NHS Waltham Forest CCG Annual Report 2017-18

NHS Waltham Forest

Clinical Commissioning Group

Annual Report

2017/18

Contents FOREWORD ...... 7 PERFORMANCE REPORT ...... 9 Performance Overview ...... 11 Performance analysis ...... 13 The performance management framework ...... 13 CCG Improvement and Assessment Framework...... 14 Urgent and emergency care (UEC) ...... 18 Discharge efficiency ...... 20 Mental Health services ...... 21 Maternity Services ...... 23 Children and Young People Services ...... 27 Learning Disability ...... 29 Cancer services ...... 31 Long Term Conditions (LTCs) ...... 32 Medicines Optimisation – Prescribing ...... 34 End of life care ...... 36 Personal Health Budgets (PHBs) ...... 38 Continuing Health Care (CHC) ...... 39 Planned care...... 40 Primary Care...... 41 Sustainable Development ...... 44 Improve quality ...... 48 Friends and Family Test (FFT) – Whipps Cross Hospital A&E ...... 49 Pressure ulcers at Whipps Cross Hospital (Grade 3 and 4) A pressure ulcer is a localised injury to the skin and/or underlying tissue usually over a bony prominence and range in severity from patches of discoloured skin to open wounds that expose the underlying bone or muscle...... 50 Emergency preparedness, response and resilience (EPRR) ...... 51

Patient Experience ...... 51 Friends and Family Test (FFT) – Whipps Cross Hospital ...... 51 Quality incentives CQUIN ...... 52 Care Quality Commission (CQC) Inspections ...... 54 GP Alert System ...... 57 Infection Prevention and Control...... 57 Safeguarding ...... 57 Child Protection Information Sharing Project ...... 58 PREVENT ...... 58 Learning Disabilities Mortality Review (LeDeR) Programme ...... 59 Engaging people and communities ...... 60 CCG Communications and Patient and Public Participation Team .... 62 Patient Reference Group ...... 63 Development of PPG local standard ...... 68 Patient and Public Participation (PPP) quarterly newsletter ...... 70 Patient and Public Participation quarterly events ...... 70 Development of Waltham Forest Children and Young People’s participation toolkit ...... 72 Increasing the uptake of cervical screening Waltham Forest ...... 73 Participation in developing Mental Health Services ...... 75 Engaging on prescribed medication ...... 76 Stay Well This Winter ...... 77 GP out-of-hours home visiting service review ...... 78 NHS 111 procurement ...... 78 Patient and public engagement in Maternity Services ...... 79 Patient and public engagement during the mobilisation of a new Community and Domiciliary Phlebotomy Service for Waltham Forest 81 Reducing health inequality ...... 83 Health and wellbeing strategy ...... 86 ACCOUNTABILITY REPORT ...... 88 Corporate Governance Report ...... 90 Members report ...... 94 Member practices ...... 94 Audit Committee ...... 100

CCG Patient Reference Group ...... 102 Medicines Optimisation Committee ...... 103 IT committee ...... 105 Locality Commissioning Committees ...... 107 Planning and Innovation Committee ...... 109 Finance and Quality, Innovation, Productivity and Prevention (QIPP) committee ...... 111 Performance and Quality committee ...... 112 Remuneration and staffing committee ...... 114 Primary Care Commissioning Committee ...... 116 Statement of Accountable Officer’s Responsibilities ...... 120 Governance Statement ...... 122 Head of Internal Audit Opinion ...... 142 Review of the effectiveness of governance, risk management and internal control 147 Remuneration and Staff Report ...... 149 Remuneration report ...... 149 Staff Report ...... 157 Parliamentary Accountability and Audit Report ...... 165 ANNUAL ACCOUNTS ...... 168 Independent Auditor’s Report to the Members of the Governing Body of NHS Waltham Forest Clinical Commissioning Group ...... 170 Accounts ...... 175

FOREWORD

Welcome to the NHS Waltham Forest Clinical Commissioning Group (CCG) annual report 2017/18.

As you may agree as you read through the following pages, it’s been quite a year for the borough as a whole in terms of health and care.

Waltham Forest’s Managed Network of Care and Support was cited as a good example, of organisations working together to reduce hospital admissions and length of stay in hospital, in Health and Social Care Secretary Jeremy Hunt’s speech We Need To Do Better On Social Care.

Baroness Julia Cumberlege, Chair of the National Maternity Better Births Review, praised the work of the team delivering the CCG’s continuity of care pilot, which forms part of Waltham Forest’s Maternity Choice and Personalisation Pioneer work with neighbouring Newham and Tower Hamlets CCGs, and the wider East London Local Maternity Services Transformation Programme.

In cancer services there was national recognition for the CCG’s focus on increasing the uptake of cervical screening, with the charity Jo’s Trust awarding the CCG the highest possible rating for undertaking comprehensive work.

Mental health service transformation over 2017/18 has seen the introduction of a single point of access for all mental health services in the borough, with the CCG's Associate Director for Strategic Commissioning leading an integrated approach to commissioning mental health services.

We have also introduced health care tools to empower people to manage their own conditions better. One example is an online patient education platform for people diagnosed with Type 2 Diabetes. Unfortunately we didn’t see as many people referred to use it as we would have liked this year, so over the next year we’ll be working to encourage more people to use it.

With the seven CCGs in north east London coming together under the leadership of a single accountable officer in 2017/18, we are looking forward to working even

closer with colleagues in neighbouring CCGs to share best practice and work together to improve healthcare for residents.

Locally in Waltham Forest, we are going to be building on our joint Better Care Together work with the Council (London Borough of Waltham Forest) and our main health care providers Barts Health NHS Trust, which manages Whipps Cross Hospital, and NELFT, which delivers the borough’s community and mental health services, to develop three integrated care systems for:

• Care ‘closer to home’ (community-based services) • Integrated urgent care • End of life and palliative care.

Last but by no means least, we’d like to mention the development of the Patient Participation Group (PPG) Local Standard in Waltham Forest and congratulate those PPGs that have already received their certificates.

As a CCG we are committed to involving residents in the design, development and review of services, and alongside the CCG’s Patient Reference Group, see our GP practices’ PPGs as key to ensuring we involve local people as we work to commission the health and care services they need. We look forward to working with you over the year ahead.

PERFORMANCE REPORT

Performance Overview

NHS Waltham Forest Clinical Commissioning Group (CCG) exceeded 59 per cent (16) of its 27 local CCG performance targets in 2017/18, and saw improvement in all but four indicators.

Highlights from the year include:

• a continued reduction in emergency admissions for high risk patients at Whipps Cross Hospital • fewer people remaining in hospital longer than necessary • introduction of a single point of access for all mental health services • Secretary of State mention for Waltham Forest approach to integrated care • more maternity choices and more home births • national charity acknowledgement of work to increase cervical cancer screening rates • GP practices doubling the number of patients who can now book appointments, order repeat prescriptions, and view their summary care records online • Improvement in patient choice through introduction of online diabetes structured education course • Improved patient satisfaction, with a year-on-year increase in the number of patients who said they were extremely likely or likely to recommend their GP practice to others.

Throughout 2017/18, NHS Waltham Forest CCG has been working with the London Borough of Waltham Forest (the Council), to develop a new strategic integrated commissioning function to join-up services and provide better person-centred care in the borough.

This builds on the work of the borough-wide Better Care Together programme, a partnership between the Council (London Borough of Waltham Forest) and healthcare providers Barts Health NHS Trust and NELFT.

The Better Care Together programme is also the foundation upon which the borough is building its integrated care system covering:

• Care ‘closer to home’ (community-based services) • Integrated urgent care • End of life and palliative care.

An analysis of NHS Waltham Forest CCG’s performance against its own CCG scorecard and the Improvement and Assessment Framework (IAF) follows in the Performance Analysis section of this report.

Against the IAF Leadership indicators the CCG is fully compliant in terms of Probity and Corporate Governance (Indicator 162a and has green ratings for both Quality of Leadership (Indicator 165a) and Assessing CCG Compliance with statutory guidance standards of public and patient participation in commissioning health care (Indicator 166a). The CCG is in the interquartile range nationally for both Staff Index Engagement (Indicator 163a) and Effectiveness of Working Relationships in the Local System (Indicator 164a). For indicator 163b Progress against Workforce Race Equality Standard, as of 2016, the variation between BME and other responses received in the NHS staff survey is 0.17, ranking the CCG 183rd out of 207 CCGs, placing the CCG in the bottom quartile when compared nationally.

In 2017/18 the seven CCGs in north east London came under the leadership of a single accountable officer. Each CCG retains its own Governing Body and the majority of decision- making still takes place at a local level. However, the seven CCGs will work collaboratively as the NEL Commissioning Alliance where it is in the best interests of patients to do so. It is expected that the seven CCGs will work together to:

• commission services jointly – e.g. London Ambulance Service and integrated urgent care, specialist commissioning • align commissioning strategies (e.g. urgent and emergency care, mental health, planned care) • provide assurance to our regulators

A good example of this is the work on NHS 111, which led to the first joint commissioning contract to be awarded by the seven CCGs. This will see our GPs, nurses, paramedics and pharmacists giving clinical and treatment advice over the phone. They can also book appointments for people with the most appropriate NHS service when they need them. The service aims to improve our urgent and emergency care services across north east London, providing a better service to local people when they need it most.

As part of this, we have developed a new NEL Joint Commissioning Committee (JCC). This will discuss items common to all CCGs – for example, how the CCGs make sure that its urgent care works in a similar way or their contracting with hospitals. For a limited number of

areas, it will also take decisions on services that are commissioned once for NEL. The JCC will start meeting formally, in public, in May 2018.

Performance analysis

The performance management framework The CCG measures and monitors performance against a range of national and local key performance indicators (KPIs) that measure the quality of services offered to local people.

The CCG reports on performance against the KPIs to the Governing Body through regular performance reports to provide assurance of good performance and, where required, of actions being taken to address areas where the required standards are not being achieved.

Where risk to the delivery of high quality services is assessed to be high, these risks are included on the CCG Board Assurance Framework. The reports received by the Governing Body include the quality report, the finance and activity report and the contract report.

Each provider of healthcare commissioned by the CCG operates under a contract agreement which includes details of the KPIs and quality standards to be delivered. These agreements are linked to the objectives of the CCG set out each year in its operating plan and include the national and local priorities and KPIs.

Each contract is managed through monthly or quarterly strategic performance reviews (SPR), which receive information on the performance of the provider on the delivery of the KPIs.

The KPIs are drawn from a range of frameworks including those contained within the CCG Improvement and Assurance Framework.

NHS Waltham Forest CCG’s scorecard figures for 2017/18 show that:

• 52% (14) indicators achieved/exceeded their targets • 85% (23) demonstrated improvement from the baseline position • 15% (4) indicators did not make recorded improvement in 17/18.

The full scorecard and analysis is available below (p16).

CCG Improvement and Assessment Framework The NHS revised Improvement and Assessment Framework (IAF) covers indicators located in four domains:

• Better health: this section looks at how the CCG is contributing towards improving the health and wellbeing of its population, and bending the demand curve • Better care: this principally focuses on care redesign, performance of constitutional standards, and outcomes, including in important clinical areas • Sustainability: this section looks at how the CCG is remaining in financial balance, and is securing good value for patients and the public from the money it spends • Leadership: this domain assesses the quality of the CCG’s leadership, the quality of its plans, how the CCG works with its partners, and the governance arrangements that the CCG has in place to ensure it acts with probity, for example in managing conflicts of interest.

The Forward View and the planning guidance set out national ambitions for transformation in a number of vital clinical priorities such as mental health, dementia, learning disabilities, cancer, maternity and diabetes. NHSE will rate these clinical areas on a four point ‘Ofsted-style’ scale. They form part of the ‘Better Health’ and ‘Better Care’ element as illustrated below.

CCG Improvement and Assessment Framework The CCG reviews Improvement and Assessment Framework (IAF) performance quarterly, in line with the release of updates to the IAF dashboard provided by NHS England. Each quarter

key performance indicators that are in the lower quartile are identified, and raised with the relevant commissioning leads to review, so that processes can be put in place to improve performance. Similarly, indicators in the upper quartiles are identified to share good practice amongst commissioners. Based on the Quarter 3 2017/18 release of the IAF dashboard, for those indicators where national comparisons are available:

Better Health Out of the nine available benchmarked indicators – the CCG is rated as follows:

• Top quartile – two indicators • Middle quartile – four indicators • Lower quartile – five indicators.

Better Care

Out of the 28 available benchmarked indicators – the CCG is rated as follows:

• Top quartile – 10 indicators • Middle quartile – eight indicators • Lower quartile – 10 indicators.

Sustainability

Out of the one available benchmarked indicator – the CCG is rated as follows:

• Top quartile – 0 indicators • Middle quartile – one indicator • Lower quartile – 0 indicators.

Leadership

Out of the three available benchmarked indicators – the CCG is rated as follows:

• Top quartile – 0 indicators • Middle quartile – two indicators • Lower quartile – one indicator.

The IAF is publicly available, ratings and performance for each of the indicators can be accessed online via the My NHS website: www.nhs.uk/mynhs

Urgent and emergency care (UEC)

Fewer people waiting four hours in A&E

The performance of Whipps Cross Hospital on the four-hour A&E target improved by two per cent in 2017/18, in contrast to the national trend. Performance for 2017/18 was 84.8 per cent compared to 82.7 per cent in 2016/17. The improved performance meant that 1,727 fewer patients waited more than four hours to be treated and discharged in 2017/18.

Emergency admissions fall

Emergency admissions to hospital for the top 20 per cent of people at the highest risk of admission have continued to drop in Waltham Forest.

As of March 2018, this had reduced to 4753 in the current year, compared with 5087 in the previous year. This represents a reduction of seven per cent, slightly below the CCG’s aim to reduce these by 10 per cent.

Contributing to this reduction is on-going work with a number of the borough’s nursing homes, which have seen a reduction in emergency admissions from the homes to the hospital of seven per cent, from 196 for 2016/17 to 183 for 2017/18. The CCG’s Medicines Optimisation Team has been actively involved in reviewing medication for vulnerable patients in care homes who were at high risk of a hospital admission, translating in to improved outcomes for patients, avoidance of unnecessary hospital admissions, a reduction in inappropriate polypharmacy (patients taking a number of medicines at the same time) and in an overall improvement in medicines management processes in the homes.

More people treated at Urgent Care Centre

Alongside the reduction in admissions, more people who arrive at the A&E department at Whipps Cross Hospital are being seen at the Urgent Care Centre (UCC) on the site. Whipps Cross' UCC reported a growth in activity of 16.9 per cent, with a decrease in emergency activity.

Contributing factors include:

• dedicated paediatric specialist support • increased senior advanced nurse practitioner and emergency care practitioner presence at the UCC

The development a whole system Emergency Care Improvement Plan, involving all of the providers, has supported a small reduction in emergency department attendances. This collaboration between urgent care providers has supported development of new pathways. The low risk Deep Vein Thrombosis (DVT) pathway has resulted in over 60 per cent of suspected DVT cases seen and treated in the Urgent Care Centre rather than attending the Emergency Department.

The CCG also funded extra winter support in urgent care to support Whipps Cross Hospital meeting its targets. Support included:

• additional streamers directing patients to the right care between core hours • an elderly care consultant in place at weekends in Whipps Cross • additional capacity in the UCC to meet the increase in demand.

Related Improvement and Assessment Framework (IAF) indicators

127b Emergency admissions for urgent care sensitive conditions

Measures the number of emergency admissions per 100,000 of the population in a rolling 12-month period for urgent care sensitive conditions, for example Chronic Obstructive Pulmonary Disease (COPD), Falls, Deep Vein Thrombosis (DVT), Urinary Tract Infections (UTI). As of September 2017, there were 2171 emergency admissions per 100,000 of the population for Waltham Forest patients.

127c Percentage of patients admitted, transferred or discharged from A&E within 4 hours

During Q4 2017/18, 85.8 per cent of Waltham Forest CCG patients attending A&E departments were received required care inside four-hour waiting times.

Discharge efficiency Delayed Transfer of Care (DTOC)

Delayed Transfers of Care (DTOC) continue to be managed. The daily average percentage of beds used by patients who could be discharged at Whipps Cross Hospital stood at 3.07 per cent against a target of 2.50 per cent. While the hospital has suffered as a result of a longer winter, months in the year where there was an improvement correlate with periods of intense support from NHS Waltham Forest CCG’s Quality team.

Medically optimised patients

The daily average number of medically optimised patients at Whipps Cross Hospital; those where their health condition is controlled as well as possible and they could potentially receive treatment elsewhere, saw a very slight improvement during the year. These successes can in part by be attributed to Waltham Forest’s approach to integrated care, through the Managed Network of Care and Support, which in March 2018 was recognised in Health and Social Care Secretary Jeremy Hunt’s speech We Need To Do Better On Social Care. The speech outlined the seven key principles that will guide the Government's thinking ahead of the social care green paper, to be published later in 2018. 2018/19 will see a review of the Integrated Discharge Team in order to deliver more consistent improvements next year.

Related Improvement and Assessment Framework (IAF) indicators

127e Delayed transfers of care per 100,000 population As of February 2018 there were an average of 4.2 delayed days per day per the population (age 18+). The CCG is in the best performing quartile nationally for this metric (21st out of 207 CCGs).

127f Population use of hospital beds following emergency admission As of Q2 2017/18 there was a total length of stay (in days) for all emergency admissions per 1000 patients of 564.6 days. Waltham Forest is ranked 173rd out of 207 CCGs nationally for this indicator placing it in the bottom quartile.

Mental Health services A single point of access for all mental health services is now in place in Waltham Forest. This was introduced in October 2017 as part of borough-wide transformation work.

As part of the transformation, the CCG's Associate Director for Strategic Commissioning is leading an integrated approach to commissioning mental health services. As lead commissioner, the CCG acts as the main contact for NELFT, which delivers the services, and liaise with the council as partners in social care.

Under the new approach there will be one integrated budget for all joint funded cases .Social workers will seek approval from one panel, rather than the previous two, and support should be accessed earlier as a result.

Funding received through the Improved Better Care Fund (iBCF) has seen improvements made to employment support, supported accommodation services for mental health service users, and the commissioning of Recovery College – an education service for service users, their families and carers and staff to gain more information and knowledge of their condition and self-help available.

Crisis care improvement

There have also been improvements to crisis care through two successful bids for NHSE funding to meet Core24 criteria for 24/7 services for psychiatric liaison, and imbed winter resilience initiatives, providing additional staff for street triage (crisis support for the emergency services) and MH Direct, the 24-hour helpline.

Dementia Services

Joint work has begun in 2017/18 to improve dementia services in the borough. An initial training summit has resulted in agreement to roll out introductory training for all social care staff at the Council (London Borough of Waltham Forest).

More people accessing psychological therapies

Mental Health services performance during the year shows that the overall number of people with anxiety and depression accessing psychological therapies increased during 2017/18, up to 4700 people, with the CCG achieving the nationally increased access rate target in Q4 2017/18

The percentage of people with anxiety and depression accessing IAPT (Increasing Access to Psychological Therapies) services was 15.3 per cent in the prior year, and is currently forecast to be 15.72 per cent.

Recovery rates though have decreased year-on-year but remain slightly above the national target of 50 per cent. People successfully completing a course of treatment and classed as ‘in recovery’ is 52.5 per cent, based on latest available local data. The percentage of people who receive Early Intervention in Psychosis treatment improved greatly during the year. In 2017/18, the percentage of people experiencing their first episode of psychosis and being treated within two weeks was 92 per cent, which compares to 70 per cent last year.

Related Improvement and Assessment Framework (IAF) indicators

123a Improving Access to Psychological Therapies (IAPT) – recovery

As of December 2017, 48.7 per cent of patients completing IAPT treatment were classed as being in recovery. The CCG ranks 147th out of 207 CCGs, putting the CCG in the middle quartile. However local data for Q4 2017/18 suggests performance for the year will be 52.5 per cent, putting the CCG above the required 50 per cent national target.

123b Improving Access to Psychological Therapies (IAPT) - access

During Q3 2017/18, 3.9 per cent of the estimated number of people with anxiety and depression entered IAPT treatment. The CCG is ranked 112th out of 207 CCGs, placing the CCG in the middle quartile. Local data shows that performance improved during Q4 2017/18 with the CCG set to achieve its target of 4.2 per cent during Q4 2017/18.

123c People with first episode of psychosis starting treatment with a NICE- recommended package of care treated within two weeks of referral

As of February 2018, 93.2 per cent of people experiencing their first episode of psychosis received treatment inside the two-week treatment target window. The CCG is ranked 14th out of 207 CCGs, placing the CCG in the best performing quartile when compared nationally.

Maternity Services Whipps Cross Maternity Services, provided by Barts Health NHS Trust, were awarded a “Good” rating by the Care Quality Commission in 2017/18, recognising the significant work and dedication by staff to improve the service and experience for local women. Further improvements will follow as 2017/18 also saw Barts charity award Whipps Cross Hospital £6.8million in charity funding to transform women and neonatal services.

The redesign of the Home Birth Team at Whipps Cross, along with the work of the CCG’s continuity of care pilot with Neighbourhood Midwives, has resulted in the successful increase of the number of home births in Waltham Forest to 2.5 per cent of all births (circa 5000).

Neighbourhood Midwives are commissioned under the CCG’s continuity of care pilot, which was launched in November 2016 providing an opportunity to test a different model of care. Working in a small team, Neighbourhood Midwives are able to provide complete midwifery care to low risk women living in Waltham Forest. Since starting work in the borough in November 2016, the team of midwives has supported more than 100 babies to be born.

The pilot is testing the quality outcomes, service user experience and financial viability during the pilot phase. Initial patient feedback and clinical outcomes have been positive, however the implementation of the pilot has not been without barriers. One of the significant challenges is using the national maternity tariff which is designed for NHS acute hospitals which support 5000 births. For a smaller service, the maternity tariff is a challenge and is one of the tests of the pilot. At the service’s first birthday celebrations at Vestry House Museum in Walthamstow Village, Baroness Julia Cumberlege, Chair of the National Maternity Better Births Review, part of the NHS Five Year Forward View, praised the success of the team, saying the success came as no surprise as continuity of care makes for better births. Victoria Frederick and her baby son Hendrix at the first birthday celebration of Neighbourhood Midwives

Maternity Choice and Personalisation Pioneers The continuity of care pilot with Neighbourhood Midwives, forms part of Waltham Forest’s joint Maternity Choice and Personalisation Pioneer work with neighbouring Newham and Tower Hamlets CCGs.

As one of seven areas selected nationwide, local health organisations in east London have been working with NHS England to develop and test new approaches for improving maternity care, and promote their national adoption.

East London Local Maternity Services (ELLMS) Transformation Programme

The Maternity Choice and Personalisation Pioneer work falls within the East London Local Maternity Services Transformation Programme, which covers the East London Health and Care Partnership and North East London Commissioning Alliance geographical footprints.

In February 2016, the National Maternity Review ‘Better Births’ set out the Five Year Forward View for NHS maternity services in England, with the aim for services to become safer and more personal and kind. In response, NHS England established a Maternity Transformation Board (MTB) to oversee the delivery of the policy and recommendations.

The MTB recognised that delivery of its vision relies on local leadership and action, and asked the system to come together to form Local Maternity Systems (LMS) to achieve this.

Within the North East London Sector, the East London Local Maternity System (ELLMS) was established with governance arrangements aligned to the East London Health and Care Partnership.

ELLMS has developed a detailed plan for the next five years to focus on how the system will coherently deliver recommendations of Better Births, both individually and collaboratively, whilst recognising that implementation will require significant transformation from providers of maternity services.

Supporting choice

Under the wider East London Local Maternity System Transformation Programme, an east London information booklet that will assist women with their choice of place of birth has been developed. The booklet titled Your Pregnancy, Your Choice Support for Choosing Your Place of Birth in East London will support notional Personal Maternity Care Budget discussions with women, to ensure they are fully informed when making decisions on where to have their baby.

Personal Maternity Care Budgets Local targets for providing 65 notional Personal Maternity Care Budgets by end of March 2018 have been exceeded.

Single Point of Access A third aspect of the Pioneer work is the development of a single point of access for maternity with pan-London work to develop the maternity website pages of MyhealthLondon (www.myhealth.london.nhs.uk/maternity) as an information hub for maternity services.

Transforming Services Together – Maternity Prior to being selected as Maternity Choice and Personalisation Pioneers, Waltham Forest CCG had already joined forces with Tower Hamlets and Newham CCGs, and Barts Health NHS Trust, under the Transforming Services Together (TST) programme.

TST is looking to invest more than £100 million in new health services and buildings over the next five years across the three boroughs and the TST Maternity workstream is focussing on increasing the number of midwife-led births. Particular to Waltham Forest is the roll-out of outpatient induction of labour pathway for women with diet-controlled diabetes at Royal London Hospital and Whipps Cross Hospital, expanding choice for place of birth for this cohort of women.

Related Improvement and Assessment Framework (IAF) indicators

125d Maternal smoking at delivery

As of Q3 2017/18 only 6.6 per cent of pregnant women were recorded as smoking at time of delivery. The CCG ranks 42 out of 207 CCGs. Placing the CCG in the highest performing quartile when compared nationally.

125a Neonatal mortality and stillbirths

As of 2015 there were 6.6 still births or deaths within 28 days of birth per 1000 births. The CCG is ranked 178th out of 207 CCGs nationally on this metric, placing the CCG in the bottom quartile when compared nationally.

125b Women’s experience of maternity services

As of 2017 Waltham Forest patients ranked their experience of maternity services as an average score of 79.2 out of a possible 100. The CCG ranks 178th out of 207 CCGs, placing the CCG in the bottom quartile when compared nationally.

125c Choices in maternity services

As of 2017, patients ranked their choices of maternity services as an average score of 63.4 out of a possible 100. The CCG ranks 50th out of 207 CCGs on the metric, placing the CCG in the highest performing quartile when compared nationally.

Children and Young People Services

Children’s dietetics waiting times

More than 95 per cent of children referred to the dietetics service were seen within two weeks in urgent cases and 18 weeks in non-urgent cases. Performance has improved over the year and reached 100 per cent in February. There was a small dip in performance in the last month of the year. Full year performance was 93 per cent 17/18, which was an improvement from 79 per cent in 16/17.

Improving Asthma Care

Improving asthma care for young people across north east London (NEL) is a priority and the CCG is working with the NEL Asthma Strategy Group to help develop consistent messaging and care planning for children and young people with asthma. Plans have been developed to improve support to schools so they are better able to manage young people with asthma in school.

Children and Adolescent Mental Health Services (CAMHS)

The borough’s transformation plan for improving local CAMHS services was refreshed in November 2017.

NELFT, the main provider raised capacity issues, which have led to longer waits for referral to treatments, and internal waits for evidenced-based treatments. Waits for specialist assessments also increased.

A mitigation plan is place and a business case under consideration to increase CAMHS funding to improve the Five Year Forward View requirements for 2018/19.

Mental Health and Youth Justice

During 2017/18 Waltham Forest CCG received £73K of additional funding for the provision of mental health care in the Youth Justice system.

Outreach and liaison services are being commissioned, along with a training programme for the Council’s Youth Offending Team staff, which will be supervised by a mental health clinician.

Special Educational Needs and Disabilities Significant progress has been made on delivering the SEND Reforms, post the Ofsted and CQC joint Inspection. A new Designated Clinical Officer (DCO) role has been funded with senior Designated Medical Officer sessions increased. This has enabled increased strategic oversight and quality assuring of the health input into Education, Health and Care (EHC) plans. The DCO also has a role in addressing parent or carer concerns regarding EHC plans and ensuring coordination of care and signposting. A senior-Board, jointly chaired by the CCG and Waltham Forest Local Authority, also helps ensure strong partnership working, progress and oversight of the SEND agenda.

Transition into Adult Services

The CCG has been working with partners to ensure good transition planning for young people who will be moving onto adult health services. This includes attendance at the Preparing for Adulthood panel to ensure robust health input into planning, the development of a CCG transition policy that sets out expectations for all services working with young people commissioned by the CCG and, with the Local Authority, delivery of multidisciplinary training to professionals in education, health and social care.

Related Improvement and Assessment Framework (IAF) indicators

102a: Percentage of children aged 10-11 classified as overweight or obese

As of 2015/16 37.9 per cent of children aged 10 and 11 were classified as overweight or obese, the CCG is ranked 175th out of 207 CCG, placing the CCG in the bottom quartile when compared nationally.

Learning Disability

There are about 4,500 people with learning disabilities in Waltham Forest, and at any one time about 750 people receive a specialist service.

Waltham Forest CCG wants to increase the number of people over 14 years old with learning disabilities, who are taking up an annual health check. In 2016- 2017 of those people on the register, 52.4 per cent had their annual health checks.

The latest data available is for February at 46 per cent, which is an improvement from the position in February 2017.

Five-year plan for services for adults with learning disabilities

2017/18 also saw the CCG and the Council (London Borough of Waltham Forest) develop a five-year plan for services for adults with learning disabilities living in the borough. The plan focusses on eight substantive areas:

• The Care Act • Accommodation • Health • Having an active life • Preparing for adulthood • Family carers • Friendships and socializing • Workforce development.

It sets out the priorities for health and social care for adults with learning disabilities in Waltham Forest and how they will be achieved over the next five years. It was developed through conversations with people who use services, advocates, providers and carers.

Transforming Care

Waltham Forest CCG is working with three other local boroughs (Tower Hamlets, City & Hackney and Newham) and NHS England to reduce the numbers of people admitted to Assessment and Treatment Units and to make sure that when people are admitted, they leave hospital as soon as possible. Locally we continue to work with positive behaviour approaches that aim to support parents and carers to have strategies and tactics to enable them to continue caring for their sons and daughters at home.

Related Improvement and Assessment Framework (IAF) indicators

124a Reliance on specialist inpatient care for people with a learning disability and/or autism

As of Q3 2017/18 there were an average of 29 inpatients with a learning disability and/or autism, the CCG is ranked 4th out of 207 CCGs, placing the CCG in the highest performing quartile when compared nationally.

124b Proportion of people with a learning disability on the GP register receiving an annual health check

As of 2016/17 43 per cent of LD patients were recorded as receiving the annual LD health check, the CCG is ranked 143rd out of 207 CCGs, placing the CCG in the middle quartile when compared nationally.

Cancer services For cancer services, the CCG’s focus remains that of prevention, and early diagnosis and treatment. In 2017/18, 95 per cent of patients referred urgently by their GP saw a consultant within two weeks and if required, 85 per cent received treatment within 62 days. Cervical screening rates amongst women aged 25 to 64 increased slightly and the CCG’s on-going public engagement work to improve this further received national recognition from Jo’s Cervical Cancer Trust. Waltham Forest CCG achieved the highest possible score for ‘undertaking comprehensive and sustained work to increase cervical screening’ in the Cervical Screening in the Spotlight, One Year On report.

Summer 2017 also saw the CCG receive national recognition for improved cancer survival rates in the borough. For the second year in a row the CCG was given an All Party Parliamentary Group on Cancer (APPGC) award. Seventy per cent of people are surviving cancer a year after diagnosis in Waltham Forest, the highest one-year survival rate the borough has had. As a comparison, in 2004, the one-year survival rate for people diagnosed with cancer was just 57 per cent. However, despite the all-time high, it’s still the case that fewer people are surviving cancer a year after diagnosis than the national average, with the national one-year survival rate being 72 per cent.

Related Improvement and Assessment Framework (IAF) indicators

122a Cancers diagnosed at early stage - As of 2016 56.7 per cent of cancers were diagnosed at early stages, the CCG is ranked 18th out of 207 CCGs, placing the CCG in the highest performing quartile when compared nationally.

122b People with urgent GP referral having first definitive treatment for cancer within 62 days of referral - As of Q3 2017/18, 87.5 per cent of all patients with an urgent cancer referral received first treatment within 62 days, the CCG is ranked 38th out of 207 CCGs, placing the CCG in the top quartile when compared nationally.

122c One-year survival from all cancers - As of 2015, 70.4 per cent of patients diagnosed with cancer in year are still alive 12 months after diagnosis, the CCG is ranked 168th out of 207 CCGs, placing the CCG in the bottom quartile when compared nationally.

122d Cancer patient experience - As of 2016, cancer patients scored the cancer services they received as 8.6 out of a possible 10, the CCG is ranked 174th out of 207 CCGs, placing the CCG in the bottom quartile when compared nationally.

Long Term Conditions (LTCs) In the diagnosis and management of long term conditions, more patients with Chronic Obstructive Pulmonary Disease ([COPD] lung diseases had their diagnosis confirmed through the use of bronchodilator spirometry breathing tests.

However the CCG faces challenges with too few diabetes patients referred to structured education courses that would help them manage their condition, and too many patients with kidney problems being referred for an initial renal outpatient appointments at Whipps Cross Hospital Nephrology department.

Chronic Obstructive Pulmonary Disease (COPD)

NHS Waltham Forest CCG exceeded its target for the number of people newly diagnosed with COPD receiving post bronchodilator spirometry test though, with 75.9 per cent receiving of patients having the test against a target of 74.62 per cent.

The success in this area can be attributed to the Medicines Optimisation Committee (MOC) taking a lead on the management of respiratory disease on the behalf of the CCG, improving the uptake of the essential diagnostic test.

Diabetes

The NHS Diabetes Prevention Programme (NDPP) was established in Waltham Forest in January 2017, since which time more than 600 eligible patients have been referred to the programme, exceeding the initial local referral aspiration of 200 patients.

Work continues to try to improve the conversion of referrals to programme attendance, as well as to try to increase the number of GP practices that are actively referring.

The North East London NDPP partnership is now being expanded to include the whole East London Health and Care Partnership/North East London Commissioning Alliance footprint, and work will continue to share learning and best practice across the partnership.

NHS Waltham Forest CCG commissioned online XPERT Type 2 diabetes patient education from Changing Health as part of an early adopter pilot. This modular digital programme also includes 100 minutes of telephone coaching. To date only 204 patients have been referred to the programme, missing the aspiration of 500. Work will continue in 2018/19 to reach 500 referrals and maximise those patients starting on the programme once referred. An evaluation is also planned to understand more about the demographics of the patients who use the online programme.

Renal

The CCG has not met its target for reducing the number of Waltham Forest residents attending a first outpatient appointment at Barts nephrology department. An average of 33 patients a month are still being referred to the department by the borough’s GPs, when the CCG had been aiming to reduce this to an average of 21 month. This will be a focus of work with the CCG’s member practices going forward in 2018/19.

Related Improvement and Assessment Framework (IAF) indicators

103a Diabetes patients that have achieved all the NICE-recommended treatment targets: Three (HbA1c, cholesterol and blood pressure) for adults and one (HbA1c) for children

As of 2016/17, 38.7 per cent of diabetic patients have received all three of the NICE- recommended treatment targets, the CCG is ranked 137th out of 207 CCGs, placing the CCG in the middle quartile when compared nationally.

103b People with diabetes diagnosed less than a year who attend a structured education course

As of 2016/17, 2.7 per cent of newly diagnosed diabetes patients attended a diabetes structured education course. The CCG is ranked 148th out of 207 CCGs, placing the CCG in the middle quartile when compared nationally.

Medicines Optimisation – Prescribing The Medicines Optimisation Committee and CCG Medicines Optimisation Team have proven crucial in ensuring there is a consistent approach to commissioning of medicines within and across different care pathways in Waltham Forest.

Reducing Trimethoprim The team implemented and actively encouraged evidence-based prescribing in line with the North East London (NEL) management of Infection Guidance for Primary Care. The continued effort has seen an improvement in prescribing of antibiotics in general and led to a reduction in the inappropriate prescribing of trimethoprim, with the CCG meeting the National Antibiotic Quality Premium on reducing the Trimethoprim: Nitrofurantoin prescribing ratio by 10 per cent or more.

Outpatient Parenteral Antimicrobial Therapy (OPAT) service redesign 2017/18 has also seen a service redesign for Outpatient Parenteral Antimicrobial Therapy (OPAT) with the aim of improving the quality of life for the patient. The service has allowed patients to obtain care closer to home, reduced their length of stay in hospital and provided an alternative pathway to access intravenous antibiotics.

Medicines Waste In July 2017, the CCG’s Medicines Optimisation team launched a Tackling Medicines Waste in Waltham Forest campaign to empower patients, prescribers and pharmacists to work collaboratively to address the issue head on, and identify solutions in prescribing to benefit the local economy as a whole. More information can be found in the Engagement section of this report. Also in the engagement section are summaries of the CCG’s support of this year’s national NHS England consultations on routinely prescribed and over the counter medicines, which both had a direct impact on prescribing.

Discharge to Pharmacy The significant financial and operation challenges in relation to medicines, has helped to conceive the discharge to pharmacy project – an innovative integrated solution to address the wide-scale problems associated with the use of medicines.

Waltham Forest CCG Medicines Optimisation Team is leading this project on the behalf of the East London Health and Care Partnership to ensure large scale implementation of this

programme enabling truly-integrated working across the organisations and helping to deliver seamless patient care.

Related Improvement and Assessment Framework (IAF) indicators

107a Antimicrobial resistance: appropriate prescribing of antibiotics in primary care

As of December 2017 there were 0.877 antibiotics prescribed per patient, the CCG is ranked 31st out of 207 CCGs, placing the CCG in the highest quartile when compared nationally.

107b Antimicrobial resistance: appropriate prescribing of broad spectrum antibiotics in primary care

As of December 2017, 11.5 per cent of all antibiotics prescribed were broad spectrum antibiotics, the CCG is ranked, the CCG is ranked 193rd out of 207 CCGs, placing the CCG in the lowest quartile when compared nationally.

End of life care Waltham Forest has the highest percentage of deaths in hospital in England. Community support is currently insufficient to allow patients to die at home, with a lack of specialist care overnight and at the weekend, when patients are most likely to deteriorate, meaning the only option is often hospital.

Waltham Forest CCG’s strategic aim is to increase the number of people who die in their preferred place and by enhancing community support and improving discharge from hospital. Whilst the CCG has seen a small reduction in the percentage of deaths in hospital, it remains the highest in the country when it knows that many people wish to die at home.

Integrated Care

End of Life Care is one of three programmes of work in the local health and care economy’s journey towards an integrated care system.

This system aims to integrate provision across all care settings (primary, urgent/acute, community, local authority and voluntary sector). The ambition is to enhance the service currently provided by the community nursing service and integrate it with the specialist palliative care service to provide compassionate care in a familiar supportive setting.

Palliative Care Register

A focus on identifying patients who are approaching the end of life means that more than 600 people are now registered on the palliative care register in Waltham Forest. This is an increase of nearly 35 per cent in the last year, and includes new patients who have been added throughout the year as patients die.

The target for patients added from the year end position in 2016/17 of 490 was 535 and this was exceeded in September 2017, following focused work with GP practices. As of March 2018 of year, 661 residents were registered on the palliative care register, which is a 35 per cent improvement from the baseline.

Whilst people with cancer still represent at least 50 per cent of those on the register, the remainder are people with a variety of long term conditions such as dementia, COPD and Chronic Heart Disease (CHD). This year, some GPs have been using severe frailty as a determinant of people approaching the end of their life, which ensures planning for their care is improved.

GPs have started to create records for those on the register that can be shared with NHS 11 and the London Ambulance Service (LAS), as well as our community nurses. They are using

Coordinate My Care (CMC), and of the first 10 records added in December, three were viewed by London Ambulance Service (LAS) resulting in them being aware of the patient’s wishes. As CMC is rolled out throughout Waltham Forest, we will see fewer people taken to hospital when they wish to remain at home at the end of their lives.

Related Improvement and Assessment Framework (IAF) indicators

The proposed measure within IAF related to end of life care is: 105C Percentage of deaths with three or more emergency admissions in last three months of life

As of Q3 2017/18 there is no data that has been published for this indicator. Data is due to be released in the Q4 2017/18 release of the Improvement and Assessment Framework.

Personal Health Budgets (PHBs) In August 2017, Waltham Forest was recognised for having the second highest uptake of Personal Health Budgets (PHBs) in London in 2016/17.

However in 2017/18 the number of people in receipt of personal health budgets has dropped to 55 people. This is due to challenges around the pathway which arose late in the financial year. People have received a PHB to enable them to access tailored services to support improved health outcomes and manage their health care needs themselves in a flexible and person centred approach.

In Waltham Forest Personal Health Budgets have been allocated to support/enable:

• adults in receipt of NHS Continuing Healthcare funding better manage their care support packages by commissioning and employing support staff themselves • families of children receiving care packages from the CCG to commission and employ the support staff required to support their children • women with Tokophobia and/or anxiety of giving birth but are pregnant.

Related Improvement and Assessment Framework (IAF) indicators

105b Personal health budgets

As of Q3 2017/18 there were 17.68 personal health budgets in place per 100,000 of the registered population. The CCG is ranked 85th out of 207 CCGs, placing the CCG in the middle quartile when compared nationally.

Continuing Health Care (CHC) The CCG has not met its target for CHC assessments within 28 days but has made improvements in performance in 17/18 due to better working between NELFT and the Council (London Borough of Waltham Forest), and performance in Q3 and Q4 was the highest in north east London.

Waltham Forest CCG received a green rating during Q3 2017/18 for the NHS-mandated key deliverables for CHC by 31 March 2018, those key deliverables being:

• 85% of all assessments for CHC should take place outside of an acute setting • assessment should be completed within 28 days of referral • and of those assessments that are not completed within 28 days, zero should breach by 12 weeks or more.

To address the issues and improve performance, the CCG has invested in increased community nursing capacity and additional social work support. This is in place from April 2018.

Related Improvement and Assessment Framework (IAF) indicators

131a Percentage of NHS Continuing Healthcare full assessments taking place in an acute hospital setting

As of Q3 2017/18 38.8 per cent of CHC assessments were completed in an acute setting. The CCG is ranked 166th out of 207 CCGs, placing the CCG in the bottom quartile when compared nationally on this indicator.

Planned care Electronic Referral System (eRS) – hospital outpatients

Local performance was above the London-level for GPs using the e-referral booking system. In March 2018 more than 53 per cent of Waltham Forest appointments were booked on eRS, five per cent about the London average of 47 per cent.

However the CCG has not reached its 80 per cent target for the percentage of hospital outpatient referral by GPs via eRS.

Joint plans are in place with Barts Health NHS Trust and the neighbouring CCGs of Newham and Tower Hamlets, through the Transforming Services Together programme, to increase the usage further in 2018/19 to meet national deadlines for the switching off of paper systems. Where some of the demand will be shifted through Advice and Guidance, Referral Assessment Service and capacity alert functionality available through eRSAs the CCG prepares for a paper switch off, the new target is for all two-week waits and Outpatients referrals to be made via eRS by 1 October 2018.

New community and domiciliary phlebotomy service

Developments in planned care include the commissioning of a new community phlebotomy service, delivered by NELFT, in November 2017. The service now includes a facility for patients to pre-book their appointments online or be allocated a specific time on arrival at the clinic, and has introduced an afternoon clinic at St James Health Centre in Walthamstow. This investment has improved the experience for patients in a service which historically had long wait times, with 97 per cent of all patients now seen within 30 minutes of their arrival or booked appointment time.

The new service has also invested in increased domiciliary capacity, with home visits now available Monday-Friday rather than just one day per week. In March 2018, 79 per cent of home visit requests were seen within one week, and 21 per cent were seen within a day.

Re-commissioned community anticoagulation service

Also in 2017/18, the CCG re-commissioned its community anticoagulation service for patients receiving warfarin therapy. The new service, delivered by Waltham Forest GP Federated Network, is currently (May 2018) in the mobilisation phase, and when it is fully launched will offer more options to patients on where to be seen for their warfarin checks.

Primary Care Personal Medical Services (PMS) and General Medical Services (GMS) review

The Personal Medical Services (PMS) and General Medical Services (GMS) review, which centred on the principle of equalising the primary care offer to patients supported by equal remuneration, has been led by the CCG since late 2016. Extensive and detailed negotiation has been undertaken through a group which consisted of GMS, PMS and LMC representation. As part of the review, a set of primary care indicators were developed which aimed to improve patients’ access to and experience of general practice. The negotiation process concluded in August 2017 after agreement on the indicators and overall offer was reached with the negotiation group. Subsequently first offer letters to PMS practices were issued and the final offer followed on 2 December 2017.

The equalisation process resulted in a number of PMS practices having an overall reduction in their income, however some PMS and all GMS practices benefitted from an increase. For those PMS practices most significantly impacted, transitional support payments have been offered to facilitate a more gradual transition to the agreed £ per patient.

GMS practices were invited to participate in the primary care access scheme in August 2017 with preparatory payment available from July 1 2017. The aim is that by 2020 transition will be complete and there will be equity between GMS and PMS with practices able to earn in the region of £104.14 per weighted patient, of which it is anticipated approximately £11.18 per weighted patient per annum will be associated with the delivery of schemes over and above the ‘core’ contract.

The new arrangements were effective from 1 January 2018, and all 22 PMS practices have now signed the new agreement and have agreed to participate in the primary care access scheme. 15/19 GMS practices signed up to the primary care access scheme in August but this has now increased to 17. The remaining two practices have been followed up to understand reasons for their decision and to offer support if necessary.

Formal measurement of practices’ achievement against the indicators started in March 2018 although informal feedback was provided in the meantime to ensure practices were in a good position to achieve against their aspiration.

GP Online

There has been a steady increase in the number of people setting themselves up to be able view their patient records, order prescriptions and book GP appointments online and the CCG has met its 20 per cent target.

This means that 19.8 per cent of the 310,538 people registered with a GP in Waltham Forest can access these services online, freeing up phone lines for patients who do not have online access.

The achievement is reflective of acknowledging the need to assist practices on the ground as the uptake figures increased significantly after practices were provided with tailored support and training, workshops and sign up sessions.

Despite in six months of the year, the CCG exceeding its 85 per cent target of people saying, via completing the friends and family test questionnaire at their GP practice, they would recommend their practice to others, a drop in recommendations in November 2017 to 65.81 per cent has meant that overall the CCG has fallen slightly short of target, performing at 83.9 per cent overall.

Quality Improvement Programme in General Practice

The CCG has delivered the first year of the local quality improvement programme supported by bespoke programmes commissioned from Southbank University and the Royal College of GPs.

The programme was commissioned to develop leadership awareness and skills to lead peers and teams to generate sustained change; support practices to work on the system-wide issues that unlock practice capacity and tackle the issues getting in the way of collaboration and securing better care for residents across the whole of the borough.

Evaluation is under way and will report in summer 2018.

Related Improvement and Assessment Framework (IAF) indicators

128c Primary care access - percentage of registered population offered full extended access

As of January 2018, 100 per cent of Waltham Forest patients have access to GP care seven days a week.

128b Patient experience of GP services

As of 2017, 77 per cent of patients rated their experience of their GP Practice as fairly good or very good. The CCG is ranked 199th out of 207 CCGs, placing the CCG in the bottom quartile when compared nationally.

128d Primary care workforce

As of September 2017, there are 0.81 full time GPs and Nurses per 1000 weighted* patients. The CCG is ranked 194th out of 207 CCGs, placing the CCG in the bottom quartile nationally.

• number adjusted to reflect the health needs of the local population

Sustainable Development The sustainable development strategy for the health, public health and social care system was launched in January 2014 and covers the period 2014 to 2020. Building on the carbon reduction strategy, which set an ambition for the NHS to help drive change towards a low carbon society, it defines where we need to be on the path to sustainable healthcare by 2020 and the measures and targets against which progress will be measured.

WFCCG supports the commitment of the NHS to be a leading sustainable and low carbon organisation and to meet the government’s target of an 80 per cent reduction in carbon emissions by 2050. We are working towards supporting this goal through, for example: minimising waste; working with our GP localities, our partners and providers to lower the impact of our carbon footprint; and encouraging staff to participate in improving environmental sustainability.

We have used the services of a sustainability consultancy that specialises in support for the healthcare sector. We have developed a sustainability development management plan to explore our environmental credentials, identify any deficiencies and plan for future improvements that will bring us financial, as well as environmental benefits.

Our plan has four areas of focus: • Leadership and accountability • Understanding our impacts • Service design • Communication and engagement.

Each of the areas has specific actions that we worked through in 2017/18 and continue to do so into 2018/19. These are detailed in the table below:

Leadership and • Established our governance structure, with clear accountability accountabilities • Defined our sustainable vision and objectives Understanding our impacts • Identified our improvement areas in terms of our internal environment and pharmaceutical waste Service design • Assessed the social and environmental impacts when considering service designs

• Engaged the public in the development of our sustainability plan Communication and • Communicated our plans to staff and took relevant engagement feedback into consideration • Developed local sustainable improvement partnerships

We also identified our key risks and opportunities in order to develop our plans for 2018/19. Aligning strategic objectives to sustainability

Our sustainable development plan also helps us to meet many of our own strategic objectives, as described in the table below.

Strategic objective Alignment to sustainability Meeting our statutory The national sustainability strategy for health and care requires us requirements to have a sustainable development plan. The Social Value Act (2012) places emphasis on goods and services procured through public funds to maximise social and environmental benefit. WFCCG is committed to “promoting environmental and social sustainability through our actions as a corporate body as well as a commissioner”. Strengthening The foundation of sustainability is partnership working, sharing collaboration with WEL, best practice, developing innovative new practices and realising local providers and efficiencies across partnerships and networks. The London establishing Borough of Waltham Forest continues to explore how we can work commissioning together to minimise negative health impact from issues such as arrangements poor air quality, align sustainable procurement strategies and maximise the benefit from cycling infrastructure improvements. Local providers are working on sustainable development plans in partnership with other CCGs (e.g. City and Hackney: Homerton and East London Foundation Trust). Improving the patient Sustainable working practices reduce duplication, improve quality experience across all and help to remove redundancy across care pathways by looking services at holistic and cross-partnership approaches to service design and delivery.

Involving patients, Encouraging and supporting community development through communities and hard service design and delivery helps to reduce inequality, reduce to reach groups isolation and support an overall approach to narrowing the gap. Commissioning good Sustainable development supports strong workforce development, organisational staff wellbeing and team development. A focus on ‘making a development difference’ and improving operational outcomes for local wellbeing programmes for helps to motivate staff teams and improve staff retention. individuals, teams and the wider organisation

Achieving wider health benefits

There are clear health benefits to developing sustainable working practices. For example: • Unemployment is a key contributing factor in the uptake of mental health support services. Improving local job opportunities, skills training and apprentices through sustainable programmes can increase employment opportunities. Gaining employment improves mental health and wellbeing, therefore reducing the need for support services and improving wellbeing. • Traffic and air pollution has a negative impact on the environment. Encouraging active travel reduces this impact, but also improves the health of the local population through improved local air quality and the benefits of more active lifestyles • Minimising duplication and redundancy in care pathways, improving patient expectation from the onset of care, and supporting self-management of many health complaints supports the improvement and quality of services. This activity will also reduce the environmental impact of services (e.g. less unnecessary travel to appointments), give time back to patients and carers (e.g. more efficient services) and improve overall health and wellbeing outcomes (e.g. a better understanding of the care pathway).

Partnerships

As a commissioning and contracting organisation, we need effective contract mechanisms to deliver our ambitions for sustainable healthcare delivery. The NHS policy framework already sets the scene for commissioners and providers to operate in a sustainable manner. Crucially for us as a CCG, evidence of this commitment will need to be provided in part through

contracting mechanisms. The table below shows the sustainability information about providers of our commissioned services. More information on these measures is available here: www.sduhealth.org.uk/policy-strategy/reporting/sdmp-annual- reporting.aspx

On track to Healthy Organisation Sustainability SDMP meet 34% Adaptation Transport Name Reporting Score reduction Plan

BARTS HEALTH Yes On track to No No Minimum NHS TRUST meet target

NORTH No No No Yes Minimum MIDDLESEX Sustainable UNIVERSITY Development HOSPITAL NHS Management TRUST Plan

NORTH EAST Yes Target No No Poor LONDON NHS included but FOUNDATION not on track TRUST to be met

HOMERTON No No No No Minimum UNIVERSITY Sustainable HOSPITAL NHS Development FOUNDATION Management TRUST Plan

LONDON Yes Target No No Minimum AMBULANCE included but SERVICE NHS not on track TRUST to be met

Improve quality Quality and Safety Performance Introduction

NHS Waltham Forest CCG’s vision remains to ‘put patients at the centre of everything it does, using its experience to shape care pathways, improve service delivery and ensure value for money’. The people of Waltham Forest deserve to receive the best possible health and wellbeing, ensuring receipt of the right care, at the right time, in the right place.

Our objective is to shape the quality of commissioned services to better support the needs of the people in Waltham Forest, whilst ensuring services are subject to the rigorous checks and balances expected from contracted services. When we talk about quality we mean patient safety, effectiveness of care and patient experience.

NHS Waltham Forest Clinical Commissioning Group continue to monitor, via the scorecard, key performance and quality targets in 2016/17 and report against the CCG’s progress. The intention of the scorecard is to identify specific measurable indicators that can be used to demonstrate improvements in patient care and outcomes over the course of the year.

The Scorecard reflects Waltham Forest priorities and objectives rather than replicating national performance frameworks. This makes the Scorecard more meaningful and relevant to the CCG. It enables the CCG to measure the effectiveness of its local strategic plans.

The two quality and safety indicators for 2076/18 were the measurement grade 3 and 4 health acquired pressure ulcers at Whipps Cross Hospital and the Whipps Cross Hospital Friends and

Family test response rate for A&E. A full review of all quality indicators is completed every month and reported by exception.

Friends and Family Test (FFT) – Whipps Cross Hospital A&E The Whipps Cross A&E Friends and Family Test response rate was added to the CCG scorecard for 2017/18, following consistent non-compliance with the 20 per cent response rate target. A good response rate ensures that the data collected is valid and more representative of the patient group compared to receiving a lower response rate.

The CCG has worked closely with Whipps Cross Hospital throughout 2017/18, meeting on a regular basis and Whipps Cross has worked to increase engagement in the A&E department around FFT. The graph below shows the response rate achieved in 2017/18 compared to 2016/17. Please note that the data for November 2017, February and March 2018 was not available at the time of writing this report.

A&E Response Rate Comparison 18%

16%

14%

12%

10%

8% Response Rate 6%

2016/17 2017/18

Pressure ulcers at Whipps Cross Hospital (Grade 3 and 4) A pressure ulcer is a localised injury to the skin and/or underlying tissue usually over a bony prominence and range in severity from patches of discoloured skin to open wounds that expose the underlying bone or muscle. Older people are more at risk of developing pressure ulcers especially those aged 70 and above, this being due to the common problems that come with age such as incontinence, dry skin, chronic systemic conditions and terminal illness. Although it is to be noted that the majority of ulcers are preventable.

Pressure ulcers often result in an extended stay in hospital, with studies reporting between a four-to-10 day longer stay. There is also a marked increase in mortality for older patients who develop a pressure ulcer.

Waltham Forest CCG recognises that avoidable pressure ulcers are a key indicator of the quality and experience of patient care and have a profound effect on the overall wellbeing of patients as they are both painful and debilitating. Whilst much has been undertaken in the health service to reduce the numbers of acquired pressure ulcers, it remains a significant healthcare problem, with 700,000 people affected each year at significant cost to the NHS.

The CCG’s target was to reduce the number of grade 3 and 4 pressure ulcers acquired at Whipps Cross Hospital by 25% on the baseline set from 2016/17.

Grade 3 and 4 Pressure Ulcers Whipps Cross Hospital 70

Pressure Ulcers - Grade 3 and 4 16/17 Pressure Ulcers - Grade 3 and 4 17/18 Trajectory Target

The chart above shows that whilst the overall number of grade 3 and 4 pressure ulcers as of February 2018 is slightly above last year, and is above the improvement trajectory, the target will not be achieved at year end.

Emergency preparedness, response and resilience (EPRR) In May 2017 Waltham Forest CCG and Whipps Cross Hospital were affected by the ‘WannaCry’ ransomware cyber-attack. The CCG was only minimally impacted and responded to the incident well. The attack was used as a real-time incident, so that learnings could be incorporated across the CCG and plan for future events. After the ransomwear event, the CCG redeveloped its Business Continuity Plan merging it with the Major Incident Plan. By incorporating into one plan, it provides the organisation with a comprehensive manual that outlines responses to triggers to emergency situations both internal and external.

During 2017/18 the CCG undertook the NHS England EPRR assurance process with a self- assessment against core standards and a formal interview with NHS England. The CCG assurance compliance was rated as substantial.

We certify that the CCG has incident response plans in place, which are fully compliant with the NHS England Emergency Preparedness Framework.

Patient Experience Waltham Forest CCG’s vision is to put patients at the centre of everything we do. We do this by actively listening to our patients, communities and hard-to-reach groups, and using their experiences to shape care. The CCG has continued to work closely with our acute and community providers to support them in relation to the patient experience agenda, as well as working with our local Healthwatch, meeting regularly.

Demonstrating the CCG’s focus on patient experience, the Whipps Cross Hospital’s Emergency Department’s Friends and Family Test response rate was added to the CCG scorecard following an action plan being put in place and support offered to the provider to support the improvement against this target.

Friends and Family Test (FFT) – Whipps Cross Hospital The NHS Friends and Family Test is a real time data collection tool that simply asks people to consider whether they would recommend services to their friends and families. This information provides the hospital with a greater understanding of needs of their patient groups and supports improvement of services.

The CCG continues to work closely with Barts Health and Whipps Cross, meeting with the Patient Experience Lead monthly to support improvement in the percentage of patients to recommend the hospital and ensuring adequate response rates especially for A&E where an action plan is in place to ensure improvement.

The graph below shows the Whipps Cross Hospital’s performance year to date, the target percentage to recommend has been increased to 95 per cent. The table below shows data for the financial year 2017/18, some of the data from November onwards was not available at the time of reporting, due to Barts Health NHS Trust changing patient experience solution provider.

Whipps Cross Friends and Family Test 120%

100%

80%

60%

% to recommend 40%

20%

Inpatients A&E Maternity Outpatients Target

Quality incentives CQUIN Waltham Forest CCG remains committed to working with Bart’s Health NHSTrust to ensure that the national CQUIN schemes deliver clinical quality improvements and drive transformational change.

2017/18 saw NHS England move to a two-year national CQUIN scheme. It is intended to deliver system-wide clinical quality improvements and drive transformational change and designed to support the ambitions of the Five Year Forward View, as well as directly linking to the NHS Mandate for promoting wellbeing and preventing ill health.

The national CQUINS focussed on two key areas:

1. Clinical quality and transformational indicators: Six indicators with subsections were defined with the aim to improve quality and outcomes for patients including: improving access to services, reducing health inequalities, encouraging collaboration across different providers and improving patient treatment. It also focused on improving the working lives of NHS staff.

2. Supporting local areas: • Sustainability and Transformation Plans (STP’s) reinforcing the critical role providers have in developing and implementing local STPs • Local financial sustainability – encouraging providers and commissioners to work together to achieve financial balance and to complement the introduction of system control totals at STP level.

Care Quality Commission (CQC) Inspections GP Practices in Waltham Forest

Of the 41 GP practices in Waltham Forest, during 2017/18 CQC rating movements were as follows:

• Nine practices (22 per cent) moved from ‘Requires Improvement’ to ‘Good’ • One practice has moved from ‘Good’ to ‘Requires Improvement’ • Five practices (12 per cent) have received a second ‘Requires Improvement’ • Two practices have been rated ‘Inadequate’:

o One ‘Inadequate’-rated practice’s contract holder returned their PMS contract and this practice is now being managed by Hurley Group under a caretaking agreement

o The other ‘Inadequate’-rated practice’s contact holder, handed back their contract and the list was dispersed as of 31 March 2018.

North East London Foundation Trust

North East London NHS Foundation Trust (NELFT) is commissioned to provide community health and mental health services in Waltham Forest. The trust provides care and treatment for a population of about 1.75million and employs around 6,000 staff.

The trust provides the following 11 mental health core services and community health core services across 11 registered locations. The Care Quality Commission (CQC) has inspected the Trust 17 times since registration and there have been five joint inspections with Ofsted.

NELFT was inspected in April 2016 as part of the CQC’s ongoing comprehensive mental health inspection programme. Fourteen services were inspected across the community and mental health services and of these 10 were rated as ‘Good’. Three areas were rated as ‘Requires Improvement’ and one as ‘Inadequate’. There were 10 breaches of the fundamental standards of care. The Trust overall rating was ‘Requires Improvement’.

Waltham Forest worked in partnership with NELFT to support the development of their CQC quality improvement plan, ensuring this was monitored at the Clinical Quality Review Meeting on a monthly basis. The CQC completed further eight inspections between 15 August and 3 November 2017 across the six core services at NELFT, including a review of end of life care and well led.

The CQC published the report in January 2018 and gave an overall rating for NELFT services of “Good”. This is an improvement from the previous rating of “Requires Improvement”. Of the 15 core services 13 were rated as ‘Good’, one as ‘Outstanding’ (children and adolescent mental health wards) and one ‘Requires Improvement’ (acute wards for adults and psychiatric intensive care). It was very positive to note that the children and adolescent mental health rating moved from “Inadequate” to “Outstanding”.

The table below indicates the movement in ratings from the last two inspection.

2016 2018

Safe Requires Improvement Requires Improvement

Effective Requires Improvement Good

Caring Good Good

Responsive Requires Improvement Good

Well led Requires Improvement Good

Overall Requires Improvement Good

Waltham Forest CCG will work with NELFT to ensure that a revised governance process is in place that provides assurance that actions highlighted in the CQC report will be addressed and this will be reviewed at the monthly Clinical Quality Review Meetings (CQRM).

Whipps Cross Hospital – Barts Health

WFCCG commissions acute care from Barts Health NHS Trust’s Whipps Cross University.The hospital is based in Waltham Forest and provides a range of general inpatient services, outpatient and day-case services, as well as maternity services and a 24-hour emergency department and urgent care centre. The hospital also supports a number of specialist services including urology, ENT, audiology, cardiology, colorectal surgery, cancer care and acute stroke care.

The Care Quality Commission (CQC) undertook an unannounced inspection to follow up on the previous inspection of Barts Health NHS Trust which took place in July 2016. This inspection highlighted a number of concerns around patient safety and the quality of care and at that time Whipps Cross University Hospital was rated overall ‘Inadequate’.

The CQC carried out further unannounced inspection in May 2017 with a focused inspection of three core services:

1. Surgery 2. End of life care 3. Outpatients and diagnostic imaging.

The inspection report stated that improvements had been noticed in both end of life care and outpatients and diagnostic imaging services but there had not been any improvement for surgical services. The overall rating for Whipps Cross improved to ‘Requires Improvement’.

Waltham Forest CCG continues to actively respond and work collaboratively with the Whipps Cross teams to address the quality issues and concerns raised to expedite recovery to ensure high levels of safe quality care and patient experience. The CQC and quality improvement plans are scrutinised at the monthly Clinical Quality Review Meetings (CQRM).

GP Alert System The aim of the Waltham Forest GP Alert System is to give our GPs a mechanism to raise non- urgent issues relating to quality and patient safety within a provider, with this leading to system level improvement. Towards the end of 2016/17 the GP Alert System was expanded to include North East London Foundation Trust (NELFT) as well as Barts Health NHS Trust. The system has seen an increase in the number of alerts received in 2017/18 compared to 2016/17. This helps to drive improvements in the care and services our patients receive and has allowed the CCG to become aware of concerns and to support resolution. The themes identified are reported to the CCG’s Performance and Quality Committee on a monthly basis and can be discussed at the provider’s Clinical Quality Review Meeting (CQRM) if required.

Infection Prevention and Control The CCG is committed to the implementation of the NHS Improvement preventing healthcare associated Gram-negative bloodstream infections by 50 per cent by 2021. The CCG is collaborating across North East London with partner CCGs and Bart’s Health NHSTrust and NELFT to roll out the recommendations, and develop projects to reduce infections. Through the CCG’s membership on the NEL Antimicrobial Resistance Strategy Group, the CCG is also implementing tools to Primacy Care and care homes that will assist with reducing programs.

The CCG has remained around the national average for attributed MRSA bacteraemia with six attributed to Whipps Cross for 2017/18. A slight increase has been seen in the number of Clostridium difficile infection cases that are community attributable. The reported figures show that Clostridium difficile cases are below the threshold to date for 2017/18, compared to the same period last year, there is a 36 per cent increase on CDI cases.

Safeguarding NHS Waltham Forest CCG has a statutory responsibility under Section 11 of the Children Act 2004 to ensure that robust arrangements are in place to safeguard and promote the welfare of all children and young people. Annual reports are provided to the CCG’s Governing Body, with quarterly reporting to the Performance and Quality Committee to provide assurance that Waltham Forest CCG has had robust child protection and safeguarding arrangements in place for 2017/18. Waltham Forest CCG holds all provider organisations to account, to ensure services commissioned and contracted out adhere to their safeguarding responsibilities and can demonstrate that robust processes are in place to safeguard children and also adults with care and support needs under the Care Act 2014.

In accordance with statutory requirements, the CCG has employed designated professionals for Child Death, Safeguarding children and Looked After Children (LAC), on behalf of the health economy, and has a governance structure with the clear lines of accountability. The CCG has also employed a Clinical Lead GP for Safeguarding in Primary Care and a Designated Lead for Safeguarding Adults. The Director of Nursing, Quality and Governance is the Executive Lead for safeguarding children, adults and Looked After Children (LAC). Waltham Forest CCG is fully compliant with the statutory guidance ‘Working Together to Safeguard Children 2015’, Safeguarding Vulnerable People in the Reformed NHS: Accountability and Assurance Framework 2015, and Children Act 1989 and 2004. Safeguarding governance arrangements have improved during 2017/18 with established health system meetings for the designated safeguarding and LAC professionals and Named GP.

Child Protection Information Sharing Project The Child Protection-Information Sharing project (CP-IS) offers a more holistic picture of care for health professionals to assess children and young people. It is a national system (across England) that connects children’s social care IT systems with those used in unscheduled care settings. CP-IS gives health professionals the ability to see whether vulnerable children are subject to protection plans regardless of the local authority where the child originates from. Equally, local authorities can see where, when and how often a child has visited unscheduled care settings. Being able to identify quickly whether a child is subject to a child protection plan or is a Looked After Child has been a longstanding problem for NHS Trusts, especially unscheduled care settings. Joining these systems up should help to open up conversations with children and carers much earlier to prevent potential harm. The CCG Leads facilitated the CPIS Cluster Group which steered the project to successful implementation on target and within timescale in March 2018. Preliminary feedback indicates that a number of vulnerable children were identified within the first week of implementation, which will enable them to be safeguarded.

PREVENT The safeguarding partnership within Waltham Forest works together to prevent children suffering harm and to promote their welfare by providing the services they require to address identified needs and safeguard children who are vulnerable. PREVENT is part of the National counter-terrorism strategy, CONTEST. Its aim is to stop people becoming terrorists or supporting terrorism. Communities and local authorities have a key role in this strategy. As a national security issue, the CCG must seek assurances from providers and evidence that they are committed to ensuring vulnerable individuals are safeguarded from supporting terrorism or

becoming terrorists themselves as part of the Home Office counter- terrorism strategy. This is addressed through contract monitoring with a clear focus on quality and safeguarding and to seek assurance that the commissioned services have implemented effective PREVENT arrangements. The CCG has offered WRAP training in PREVENT to eligible staff in Primary Care whilst all other CCG staff have had access to basic level online PREVENT awareness training and face to face training. CCG PREVENT training compliance for 2017/18 is 97 per cent. There have been no PREVENT referrals made by the CCG in 2017/18.

Learning Disabilities Mortality Review (LeDeR) Programme The Learning Disabilities Mortality Review (LeDeR) Programme is a national programme commissioned by the Healthcare Quality Improvement Partnership (HQIP) on behalf of NHS England. It was set up following the Confidential Inquiry into Premature Deaths (CIPOLD) of people with learning disabilities in 2013. Health and social care providers were required from April 2017 to report all deaths of people with a learning disability in their area, and provide a review of circumstances surrounding their death and care.

Waltham Forest CCG in partnership with the Local Authority and our commissioned providers, has established a steering group that has successfully created a local process meeting the requirements of the LeDeR programme. This is chaired by the CCG LeDeR local area contact and reports annually to the Health and Wellbeing Board and quarterly to the Safeguarding Adults Board. In addition, LeDeR will report to the Local Learning Disability Health Transformation Board. A cohort of local reviewers has been trained and is supported by the steering group. In 2017/18 there were 10 deaths reported which will all be reviewed, with lessons learned reported nationally but also used to improve the commissioning and delivery of local services for people with a disability.

Engaging people and communities

IAF – Patient and Community Engagement Indicator Improvement plan NHS Waltham Forest CCG achieved a green rating, with an overall score of 10, following assessment against the domains and criteria for the new ‘patient and community engagement’ indicator, introduced in 2017 as a standalone indicator within the CCG Improvement and Assessment Framework (IAF).

The CCG’s ratings included one ‘Outstanding’, three ‘Good’ and one ‘Requires Improvement’ rating as set out below.

What the domain Rating CCG name looks at NHS WALTHAM FOREST CCG

Overall RAG rating GREEN

Overall score 10

- Involve the Outstanding public in governance - Implement assurance and improvement systems - Hold providers to Domain A grade 3 account

- Demonstrate Good public Involvement in Domain B grade 2 annual reports

- Explain public Good involvement in commissioning plans - Promote and publicise public involvement Assess, plan and take action to involve - Provide support Domain C grade for effective 2 engagement

- Feedback and Requires evaluate Domain D grade 1 Improvement

- Advance Good equality and Domain E grade reducehealth 2 inequality

The domain requiring improvement, Domain D, covers how the CCG evaluates its engagement with patients and the public, and uses the feedback it receives in the commissioning process.

Both an internal audit and the 2016 360 stakeholder survey also found a lack of evidence to support this and identified it as a weakness in the commissioning process at Waltham Forest CCG. Since then CCG’s Communications and Patient and Public Participation Team has been working with individual commissioners on improving processes in this area.

A communications and engagement toolkit had already been introduced in 2016 to support CCG staff in planning and recording communications and patient and public participation activity. This consists of three main templates:

• Communications and engagement plan

• Engagement log

• Feedback log.

The Communications and Patient and Public Participation team works with individual teams to support them in the use of the toolkit and also holds an overall planner through which they coordinate activity and content.

Throughout 2017/18, particularly following the IAF assessment there has been a focus on improving the use of the engagement and feedback log templates.

• A ‘You Said, We Did’ template has been developed to be used to ensure a consistent approach by commissioners in evidencing the involvement of patients and the public in the commissioning process.

• The You Said, We Did reports are shared with the CCG’s Patient Reference Group and published online on the Get Involved pages on the CCG website.

• The Get Involved pages on the CCG’s website have also been reviewed overall and the Patient Reference Group’s agendas, presentations and minutes are published retrospectively.

• An introduction to the CCG’s communications and engagement toolkit and statutory requirements has also been developed for inclusion in the CCG’s staff induction pack and sessions.

• A staff lunch and learn session on the statutory requirements of patient and community engagement in the commissioning process has also been developed.

CCG Communications and Patient and Public Participation Team The commissioning team at Waltham Forest CCG is supported in involving patients by the CCG’s Communications and Patient and Public Participation (Engagement) Team.

Developed since January 2016, the joint Communication and Patient and Public Participation (Engagement) team consists of:

• Head of Communications and Community Participation (Since January 2016) • Communications and Engagement Manager (since October 2016) • Communications and Engagement Officer (since May 2016).

The team is supported by NELCSU, through a service level agreement (SLA), with media, public affairs and Freedom of Information requests, and additional communications and patient and public participation support where needed.

There is both a Communications Strategy and Community Participation (Patient and Public [Engagement]) Strategy in place. Running from 2015 to 2018, these are due to be reviewed in 2018.

Patient Reference Group NHS Waltham Forest CCG’s Patient Reference Group (PRG), established in 2013, now sits at the heart of the CCG’s patient and public participation cycle, and as such is a key forum for patient and public involvement in the borough.

As a formal sub-committee of the CCG’s Governing Body, the CCG’s aim is for the PRG to have the following qualities:

2017 saw a refresh of the PRG membership and the implementation of the vision developed in 2016, to create a network of patient and public involvement across Waltham Forest with the PRG at the heart.

Developments in 2017 included:

• increased membership of the PRG to 12 patient representatives per meeting, with new members recruited so that the PRG’s membership broadly reflects the diversity of the borough’s population better

• the establishment of a formal link between practice PPGs and the PRG through each locality (Chingford, Leytonstone and Walthamstow), having identified PPG reps on the PRG

• the commissioning of speech to text support to enable the active participation of PRG members with sight and hearing impairments.

The current membership of the Patient Reference Group is as follows:

1. Chair Richard Griffin, Lay Person

2. Co -Chair Caroline White, Lay Person

3. PPG Chingford locality representative Jim Sarginson

4. PPG Walthamstow locality representative Khadija Gitay and Patricia Stephenson

5. PPG Leyton & Leytonstone locality representative Liz Phillips and Gary Sultanti

6. Save Our NHS Representative Mary Logan

7. Community member Alex Kafetz and Ana da Cunha Lewin

8. Community member Sylvia Debreczeny and Adrian Dodd

9. Faith community representative Fatima Khasimi

10. Sensory impaired representative Neil Adie

11. Young Person Representative vacant Vacant

12. Carers Representative Vacant

Additional standing members

13. Head of Communications & Community Participation Julia Walsh

14. Communications & Engagement Manager Rebecca Waters

15. Healthwatch Waltham Forest Representative Althea Bart / Sumita Ahmed

The PRG meets ten times a year, with its members supporting at the CCG’s formal patient and public participation events and in between meetings, on an adhoc basis, as required.

A forward plan is in place, with agenda items for formal meetings aligned to the CCG’s commissioning activity, with guest presenters encouraged to join from the wider local health and care economy. PRG members are also invited to identify topics they wish to call in for discussion.

Agendas, presentations and minutes from the meetings are retrospectively published on the CCG’s Get Involved pages.

Topics per meeting in 2017/18 were as follows:

April 2017 • Meeting cancelled May 2017 • Terry Huff Chief Officer: What is commissioning? What does the CCG do? - The CCG Performance Dashboard - Accountable care systems • Governing Body papers • Digital Health event update • Children and Young People’s participation strategy. June 2017 • Self care – Medicines Optimisation - Waste Medicines campaign • New pharmacy project WF FedNet • PRG Terms of Reference • How to read Governing Body papers • PRG members on other committees • Patient Participation Group locality feedback. July 2017 • Community anticoagulation service specification and procurement • Home visiting service procurement and patient survey • CCG Patient Experience and GP alerts report • CCG update • 360 stakeholder survey results discussion • PPG Local Standard development update • Filming local case studies for CCG AGM. August 2017 • No meeting held in August. Email update sent. September 2017 • Whipps Cross Hospital site redevelopment – Guest presentation by Barts Health NHS Trust • AGM debrief • CCG committee update. October 2017 • Development of a Patients Charter for Waltham Forest practices

• End of Life Care service review • Public and patient engagement event planning • PRG members survey • SMS New community and domiciliary phlebotomy service – patient information leaflet review and procurement update • Royal College of General Practitioners (RCGP) North East London Faculty Lay Person. November 2017 • CCG Chair Dr Anwar Khan - Accountable Care Systems update • Making safeguarding personal discussion • Healthwatch: Health and Wellbeing Forum and Advocacy service • Preparing for the NHS 70th Birthday celebrations December 2017 • No meeting held in December. Email update sent. January 2018 • Primary Care Transformation - Online consultations discussion • Review of the year - Being patient representatives - Each member to present on how they connect their community to the PRG • Renal • Community and Domiciliary Phlebotomy service mobilisation - You said, We did. February 2018 • Over the counter medicines • Primary Care Transformation - Discharge to pharmacy • Integrated Sexual Health – Guest presenter from Barts Health NHS Trust • NEL Commissioning Alliance update - following Lay Members meeting with Accountable Officer • Patient and Public Participation in Health and Care Convention (21 February 2018). March 2018 • CCG Commissioning Strategic Plan (CSP) • Primary Care and Estates Strategy Update: What is a network/hub? • GP practice receptionists training • Group debrief on Patient and Public Participation in Health and Care Convention (21 February 2018) • Look forward to next month - NEL Commissioning Alliance Single Accountable Officer to attend.

PRG members also represent patients and the public on a number of CCG committees and project/programme groups or in specific procurements. In 2017/18 this has included:

• Ana da Cunha Lewin – Cancer Task and Finish Group, NHS 111 procurement

• Adrian Dodds – CCG IT Committee

• Khadija Gitay – Care and Support Hub Steering Group

• Alex Kafetz – CCG Remuneration Committee

• Liz Phillips – Care and Support Hub Steering Group

• Caroline White – CCG Primary Care Commissioning Committee, CCG Primary Care Advisory Committee, CCG Governing Body

Development of PPG local standard

Building on the 2015/16 CCG-commissioned Patients Association Patient Participation Group (PPG) project, work by the CCG’s Patient and Public Participation and Primary Care teams in 2017/18, has seen the development and launch of a PPG Local Standard in Waltham Forest.

The CCG’s Communications and Engagement Manager has worked with PPGs to develop the local standard, which aims to support PPG members and practice staff to review the format their group takes, the impact it has and how it is connected to patients and the wider health community.

With the Local Standard co-designed through an intense engagement process during the summer of 2017 across the borough’s three localities, the engagement process with both with patients, GPs and wider practice staff, allowed those involved to influence the content and user experience by phone, email and in person.

The Local Standard, which takes the form of a check list, was launched for a year-long trial with PPGs at the CCG’s AGM in September 2017. I like the document I think it is really useful. Nine PPGs submitted trial checklists and reviewed by a panel in January 2018. PPG feedback

The panel included:

• Five locality representatives with all three localities were represented • A representative of the CCG’s Primary Care Team and Communications and Patient and Public Participation • A CCG lay member.

As this was the first time the CCG had awarded the PPG Local Standards, the panel was also asked for input into the scoring and awards process. The January 2018 panel’s scores and process were reviewed by the CCG’s Primary Care Commissioning Committee.

To date (31 March 2018) three PPGs have received local standard certificates as follows:

• St James Practice - Silver • Lime Tree Surgery - Gold • Handsworth Medical Practice – Gold.

Handsworth PPG awarded ‘Gold’ status for PPG Local Standard.

A copy of the Waltham Forest PPG local standard and more information about the 2017/18 awards is available on the Get Involved pages on www.walthamforestccg.nhs.uk

As a result of the project, NHS Waltham Forest CCG escalated two practices for non- compliance of their PPG to NHS England.

Key benefits for the CCG as a whole include:

• Teams at the CCG now have a better understanding of the patient participation landscape in primary care and know the key influencers in the patient community.

• Improved contact means the CCG has a better infrastructure with which to engage patients with CCG strategic activities.

• The delivery of the PPG Local Standard has raised the profile of the CCG with patients, and demonstrated the CCG’s commitment to patient involvement in Primary Care

Going forward in 2018 work is I think it’s great. Please let me have the final under way to collect the version and let me know whether it can be more remaining 34 PPG checklists and widely distributed as we would like to put this on to communicate with practices the PPG section of our website. and PPGs that the standard is Patients Association not going to penalise any PPG but is a tool for the CCG, practices and PPGs to understand how the different groups operate and give everyone the opportunity to improve by providing examples of best practice. We believe that the PPG local standard may be the only local standard for PPGs in the UK.

Patient and Public Participation (PPP) quarterly newsletter Winter 2017/18 saw the launch of a trial quarterly patient and public participation newsletter. Designed to connect the CCG’s patient and public participation work with the wider public involvement network across Waltham Forest, the first two editions of the newsletter are available on the Get Involved pages of the CCG’s website.

• PPP newsletter – Winter 2017/18

• PPP newsletter – Spring 2018

Patient and Public Participation quarterly events 2017/18 has also seen the first full cycle of scheduled patient and public participation quarterly events in Waltham Forest. With the four events including the CCG’s Annual General meeting, content of the events is driven by both the commissioning agenda and activity in the local health and care system.

More information on each event is available on the CCG website (via the links below) but in summary events of 2017/18 included:

1. Digital Health - Tuesday 18 April 2017

A partnership event led by the CCG and involving NHS England, the Council (London Borough of Waltham Forest, CCG Clinical Directors and Leads and Digital Unite, the agenda covered:

• Digital Champions programme run by Digital Unite

• The benefits of GP Patient Online services

• Digital Wellbeing demonstration

• Co-design sessions

• Future of digital health – open discussion.

Since the event Digital Unite has gone on to include GP Patient Online (now GP Online Services) in its digital champions support package to residents.

2. Involving children and young people in health and care service design - Saturday 15 and Sunday 16 July 2017 NHS Waltham Forest CCG took part in the Health Zone marquee at the Walthamstow Garden Party to gather feedback to inform how we involve children and young people in shaping health care. The findings from the event are being used to shape a Children’s and Young People’s participation toolkit being developed in partnership with the borough’s commissioners and providers of children’s services. The event was planned and delivered by the CCG Communications and Engagement Team, with volunteers from the London Borough of Waltham Forest’s Young Independent Advisory Group (YIAG) and Young Advisors helping on the day.

3. CCG AGM and Shaping Health Services Together Community Conference - Thursday 14 September 2017

Nearly 300 people registered to attend the CCG’s September 2017 AGM and Shaping Health Services Together Community conference. It showcased work going on to develop and deliver health and care services in the borough. The presentation, audio and full transcript from the event are available online along with links to the videos shown at the event. Also available online is the booklet delivered to every home in the borough, inviting residents to the event.

4. Patient and Public Participation in Health and Care Convention, Chingford - Wednesday 21 February 2018

People living and working in Waltham Forest, Redbridge and West Essex, who consider Whipps Cross their local hospital, were invited to an event to explore existing and emerging opportunities and forums for sharing their views to shape services. Organised by the CCG, the Patient and Public Participation in Health and Care Convention was held at Chingford Assembly Hall.

The event showcased the ways patients and the public can help shape health and care services. Specific workshops included:

• looking at how local people can get involved in the redevelopment of Whipps Cross Hospital • exploring how to engage children and young people.

The event was produced in partnership with Barts Health NHS Trust, and supported by NELFT, Redbridge and West Essex CCGs, local Healthwatch and voluntary sector organisations. More than 70 members of the public attended.

Development of Waltham Forest Children and Young People’s participation toolkit In April 2017 the SEND Review Board requested that an inclusive, across borough participation strategy for children be developed.

NHS Waltham Forest CCG is co-ordinating the drafting of the strategy with the involvement of London Borough of Waltham Forest, Public Health Waltham Forest, Healthwatch Waltham Forest, Community Waltham Forest, NELFT, Barts Health NHS Trust and the Metropolitan Police.

Outreach work was undertaken at the July 2017 Walthamstow Garden Party to understand how young people would like to be engaged. A video about the project is available online on the CCG’s website.

During the initial engagement with partners, mapping exercise identified that there were a plethora of channels already in existence. What people needed to know was how and when to use them. Partners decided that rather than developing a cross-borough strategy that sets out a vision for children and young people (CYP) participation, there is a need for a central resource that staff can draw on when designing and shaping health and care services. This resource would provide local and national best practice, but most importantly a list of the local channels with which to reach the target group.

It has been agreed that the toolkit will be hosted on a London Borough of Waltham Forest digital platform that is being developed by the council’s Strategic Partnerships Team. This team has also created a multi-agency engagement forum, which the CCG is a member of. This forum seeks to co-ordinate engagement activity across the borough and build an infrastructure for us to do so across partners organisations. This forum has created an agreed set of engagement principles. Updates on the project have featured at the London Councils - Children & Young People's Participation event.

Increasing the uptake of cervical screening Waltham Forest 2017/18 has seen the work under way in Waltham Forest to increase the uptake of cervical screening recognised by Jo’s Trust, the charity which works to raise awareness of cervical cancer screening. NHS Waltham Forest CCG received the highest possible rating from the charity for CCGs undertaking comprehensive work to improve screening uptake. The Jo’s Trust report - Cervical Screening in the Spotlight: One Year on is available online

Waltham Forest CCG set a target for the 2017/18 performance scorecard of improving uptake of cervical screening amongst women aged 25-64 to 71 per cent. This is in response to a declining rate of screening, which has fallen locally from over 74 per cent in 2009/10 to 68 per cent in 2015/16. In 2017/18 the approach has focussed on three clear areas:

• GP practices • ‘hard to reach’ cultural communities • the general public, particularly younger women.

Funding was agreed to:

• reinstate a calling service trialled in 2016/17 but on a larger scale with a more robust project plan • carry out focused community engagement with groups whose feedback indicated that they are less likely to attend screening • run a ‘mass’ communications/marketing campaign targeting some of the common preconceptions about cervical screening.

Calling service

The calling service work has involved working with selected GP practices to identify women in the target age range whose cervical screening is overdue, and making direct calls to these patients to discuss screening and book an appointment for them. As of 2 February 2018, the

calling service had made 1422 calls against a target of 2000, with 14 per cent of these were converted into a booked appointment (195 appointments).

Key feedback from the work being done in practices is as follows:

• Some patients said that they were reluctant to book a smear test for cultural or religious reasons

• Practices reported that high turnover in their lists makes it more difficult to keep patient details up to date and get women to attend for smear test appointments

• Some practices had a high number of patients contacted who accessed smear tests in their home country on an annual basis

• There were difficulties getting some practices to engage with the programme, and the cancer clinical leads are supporting discussions with these practices.

Community engagement

This work has been carried out by community health champions who are attending local events and workshops to discuss screening with target groups. Sessions have included school fairs, libraries, the Waltham Forest Women’s Network, groups at local mosques and temples.

Mass communications/marketing campaign

Using feedback gained from the previous year’s work and from the calling service and community engagement work in 2017/18, a workshop was held on 15 February 2018 at Leytonstone Library to gather ideas for the development of the marketing concepts for a cervical screening communications campaign. The event was attended by members of the public, practice nurses and Barts Health. The views are being used to shape a targeted mass communications. The launch of the campaign was delayed purdah, which began on 26 March 2018. More information is available on the Get Involved page on the CCG website.

GP Online

As a result of the Digital Health patient and public participation event in February 2017, the CCG and NHS Digital have forged a relationship with the council’s (London Borough of Waltham Forest) Digital Team.

Working with NHS Digital and the council’s Digital Team, the CCG’s IT Change Facilitator has developed a programme to with the council’s Digital Champions to support patients to sign up to GP Online on-site in practices with low sign-up rate, and who opt to make use to the support supplied.

This programme commenced in March 2018 at Wood Street Health Centre in Walthamstow and Crawley Road, Leytonstone. There are 70 Digital Champions in Waltham Forest. The roles were created as part of London Borough of Waltham Forest Assisted Digital Strategy to support residents with accessing and understanding the benefits of using digital. Digital Champions are from a variety of different backgrounds and age groups and run free drop in sessions in community buildings such as libraries where support is provided.

Participation in developing Mental Health Services

Child and Adolescent Mental Health Services (CAMHS)

Seven young people were recruited from 10 applicants to become Young Mental Health Champions for Waltham Forest.

The Young Mental Health Champions are focusing on developing an early intervention/prevention service. In February and March 2018, they facilitated three workshops in schools. The workshop questions identified what young people in Waltham Forest understand about mental health, what the issues are, the services available and what they would like to be available in an ideal world. The information gathered will be used to create a specification for a service that meets the needs and requirements of young people in the borough.

The champions all attended a one-day mental health first aid training course in January to provide them with the knowledge required to undertake this project work.

Mental Health Employment Service

A workshop was held on 5 December 2017 with commissioners, service providers and service users. The Five Year Forward View target is that all services will double the access to mental health employment services with fidelity to the Individual Placement Support (IPS) model.

Working collaboratively the participants identified what worked well and where improvements were required. All of the feedback was used in the completion of the bid documents submitted to NHSE in March for additional funding to develop the services across the north east London STP footprint.

Crisis services

A workshop was held on 23 October with commissioners, service providers, service users and family/friends/carers.

The aim of the workshop was to discuss NHSE plans for health-based places of safety and how to promote these for use rather than A&E for people in mental health crisis. Feedback received from all participants was used and it was agreed that this identified a mental health training need, which resulted in a successful bid being submitted from the STP group for funding to provide training. The training is in the planning phase and will be facilitated in this financial year.

Recovery College

For the development of the Recovery College specification, mental health services were asked to engage services users in identifying what they felt would be useful if we were to develop this service. The services provided the feedback, which was used in developing the service specification. As a result of the feedback the specification details how service users/carers will be required to co-produce the courses that will be developed by the Recovery College.

Engaging on prescribed medication 2017/18 has seen NHS Waltham Forest CCG’s communications and engagement team work with the CCG’s Medicines Optimisation Team to ensure the local delivery of two national consultations on routinely prescribed medicines (ended October 2017) and the prescribing of the over-the-counter medicines (ended March 2018).

The teams facilitated these consultations by engaging with key stakeholders in Waltham Forest including patients, clinicians and staff to raise awareness and ensure that the voice of the borough was heard.

This included identifying groups that were likely to be most affected by the planned changes should they go ahead - such as younger people, parents, older people and patient representatives and groups - and engaging with them directly. Both consultations were also discussed at the CCG’s regular Patient Reference Group. The local hospital trust also circulated information to their staff.

Staff from the CCG also had a stand at the February 2018 Waltham Forest Patient and Public Participation in Health and Care Convention, where they engage directly with around 20

members of the public on the over-the-counter medicines consultation, answering questions and directing them to the national consultation survey. This activity was supported by media releases sent to the local press and sustained awareness campaigns on social media.

Medicines Waste

The CCG’s Medicines Optimisation Team has also been proactive in delivering the national medicine’s waste campaign in Waltham Forest to empower patients, prescribers and pharmacists to work collaboratively to address the issue head on and identify solutions in prescribing to benefit the local economy as a whole.

GP practices were supplied with a template letter to send to their patients, detailing the issues faced and what people could do to help. A medicines waste toolkit was also circulated to PPG representatives, while a series of posters and postcards were shared with GP practices and pharmacies. The campaign was supported by social media activity.

Stay Well This Winter Waltham Forest CCG supported the national Stay Well This Winter campaign, implementing this campaign locally and working with health and care partners to ensure clear and consistent messages were communicated to local people.

The winter campaign focused on raising awareness of how to stay well and preventing avoidable use of NHS services during the busy winter period, as well as letting people know where to go if they were injured or unwell over Christmas. The campaign encompassed a range of messages aimed at reducing A&E attendance, increasing flu vaccine update, and encouraging people to choose the right care for them by using NHS 111, pharmacies and by looking after themselves at home.

This was achieved by:

• series of targeted media releases to the local papers in Waltham Forest • sharing localised content on social media and sharing content from partners • advertising in local papers and on social media • sharing information and materials including posters and booklets with a variety of local venues including community centres, libraries, children’s centres and nurseries

• developing a poster advertising GP opening hours over the Christmas and New Year holiday, and sharing it with GPs, pharmacies, dentists and the local hospital trust to display • sharing information with CCG staff, primary care staff and with partners • working with care homes to raise awareness amongst staff of what actions they should take while caring for residents.

GP out-of-hours home visiting service review Patients and the public were given the opportunity to give their feedback on home visiting services in Waltham Forest. The GP out-of-hours service offers home visits outside of normal appointment hours for patients who are housebound and have urgent medical needs that cannot wait until the next day to be treated. The rapid response service, provided by North East London NHS Foundation Trust (NELFT), offers assessment, treatment and support to patients who are experiencing a crisis and who might otherwise be admitted to hospital.

Patients, their carers and their families were asked to give their feedback on the service, including anything they thought needed to change and their ideas for how it could be improved, by filling out a short questionnaire. This was publicised in the local media, on the CCG website, on social media, and to primary care staff, clinicians and CCG staff. The NELFT rapid response team also took copies of this survey with them on their patient visits to improve uptake with the people that use the service the most.

In total 18 users of the service provided detailed responses about the service and their views on how they currently access medical support when their GP is closed. This patient feedback, along with the results of an ongoing pilot, will be used to shape how this service is developed during 2017/18. The feedback was used to inform a business case, which was approved by the CCG Planning and Innovation Committee in January 2018. The pilot has been running successfully and learning will be used to form the model from 1st April 2018.

NHS 111 procurement In January 2018 a new integrated NHS 111 and clinical assessment service was commissioned jointly across the seven north east London (NEL) NHS CCGs.

Local people from across the community helped shape the new service and the process for selecting the organisation which would deliver it. This included young people, carers, older people, representatives of the traveller community and different faith groups, who all took part in planning the specification for the service to make sure it would truly meet the needs of those who live in the area.

In Waltham Forest, engagement on the patient experience of NHS 111 has been an ongoing priority, forming a key part of the development of a new integrated urgent care strategy in September 2015, and the development of a new urgent care centre specification in 2017. A NEL-wide patient survey on NHS 111 was advertised in the local media and shared with patient participation groups. A member of the Waltham Forest CCG Patient Reference Group was also involved in the NEL-wide NHS 111 engagement workshops. In total, across the seven NEL boroughs over 1000 patients and members of the public contributed feedback on the NHS 111 service.

Engaging on the Joint Strategic Vision and Commissioning Plan for Adults with Learning Disabilities

There are about 4500 people with learning disabilities in Waltham Forest and at any one time about 750 people receive a specialist service. During 2017/18 the CCG and Council (London Borough of Waltham Forest) gathered views on a joint draft five-year plan for services for adults with learning disabilities living in the borough.

Developed through conversations with people who use services, advocates, providers and carers, the draft Joint Strategic Vision and Commissioning Plan for Adults with Learning Disabilities then went out for consultation, led by the Council, with further views gathered through an online survey and face-to-face engagement with relevant groups. An easy read version of the document was created to support the involvement of service users.

Patient and public engagement in Maternity Services Waltham Forest CCG wants to make sure that local mums have the best possible experience of pregnancy, birth and postnatal care and funds a local organisation (Social Action for Health) to speak to women 'on the ground' in the community and hear about their experience of using maternity services.

Social Action for Health also facilitates the Maternity Voices Partnership (MVP), previously known as the Maternity Services Liaison Committee. This committee is made up of user representatives (such as parents or birth companions), Waltham Forest CCG and healthcare providers such as midwives, doctors and health visitors.

The MVP meets regularly to discuss issues that have been raised and to work together to improve maternity services. All feedback obtained by Social Action for Health and discussed by

the MVP is given to Waltham Forest CCG More information is available on the Social Action for Health website: www.safh.org.uk/waltham-forest-mvp

In 2017/18 the MVP has been key to the development of a booklet titled Your Pregnancy, Your Choice, Support for Choosing Your Place of Birth in East London. The booklet will be used to support notional Personal Maternity Care Budget discussions with women, to ensure they are fully informed when making decisions on where to have their baby. Developed with input of both maternity health care professionals and local women, the booklet is undergoing user- testing, with a limited trial of 300 copies, with women across east London from March 2018 as part of the transformation work taking place under East London Maternity Services.

Patient and public engagement during the mobilisation of a new Community and Domiciliary Phlebotomy Service for Waltham Forest

A dedicated resource was assigned to log feedback and coordinate responses to public and professional feedback during the mobilisation of a new community and domiciliary phlebotomy service with online booking system.

During a seven-week period 73-enquiries were received and the feedback dynamically used to shape the service during the mobilisation phase.

Instead of having to wait for a slot, I can now book an appointment on the way to the shops using the kiosk. Patient feedback

Knowing I can book an appointment in advance and arrive at the blood centre at an allotted time means the new Face-to-face engagement with an official launch at service will be much better than the old one. Silverthorn Medical Centre, Chingford, on 12 December 2017, gave representatives from local Patient feedback patient groups the chance to use a check-in kiosk designed to cut waiting times.

Other comments by service users included highlighting the need to have support staff near the check-in kiosks to help patients who haven’t used them before, as well as avoiding long waits for patients instructed by their GP to fast prior to having their blood taken.

In response, the booking system was set up to offer pre-booked appointments between 8.15am and 10am to patients who are fasting. Support staff have been put in place to show patients how to use the kiosk if needed.

More information is available on the CCG’s Get Involved page in the You said, We did feedback report.

Reducing health inequality

Health inequalities are the preventable, unfair and unjust differences in the health status of a person or population that is caused by the unequal distribution of social, environmental and economic conditions within society.

In 2017/18, Waltham Forest CCG maintained its commitment to equality and diversity. This commitment is reflected in our equality and diversity strategy, which has four key objectives:

• To develop and commission targeted initiatives to address heath inequalities among protected groups

• To improve access to services by all groups

• To implement the Equality Delivery System (EDS) to manage equality performance across all functions; and

• To develop an inclusive working culture which values diversity and supports staff to feel confident in challenging any harassment, bullying or perceived victimisation.

These objectives cut across the CCG’s broader work plan, seeking to ensure equality and diversity is embedded throughout WF CCG, and the services we commission.

An equality analysis section is included in the cover sheet that accompanies all reports to the CCG’s Governing Body, and all Waltham Forest CCG committees, ensuring that equality and diversity impacts are considered for all items on the agenda, and promoting the use of equality analysis throughout the organisation.

Waltham Forest CCG continues to review where groups of people in the borough have the worst experience of care and the worst care outcomes to inform our plans to tackle inequality. The CCG identified and collated evidence on the areas where there are major opportunities to improve health outcomes for the local population, based on the key findings emerging from the Waltham Forest Joint Strategic Needs Assessment (JSNA).

This found that:

Waltham Forest has a younger than average population with higher proportion of children aged 0-15 (22 per cent compared 20 per cent in London and 19 per cent nationally).

The proportion of children who are overweight or obese at age 10-11 in Waltham Forest (40 per cent) is significantly higher than in London (38 per cent) and England (34 per cent) overall. In comparison to other London boroughs Waltham Forest ranks 8th (the worst out of 33) and seen a significant increase since 2014/15 (from 36 per cent to 40 per cent).

Waltham Forest is 9th worst of the London boroughs in terms of prevalence of excess weight amongst children in Reception, and 8th worst in London in terms of prevalence of excess weight in children in Year 6 (out of 32 London borough, excluding the City)

For children and young people in Waltham Forest hospital admissions for mental health conditions (MHC) and self-harm are significantly lower (MHC 34 per 100,000, self-harm 121 per 100,000) compared to London (MHC 82 per 100,000, self-harm 210 per 100,000) and England (MHC 86 per 100,000, self-harm 431 per 100,000).

Childhood immunisations is reducing year on year with only 74 per cent of children being immunised for measles, mumps, rubella by age five

The incidence of tuberculosis in Waltham Forest (41 per cent) was significantly higher than both London (35 per cent) and England (14 per cent) averages and ranks 9th worst in comparison to other London boroughs.

The rate of Chlamydia screening is decreasing with rates the lowest in five years at 22 per cent, which potentially indicates an underperformance in detection. The detection rate of chlamydia for those under 25 years old in Waltham Forest (2,099 per 100,000) is below the nationally set benchmark (2,300 per 100,000). However, detection rates are higher compared to England (1,887 per 100,000) and similar to London (2,220 per 100,000)

Flu vaccination coverage is lower in Waltham Forest for those over 65 years of age (68%) is better than London overall (66%) but worse than the England average (71%).

The HIV prevalence in Waltham Forest (5.3 per 1,000) is lower than London (5.8 per 1,000) but higher than England (2.2 per 1,000) averages.

The diagnosis rate for Gonorrhoea has steadily increased in the borough over time (2010=98 per 100,000, 2015=208 per 100,000), which is in line with London (2010=80 per 100,000, 2015=222 per 100,000) and England (2010=30 per 100,000, 2015=71 per 100,000).

The increase in our older population clearly has major implications for both the NHS and social care within the borough, with prevention through joint work between social care and healthcare providers being particularly important (e.g. hospital admissions for falls are significantly higher than comparators and there is a significantly higher rate of mortality from fracture of femur for the 65 to 84 years age group than comparators).

Whilst cardiovascular disease mortality in older adults is not significantly different to London and England averages, the mortality rate from cardiovascular disease for those under 75 years of age in Waltham Forest (88 per 100,000) is significantly higher than London (77 per 100,000) and England (75 per 100,000) averages, ranking 9th amongst London boroughs.

The prevalence of diabetes amongst adults in the borough (seven per cent) is in line with London (six per cent) and England (seven per cent) overall.

The proportion of people diagnosed with depression in Waltham Forest has increased year on year between 2012/13 (four per cent) and 2015/16 (six per cent). This could reflect the better identification of residents with depression; this is in line with the London average at six per cent.

Health and wellbeing strategy NHS Waltham Forest CCG was instrumental in producing the borough’s joint Health and Wellbeing Strategy (2016-20) for the Waltham Forest Health and Wellbeing Board (HWBB) This section of the 2017/18 annual report has been shared with Health and Wellbeing Board colleagues and their feedback incorporated where received.

The HWBB provides a forum where key leaders from the health and care system work together to improve the health and wellbeing of Waltham Forest residents and reduce inequalities in health.

The strategy sets out plans to improve health and reduce inequalities in health outcomes across the borough. A video was produced when the strategy was first published to help engage local people in the work of the HWBB.

The CCG’s senior management staff played a key role in determining the scope, format and focus of the strategy, which includes a foreword from the CCG’s Chair Dr Anwar Khan. The then CCG Chief Officer (Terry Huff) co-authored the introduction.

A range of WF CCG staff provided content and ensured that that CCG’s programmes, aims and strategies were integrated into the final report.

A number of the outcomes set out in the Health and Wellbeing dashboard are existing CCG indicators.

These are listed below along with the performance against these specific indicators in 2017/18.

• Diabetes – Structured Education Referrals

o The latest year to date position shows that the CCG has increased the number of diabetic patients who are referred to the diabetes structured education courses. This is up 14 per cent year on year. • Early Intervention in Psychosis – two-week referral to treatment target

o The latest year to date position shows that over 92 per cent of patients suffering their first episode of psychosis receive their first treatment inside two weeks. This is above the national target of 66 per cent and above our prior year performance of 70 per cent. • Emergency admissions for integrated care cohort

o The CCG has successfully reduced emergency admissions for those patients in the integrated care cohort. Performance is below the CCGs ambition of a 10 per cent reduction but the latest year to date position shows that the CCG has achieved a reduction of 8 per cent.

• Emergency admissions from targeted nursing homes

o The latest year to date position shows that emergency admissions from the targeted care homes are down year on year by 8 per cent. This is below ambition of 10 per cent but an improvement on prior year performance. • Palliative Care Register

o Waltham Forest CCG has successfully achieved the year-end target to have 535 patients or more on the palliative care register by March 2018. As of March 2018 this stands at 661. • GP Friends and family test

o Waltham Forest CCG has managed to improve the percentage of patients that respond likely or extremely when asked if they would recommend their GP practice to others. The latest year to date position shows current performance at 85.2 per cent, which is just above the CCGs ambition of 85 per cent and better than the prior year performance of 83.36 per cent.

Summary details of where the CCG has contributed to the Health and Wellbeing Board’s four priorities (listed below) over the year, can be found in the performance overview and analysis sections of this report.

• Healthy weight for children (p.27)

• Substance misuse

• Mental health (p.21)

• End of life care. (p.36)

ACCOUNTABILITY REPORT

Corporate Governance Report Introduction and context

The clinical commissioning group was licenced from 1 April 2013 under provisions enacted in the Health and Social Care Act 2012, which amended the National Health Service Act 2006.

Scope of responsibility

As Accounting 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 in my Clinical Commissioning Group Accountable Officer Appointment Letter.

Compliance with the 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 and best practice. Specifically this applies to our leadership; effectiveness; accountability; remuneration; and relations with patients, the public, providers and other stakeholders.

Clinical Commissioning Group Governance 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.

Our CCG constitution describes our overarching governance arrangements, including the management of conflicts / potential conflicts of interest, standing orders arrangements for delegation and prime financial policies. It includes expectations that member practices are responsible for the content of the CCG constitution and election of the CCG Chair and clinical

90 members of the Governing Body. All other decisions are delegated to the CCG Governing Body.

The CCG’s governance structure is described in the figure below. 2017/18 attendance records for our governing body and committees are available at the end of this report.

NHS NEL Commissioning Alliance

The seven CCGs in north east London; Barking and Dagenham, City and Hackney, Havering, Newham, Redbridge, Tower Hamlets and Waltham Forest are now working together as the NHS NEL Commissioning Alliance. The CCGs have come together to deliver commissioning efficiencies and develop an aligned approach to working with providers to ensure long-term sustainability and support the delivery of effective integrated care systems.

By working together as an Alliance the CCGs will:

• Harness the benefits of greater collaboration across the system with CCGs, NHS organisations, local authorities and the voluntary and community sector working closer together • Reduce duplication by adopting common approaches and doing things once where it is appropriate and beneficial to do so. Some things are done really well in north east London, and this is an opportunity to learn from each other and share best practice. • Make sure that commissioning is truly integrated around local people and will improve both services and health outcomes • will really drive and improve outcomes for people who live and work across north east London.

At a north east London level, it is expected that the seven CCGs will work together to:

The vast majority of what CCGs do will be locally led, working closely with local people and communities, the council and the voluntary sector. This focuses particularly on improving local health outcomes.

A major part of the new alliance arrangements in 2017/18 was the development of the new NEL Joint Commissioning Committee (JCC). This committee will consider items common to all CCGs – for example, how the CCGs make sure that its urgent care works in a similar way or their contracting with hospitals. For a limited number of areas, it will also take decisions on

services that are commissioned once for NEL. The JCC will start meeting formally, in public, in May 2018. All CCGs and local authorities are represented on the committee.

Waltham Forest CCG Chair Dr Anwar Khan is Chair of the JCC, while Barking and Dagenham CCG vice chair, Kash Pandya, has been appointed as lay member and Vice Chair of the JCC.

Members report

Member practices

Leyton/Leytonstone

• The Allum Medical Centre - Fairlop Rd, E11 1BN • Leyton Healthcare - 4th Floor Leyton Healthcare Oliver Road, E10 5LG • Hampton Medical Centre - 1 Pretoria Rd, E11 4BB • Francis Road Medical Centre - 94 Francis Rd, E10 6PP • Green Man Medical Centre - 1 High Rd Leytonstone, Hanbury Dr, E11 1HR • Harrow Road Surgery - Triangle House Health Centre, 2-8 Harrow Road, E11 3QF • Crawley Road Surgery - 479 High Rd Leyton, E10 5EL • The Ecclesbourne Practice - Ecclesbourne Warwick Terrace, Lea Bridge Rd, E17 9DP • Langthorne Sharma Family Practice - 13 Langthorne Rd, E11 4HX • Lyndhurst Surgery - 53 Lyndhurst Dr, E10 6JB • The Manor Practice - 454 Lea Bridge Rd, E10 7DY • High Road Surgery - 287 High Rd Leytonstone, E11 4HH • LL Medical Care (Langthorne) - 13 Langthorne Rd, E11 4HX • Lime Tree Surgery - 321 High Rd Leytonstone, E11 4JT • Kiyani Medical Practice - 13 Langthorne Rd, E11 4HX • The Orient Practice - 75 Oliver Rd, E10 5LG • Leyton Green Neighbourhood - 180 Essex Rd, E10 6BT • SMA Medical Centre - 693 High Rd Leyton, E10 6RA.

Walthamstow

• The Grove Medical Practice - 103-105 Grove Rd, E17 9BU • Queens Road Medical Centre - 48 Queens Rd, E17 8PX • Higham Hill Medical Centre - 258-260 Higham Hill Rd, E17 5RQ • Waltham Forest Community & Family Health Services Ltd - 6 Linford Rd, E17 3LA • The Forest Surgery 2 Macdonald Road, E17 4BA • Firs - 26 Stephenson Road, E17 7JT • Dr Dhital Practice - 6 Linford Rd, E17 3LA • Addison Road Medical Practice - 46 Ravenswood Rd, , E17 9LY • Forest Road Medical Centre - 354-358 Forest Road, Greater London, E17 5JL • St James Practice - 47 St James St, E17 7NH • Bailey Practice - 107A Shernhall St, E17 9HS • Penrhyn Surgery - 2A Penryhn Avenue, E17 5DB • Seymour Road Practice - 266 Lea Bridge Road, E10 7LD

• Lime Tree & Sinnot Healthcare Ltd - 12A Sinnott Rd, E17 5QB • Claremont Medical Centre 29-31 Claremont Rd, E17 5RJ • The Forest Surgery - 2 Macdonald Road, Walthamstow, E17 4BA.

Chingford

• Churchill Medical Centre - 1 Church Terrace, E4 8DA • Handsworth Medical Practice - Handsworth Avenue, Highams Park, E4 9PD • The Ridgeway Surgery - 1 Mount Echo Avenue, E4 7JX • The Microfaculty - 107 Chingford Mount Road, E4 8LT • Old Church Surgery - The Silverthorn Centre, 2 Friars Close, Larkshall Road, E4 6UN • Kings Head Medical Practice - 178 Kings Head Hill, E4 7NX • Larkshall Medical Centre - 1 Larkshall Road, E47HS • Chingford Medical Practice Chingford Health Centre - 109 York Road, E4 8LF.

Member profiles/Composition of Governing Body

Details of NHS Waltham Forest CCG’s Governing Body, including profiles of its members are published on the CCG’s website. The Governing Body’s role is to make sure the CCG carries out its work effectively, efficiently and economically, by applying best practice principles of good governance. It currently consists of 18 members, seven of whom are GP clinical directors and are directly elected by members.

Key for all committee member and attendance tables below:

Present Apology Prior to No Meeting *Delegated Attendance appointment/after *Delegated Attendance Apology departure *Delegated Attendance Present

Governing Body Attendance 2017/18 Governing Body Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Members Dr Anwar Khan (AK) Helen Davenport (HD) Dr Dinesh Kapoor (DK) Dr Abdul Sheikh (AS) Dr Mayank Shah (MS) Dr Ravi Gupta (RGu) Henry Black (HB) Jane Milligan (JMi) Dr Ken Aswani (KA) Vineeta Manchanda (VM) Jane Mehta (JMe) Dr Tonia Myers (TM) Dr Rizwan Hasan (RH) Tim Spilsbury (TS) * Alan Wells (AW) Caroline White (CW) Previous members Terry Huff (TH) Les Borrett (LB) Dr Syed Ali (SA) Richard Griffin (RGr) Non-Voting Members Althea Bart (AB) * Joe McDonnell (JMc) Linzi Roberts-Egan (LRE)

Performance of the Membership Body and Governing Body, including their own assessment of their effectiveness

This year the CCG has built on the work of development sessions centred on the membership body and governing body’s assessment of their effectiveness. An all staff conference was held with the governing body in April 2017, setting out key priorities for 2017/18. A governing body work plan and delivery plan was developed as a result. An all staff development session was also held in April 2017 to examine progress against these priorities.

A number of development sessions for the governing body took place throughout the year, including those on:

• working with our healthcare partners to develop accountable care organisations

• conflict of interest management and review

• the practice portal for GPs and the CCG’s commissioning intentions

• cervical screening, transforming care partnerships and primary care commissioning intentions

• Whipps Cross Hospital ‘case for change’ and transformation of clinical pathways

• Primary care strategy, understanding what ‘primary care at scale’ means, quality improvement, working with our federation and innovations in tackling cardiovascular disease.

As part of a wider NHS England initiative the CCG continues to receive useful information for an intelligent and effective board to enhance its oversight function.

This includes the CCG’s board members continuous self-assessment against a number of key elements of good governance and identifying its aspirational aims for the next 12 months against key elements.

Following an assessment of its effectiveness through the NHS England process, the CCG has continued to work towards achievement against the resultant action plan in order to meet its aspirational aims, as it continues on its journey of continually improving the effectiveness of the membership body and Governing Body.

The CCG’s Governing Body members review their own effectiveness individually and collectively through the established appraisal and board development processes.

The table below summarises how these activities contribute to the governing body’s assessment of its own effectiveness.

Effectiveness indicator Promoted Promoted through through board development appraisals sessions

Individually and collectively understand what is   expected of them

Effectively carry out its functions in relation its  provision of strategic leadership to the organisation

Monitor the implementation of the strategic plans that  it sets for the organisation

Maintain an effective collaborative working relationship between the board and the executive management team on the one hand and, the board  and its internal and external stakeholders on the other hand

Makes effective use of governing body meetings 

Are satisfied that they make meaningful, informed and robust contributions to discussions at board meetings, and that the processes in place to facilitate  the conduct of the governing body meetings are sufficiently supportive to members of the board

Committee(s), including Audit Committee

Audit Committee The Audit Committee’s role is to provide assurance to the Governing Body that effective governance systems are in place to manage risk and support delivery of the CCG’s objectives.

The committee carries out this function by reference to the work of its independent assurance providers including external audit, internal audit and the local counter fraud specialist. It sets out an annual work programme that assesses compliance against key systems, including financial governance, information governance, policy management and the risk management framework including the board assurance framework.

The Audit Committee has developed an assurance map that allows it to map assurance across the wide range of activities at the CCG, and not rely too greatly on internal audit. This assurance map is reviewed regularly and updated.

The committee also undertakes regular deep dive sessions, where the committee scrutinises particular issues in greater depth.

The members of the committee and their attendance in 2017/18 is detailed below:

Member name Post

Vineeta Manchanda Lay Member, Chair Audit Committee

Alan Wells OBE CCG Vice Chair and Lay Member for Governance

Dr Rizwan Hasan Secondary Care Consultant

100

Audit Committee 2017/18 Members Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Vineeta Manchanda Alan Wells Dr Rizwan Hasan Other Les Borrett David Pearce Ian Clay Jon Hanlon Neil Hewitson Ali Azam Henry Black Steve Collins John Elbake Toyin Ajidele

Nick Atkinson Gemma Higginson Jack Stapleton

Abdel Montasir

101

CCG Patient Reference Group NHS Waltham Forest CCG’s Patient Reference Group (PRG), established in 2013, now sits at the heart of the CCG’s patient and public participation cycle, and as such is a key forum for patient and public involvement in the borough.

As a formal sub-committee of the CCG’s Governing Board, the CCG’s aim is for the PRG to have the following qualities:

• an active membership, that is, as far as possible, representative of the local population in terms of locality and demographics • to be well-led and supported • to be listened to • have members who seek to represent the community and are informed • engage with other patient involvement structures particularly PPGs, while recognizing its specific role. 2017/18 has seen a refresh of the PRG membership and the implementation of the vision developed in 2016, to develop a network of patient and public involvement across Waltham Forest with the PRG at the heart.

The members of the 2017/18 Patient Reference Group and their attendance 2017/18 is below:

Patient Reference Group 2017/18 Members Apr May Jun Jul A Sep Oct Nov Dec Jan Feb Mar ug

Adrian Dodd Alex Kafetz Ana da Cunha Lewin Caroline White Debbie Barker Fatima Khasimi Gary Sultanti Georgina Wright Jim Sarginson Khadija Gitay Liz Phillips Mary Logan Neil Adie Patricia Stephenson Richard Griffin Sylvia Debreczeny

Healthwatch Waltham Forest representative

102

Medicines Optimisation Committee The Medicines Optimisation Committee function is crucial in ensuring there is a consistent approach to commissioning of medicines within and across different care pathways. The Medicines Optimisation Committee work collaboratively with all stakeholders to ensure that robust standards and governance underpin all medicines optimisation functions. The Committee provides accountability for borough wide decision making to support and advice on all aspects of prescribing. The primary focus of the Medicines Optimisation Team has always been to provide continuous support to prescribers with the aim of improving the outcomes for patients. Hence the goal for 2017-18 was very much to ensure we begin to address the unwarranted variation in prescribing. Whilst maintaining a patient-centred focus, the Medicines Optimisation Team encourage cost-effective, evidence based prescribing thus ensuring value for money and improved outcomes for our local population.

This continued concerted effort to improve outcome for patients has translated into success in the following therapeutic areas:

• Respiratory - The Medicines Optimisation Committee (MOC) have taken a lead on the management of respiratory disease on the behalf of the CCG and has made waves in improving the uptake of spirometry; an essential diagnostic test to confirm Chronic Obstructive Pulmonary Disease (COPD). Hence, the local CCG quality performance indicator was met, enabling patients with COPD to be managed appropriately, improve their outcomes and also reduce medicines waste. • Antibiotics - The Medicines Optimisation Team (MOT) implemented and actively encouraged evidence based prescribing in line with the of the North East London (NEL) management of Infection Guidance for Primary Care. Hence this continued effort has seen an improvement in prescribing of antibiotics in general but has led to a reduction in the inappropriate prescribing of trimethoprim. Thus as a result of this work the CCG is now forecasted to meet the National Antibiotic Quality Premium on reducing the Trimethoprim: Nitrofurantoin prescribing ratio by 10% or more. • Outpatient Parenteral Antimicrobial Therapy (OPAT) - The team led on service redesign for Outpatient Parenteral Antimicrobial Therapy (OPAT) with the aim to improve the quality of life for the patient. The service has allowed patients to obtain care closer to home, reduced their length of stay in hospital and provided an alternative pathway to access intravenous antibiotics.

103

• National Consultations - 2017-18 addressed two national NHS England consultations, which both had a direct impact on the prescribing. The team facilitated these consultations by engaging with all key stakeholders in Waltham Forest including patients, clinicians and staff to raise awareness of these and to ensure that the voice of the borough was heard. • Medicines Waste - The team launched the “Tackling Medicines Waste in Waltham Forest” campaign in July 2017 to empower patients, prescribers and pharmacists to work collaboratively to address the issue head on and identify solutions in prescribing to benefit the local economy as a whole. • Care Homes - The Medicine’s Optimisation Team has been actively involved in reviewing medication for vulnerable patients in care homes who were at high risk of a hospital admission. Success of this work, led by the Medicine’s Optimisation Team, has translated in improved outcomes for patients, avoidance of unnecessary hospital admissions, a reduction in inappropriate polypharmacy and in an overall improvement in medicines management processes in the homes. • Discharge to Pharmacy - The significant financial and operation challenges in relation to medicines has helped to conceive the discharge to pharmacy project; an innovative integrated solution to address the wide scale problems associated with the use of medicines. The Medicines Optimisation Team is leading this project on the behalf of the East London Health and Care Partnership, to ensure large scale implementation of this programme, which gives rise to a number of patient orientated outcomes and enable true integrated working across the various organisations and help deliver seamless patient care of the various interfaces. • Prescribing Budget Management –The Medicines Optimisation Team manages the complete prescribing budget and is currently in a good position to meet the financial envelope and deliver the QIPP medicines target of £1 million.

104

IT committee The role of the IT committee is to direct the implementation of the IT and Digital strategy and take decisions as needed, such that the objectives of the local IT and Digital strategy are achieved and aligned to Sustainability and Transformation Partnership (STP) strategic direction.

Highlights from the committee in 2017/18 are below:

• In 17/18, Waltham Forest CCG started a three-year upgrade programme to have all practices to begin to offer online / video consultations. We continue to upgrade (where possible) our fibre backbone and improving our network wiring in practices.

• We are preparing as part of our STP to migrate from the old N3 to the new HSCN Infrastructure.

• Improved real-time information sharing between practices and Barts Health NHS Trust is fully implemented (eLPR). All 41 practices are now sharing data. Through this, Barts Health NHS Trust staff can view a summary of a patient’s GP record, subject to explicit consent (investigation underway to change to implied consent – aligning to the new European GDPR regulation. We in the process of further expansion to our real-time information sharing platform allowing sharing of mental and community data available to GP and vice versa.

• We are working in partnership with the Council (London Borough of Waltham Forest) we are in the process of introducing Digital Champions to assist GP practices in signing up patients to the GP online services.

• Currently, all practices are able to request pathology tests electronically. Barcodes are printed on to sticky labels and attached to samples, so when they arrive at the pathology lab they can be easily matched against the electronic request. We are in the process of further expanding implementation of electronic requests for radiology in all practices

• All 41 practices have a 2-way text messaging service to confirm patient appointments, this also allows automatic cancellations, thereby releasing appointment slots for other patients to use. Practices use text messages for informing patients about campaigns and the plan is to use the technology for further communication to patients (e.g. availability of test results). Following pilot last year regarding SMS data usage, via the Patient Online iPlato app (myGP), we have begun a full rollout of the myGP App, which is currently fully being used by 22 practices.

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• In partnership with Tower Hamlets, City & Hackney and Newham CCGs and Barts Health NHS Trust and the Homerton University NHS Foundation Trust, we have embarked on a collaborative project to deliver a new linked data service to support direct care diagnosis locally, as well as supporting the development of north east London as a learning health system that has benefits for direct quality of care, population health management and research to improve health at a population level.

• We are still investigating how to use available technology to enable GPs to work more flexibly by giving access to patient records during home visits.

Committee members and their attendance throughout 2017/18 is listed below:

IT Committee 2017/18 Members Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Dr Mayank Shah (MS) Harry Nyantakyi (HN) Dr Dinesh Kapoor (DK) Phil Koczan (PK) Carl Edmonds (CE) Adrian Dodd (AD) Shahnaz Begum (SB) Jessica Johnny (JJ) Edward Keating (EK) Aysha Patel (AP) Bill Jenks (BJ) Nicola Pearce-McGinn (NP-M) Other Richard Griffin (RG) Amanda Ellis (AE) Joan Fratter (JF) Simon Wheat (SW) Rebecca Waters (RW) Dr Thaven Chetty (TC) Ed Keating (EK) Les Borrett (LB) Aklasur Ahmed (AA) Ada Onyeagwara (AO)

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Locality Commissioning Committees There are three localities within Waltham Forest CCG - Walthamstow, Chingford and Leyton and Leytonstone. Their role includes providing direction to the Governing Body regarding future commissioning intentions, in line with the locality priorities; informing and shaping strategic proposals and developments; reviewing finance and activity data at locality level to drive improvements in quality and outcomes; and reducing inequalities.

In 2016/17 changes were made to the format in consultation with all three locality members. This involved revising the number of meetings per year and its format. As such the Clinical Directors agreed to have six CCG-led locality meetings per year and five Clinical Director/GP- led meetings to discuss locality specific issues and free up time for Commissioning Managers to be the first point of contact as a facilitator for practices and improve and strengthen the dialogue between CCG and members. The meetings continue to take place within a few days of each other with a consistent agenda across localities.

As a result of this, during 2017/18, Commissioning Managers and the Primary Care Managers jointly completed practice visits to all GPs to discuss the future of Primary Care, resilience/sustainability, Quality Improvement, CQC and the Primary Care Dashboard, and how the CCG and GP Practices can work together more effectively to meet the challenges and targets set out in the GP Five Year Forward View. This offers the opportunity to share information and have conversations regarding the future of Primary Care and how we are jointly preparing to address resilience and sustainability in Waltham Forest. During these practice visits we also discuss how the practice can be more effective and meet patients demand through usage of technology such as Patient Online, Friends and Family Test online and increasing usage of electronic referral services. We have shared and received feedback on the Estates Strategy and we support practices receiving funding to upgrade their premises to be fully compliant. We are continuously working collaboratively with the Council (London Borough of Waltham Forest) around new estate / development to offer our practices any available opportunity to move to newer and purpose-built premises which also promote practices working together and pool resources.

Throughout the year many topics have been covered, some for information others for review and feedback. A few highlights include:

• Regular medicines management updates • Regular public health updates • Regular primary care dashboard updates

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• Updates on the GP Federation Network • Feedback on pathology services, which has resulted in changes being implemented • Reviewing the pharmacy needs assessment • Feedback on pathology services, which has resulted in changes being implemented • Regular feedback on the CCG’s financial performance and quality, innovation, productivity and prevention reports • Input and updates relating to infrastructure and clinical programmes • The locality meetings continue to be reviewed to ensure that they remain an effective tool for GPs in their commissioning roles.

All GPs attend meetings on a regular basis. Practices for each locality are listed in the Members Report.

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Planning and Innovation Committee The role of the planning and innovation committee is to provide a forum that enables the identification of opportunities for new, evidence-based ways of working. This includes identification of new care pathways the CCG could introduce, ensuring that healthcare needs identified in the Joint Strategic Needs Assessment are factored into future plans, including the commissioning strategy plan and overseeing all groups and functions within the CCG that have responsibility for planning and redesigning services.

It provides the opportunity for clinicians to shape and inform service specifications. The committee oversees all groups and functions within the CCG that have responsibility for planning and redesigning services. The planning and innovation committee oversaw, reviewed and approved relevant projects and workstreams which support the CCG's strategic objectives and operational delivery workstreams.

Throughout 2017/18 the planning and innovation committee had oversight of the annual planning process and transformation agenda. Some highlights from the overall achievements of the committee are below.

• Supported the Atrial Fibrillation Clinic Care City pilot proposal for a one stop service for improving access and timely treatment for people in the community identified with atrial fibrillation.

• Provided clinical input into the service specification for the Outpatient Parental Antimicrobial Therapy (OPAT) service to enable administration of intravenous antibiotics to Waltham Forest patients in their homes or a nursing/residential care home

• Supported an innovative model for end of life care

• Provided clinical leadership and support for a range of programmes including the 111 procurement and the integrated urgent care collaboration

• Approved the planned care pathways implementation plan intended to set out Waltham Forest CCG’s strategy and approach to planned care services

The members of the committee and their attendance throughout 2017/18 is detailed below:

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Planning & Innovation 2017/18 Members Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Richard Griffin Enrico Panizzo Ken Aswani Ravi Gupta Gail Foord Abdul Sheikh Dinesh Kapoor Jane Mehta Tonia Myers Anwar Khan Anne Walker Ian Clay Mayank Shah Syed Ali Sharon Yepes -Mora Other Kelvin Hankins Nuzhat Anjum Lynn Snowden Lily Barnett Lindy Shufflebotham David Culley Dean Rigg Stephanie Good John Craig Hassan Serghini Paul Smollen

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Finance and Quality, Innovation, Productivity and Prevention (QIPP) committee The Finance and QIPP Committee’s role is to assure the Governing Body that effective controls are in place to meet the CCG’s financial targets, oversee the delivery of the QIPP (quality, innovation, productivity and prevention) plan and to review and approve business cases. It receives monthly reports on QIPP delivery and identifies actions needed to ensure compliance with targets. The members of the committee and their attendance throughout 2017/18 is detailed below.

Finance and QIPP Attendance 2017/18 Members Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Alan Wells (AW) Enrico Panizzo (EP) Ian Clay (IC) Jane Mehta (JM) Vineeta Manchanda (VM) Abdul Sheikh (AS) Kelvin Hankins (KH) Sharon Yepes-Mora

(SYM) Steve Collins (SC)

Other Paul Smollen Sharon, Nicola Ellie Sahin (Minutes) Les Borrett (LB) Ben Jupp (BJ)

In 2017/18 the committee considered a range of business cases for service developments, monitored the development of the 2018/19 budget, received quarterly monitoring reports regarding the CCG’s medicines optimisation programme, received regular updates on collaborative work ongoing within Waltham Forest around the urgent care and end of life pathways and approved the CCG’s operational resilience investment programme.

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Performance and Quality committee The role of the performance and quality committee is to ensure that the CCG acts with a view to securing the safety and continuous improvement in the quality of services, as well as performance in line with national and regional targets. This includes overseeing the execution of the CCG’s duties in relation to safeguarding of children and adults, and ensuring active and consistent engagement with the local Children’s Safeguarding Board and the Multi-agency Adult Safeguarding Board.

Highlights include:

Quality assurance visits: the committee set out an annual programme of quality assurance visits for acute providers, care homes, and residential looked after children's homes. The 2016/17 programme was closely monitored and completed. Reports have been aligned to the Care Quality Commissions key domains highlighting areas of concern and good practice. The reports are reviewed at the clinical quality review meetings and assurance sought that action has been taken to improve standards.

Performance scorecard: the committee oversaw development of a performance scorecard to be used as a tool to help monitor and manage performance. There has been enhanced reporting of quality performance across the CCG’s key providers. The scorecard has been implemented and is working successfully.

The Patient Experience report has been redesigned and provides feedback to the Committee in relation to all aspects of patient experience with provider services. It offers information from our providers that reflects patient perceptions.

Deep dives: the committee oversaw deep dives in certain areas, to gain further assurance on specific performance and quality issues.

Development of the Joint Quality Assurance Governance Model: Care homes across Waltham Forest have quality assurance visits and inspectors from the CCG, the Council (London Borough of Waltham Forest) and Healthwatch. Each of these visits focuses on a number of common elements and is undertaken at different times. There was no communication of results and co-ordinating of visits. In response, the committee worked with the Waltham Forest Adult Safeguarding Board, London Borough of Waltham Forest and Healthwatch to develop a joint quality assurance visit model and tools that will coordinate an effective multi-agency review and standardise the approach to undertaking visits in the care

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home sector. The ambition is to optimise the standard of care delivered by care homes, domiciliary care providers and partner agencies in Waltham Forest in order to reduce quality in care issues and safeguarding adult concerns to optimise safety, wellbeing and quality of life. By improving the standards of care, we can support the dignity and quality of life of adults in receipt of health and social care. The members of the committee and their attendance throughout 2017/18 is listed below.

Performance and Quality Attendance 2017/18 Members Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Helen Davenport Les Borrett Anne Walker Jonathon Cox Dee Parker Isabelle Davies Tutt Kelvin Hankins Ada Onyeagwara Dr Sabeena Pheerunggee Hassan Serghini Carl Edmonds Dr Tonia Myers Dr Mayank Shah Enrico Panizzo Dr Ken Aswani Zitha Moyo Sultana Rahman Korkor Ceasar Other Dr Minesh Mistry Kay Saini Paul Smollen Stephanie Good Tony Lawlor Helen Pace Sue Maugha Rachel Ustra Dr Lesley Perkins Mary Jamal Mark Emanuele Christine Kane Alison Glynn Nuzhat Anjum Alison Glynn Alex Lloyd Matthew Henry

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Remuneration and staffing committee In order to fulfil the fair pay criteria, senior management salaries for very senior managers (VSM) such as the Managing Director and Director of Finance at WFCCG are agreed by the remuneration and staffing committee, with due regard to NHS England guidance.

The role of the remuneration and staffing committee is to support the Governing Body in ensuring appropriate remuneration, allowances and terms of service for the staff and those who provide services to the CCG; having proper regard to the circumstances and performance of the organisation, and to the provisions of any national arrangements. The committee does not meet less than once a year and can be called to meet by the Chair of the committee as frequently as the need arises.

The committee has delegated authority to oversee the pay, terms and conditions of senior managers. When making decisions, the committee selects the appropriate rate within the range, taking into account the prevailing economic climate, local market conditions and the requirement to obtain the best possible value for money.

All other employee pay is set in accordance with the national agreements on pay and conditions of service for NHS staff. The CCG does not have a performance-related pay scheme, although it does have a robust performance management regime and all staff have clear objectives against which their performance is regularly reviewed.

In 2017/18 the Remuneration Committee for Waltham Forest CCG met three times. Once in March 2017 and twice in November 2017. In March they discussed protecting the inner London payment for CSU staff that had been TUPE across to the CCG and also the temporary extension of a lay person and secondary care clinician’s term of office. In November 2017 they discussed the interim Managing Director salary, the Accountable Officer notice period and the Accountable Officer salary.

The Remuneration Committee in Common met in January 2018 and October 2017. In October they discussed the salary for the single Accountable Officer, in January they discussed the Managing Director recruitment process, the Terms of Reference for the Remuneration Committee in Common and the performance-related bonus for the Single Accountable Officer.

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The members of the committee are:

Member name Post

Alan Wells OBE CCG Vice Chair and Lay Member (Chair)

Dr Syed Ali GP and Clinical Director (until January 2018)

Dr Rizwan Hasan Secondary Care Consultant

Terry Huff Chief Officer (until November 2017)

Dr Abdul Sheikh GP and Clinical Director

Alex Kafetz Independent member

Richard Griffin Lay Member

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Primary Care Commissioning Committee

The Primary Care Commissioning Committee’s function is to make collective decisions on the review, planning and procurement of primary care services in Waltham Forest under the CCG’s delegated authority responsibilities for primary care.

The committee enables the CCG to work according to its fully delegated status for primary care services and allows for co-commissioning functions which support quality, efficiency, productivity and value for money and help to remove administrative barriers. The functions mean that the CCG is able to work towards providing patients with a better experience through more joined up services and joint up care.

The committee aims to support the delivery of the primary care strategy, other CCG strategies and priority areas and the wider primary care agenda. The core aim of this work involves improving performance and quality, addressing variation, supporting practices and patients to work towards transforming primary care in the borough to ensure sustainable and integrated primary care service delivery and improved outcomes.

Key highlights for 2017/18

There have been a range of areas that the committee has been involved in the previous year including the development of primary care Quality Improvement programme, monitoring of the primary care dashboard as a tool to support and drive quality improvement development and agreement of schemes linked to the GP Five Year Forward View, including the practice resilience and sustainability programme, developing training for new roles within general practice and taking forward the digital transformations and working at scale projects.

The committee also managed and made decisions in regard to a wide range of contractual areas including the agreement of commissioning intentions in regard to the PMS/GMS review, agreement of mergers, dispersals, procurements of new services.

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Primary Care Attendance 2017/18 Members Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Alan Wells Terry Huff Les Borrett Attracta Asika Dr Azeem Nizamuddin Vineeta Manchanda Jane Mehta Aysha Patel Sultana Rahman Caroline White Anne Walker Alison Goodlad Joe McDonnell Jonathan Cox Darren Newman Dr Tonia Myers Dr A Sheikh Dr D Kapoor Dr Gabriel Ivbijaro Other Linda Finch Jacqueline Pluck Lorna Hutchinson Aklasur Ahmed Matthew Henry Scott Smith Tarlochan Boparai Althea Bart Janaka Perera Richard Griffin Sharon Yepes-Mora Shahnaz Begum Carl Edmonds Harry Nyantakyi Rebecca Waters Kasia Gaj

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NHS Waltham Forest CCG is committed to the principles of good governance and works to ensure that it is transparent, effective and ethical in its decision making. In line with the most up-to-date statutory guidance, a policy to manage conflicts and potential conflicts of interest has been established to ensure that decisions made by the CCG are taken, and are seen to be taken, without any possibility of the influence of external or private interests. The management of conflicts of interest is linked to the CCG’s management of gifts and hospitality, for which there is a separate policy.

The CCG keeps registers of interest, which are reviewed regularly and updated, for Governing Body Members, CCG staff and GP practice staff, who may be involved in any of its commissioning decisions. Additionally the CCG keeps and maintains a register of any gifts and hospitality, and a register of procurement decisions taken. Registers of Interest are published on the CCG’s website. During 2017/18 there was one recorded breach reported to NHS England. Details of breaches are again published on the CCG’s website.

Personal data related incidents NHS Waltham Forest CCG has submitted a satisfactory level two compliance with the information governance toolkit assessment. We have not experienced any serious untoward incidents relating to data security breaches between 1 April 2017 and 31 March 2018

Statement of Disclosure to Auditors

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

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

Modern Slavery Act

NHS Waltham Forest CCG fully supports the Government’s objectives to eradicate modern slavery and human trafficking. NHS Waltham Forest CCG’s Slavery and Human Trafficking Statement for the financial year ending 31 March 2017 will be published on the CCG’s website at www.walthamforestccg.nhs.uk by 28 June 2018.

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Statement of Accountable Officer’s Responsibilities 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 Jane Milligan to be the Accountable Officer of NHS Waltham Forest 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 CCG’s assets (and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities); • The relevant responsibilities of accounting officers under Managing Public Money; • Ensuring the CCG exercises its functions effectively, efficiently and economically in accordance with Section 14Q of the 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:

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• Observe the Accounts Direction issued by NHS England, including the relevant accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis; • Make judgements and estimates on a reasonable basis; • State whether applicable accounting standards as set out in the 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 CCG’s 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.

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.

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Governance Statement Introduction and context

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

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

As at 1 April 2018, the clinical commissioning group is not subject to any directions from NHS England issued under Section 14Z21 of the National Health Service Act 2006

Scope of responsibility

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

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

Governance arrangements and effectiveness

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

The CCG’s Constitution sets out the arrangements it has made to meet its responsibilities for commissioning care for the people for whom it is responsible. The Constitution describes the governing principles, rules and procedures that the Group will establish to ensure probity and accountability in the day to day running of the clinical commissioning Group; to ensure that decisions are taken in an open and transparent way and that the interests of patients and the

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public remain central to the goals of the Group. This includes, for example, specific details relating to the CCGs functions and responsibilities, decision making structures and how it manages conflicts and potential conflicts of interest.

Responsibilities for decision making is distributed throughout the CCGs governance structure. These are defined in what is referred to as the Scheme of Reservation and Delegation which sits as an appendix to the main body of the Constitution.

The Scheme of Reservation and Delegation sets out:

• those decisions that are reserved for the membership as a whole

• those decisions that are the responsibilities of its Governing Body (and its committees), the Group’s committees and sub-committees, individual members and employees.

The Group remains accountable for all of its functions, including those that it has delegated.

Further information regarding the split of responsibilities and decision making between the CCG’s Membership and the Governing Body can be found in the constitution on the CCG’s website

For information about:

• Waltham Forest CCG’s Membership Body and Governing Body, including key responsibilities, membership, attendance records, and highlights of work over the year see page 90

• Any committees and sub-committees of the above, including key responsibilities, membership, attendance records, and highlights of their work over the year see from page 100 onwards

• the performance of the Membership Body and Governing Body, including their own assessment of their effectiveness, see page 98.

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UK Corporate Governance Code NHS Bodies are not required to comply with the UK Code of Corporate Governance, however the CCG has reported on our corporate governance arrangements by drawing upon best practice available, including those aspects of the UK Corporate Governance Code we consider to be relevant to the CCG and best practice. Specifically this applies to our leadership; effectiveness; accountability; remuneration; and relations with patients, the public, providers and other stakeholders.

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

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

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Risk management arrangements and effectiveness

The CCG recognises that risk management is a supporting element in the delivery of its strategic initiatives and corporate objectives. Our approach to risk management and assurance seeks to embed recognised and developed best practices, in accordance with legislation and both national and local guidance.

Our risk identification process is wide-ranging, continuous and comprehensive and is subject to regular reviews and improvements. The process involves viewing all potential sources of risk from different perspectives and using a variety of methods to tackle them. These methods include:

• Frontline staff identifying and reporting risks through our established processes

• Business planning including strength, limitation, opportunity and threat analysis

• Feedback from service users (e.g. complaints, surveys, and through our CCG Patient Reference Group)

• Performance monitoring of organisational data and use of performance indicators in benchmarking, including delivery of QIPP schemes

• Adverse incident, near miss reporting and incident investigation, including root cause analysis

• Results of internal and external audits

• Using external organisations and sources.

The CCG’s board assurance framework is the vehicle through which the Governing Body takes assurance that the controls and actions applied in the mitigation of the CCG’s strategic risks are operating effectively. Hence the board assurance framework is a key element of the risk management process.

The purpose of the CCG’s risk management framework is therefore to:

• Ensure compliance with all standards and regulations that apply to healthcare for all commissioned services.

• Ensure as far as reasonably possible, a common and integrated approach to risk management across the CCG.

• Implementation and management of a robust assurance framework that addresses CCG key risks with a relevant and appropriate escalation mechanisms

• Ensure common understanding of terminology used in relation to risk issues.

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The reporting and escalation of risks is shown in the diagram below:

The Risk Management Structure in Waltham Forest Clinical Commissioning Group

This illustrates the CCG’s structured approach to risk management across all its activities. The BAF is subject to review and challenge by the Audit Committee on behalf of the Governing Body.

To provide additional assurance, and thereby providing a further control mechanism, the BAF includes details of those with responsibility of providing management oversight of individual risk areas and who are responsible for reviewing in detail the effectiveness of the controls and risk mitigation plans. Consequently, the detailed management of risk in the main is not managed by the Governing Body or the Audit Committee but by the relevant committee that reports to the Governing Body. This is where the Board Assurance Framework risk issues are addressed in detail thereby providing an additional layer of assurance.

An additional control mechanism, and consequential level of assurance of the risk management process, is provided through the internal audit plan, a key element of which is a review of the effectiveness of the CCG’s risk management framework, governance arrangements and counter fraud.

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The internal audit plan is but one element of the CCG’s overall risk management assurance plan which is overseen by the Audit Committee and includes such things as the CCG’s corporate responsibilities, management of the CCG’s policies and oversight of the NELCSU provided services, including information governance. The totality of the assurance plan thereby provides the necessary assurances to the Governing Body in respect to the CCG’s management of risk in relation to their prevention, deterrence, including fraud deterrents, and the effectiveness of the management of the CCG’s current risks at any one time.

Risk management is therefore embedded within the organisation in a number of ways. This includes the work of the Audit Committee and its supporting assurance plan referred to above along with a proactive approach to the management of the CCG’s individual risk registers and reports to the Governing Body, each of which includes an equality impact assessment in the report’s accompanying cover sheet.

At the moment the CCG does not specifically record which risks are likely to impact on public stakeholders. However the CCG’s structure allows the public to participate in managing organisational risks in a number of ways, including:

• Governing Body papers are published on our website; our Governing Body meetings are open to the public; and the public are able to ask questions.

• Governing Body meetings are regularly attended by representatives of the ‘Waltham Forest Save Our NHS’ group

• CCG plans are also discussed at the Waltham Forest overview and scrutiny committee and Health and Wellbeing Board, which are also open to the public.

• We engage the local community via our face-to-face Patient Reference Group and virtual rapid feedback network.

• When we are considering medium or large scale service change, we run formal consultation processes.

• Active participation on specific committees of the CCG including the IT Committee.

• We record that there is a risk of the ‘lack of involvement of patients, communities and hard to reach groups in WFCCG activities’ as a zero tolerance risk on our BAF.

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Risk assessment

The severity of any particular risk is assessed on its likelihood of occurring and the consequences that the risk would have were it to materialise. This is based on the universally acknowledged approach to assessing risks through a consideration of risk likelihood and risk consequence.

The resultant risk ratings are moderated by the CCG’s executive management team and the audit committee, to ensure consistency in application of ratings to reflect the CCG’s risk appetite against any individual risk.

The CCG has determined that it’s risk appetite for risks to be considered for escalation to the BAF are those directorate recorded risks with a risk score of 12 as determined by combination of its likelihood and impact as described below, or those risks which have remained as a high rated risk for a period of 6 months or more.

This acknowledges that there is no risk classification system that is applicable to all types of organisations and consequently respects the variability and dynamism of the CCG activities.

The likelihood of a particular risk occurring is assessed against the criteria shown below. A score of 1 to 5 is allocated dependent upon the assessed likelihood category determined.

Score 1 2 3 4 5 Description Rare Unlikely Possible Likely Certain Frequency The risk may The risk is not The risk might There is a The risk is occur but only in expected to occur at some strong expected to exceptional happen but time. There is possibility occur. circumstances there is a some history that the risk possibility that of it, or similar will occur. There is a it could occur occurrences, There is a history of it, at some time having history of it, or similar occasionally or similar occurrences, happened in occurrences, regularly the past frequently happening in happening the past in the past

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The impact (or consequence) of a risk occurring is assessed against the criteria shown below.

A score of 1 to 5 is allocated dependent upon the assessed impact that the risk would have on the organisation’s corporate, principle and business objectives, if it were to occur.

Score Description Impact Description

5 Severe There is a very major and potentially disastrous impact on the achievement of the corporate objective(s) 4 High There is a major impact on the achievement of the corporate objective(s) 3 Moderate There is a significant impact on the achievement of the corporate objective 2 Minor There is some impact, albeit not significant, on the achievement of the corporate objective(s) 1 Negligible There is minimal impact on the achievement of the corporate objective(s)

The CCG therefore has a robust and effective risk management framework in place, describing how risks for individual projects and work streams, directorates and strategic risks are reported through the BAF to the governing body.

Risks are assessed, as described above, based on the likelihood of the risk occurring and an assessment of the impact of the risk if it was to occur. This establishes a risk score which in turn determines the profile of risks across the CCG and how and where individual risks are being managed. The majority of risks are managed within the individual CCG directorates. However risks of a strategic nature which have a high score rating reflective of the CCGs risk appetite and are seen as having significant impacts on the CCG achieving its corporate objectives are identified to the governing body through the BAF.

At March 2018 the CCG had recorded 47 risks across its directorate risk registers, of which 6 had been escalated to the BAF. Key risk areas reported through to the BAF include provider performance in respect to compliance to the Care Quality Commission’s (CQC) prescribed standards of care, compliance to national targets in respect to A&E 4 hour wait targets and referral to treatment (RTT) times, and the achievement of the CCGs financial targets. New

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risks added in - year relate to a variation in the delivery of primary care services and achievement of a balanced financial plan for 2018/19

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Risk appetites are determined by individual risk owners and moderated by the executive management team during the monthly review of the BAF. The audit committee and Governing Body approve the BAF periodically, as set out in the constitution, including the risk appetite scores. Control mechanisms have been chosen according to best practice and management approaches agreed as appropriate by risk leads.

Current risk Directorate Risk Description rating reporting Progress to date the risk Risk No 4 Finance First reported on the BAF: June 2017 Planned Surplus: First reported BAF risk rating:

The CCG fails to achieve its planned surplus : due to (i) non- achievement of its £14.2M QIPP Changes in the risk rating since first reporting

plan; (ii) performance against acute contracts and continuing health care costs 2017/18

15 The risk rating has increased from risk rating 12 to risk rating 15 following significant This risk aligns to: increases in costs through the Bart’s Health contract from month 9 to month 10.

Corporate Objective 1: Forecast rating of the risk to its acceptable level: Meeting our statutory requirements

Corporate Objective 3: Target risk rating: Date expected to reach Target Risk Rating March 2018 Latest predicted risk rating Strengthening collaboration across NEL CCGs and providers to transform services to achieve Predicted rating last time reported to the Governing Body (January 2018) the national ambition for the NHS Management oversight of this risk is provided through the Finance and QIPP Committee.

Risk Mitigation Actions: 1. Budget agreed by the CCG Governing Body in March 2017 with identified project leads and risk assessments in place. Target action complete date: March 2018

2. Further schemes have subsequently been identified totalling £1.1M and a process to review all commissioned services completed with £0.5 M additional QIPP so far identified. Target action complete date: March 2018

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3. Settlement has been reached with Bart’s Health in relation to closing down the 2017/18 contract albeit that the impact at individual CCG level has yet to be finalised. Target action complete date: March 2018

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Interpreting the BAF Templat

Current risk Directorate Risk Description rating reporting the risk Progress to date : EXAMPLE FOR ILLUSTRATION ONLY

Finance First reported on the BAF : April 2014 This risk aligns to Corporate Objective 1: Shows full BAF history First reported BAF risk rating: Meeting our statutory requirements including previous Changes in the risk rating since first reporting: years and to Corporate Objective 3: 2014/15 Strengthening collaboration with WEL/WELC, local providers and establishing commissioning 16 arrangements

Risk F4: 2015/16 Specific target The CCG does not achieve its target for 95% of reached date A&E attendees to be treated within 4 hours, as per the NHS Constitution, due to poor performance by Barts Health and other key providers. The risk rating has remained unchanged since the last report to the Governing Body There is an associated reputational risk for Committee where risk Forecast rating of the risk to its acceptable level: WFCCGas the lead commissioner for services is reviewed in detail at Whipps Cross Hospital. Target risk rating: Date expected to reach Target Risk Rating March 2016

Latest predicted risk rating

Pedicted rating last time reported to the Governing Body (March 2015) Links to 2015/16

Corporate Objectives Management oversight of this risk is provided through the Performance and Quality Committee

Action plans: Date action planned to The CCG is working with Whipps Cross to agree plans to deliver the revised A&E be completed trajectory in 2015/16. This includes providing funding for support implementation at the 'One Version of the Truth' McKinsey review. (June 2015)

The CCG is commissioning a pilot for extended access to primary care, intended to reduce A&E demand. (September 2015)

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The number and scope of risks reflects both the CCG’s increasing maturity in its ongoing development of its risk management processes and awareness and the increasing scope of the CCG’s activity portfolio. As previously identified, of particular note are the risks reported through the BAF, a majority of which relate to the performance of the CCG’s key providers within the local health economy and that impact on achievement of the CCG’s strategic objectives.

The success of the CCG in managing its risk profile has been demonstrated through the outcome of two independent audits of its risk and BAF management processes which resulted in the CCG receiving substantial assurance ratings.

Risks are reviewed on a regular basis, with directorate risks registers being updated and reviewed by individual directors on a monthly basis and the BAF on a bi-monthly basis. This ensures alignment with the Audit Committee, whilst directing the Governing Body meeting agendas thereby ensuring it maintains a high degree of rigour and oversight of the CCG’s performance, including its management of key strategic risks.

Whilst the Governing Body has overall oversight and accountability for the risk management framework, it receives assurances from the Audit Committee Chair that the processes for managing its strategic risks are effective. The Audit Committee in turn receives support from the internal auditors and the outcomes from the internal audit plan, which specifically includes assurances on the risk management process.

The Audit Committee also provides the same scrutiny and challenge on individual directorate risk registers. These are further supported through a schedule of deep dive reviews to ensure that effective controls are in place on key assurance areas such as performance and quality reporting processes.

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At March 2018, the risks to the CCG with the highest residual scores were:

Risk No 1:

NHS Waltham Forest CCG does not achieve its targets for Referral to Treatment (RTT) waiting times due to poor performance by its providers, particularly Bart’s Health.

There is an associated reputational risk for the CCG as the lead commissioner for services at Whipps Cross Hospital (WXH).

Risk No 2:

The CCG is not achieving its target for 95% of A&E attendees to be treated within 4 hours, as per the NHS Constitution, due to poor performance by Barts Health and other key providers.

There is an associated reputational risk for WFCCG as the lead commissioner for services at Whipps Cross Hospital (WXH).

Risk No 3

Performance Targets

The CCG does not meet its national and local performance targets. This means that the CCG may fail to ensure that there are improvements to the quality and performance of commissioned services leading to potential harm to patients.

There is an associated reputational risk for the CCG as the lead commissioner for the provision of services.

Risk No 4

Planned Surplus:

The CCG fails to achieve its planned surplus due to (i) non- achievement of its £14.2M QIPP plan; (ii) performance against acute contracts and continuing health care costs

Risk No 5

Primary Care

There is a risk that a variation in the delivery of primary care compromises patient safety, patient experience and the provision of quality of care, highlighted in the Integrated Assessment Framework (IAF) report. This means that patients are not receiving equitable standards of service leading to poor outcomes.

Risk No 6

2018/19 Budget:

The CCG has a total draft QIPP plan of £12million for 2018/19. At February 2017/18 there is £5million that remains unidentified or under assessment. This means that there is a risk to achievement of a balanced plan for 2018/19.

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Capacity to handle risk

The CCG’s Audit Committee, acting on delegated authority from the Governing Body, ensures that there are robust and independent assurance mechanisms in place that provide for effective risk management systems and processes, including escalation. Reports relating to the management of risks within the CCG’s individual directorates are regularly reported to the Audit Committee. The Audit Committee Chair regularly updates the Governing Body on risk issues and the effectiveness of risk management within the CCG.

The Audit Committee is supported in its work by the CCGs internal auditors who carry out their work to an agreed internal audit plan. Resultant audits and deep dives highlight, where appropriate, areas of improvement based on recognised guidance and emerging best practices.

The Governing Body has overall responsibility for ensuring that they are assured that the processes of risk identification, evaluation and control are effective. This is achieved through the management and application of the board assurance framework.

The provision of appropriate and targeted training is a key ingredient in the achievement of embedding risk management systems and processes within the CCG, and this is delivered through a number of channels that include real time coaching by risk leads and, if deemed appropriate, formal training sessions.

Other sources of assurance

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

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

NHS Waltham Forest CCG’s Governing Body is collectively accountable for maintaining a sound system of internal control, and is responsible for putting in place arrangements for gaining assurance about the effectiveness of that overall system.

It achieves this through its various committees to which it delegates its authority. Assurances on the effectiveness of the internal control processes, clinical and non–clinical, are provided to the Governing Body through the Audit Committee.

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In particular, the audit committee reviews the adequacy and effectiveness of:

• All risk and control related disclosure statements together with any accompanying Head of Internal Audit statement, external audit opinion or other appropriate independent assurances, prior to endorsement by the CCG’s Governing Body

• The underlying assurance processes that indicate the degree of the achievement of corporate objectives, the effectiveness of the management of principal risks and the appropriateness of the above disclosure statements

• The policies for ensuring compliance with relevant regulatory, legal and code of conduct requirements and related reporting and self-certification

• The policies and procedures for all work related to fraud and corruption as set out in Secretary of State Directions and as required by NHS Counter Fraud Authority

• The CCG’s arrangements for effective management of all matters relating to contractual performance and associated financial performance

• The CCG’s arrangements for the effective management of conflicts of interest in order to ensure compliance with statutory guidance.

In carrying out its work the Audit Committee primarily utilises the work of internal audit, external audit and other assurance functions, but is not limited to these sources. As such it also seeks reports and assurances from directors and managers, as appropriate, concentrating on the over-arching systems of integrated governance, risk management and internal control, together with indicators of their effectiveness including a scheduled deep dive process within the audit committees overall assurance plan.

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.

During the 12 month period from 1 April 2017 to 31 March 2018 there have been no significant internal control issues identified.

Annual audit of conflicts of interest management The revised statutory guidance on managing conflicts of interest for CCGs (published June 2016) 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.

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The CCG’s internal auditors have undertaken a conflicts of interest audit for the management of conflicts of interest as part of their annual audit plan. The auditors determined that at the point of the audit, the Governing Body could take substantial assurance that the controls in place to manage risks associated with the management of conflicts of interest are suitably designed and consistently applied.

The CCG has further undertaken its annual conflicts of interest audit for the management of conflicts of interest using an NHS England published audit framework against which the CCG was fully compliant, whilst noting that the requirement for mandatory training by some staff groups had been extended to May 2018.

Data Quality NHS Waltham Forest CCG’s approach is to ensure data quality is embedded across everything the CCG’s manages directly, and through our contracted relationship with North and East London Commissioning Support Unit and acute and community providers.

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.

NHS Waltham Forest CCG places high importance on ensuring there are robust information governance systems and processes in place to help protect patient and corporate information. The CCG has established an information governance management framework and developed information governance processes and procedures in line with the information governance toolkit, (IGT).

In achieving of the mandatory IGT level 2 compliance, the CCG has ensured its staff are compliant with information governance training requirements, and has implemented a staff information governance handbook. This is supported by regular all staff communications, to ensure that employees are aware of their information governance roles and responsibilities, and the latest developments within information governance management.

Where personal information is to be shared between any two or more of the partners then individual data sharing agreements setting out the common set of rules to be adopted by those

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involved in the sharing arrangements are established. This ensures legal basis for sharing information between parties by consent or under the Data Protection Act 1998 or other statute.

NHS Waltham Forest CCG has a secure email transmission network in place. This is supported and maintained through the local commissioning support unit and ensures that data transmitted within the network is done so securely. Where it is necessary to transmit personal information outside of the CCG’s own secure network, then The Information Security Management: NHS code of practice should be followed.

NHS Waltham Forest CCG’s agreement with NHS Digital ensures that we have safe and secure arrangements and controls in place that allow us to use anonymised data in the analysis of health care provision to support the needs of our local population, based on analysis of patient data across health pathways.

There are processes in place for incident reporting and investigation of serious incidents. We continue to develop our information risk assessment and management procedures and to embed an information risk culture throughout the organisation against identified risks.

Business Critical Models

In line with best practice recommendations of the 2013 MacPherson Review into the quality assurance of analytical models, NHS Waltham Forest CCG can confirm that an appropriate framework and environment is in place to provide quality assurance of business critical models. Quality assurance processes for those models are also continually monitored by the governance team.

The CCG has an equal opportunities policy and procedure, and our recruitment advertising is designed to attract suitably qualified, skilled and experienced candidates from all sections of the community and the existing workforce. Appropriate training is available to ensure that those responsible for making selection decisions will not discriminate, consciously or unconsciously, when making such decisions.

All employees have equal access to training and development activities and are protected by the dignity at work policy for discrimination, victimisation and/or harassment.

The CCG recognises the importance in making decisions about the services it procures in a way that does not call into question the motives behind the procurement decision that has been made.

The CCG is committed to procuring services in a manner that is open, transparent, non- discriminatory and fair to all potential providers.

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Third party assurances Where the CCG relies on third party providers, The Audit Committee provides assurance to the Governing Body based on the facts and merits of specific contracts and business cases. This provides an avenue for robust and effective scrutiny aligned with the governance processes of the CCG. The CCG will continue to seek ways to improve its internal governance mechanisms in line with best practice, relevant guidance issued by NHS England and relevant bodies; as well as applicable laws.

Control Issues

As at Month 9 2017/18, there were no known governance or performance issues significant enough to highlight via the CCG Governance Statement to NHS England.

The Finance and Quality Innovation Productivity and Prevention (QIPP) committee provides a forum for the review of NHS Waltham Forest CCG’s finances and QIPP delivery; it also gives the Governing Body information and an analysis of the financial position and helps shape the organisation’s financial strategy. The committee reviews the financial performance of services commissioned by the CCG and provides members with detailed information on the financial performance of contracts in terms of cost, activity, effectiveness and value for money. It also provides advice and support to CCG members in developing plans, undertaking analyses, receives commissioning proposals and business cases and advises on the implications of each. The Finance and QIPP Committee is ultimately accountable to the CCG Governing Body.

The Planning and Innovation Committee provides a forum that enables the identification of opportunities for new, evidence-based ways of working. This includes identification of new care pathways the CCG could introduce, ensuring that the Joint Strategic Needs Assessment is factored in to future plans (including the Commissioning Strategy Plan), and overseeing all groups and functions within the CCG that have responsibility for planning and redesigning services. The Planning and Innovation Committee is ultimately accountable to the CCG Governing Body.

The Audit Committee was established in order to provide the Governing Body with an independent and objective review of their financial systems, financial information and compliance with laws, guidance and regulations governing the NHS. The committee critically reviews the CCG’s financial reporting and internal control principles and ensures an appropriate relationship with both internal and external auditors is maintained.

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The Primary Care Commissioning Committee has been established to enable members to make collective decisions on the review, planning and procurement of primary care services in Waltham Forest under delegated authority from NHS England. The functions of the Committee are undertaken in the context increasing quality, efficiency, productivity and value for money.

The Governing Body has overall responsibility and powers to decide and act on behalf of the CCG except where stated otherwise in law and within the CCG constitution. It ensures that the CCG has appropriate arrangements in place to exercise its functions effectively, efficiently and economically and in accordance with principles of good governance. It also approves commissioning plans and the performance monitoring of those plans and ensures value for money.

Delegation of functions Waltham Forest CCG took on delegated commissioning for primary care services in April 2015. In order to effectively manage the resources involved, it established a Primary Care Commissioning Committee which oversees the CCG’s primary care strategy and reports to the Governing Body. The committee is chaired by a lay member, and has external GP and lay representation, as well as members from the local authority.

The CCG’s internal auditors reviewed the systems for delegated commissioning as part of their annual plan. The CCG continues to receive support from NHS England in discharging these functions, including contract management and financial assurance. This support is described in a memorandum of understanding agreed across the North East London CCGs and NHS England. The CCG’s internal auditors review the systems for delegated commissioning, as part of their annual plan.

The CCG also receives a range of services provided through the North East London Commissioning Support Unit (NEL CSU) which are detailed in an agreed Service Level Agreement (SLA). The CCG receives assurances on the quality of services and any associated risks or control failures provided by NEL CSU through regular reports to its Audit Committee.

The CCG strengthened its management of conflicts of interest in line with revised statutory guidance published by NHS England.

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Counter fraud arrangements NHS Waltham Forest CCG is committed to reducing fraud and bribery against the NHS and has appointed an accredited Local Counter Fraud Specialist (LCFS) through the CCG’s internal auditors, RSM.

The LCFS works to a risk-based annual plan, agreed by the Director of Financial Strategy and the Audit Committee. The plan is designed around the NHS Counter Fraud Authority Standards for Commissioners and compliance with these standards is reported to the Audit Committee.

The CCG works closely with NHS Counter Fraud Authority to implement any actions arising from quality assurance reviews, to ensure that our anti-fraud and bribery arrangements are sufficiently robust.

The CCG has anti-fraud and bribery policies in place, which are kept up to date to reflect current legislation.

The LCFS provides advice and fraud awareness to CCG staff and members, and is the first line of defence against fraud and bribery within the CCG.

Head of Internal Audit Opinion

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

For the 12 months ended 31 March 2018 the Head of Internal Audit concluded that the organisation has an adequate and effective framework for risk management, governance and internal control. However our work has identified further enhancements to the framework of risk management, governance and internal control to ensure that it remains adequate and effective.

Based on the work undertaken in 2017/18 there is generally a sound system of internal control, designed to meet the CCG’s objectives, and controls are generally being applied consistently.

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CCG Internal Audit Plan

We have provided either a substantial or reasonable level of assurance in the areas reviewed throughout the course of this year.

Substantial Assurance

The following reports have been issued with reasonable assurance opinions assigned:

• Board Assurance Framework and Risk Management • Provider - Quality and Performance Management • Budget Setting, Budgetary Control and Financial Reporting • Conflicts of Interest Reasonable Assurance

The following reports have been issued with reasonable assurance opinions assigned:

• Patient Engagement • QIPP

CSU Quality Assurance Plan

We have provided reasonable assurance in the areas reviewed, with two exceptions relating to Procurement and Continuing Healthcare where partial assurance opinions were assigned, meaning that the Governing Body can take partial assurance that the controls to manage risks were suitably designed and consistently applied, and that action was needed to strengthen the control framework to manage the identified risks.

Procurement

There was limited service specification within the SLA with the CSU. More clarity was required to define roles and responsibilities of the two parties whilst confirming the CCG expectations on reporting and monitoring on procurement from the CSU. We also found inadequate documentation held on the conflicts of interest declarations and quotation documentation for a sample of procurement exercises undertaken by the CSU.

Continuing Healthcare

A number of quality issues were found relating to three month and annual reviews which were neither always completed, nor completed within the timescales by Providers. In addition; the

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completion of the fast track tools was not undertaken by the Provider before decisions were made to fast track patients.

Furthermore, there were non-compliance and control issues on Individual Service User Placement Agreements being in place, the uploading of panel decision letters onto Broad Care, timely invoicing and Standing Operating Procedures not reflecting current practices.

Reasonable Assurance

We have issued the following reviews with reasonable assurance opinions assigned; these reviews relate to the following:

• Recruitment • Provider Quality Management • Acute and Non-Acute Contracting • Data Quality and Performance Management

In addition to the reports, there were also two advisory follow up reviews on Information Governance Toolkit and a follow up report on Cyber Security Follow Up and Risk Assessment. Our review on Cyber Security follow up concluded that the CSU has demonstrated some progress in implementing the agreed management actions that had arisen from the original Cyber Security review undertaken in 2016/17.

We are continuing to follow up on outstanding actions and continually reporting to the audit committee on progress through our progress reports.

Topics judged relevant for consideration as part of the annual governance statement

Based on the work we have undertaken to date on the CCG’s system on internal control, we do not consider that within these areas there are any issues that need to be flagged as significant control issues within the Annual Governance Statement (AGS), although the CCG may wish to consider the potential significance of the control issues identified during the course of the CSU Continuing Healthcare and Procurement reviews, all provided with partial assurance opinions. The CCG may also wish to consider whether any other issues have arisen, including the results of any external reviews which it might want to consider for inclusion in the Annual Governance Statement.

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Other factors considered for this opinion

We have reviewed the Service Auditor Report for National Shared Business Services, who provide financial transactional support to the CCG, via its contract with NHS England. No notable exceptions were reported.

The Service Auditor Report for NHS Digital did not raise any exceptions. NHS Digital (the trading name of the “Health and Social Care Information Centre”) provides IT services as part of the end to end service alongside other organisations to support processing of NHS payments and deductions to providers of general practice (“GP”) services in England. The service auditor report was for the year ending 31 March.

We reviewed the Service Auditor Reports for Capita, who process payments to providers of general practice via a contract with NHS England, from whom the CCG has delegated primary care commissioning responsibilities. Whilst there has been some improvement in the number of control exceptions, there remained seven out of sixteen key controls assessed as suitably designed but not appropriately complied with over the period October 2017 to March 2018. Management action plans are in place to remedy the issues identified.

We have reviewed the Service Auditor Report for NEL Commissioning Support Unit, who provide some financial and payroll services to the CCG. We reviewed reports covering the eleven months to 28 February 2018 and the accompanying bridging letter to take the period covered up to 31 March 2018. Whilst we noted a number of exceptions were identified, we do not consider amongst these there are any which represent a significant risk to the CCG’s control environment.

We have also liaised with the Local Counter Fraud Specialist and External Audit as appropriate.

Annual opinions

The following shows the full range of opinions available to us within our internal audit methodology to provide you with context regarding your annual internal audit opinion.

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Annual opinions Factors influencing our opinion

The factors which are considered when influencing our opinion are: • inherent risk in the area being audited;

• Limitations in the individual audit assignments

• The adequacy and effectiveness of the risk management and / or governance control framework

• The impact of weakness identified

• The level of risk exposure

• The response to management actions raised and timeliness of actions taken.

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Review of the effectiveness of governance, risk management and internal control My review of the effectiveness of the system of internal control is informed by the work of the internal auditors and by the 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.

The whole Governing Body is collectively accountable for maintaining a sound system of internal control and is responsible for putting in place arrangements for gaining assurance about the effectiveness of that overall system.

The CCG’s Audit Committee, acting on delegated authority from the governing body, ensures that there are robust and independent assurance mechanisms in place that provide for effective risk management systems and processes. The Audit Committee’ Chair regularly updates the Governing Body on risk issues and the effectiveness of risk management within the CCG.

Internal audit supports the Audit Committee through its provision of independent and objective assurance. It is a key part of the CCG’s assurance mechanisms, through its undertaking and reporting against a range of activity areas that are agreed with the CCG as part of its overall assurance plan. Internal audit supports the audit committee in its deep dive activities where the committee scrutinises particular issues in greater depth.

We have considered the findings of the service auditor report, carried out by the internal auditors of NHS England at the CSU, on behalf of the CSU customers, including Waltham Forest CCG. Whilst we note a number of exceptions have been identified, we have liaised with the CSU and do not believe that there is anything significant requiring inclusion within the Annual Governance Statement (AGS).

The AGS is an annual statement by the Accountable Officer, on behalf of the governing body, setting out:

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• how the individual responsibilities of the Accountable Officer are discharged with regard to maintaining a sound system of internal control that supports the achievement of policies, aims and objectives; • the purpose of the system of internal control as evidenced by a description of the risk management and review processes, including the Assurance Framework process; and • the conduct and results of the review of the effectiveness of the system of internal control including any disclosures of significant control failures, together with assurances that actions are or will be taken where appropriate to address issues arising.

The organisation’s Assurance Framework is one of the key mechanisms that the Accountable Officer can use to support the AGS.

I have been advised on the implications of the result of my review of the effectiveness of the system of internal control by the governing body and the audit committee and I am assured that a plan to address weaknesses and ensure continuous improvement of the system is in place.

Conclusion No significant internal control issues have been identified during 2017/18 and the CCG is satisfied that the systems outlined in this statement reflect an organisation that generally operates with effective and sound systems of internal control.

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Remuneration and Staff Report

Remuneration report There is no compensation on early retirement or for loss of office to report.

There is no comment to be made on the relationship between the remuneration report and exit packages, severance payments and off-payroll engagements disclosures.

Policy on the remuneration of senior managers

We follow the remuneration guidance for senior managers set out by NHS England and underpinned by the standards set out in the Hutton Fair Pay Review.

Senior managers are those defined as persons in senior positions who have authority or responsibility for directing or controlling the major activities of WFCCG, i.e. those who influence the decisions of the CCG as a whole, rather than the decisions of individual departments or directorates. In this report we have considered our senior managers to be regular attendees at the governing body.

The key principles for senior manager remuneration are that:

• Executive remuneration should fairly reward each individual’s contribution to their organisation’s success and should be sufficient to recruit, retain and motivate executives of sufficient calibre (although organisations should be mindful of the need to avoid paying more than is necessary in order to ensure value for money in the use of public resources).

• Executive remuneration must be set through a process that is based on a consistent framework and independent decision-making based on accurate assessments of the weight of roles and individuals’ performance in them.

• Executive remuneration must be based on the principle of equal pay for work of equal value.

• Executive remuneration should be determined through a fair and transparent process, via bodies that are independent of the executives whose pay is being set, and who are qualified or experienced in the field of remuneration.

In order to fulfil the fair pay criteria, senior management salaries for the Chief Officer and Director of Financial Strategy at WFCCG are agreed by the remuneration and staffing committee, with due regard to NHS England guidance.

The role of the remuneration and staffing committee is to support the governing body in ensuring appropriate remuneration, allowances and terms of service for the staff and those who provide services to the CCG; having proper regard to the circumstances and performance of the

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The table below shows the Salaries and Allowances of Senior Managers in 2017/18

2017/18 Dates served Annual Long term Expense All Pension- Performance Performance Salary Payments Related Total pay and pay and Note Nam e Title (taxable) Benefits Bonuses bonuses Fr om To (bands of (to nearest (bands of (bands of (bands of (bands of £5000) £100) £5000) £5000) £2,500) £5000) £000 £00 £000 £000 £000 £000 Executive Directors Chief Officer to 30 Nov 2017 1 Terry Huff 90 to 95 0 0 0 45 to 47.5 135 to 140 01/04/2017 30/11/2017

Chief Finance Officer to 31 Jan 1 Leslie Borrett 110 to 115 0 0 0 40 to 42.5 155 to 160 01/04/2017 31/01/2018 2018 Jane Mehta Director of Strategic Commissioning 120 to 125 0 0 0 20 to 22.5 140 to 145 01/04/2017 31/03/2018 Director of Nursing, Quality & Helen Davenport 115 to 120 0 0 0 55 to 57.5 170 to 175 01/04/2017 31/03/2018 Governance STP Alliance Accountable Officer from 1 1&2 Jane Milligan 5 to 10 0 0 0 0 to 2.5 5 to 10 01/12/2017 31/03/2018 Dec 2017 Chief Finance Officer - Tow er Hamlets & 1&3 Henry Black 5 to 10 0 0 0 0 to 2.5 10 to 15 01/02/2018 31/03/2018 Waltham Forest CCG from 1 Feb 2018 Non Executive Directors 5 Dr Anw ar Khan Chair and Clinical Director (Chingford) 75 to 80 0 0 0 0 75 to 80 01/04/2017 31/03/2018 Vice-Chair and Lay Member for Alan Wells OBE 20 to 25 0 0 0 0 20 to 25 01/04/2017 31/03/2018 Community Participation 5 Dr Kanyalal Asw ani Clinical Director (Leyton/Leytonstone) 45 to 50 0 0 0 0 45 to 50 01/04/2017 31/03/2018 5 Dr Mayank Shah Clinical Director 45 to 50 0 0 0 0 45 to 50 01/04/2017 31/03/2018 Dr Abdul Sheikh Clinical Director (Walthamstow ) 40 to 45 0 0 0 0 40 to 45 01/04/2017 31/03/2018 Clinical Director (Leyton/Leytonstone) to 1 Dr Syed Ali 30 to 35 0 0 0 0 30 to 35 01/04/2017 31/01/2018 31 Jan 2018 5 Dr Tonia Myers Clinical Director (Chingford) 45 to 50 0 0 0 0 45 to 50 01/04/2017 31/03/2018 Rizw an Hasan Secondary Care Consultant 10 to 15 0 0 0 0 10 to 15 01/04/2017 31/03/2018 Dr Ravindra Kumar Gupta Clinical Director (Walthamstow ) 40 to 45 0 0 0 0 40 to 45 01/04/2017 31/03/2018

Richard Griffin Audit Chair, Lay Member for Governance 10 to 15 0 0 0 0 10 to 15 01/04/2017 31/03/2018

Dr Dinesh Kapoor Clinical Director (Leyton/Leytonstone) 40 to 45 0 0 0 0 40 to 45 01/04/2017 31/03/2018 4 Jaime Walsh Healthw atch Manager, Waltham Forest 0 0 0 0 0 0 01/04/2017 31/03/2018 Acting Healthw atch Manager Waltham 4 Althea Bart 0 0 0 0 0 0 01/04/2017 31/03/2018 Forest Deputy Chief Executive - Families 4 Linzi Roberts-Egan Directorate, London Borough of Waltham 0 0 0 0 0 0 01/04/2017 31/03/2018 Forest Interim Director for Public Health, London 4 Andrew Taylor 0 0 0 0 0 0 01/04/2017 31/03/2018 Borough of Waltham Forest Acting Director of Public Health, London 4 Joe McDonnell 0 0 0 0 0 0 01/04/2017 31/03/2018 Borough of Waltham Forest Vineeta Manchanda Lay Member 20 to 25 0 0 0 0 20 to 25 01/04/2017 31/03/2018 Notes:

1. These members were in post for part of the 2017/18 financial year.

2. Ms Jane Milligan held the position of Accountable Officer for NHS Tower Hamlets CCG throughout the period. However from 1 December 2017 she took on the Single Accountable Officer role for NHS Barking and Dagenham, Havering, Redbridge, Waltham Forest, Newham, Tower Hamlets, City and Hackney. Her total salary for the 12 month period for these NHS roles was £140k-£145k, expenses £nil and pension-related benefits £27.5k-£30k. Corresponding entries are shown in the other CCG account.

3. Mr Henry Black held the position of Chief Financial Officer for NHS Tower Hamlets CCG throughout the period. However from 1 February 2018 he took on the Chief Financial Officer role for Tower Hamlets and Waltham Forest. His total salary for the 12 month period for these NHS roles was £115k-£120k, expenses £nil and pension-related benefits £25k-£27.5k. Corresponding entries are shown in NHS Tower Hamlets CCG’s accounts.

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4. These GPs has a contract for service and the above "Salary" figure include employer pension

contributions as follows:

Remuneration Employer pension "Salary" total contribution Name (bands of £5,000) (bands of £5,000) (bands of £5,000) Dr Anwar Khan 60 - 65 5 - 10 70 - 75 Dr Kanyalal Aswani 40 - 45 5 - 10 45 - 50 Dr Mayank Shah 40 - 45 5 - 10 45 - 50 Dr Tonia Myers 40 - 45 5 - 10 45 - 50

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The table below shows the Salaries and Allowances of Senior Managers in 2016/17

2016/17 Salary Expense Performance Long term All Pension Total Dates served Payments pay and Performance Related (taxable) Bonuses pay and Benefits Note Name Title bonuses

(bands of (to nearest (bands of (bands of (bands of (bands of £5000) £100) £5000) £5000) £2500) £5000) £000 £ £000 £000 £000 £000 From To

Executive Directors

Terry Huff Chief Officer 135 - 140 0 0 0 35 - 37.5 175 - 180 01/04/2016 31/03/2017

Leslie Borrett Chief Finance Officer 135 - 140 0 0 0 35 - 37.5 170 - 175 01/04/2016 31/03/2017

Jane Mehta Director of Strategic Commissioning 115 - 120 0 0 0 25 - 27.5 140 - 145 01/04/2016 31/03/2017

Helen Davenport Director of Nursing, Quality & Governance 110 - 115 0 0 0 57.5 - 60 170 - 175 01/04/2016 31/03/2017

Non-executive directors

3 Dr Anwar Khan Chair and Clinical Director (Chingford) 70 - 75 0 0 0 0 70 - 75 01/04/2016 31/03/2017

Vice-Chair and Lay Member for Community Alan Wells OBE 20 - 25 0 0 0 0 20 - 25 01/04/2016 31/03/2017 Participation

3 Dr Kanyalal Aswani Clinical Director (Leyton/Leytonstone) 40 - 45 0 0 0 0 40 - 45 01/04/2016 31/03/2017

3 Dr Mayank Shah Clinical Director 40 - 45 0 0 0 0 40 - 45 01/04/2016 31/03/2017

Dr Abdul Sheikh Clinical Director (Walthamstow) 35 - 40 0 0 0 0 35 - 40 01/04/2016 31/03/2017

Dr Syed Ali Clinical Director (Leyton/Leytonstone) 35 - 40 0 0 0 0 35 - 40 01/04/2016 31/03/2017

3 Dr Tonia Myers Clinical Director (Chingford) 40 - 45 0 0 0 0 40 - 45 01/04/2016 31/03/2017

Rizwan Hasan Secondary Care Consultant 10 - 15 0 0 0 0 10 - 15 01/04/2016 31/03/2017

Dr Ravindra Kumar Gupta Clinical Director (Walthamstow) 35 - 40 0 0 0 0 35 - 40 01/04/2016 31/03/2017

Richard Griffin Audit Chair, Lay Member for Governance 10 - 15 0 0 0 0 10 - 15 01/04/2016 31/03/2017

Dr Dinesh Kapoor Clinical Director (Leyton/Leytonstone) 35 - 40 0 0 0 0 35 - 40 01/04/2016 31/03/2017

1 & 2 Jaime Walsh Healthwatch Manager, Waltham Forest 0 0 0 0 0 0 01/04/2016 28/02/2017

Acting Healthwatch Manager Waltham 1 & 2 Althea Bart 0 0 0 0 0 0 01/11/2016 31/03/2017 Forest Deputy Chief Executive - Families 2 Linzi Roberts-Egan Directorate, London Borough of Waltham 0 0 0 0 0 0 01/04/2016 31/03/2017 Forest Interim Director for Public Health, London 1 & 2 Andrew Taylor 0 0 0 0 0 0 01/04/2016 31/07/2016 Borough of Waltham Forest

Acting Director of Public Health, London 1 & 2 Joe McDonnell 0 0 0 0 0 0 01/09/2016 31/03/2017 Borough of Waltham Forest

Vinetta Manchanda Lay Member 5 - 10 0 0 0 0 5 - 10 01/04/2016 31/03/2017

Notes: 1. These members were in post for part of the 2016/17 financial year. 2. No remuneration is paid to these members for their Governing Body services.

3. These GPs have a contract for service and the above “Salary” figures include employer pension contributions as follows:

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Remuneration Employer pension "Salary" total contribution

Name (bands of £5,000) (bands of £5,000) (bands of £5,000) Dr Anwar Khan 60 - 65 5 - 10 70 - 75 Dr Kanyalal Aswani 35 - 40 5 - 10 40 - 45 Dr Mayank Shah 35 - 40 5 - 10 40 - 45 Dr Tonia Myers 35 - 40 5 - 10 40 - 45

Pension Benefits as at 31 March 2018

The table below shows the Pension Benefits of Senior Managers in 2017/18

2017/18 Lump sum at Re al Total accrued pension age Cash Real increase Cash Employer's Real increase increase in pension at related to equivalent in cash equivalent contribution to in pension at pension pension age accrued transfer value equivalent transfer value stakeholder pension age lump sum at at 31st March pension at at 1st April transfer at 31st March pension Nam e Title pension age 2018 31st March 2017 value 2018 2018 (bands of (bands of (bands of (bands of (to nearest (to nearest (to nearest (to nearest £2,500) £2,500) £5,000) £5,000) £1,000) £1,000) £1,000) £1,000)

£000 £000 £000 £000 £000 £000 £000 £00 Terry Huff Chief Officer to 30 Nov 2017 0 to 2.5 0 to 2.5 55 to 60 150 to 155 882 59 979 0 Chief Finance Officer to 31 Jan Leslie Borrett 0 to 2.5 0 to 2.5 50 to 55 135 to 140 824 71 916 0 2018 Director of Strategic Jane Mehta 0 to 2.5 5 to 7.5 50 to 55 150 to 155 946 95 1,051 0 Commissioning Director of Nursing, Quality & Helen Davenport 2.5 to 5 2.5 to 5 35 to 40 90 to 95 552 81 639 0 Governance STP Alliance Accountable Officer Jane Milligan 0 to 2.5 -2.5 to 0 40 to 45 100 to 105 666 59 732 0 from 1 Dec 2017 Chief Finance Officer - Tow er Henry Black Hamlets & Waltham Forest CCG 0 to 2.5 -2.5 to 0 20 to 25 50 to 55 272 37 312 0 from 1 Feb 2018

The Pensions Related Benefits (PRB) figure is calculated using the method set out in the Finance Act 2004(1), and includes using the member's current and prior year pension and lump sum figures. Where there has been only a small increase in pension and lump sum benefits current year compared to last year, this formula can sometimes generate a negative figure. Where this is the case, Department of Health guidance states that a "zero" should be substituted for any negative figures

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Certain individuals disclosed in the Salary and Allowances table are not included in the Pension Benefits table. The reasons for this include:

• Non-Executive members do not receive pensionable remuneration; • An executive director may have opted out of the pension scheme; or • For those Governing Body members who are GPs, and who have a contract for service for their Governing Body duties, pension benefits disclosures are not required.

The table below shows the Pension Benefits of Senior Managers in 2016/17

2016/17 Real Total Lump sum at Cash Real Cash Employer's Real increase increase in accrued pension age equivalent increase in equivalent contribution in pension at pension pension at related to transfer cash transfer to pension age lump sum at pension age accrued value at 1st equivalent value at 31st stakeholder pension age at 31st pension at April 2016 transfer March 2017 pension Name Title March 2017 31st March value 2017 (bands of (bands of (bands of (bands of (to nearest (to nearest (to nearest (to nearest £2,500 £2,500) £5,000) £5,000) £1,000) £1,000) £1,000) £1,000) £000 £000 £000 £000 £000 £000 £000 £000 Terry Huff Chief Officer 2.5 - 5 0 - 2.5 50 - 55 145 - 150 828 54 882 0 Leslie Borrett Chief Finance Officer 2.5 - 5 0 - 2.5 50 - 55 130 - 135 771 52 824 0 Jane Mehta Director of Strategic Commissioning 0 - 2.5 5 - 7.5 45 - 50 140 - 145 870 76 946 0 Helen Davenport Director of Nursing, Quality & Governance 2.5 - 5 2.5 - 5 30 - 35 85 - 90 492 61 552 0

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

155 are calculated within the guidelines and framework prescribed by the Institute and Faculty of Actuaries.

Real increase in CETV

This reflects the increase in CETV that is funded by the employer. It does not include the increase in accrued pension due to inflation or contributions paid by the employee (including the value of any benefits transferred from another scheme or arrangement).

Pension Contribution Rates

All staff including senior managers are eligible to join the NHS pension scheme. The scheme has fixed the employer’s contribution at 14.38% of the individual’s salary, per NHS pension regulations. Employee contribution rates for CCG officers and practice staff are as follows:

Full time pensionable pay/earnings used to Full time pensionable pay/earnings used 2017/18 2016/17 determine contribution rate to determine contribution rate

Up to £15,431.99 5.00% Up to £15,431.99 5.00% £15,432.00 to £21,387.99 5.60% £15,432.00 to £21,477.99 5.60%

£21,488.00 to £26,823.99 7.10% £21,478.00 to £26,823.99 7.10% £26,824.00 to £49,472.99 9.30% £26,824.00 to £47,845.99 9.30% £49,473.00 to £70,630.99 12.50% £47,846.00 to £70,630.99 12.50%

£70,631.00 to £111,376.99 13.50% £70,631.00 to £111,376.99 13.50% £111,377.00 and over 14.50% £111,377.00 and over 14.50%

Pay multiples 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/Member in NHS Waltham Forest CCG in the financial year 2017/18 was £140k – £145k (2016/17: £140k - £145k). This was 3.49 times (2016/17: 3.61) the median remuneration of the workforce, which was £40,320 (2016/17: £38,880).

In 2017/18, no employees received remuneration in excess of the highest-paid director/Member. Remuneration ranged from £0k - £5k to £140 - £145k (2016/17: £0k - £5k to £140k - £145k). Total remuneration includes salary, non-consolidated performance-related pay, benefits-in-kind, but not severance payments. It does not include employer pension contributions and the cash equivalent transfer value of pensions.

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Staff Report Number of senior managers

Payscale F M TOTAL

Band 8C 3 2 5 Band 8D 5 5 Band 9 1 1 2 VSM 1 2 3

Grand Total 10 5 15

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Staff numbers and costs

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Staff composition Payscale F M TOTAL Band 5 9 0 9 Band 6 5 3 8 Band 7 5 2 7 Band 8A 9 3 12 Band 8B 4 3 7 Band 8C 3 2 5 Band 8D 5 0 5 Band 9 1 1 2 VSM 1 2 3 Governing body members 1 2 3 Clinical Leads (sessional) 2 1 3 Grand Total 45 19 64

Sickness absence data

2017/18 2016/17

Total full time employee 235 191 sick days

Average full time 59 51 equivalent staff numbers

Average annual sick 4.0 3.7 days per full time employee

Staff policies

WFCCG is committed to equality of opportunity for all employees. We are also committed to employment practices, policies and procedures which ensure that no employee, or potential employee, receives less favourable treatment on the grounds of gender, race, colour, ethnic or national origin, sexual orientation, marital status, religion or belief, age, trade union membership, disability, offending background, domestic circumstances, social and employment status, HIV status, gender reassignment, political affiliation or any other personal characteristic.

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Diversity is viewed positively and, in recognising that everyone is different, the unique contribution that each individual’s experience, knowledge and skills can make is valued equally.

The promotion of equality and diversity are actively pursued through our policies, and ensure that employees receive fair, equitable and consistent treatment. They also ensure that employees and potential employees are not subject to direct or indirect discrimination.

We have developed equality schemes that outline the plans to deliver our obligations under the Equality Act (2010). This policy is in support of our statement of culture, values and behaviour, specifically those of respect and dignity for the individual. The policy is also complementary to the NHS staff council equality and diversity and dignity at work agreements, and our prevention of harassment and bullying at work policy.

It is a condition of employment that all employees respect and act in accordance with the equality and diversity policy. Failure to do so will result in the disciplinary procedure being instigated, which could result in dismissal.

Where statutory guidance exists we ensure that our policies reflect this.

Expenditure on consultancy

Total Admin Programme £'000 £'000 £'000

134 59 75

Off-payroll engagements

Table 1: Off-payroll engagements longer than 6 months

For all 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 1 Of which, the number that have existed:

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for less than one year at the time of reporting 1 for between one and two years at the time of reporting for between 2 and 3 years at the time of reporting for between 3 and 4 years at the time of reporting for 4 or more years at the time of reporting

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

Table 2: New off-payroll engagements

Where the reformed public sector rules apply, entities must complete Table 2 for all new off- payroll engagements, or those that reached six months in duration, between 1 April 2017 and 31 March 2018, for more than £245 per day and that last for longer than 6 months:

Number Number of new engagements, or those that reached six months in

duration, between 1 April 2017 and 31 March 2018 Of which: Number assessed as caught by IR35 3 Number assessed as not caught by IR35 10

Number engaged directly (via PSC contracted to department)

and are on the departmental payroll

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Table 3: Off-payroll engagements / senior official engagements

For any off-payroll engagements of Board members and / or senior officials with significant financial responsibility, between 01 April 2017 and 31 March 2018.

Number of off-payroll engagements of board members, and/or senior officers with significant financial responsibility, during the 0 financial year Total no. of individuals on payroll and off-payroll that have been deemed “board members, and/or, senior officials with significant financial responsibility”, during the financial year. 15 This figure should include both on payroll and off-payroll engagements.

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Exit packages, including special (non-contractual) payments

Table 1: Exit Packages Redundancy and other departure cost have been paid in accordance with the provisions of Agenda for Change. Exit costs in this note are accounted for in full in the year of departure. Where Waltham Forest CCG has agreed early retirements, the additional costs are met by Waltham Forest CCG and not by the NHS Pensions Scheme. Ill-health retirement costs are met by the NHS Pensions Scheme and are not included in the table.

Exit package Number of Cost of Number of Cost of other Total number Total cost of Number of Cost of special cost band (inc. compulsory compulsory other departures of exit exit packages departures payment element any special redundancies redundancies departures agreed packages where special included in exit payment agreed payments have packages element £ £ £ been made £ Less than £10,000 £10,000 - £25,000 £25,001 - £50,000 £50,001 - £100,000 £100,001 - £150,000 £150,001 – 1 160,000 £200,000 >£200,000 TOTALS 1 160,000 Agrees to A below

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Table 2: Analysis of Other Departures

Agreements Total Value of agreements Number £000s Voluntary redundancies including early retirement contractual costs Mutually agreed resignations (MARS) contractual costs Early retirements in the efficiency of the service contractual costs Contractual payments in lieu of notice* Exit payments following Employment Tribunals or court orders Non-contractual payments requiring HMT approval** TOTAL A – agrees to total in table 1

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

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

**includes any non-contractual severance payment made following judicial mediation, and X (list amounts) relating to non-contractual payments in lieu of notice.

0 non-contractual payments were made to individuals where the payment value was more than 12 months’ of their annual salary.

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

Parliamentary Accountability and Audit Report

Waltham Forest 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.

An audit certificate and report is also included in this Annual Report at page 170.

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ANNUAL ACCOUNTS

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Independent Auditor’s Report to the Members of the Governing Body of NHS Waltham Forest Clinical Commissioning Group

REPORT ON THE AUDIT OF THE FINANCIAL STATEMENTS

Opinion

We have audited the financial statements of NHS Waltham Forest 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.

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Other information in the Annual Report

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

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

Annual Governance Statement

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

Remuneration and Staff Report

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

Accountable Officer’s responsibilities

As explained more fully in the statement set out on page 120, 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.

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Auditor’s responsibilities

Our objectives are to obtain reasonable assurance about whether the financial statements as a whole are free from material misstatement, whether due to fraud or error, and to issue our opinion in an auditor’s report.

Reasonable assurance is a high level of assurance, but does not guarantee that an audit conducted in accordance with ISAs (UK) will always detect a material misstatement when it exists. Misstatements can arise from fraud or error and are considered material if, individually or in aggregate, they could reasonably be expected to influence the economic decisions of users taken on the basis of the financial statements.

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

REPORT ON OTHER LEGAL AND REGULATORY MATTERS

Opinion on regularity

We are required to report on the following matters under Section 25(1) of the Local Audit and Accountability Act 2014.

In our opinion, in all material respects, the expenditure and income recorded in the financial statements have been applied to the purposes intended by Parliament and the financial transactions conform to the authorities which govern them.

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

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

We have nothing to report in this respect.

Respective responsibilities in respect of our review of arrangements for securing economy, efficiency and effectiveness in the use of resources

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As explained more fully in the statement set out on page 120, 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.

We have nothing to report in these respects.

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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 Waltham Forest CCG, as a body, in accordance with Part 5 of the Local Audit and Accountability Act 2014. Our audit work has been undertaken so that we might state to the Members of the Governing Body of the CCG, as a body, those matters we are required to state to them in an auditor’s report and for no other purpose. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the Members of the Governing Body, as a body, for our audit work, for this report or for the opinions we have formed.

CERTIFICATE OF COMPLETION OF THE AUDIT

We certify that we have completed the audit of the accounts of NHS Waltham Forest CCG in accordance with the requirements of the Local Audit and Accountability Act 2014 and the Code of Audit Practice.

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

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Accounts

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