP practices and other bodies, allowed under the direction of the Secretary of State in England and Wales. They are not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities.

Therefore, each scheme is accounted for as if it were a defined contribution scheme: the cost to the NHS body of participating in each scheme is taken as equal to the contributions payable to that scheme for the accounting period.

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

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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 2018, is based on valuation data as 31 March 2017, updated to 31 March 2018 with summary global member and accounting data. In undertaking this actuarial assessment, the methodology prescribed in IAS 19, relevant FReM interpretations, and the discount rate prescribed by HM Treasury have also been used.

The latest assessment of the liabilities of the scheme is contained in the report of the scheme actuary, which forms part of the annual NHS Pension Scheme Accounts. These accounts can be viewed on the NHS Pensions website and are published annually. Copies can also be obtained from The Stationery Office.

4.4.2 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 2017-18, employers’ contributions of £868,601 (2016-17: £784,535) were payable to the NHS Pension Scheme at the rate of 14.38% (2016-17 14.3%) of pensionable pay. The increase of 0.08% in employer contribution is an administrative levy by NHS Pension Scheme. The scheme’s actuary reviews employer contributions, usually every four years and now based on HMT Valuation Directions, following a full scheme valuation. The latest review used data from 31 March 2012 and was published on the Government website on 9 June 2012. These costs are included in the NHS pension line of note 4.1.1

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5. Operating expenses 2017-18 2017-18 2017-18 2016-17 Total Admin Programme Total £'000 £'000 £'000 £'000 Gross employee benefits Employee benefits excluding governing body members 9,711 2,575 7,136 9,652 Executive governing body members 651 651 0 1,071 Total gross employee benefits 10,362 3,226 7,136 10,723 Other costs Services from other CCGs and NHS England 2,687 1,549 1,138 2,958 Services from foundation trusts 104,379 0 104,379 101,521 Services from other NHS trusts 130,285 0 130,285 124,373 Services from other WGA bodies* 1 0 1 0 Purchase of healthcare from non-NHS bodies 85,736 0 85,736 81,683 Chair and Non Executive Members 455 455 0 494 Supplies and services – clinical 672 0 672 460 Supplies and services – general 588 247 341 275 Consultancy services 277 43 234 391 Establishment 1,223 152 1,071 1,005 Transport 2,718 0 2,718 1,271 Premises 4,683 341 4,342 3,398 Impairments and reversals of receivables 81 59 22 (812) Depreciation 35 35 0 11 Audit fees 55 17 38 65 Prescribing costs 39,948 0 39,948 39,513 General ophthalmic services 1 0 1 0 GPMS/APMS and PCTMS 4,661 0 4,661 4,192 Other professional fees excl. audit 645 19 626 761 Legal fees 31 20 11 44 Research and development (excluding staff costs) 0 0 0 5 Education and training 252 145 107 478 Provisions 79 0 79 93 CHC Risk Pool contributions 0 0 0 418 Other expenditure 463 0 463 56 Total other costs 379,955 3,082 376,873 362,653

Total operating expenses 390,317 6,308 384,009 373,376

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External Audit is provided by KPMG LLP, with the fee for 2017-18 being £46,091 (excluding VAT).

Audit Fees - In accordance with SI 2008 no.489, The Companies (Disclosure of Auditor Remuneration and Liability Limitation Agreements) Regulations 2008, the contract signed on 14 March 2017, states that the liability of KPMG, its members, partners and staff (whether in contract, negligence or otherwise) shall in no circumstances exceed £2m, aside from where the liability cannot be limited by law. This is in aggregate in respect of all services.

*WGA- Whole of Government Accounts

6. Better Payment Practice Code

Measure of compliance 2017-18 2017-18 2016-17 2016-17 Number £'000 Number £'000 Non -NHS Payables Total Non-NHS Trade invoices paid in the Year 21,181 171,960 22,373 178,807 Total Non-NHS Trade Invoices paid within target 20,356 166,427 21,533 168,484 Percentage of Non-NHS Trade invoices paid within target 96.10% 96.78% 96.25% 94.23%

NHS Payables Total NHS Trade Invoices Paid in the Year 3,209 244,419 3,118 235,112 Total NHS Trade Invoices Paid within target 2,792 243,061 2,771 231,478 Percentage of NHS Trade Invoices paid within target 87.01% 99.44% 88.87% 98.45%

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7. Operating Leases

7.1 As lessee

7.1.1 Payments recognised as an Expense 2017-18 2016-17 Buildings Other Total Buildings Other Total £'000 £'000 £'000 £'000 £'000 £'000

Payments recognised as an expense 3,188 Minimum lease payments 3,184 4 2,879 6 2,885 0 Contingent rents 0 0 0 0 0 0 Sub-lease payments 0 0 0 0 0 Total 3,184 4 3,188 2,879 6 2,885

Whilst our arrangements with NHS Property Services Limited fall within the definition of operating leases, rental charge for future years has not yet been agreed . Consequently this note does not include future minimum lease payments for these arrangements. In 2017/18 the CCG signed a 10 year lease for the Cedar Court building which houses NHS Surrey Downs CCG staff so details of future lease payments has been included in note 7.1.2 below

7.1.2 Future minimum lease payments 2017-18 2016-17

Buildings Other Total Buildings Other Total £'000 £'000 £'000 £'000 £'000 £'000

Payable:

No later than one year 217 4 221 - 4 4

Between one and five years 1,085 3 1,088 - 7 7 561 After five years 561 0 - - 0 Total 1,863 7 1,870 0 11 11

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8 Property, plant and equipment

Information Furniture 2017-18 technology & fittings Total £'000 £'000 £'000 Cost or valuation at 01 April 2017 227 0 227

Additions purchased 91 18 109 Cost/Valuation at 31 March 2018 318 18 336

Depreciation 01 April 2017 11 0 11

Charged during the year 35 0 35 Depreciation at 31 March 2018 46 0 46

Net Book Value at 31 March 2018 272 18 290

Purchased 272 18 290 Total at 31 March 2018 272 18 290

Asset financing:

Owned 272 18 290

Total at 31 March 2018 272 18 290

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8.1 Economic lives Minimum Maximum Life Life (years) (Years)

Information technology 3 3 Furniture & fittings 5 5

9 Trade and other receivables Current Non-current Current Non-current 2017-18 2017-18 2016-17 2016-17 £'000 £'000 £'000 £'000

NHS receivables: Revenue 1,196 0 1,228 0 NHS prepayments 586 0 754 0 NHS accrued income 358 0 0 0 Non-NHS and Other WGA* receivables: Revenue 348 0 600 0 Non-NHS and Other WGA* prepayments 348 0 355 0 Provision for the impairment of receivables (183) 0 (117) 0 VAT 95 0 62 0 Other receivables and accruals 6 0 0 0 Total Trade & other receivables 2,754 0 2,881 0

Total current and non current 2,754 2,881

Included above: Prepaid pensions contributions 0 0

* WGA - Whole of Government Accounts

Of the receivables that are neither past due nor impaired of £861k, £849k are with other NHS organisations or Local Government and, as such, do not pose a credit risk. The remaining receivables of £12k have an agreement in place which helps to mitigate risk.

The carrying amount of financial assets that would otherwise be past due or impaired but whose terms have been renegotiated is £7k

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9.1 Receivables past their due date but not impaired 2017-18 2017-18 2016-17 £'000 £'000 £'000 Non DH All DH Group Group receivables Bodies Bodies prior years

By up to three months 371 2 0 By three to six months 50 0 1 By more than six months 1 7 164 Total 422 9 165

£165k of the amount above has subsequently been recovered after 31/03/2018.

9.2 Provision for impairment of receivables 2017-18 2017-18 2016-17 £'000 £'000 £'000 Non DH All DH Group Group receivables Bodies Bodies prior years

Balance at 01 April 2017 (117) 0 (929)

Amounts written off during the year 0 0 0 Amounts recovered during the year 0 15 0 (Increase) decrease in receivables impaired 0 (81) 812 Transfer (to) from other public sector body 117 (117) 0 Balance at 31 March 2018 0 (183) (117)

Non-NHS receivables over one year have been fully impaired although SDCCG is in discussion with the debtor concerning the recharge. 2017-18 2016-17 £'000 £'000 Receivables are provided against at the following rates: NHS debt 0% 0% Over 1 year 100% 100% Over 6 months 50% 50% Over 3 months 25% 25%

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10 Cash and cash equivalents

2017-18 2016-17 £'000 £'000 Balance at 01 April 2017 50 51 Net change in year 5 (1) Balance at 31 March 2018 55 50

Made up of: Cash with the Government Banking Service 53 49 Cash in hand 2 1 Cash and cash equivalents as in statement of financial position 55 50

Balance at 31 March 2018 55 50

Surrey Downs CCG does not hold any money on behalf of patients.

Current Current 11 Trade and other payables 2017-18 2016-17 £'000 £'000

NHS payables: revenue 8,029 5,479 NHS accruals 3,122 4,833 Non-NHS and Other WGA payables: Revenue 11,781 13,553 Non-NHS and Other WGA accruals 15,661 13,503 Social security costs 117 102 Tax 105 85 Other payables and accruals 6,821 1,054 Total Trade & Other Payables 45,636 38,609

Total current and non-current 45,636 38,609

Other payables include £136,280 outstanding pension contributions at 31 March 2018 (£121,267 at 31 March 2017) 138

12 Provisions Current Non-current Current Non-current 2017-18 2017-18 2016-17 2016-17 £'000 £'000 £'000 £'000 Continuing care 312 39 197 174

Total current and non-current 351 371

Continuing Care Total £'000 £'000

Balance at 01 April 2017 371 371

Arising during the year 396 396 Utilised during the year (100) (100) Reversed unused (316) (316) Balance at 31 March 2018 351 351

Expected timing of cash flows: Within one year 312 312 Between one and five years 39 39 After five years 0 0 Balance at 31 March 2018 351 351

Under the accounts direction issued by NHS England on 12th February 2014, NHS England is responsible for accounting for liabilities relating to NHS Continuing Healthcare claims relating to periods of care before the establishment of SDCCG (although the legal liability remains with SDCCG).

The total value of legacy NHS Continuing Healthcare provisions utilised by NHS England on behalf of SDCCG in the year ended 31st March 2018 is £395k (£141k in year ended 31 March 2017).

The provision in the financial statements relates to retrospective periods of care dating from April 2013 onwards for which SDCCG is financially liable.

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13 Contingencies 2017-18 2016-17 £'000 £'000 Contingent liabilities Continuing Healthcare 341 0 Net value of contingent liabilities 341 0

Surrey Downs CCG recognises a contingent liability for Continuing Healthcare claims for previously unassessed periods of care from April 2013 onwards that have not been received or fully quantified yet but are based upon previous claims made over the life of SDCCG.

14 Commitments

14.1 Other financial commitments

The NHS clinical commissioning group has entered into non-cancellable contracts (which are not leases, private finance initiative contracts or other service concession arrangements) which expire as follows: 2017-18 2016-17 £'000 £'000 In not more than one year 0 418 In more than one year but not more than five years 0 0 In more than five years 0 0 Total 0 418

NHS England has established a risk pool arrangement for retrospective claims relating to Continuing Healthcare. This pool is funded by charges to clinical commissioning groups and covers all claims prior to April 2013. SDCCG's contribution in 2016/17 was £418k and no further contribution has been taken.

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15 Financial instruments

15.1 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 SDCCG 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. SDCCG 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 SDCCG in undertaking its activities.

Treasury management operations are carried out by the finance department, within parameters defined formally within SDCCGs standing financial instructions and policies agreed by the Governing Body. Treasury activity is subject to review by SDCCG and internal auditors.

15.1.1 Currency risk SDCCG is principally a domestic organisation with the great majority of transactions, assets and liabilities being in the UK and sterling based. SDCCG has no overseas operations and therefore has low exposure to currency rate fluctuations.

15.1.2 Interest rate risk SDCCG 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. SDCCG therefore has low exposure to interest rate fluctuations.

15.1.3 Credit risk Because the majority of SDCCGs revenue comes through parliamentary funding, it 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.

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15.1.4 Liquidity risk SDCCG is required to operate within revenue and capital resource limits, which are financed from resources voted annually by Parliament. SDCCG draws down cash to cover expenditure, as the need arises. SDCCG is not, therefore, exposed to significant liquidity risks.

15 Financial instruments cont'd

15.2 Financial assets

Loans and Receivables Total 2017-18 2017-18 £'000 £'000

Receivables: · NHS 1,554 1,554 · Non-NHS 348 348 Cash at bank and in hand 55 55 Other financial assets 6 6 Total at 31 March 2018 1,963 1,963

Loans and Receivables Total 2016-17 2016-17 £'000 £'000

Receivables: · NHS 1,228 1,228 · Non-NHS 600 600 Cash at bank and in hand 50 50 Total at 31 March 2017 1,878 1,878

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15.3 Financial liabilities

Other Total 2017-18 2017-18 £'000 £'000

Payables: · NHS 11,152 11,152 · Non-NHS 34,263 34,263 Total at 31 March 2018 45,416 45,416

Other Total 2016-17 2016-17 £'000 £'000

Payables: · NHS 10,312 10,312 · Non-NHS 28,110 28,110 Total at 31 March 2017 38,422 38,422

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16 Operating segments

Gross Net Income Total assets Total liabilities Net assets expenditure expenditure £'000 £'000 £'000 £'000 £'000 £'000 Purchase of Healthcare 390,318 (8,091) 382,227 3,099 (45,988) (42,889) Total 390,318 (8,091) 382,227 3,099 (45,988) (42,889)

17 Pooled budgets

S urrey Downs CCG is a party to three pooled budgets - Better Care Fund (BCF), Community Equipment Store (CES) and Child and Adolescent Mental Health (CAMHS)

BCF 2017-18 2016-17 £'000 £'000 Income 16,775 16,400 Expenditure (16,393) (16,422)

CES 2017-18 2016-17 £'000 £'000 Income 454 454 Expenditure (454) (454)

CAMHS 2017-18 2016-17 £'000 £'000 Income 422 426 Expenditure (419) (424)

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Better Care Fund (BCF) NHS Surrey Downs CCG and Surrey County Council (SCC) jointly run a pooled budget under section 75 of the NHS Act 2006 for the Better Care Fund for which SCC is the lead commissioner. SDCCG contributed £16.7m to the pooled budget in 2017/18. £4.7m of the £16.7m was retained by the CCG to fund Out of Hospital Services and a further £2.0m was returned to the CCG for investment in joint Health and Social Care initiatives where the contract was held by SDCCG. The balance of £10.0m included £6.2m which was used by SCC for protection of Adult Social Care services. The pooled budget underspend was £382k.

Surrey Downs CCG joint initiatives underspent by £65k Surrey County Council joint investments underspent by £318k

£144k of the underspend will be carried forward to support two schemes and the remaining underspend is shared equally between Surrey Downs CCG and Surrey County Council. The financial statements include gross income and expenditure in relation to this pooled budget.

Community Equipment Store (CES) The six Surrey Clinical Commissioning Groups: North West Surrey CCG Surrey Downs CCG Guildford and Waverley CCG East Surrey CCG Surrey Heath CCG North East Hampshire and Farnham CCG (Farnham only) collectively purchase equipment from a pooled budget under section 75 of the National Health Service Act 2006 jointly run by three Surrey community providers and Surrey County Council. The legal parties to the pooled budgets are all six CCGs and Surrey County Council and all Surrey Clinical Commissioning Groups make their payments into the pooled budget. In these financial statements we have recognised Surrey Down's expenditure to the pooled budget only.

Child and Adolescent Mental Health (CAMHS) The Child and Adolescent Mental Health Services Pooled Budget is hosted on behalf of the Surrey Clinical Commissioning Groups by NHS Guildford and Waverley Clinical Commissioning Group. The legal parties to the pooled budget are the same six CCGs shown in the CES pooled budget above and Surrey County Council. In these financial statements we have recognised Surrey Downs expenditure to the pooled budget only.

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18 Related party transactions

The related parties listed below include those entities where SDCCG considers the transactions to be material to the CCG. Member GP practice transactions are deemed to be material regardless of the value involved. 2017-18 2016-17

Governing Body Receipts Amounts Amounts Payments Receipts Amounts Amounts Organisation member/ Senior Payments from owed to due from to from owed to due from

Manager to Related Related Related Related Related Related Related Related Party Party Party Party Party Party Party Party £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Ashlea Medical Practice 367 92 452 69 Ashley Centre Surgery Dr Andrew Sharpe 91 24 160 59 Brockwood Medical Practice 629 48 720 35 Capelfield Surgery 90 16 115 38 Cobham Health Centre 89 23 122 17 Derby Medical Centre 163 25 172 32 Dorking Medical Practice 424 39 436 31 Eastwick Park Medical Practice 156 19 159 24 Esher Green Surgery 82 25 69 11 Fairfield Medical Centre 159 25 164 28 Fountain Practice 96 24 101 25 Glenlyn Medical Centre 580 56 529 67 Heathcote Medical Centre 161 27 155 29 Integrated Care Partnership Dr Russell Hills 1,088 329 1,120 176 Lantern Surgery Dr Hannah Graham 54 35 50 27 Leith Hill Practice Dr Louise Keene 948 25 994 16 Littleton Surgery 38 24 42 5 Longcroft Clinic Dr Claire Fuller 229 29 232 29 Medwyn Surgery 204 65 152 30 Molebridge Practice 160 44 110 14 Nork Clinic 87 13 79 16 Oxshott Medical Practice 55 9 72 22 Riverbank Surgery 178 2 164 2 Shadbolt Park House Surgery 93 20 123 67 Spring Street Surgery 59 7 70 11 St Stephens House Surgery 82 16 71 9 146

Stoneleigh Surgery 29 5 28 9 Tadworth Medical Centre 131 26 119 23 Tattenham Health Centre 79 19 66 11 Thorkhill Surgery 62 13 43 2 Vine Medical Centre 54 7 45 6

Details of related party transactions with other organisations with which members of the governing body have an interest are as follows:

2017-18 2016-17

Governing Body Receipts Amounts Amounts Payments Receipts Amounts Amounts Organisation member/ Senior Payments from owed to due from to from owed to due from

Manager to Related Related Related Related Related Related Related Related Party Party Party Party Party Party Party Party

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Care UK Elena Cochrane 1,781 203

Competex Umbrella Ltd Andrew Demetriades 144

Dorking Healthcare Ltd Dr Louise Keene 6,658 0 332 7,819 224

Epsomedical Ltd Dr Russell Hills 6,541 805 6,575 216 GP Health Partners Ltd Dr Russell Hills Dr Andrew Sharpe Dr Claire Fuller 1,631 805 196 0 Honeywood House Nursing Home Dr Louise Keene 94 10 172

JLD Associates Ltd Andrew Demetriades 113 26

Princess Alice Hospice Jonathan Perkins 1,515 49 1,241 0

Surrey Medical Network Ltd Dr Hannah Graham 857 352 777 20

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The terms and conditions of these transactions are consistent with transactions with non-related parties. Provision is made for debt where Surrey Downs CCG considers it prudent to do so.

The Department of Health and Social care (DHSC) is also regarded as a related party. During the year Surrey Downs CCG has entered into transactions with a number of entities for which the DHSC is regarded as the parent. Those entities listed below have material transactions with Surrey Downs CCG.

Ashford and St Peters Hospitals NHS Foundation Trust Epsom and St Helier University Hospital NHS Trust Guys and St Thomas' NHS Foundation Trust Kingston Hospital NHS Foundation Trust Moorfields Eye Hospital NHS Foundation Trust NHS NEL CSU NHS Property Services Royal Surrey County Hopsital NHS Foundation Trust South East Coast Ambulance Service NHS Foundation Trust St Georges University Hospital s NHS Foundation Trust Surrey and Borders Partnership NHS Foundation Trust Surrey and Sussex Healthcare NHS Trust The Royal Marsden NHS Foundation Trust University College London Hospitals NHS Foundation Trust Surrey County Council

19 Events after the end of the reporting period

There were no events after the reporting period that require disclosure

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20 Financial performance targets

S urrey Downs CCG have a number of financial duties under the NHS Act 2006 (as amended). Surrey Downs CCG performance against those duties was as follows:

2017-18 2017-18 2017-18 2017-18 Target Performance Variance Duty achieved N43A N43B £'000

Expenditure not to exceed income 375,570 390,318 (14,748) No Capital resource use does not exceed the amount specified in Directions 109 109 0 Yes Revenue resource use does not exceed the amount specified in Directions 367,479 382,227 (14,748) No Capital resource use on specified matter(s) does not exceed the amount specified in Directions 109 109 0 Yes Revenue resource use on specified matter(s) does not exceed the amount specified in Directions 0 0 0 Yes Revenue administration resource use does not exceed the amount specified in Directions 6,441 6,218 223 Yes

As a result of an amended calculation methodology from NHS England, the 2017/18 in year revenue allocation has been calculated on the basis of the total allocation, adjusted for the historic financial outturn of the CCG. In 2016/17 the figure was recorded as just the total in year allocation notified to the CCG.

2016-17 2016-17 2016-17 2016-17 Target Performance Variance Duty achieved N43C N43D £'000

Expenditure not to exceed income 339,522 373,376 (33,854) No Capital resource use does not exceed the amount specified in Directions 193 193 0 Yes Revenue resource use does not exceed the amount specified in Directions 330,997 364,851 (33,854) No Capital resource use on specified matter(s) does not exceed the amount specified in Directions 193 193 0 Yes Revenue resource use on specified matter(s) does not exceed the amount specified in Directions 0 0 0 Yes Revenue administration resource use does not exceed the amount specified in Directions 6,410 6,409 1 Yes

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21 Continuing Healthcare

Details of the revenue and expenditure relating to Surrey CCGs collaborative

2017-18 2016-17 £000s £000s Surrey CCGs collaborative

Total Revenue (75,963) (73,400)

Total Expenditure 100,741 97,134

2017-18 2016-17 £000s £000s Surrey Downs CCG only

Revenue included on Note 2 (3,472) (3,446)

Expenditure included on Note 5 28,250 27,180

See Note 1.4 for further details of the policies for Continuing Healthcare accounting.

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Losses and special payments

22 Losses

The total number of NHS clinical commissioning group losses and special payments cases, and their total value, was as follows:

Total Total Total Number of Value of Number of Total Value Cases Cases Cases of Cases 2017-18 2017-18 2016-17 2016-17 Number £'000 Number £'000 Administrative write-offs 8 81 83 (811)

Total 8 81 83 (811)

Special payments Total Total Total Number of Value of Number of Total Value Cases Cases Cases of Cases 2017-18 2017-18 2016-17 2016-17 Number £'000 Number £'000 Extra contractual payments 1 328 0 0 Total 1 328 0 0

In 2016 Guildford and Waverley CCG ran a procurement process for the Surrey Children’s Community Health Service on behalf of itself, 5 other CCGs, NHS England (together the “NHS Commissioners”) and Surrey County Council.

The procurement process was challenged and, following legal advice and a mediation process, the parties involved agreed on an out of court settlement and a total payment of £1.565 million has been made in 2017-18 on behalf of all of NHS commissioners. As an organisation NHS Surrey Downs CCG paid £328k of the settlement sum.

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Matthew Tait Joint Accountable Officer 25 May 2018

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If you have any comments about this report we would very much like to hear from you.

You can call us on 01372 201500, email us at [email protected], send an SMS message to 07747 476511 or you can write to us:

Communications team NHS Surrey Downs Clinical Commissioning Group Cedar Court Guildford Road Leatherhead Surrey KT22 9AE

To find out more about Surrey Downs CCG see our website www.surreydownsccg.nhs.uk

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