Richmond Clinical

Commissioning Group Annual Report and Financial Accounts 2019/20

NHS Richmond Clinical Commissioning Group Annual Report 2019/20 1

Contents Section 1: Performance Report Welcome from Accountable Officer and Chair Page 4 Performance overview Page 8 Corporate objectives Page 8 Statutory duties Page 9 The Richmond story Page 10 Summary of achievements during 2019/20 Page 12 Funding healthcare in Richmond Page 24 Performance analysis Page 27 Improve Quality: Monitoring the quality of health services Page 27 Patient advice and liaison services and complaints Page 29 Freedom of Information (FOI) Page 29 Performance summary Page 30 Sustainability report Page 35 Patient and public engagement (PPE) Page 39 Equality report Page 47 Reducing health inequalities Page 48 Health and wellbeing strategy Page 51 Section 2: Accountability Report Corporate governance report Page 54 Members’ report Page 54 Statement of Accountable Officer’s responsibilities Page 76 Governance statement Page 79 Risk management arrangements and effectiveness Page 82 Head of Internal Audit Opinion Page 93 Remuneration and staff report Page 93 Remuneration report Page 93 Staff report Page 101 Parliamentary Accountability and Audit Report Page 115

NHS Richmond Clinical Commissioning Group Annual Report 2019/20 2

Section 3: Annual Accounts

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Welcome from Accountable Officer and Chair

Welcome to NHS Richmond Clinical Commissioning Group’s Annual Report for the financial year 2019/20.

This is a significant annual report for NHS Richmond Clinical Commissioning Group (CCG) this year, as we became part of the new NHS South West London CCG on 1 April 2020. As we look forward to the new, it’s an opportunity to reflect on not only our achievements this financial year, but also since we began in 2013.

We have always championed clinically-led commissioning, informed by patient insight and supported by management expertise. We have continued to put the quality of services at the top of our agenda. And by focusing on the needs of the people of Richmond we have been able to design care which really works for them.

This year has been no different. Examples of improvements achieved in 19/20 include.

This year we continued to work on a series of projects aimed at improving access rates to bowel cancer screening and increasing the number of people who are screened through giving GPs a tool to help them spot the signs and make appropriate referrals. This has resulted in 1,149 telephone calls to identified patients and 188 patients accessing screening as a result.

From 1 January 2020, we started a community optometry service with 11 participating opticians across Richmond. Known as the Primary Eye Care Service (PECS) the purpose of this service is for patients to be assessed and receive treatment for routine and non-urgent eye conditions in local opticians (e.g. Specsavers) who agree to participate in the service. This is to avoid patients attending GP appointments, attending A&E and subsequent hospital outpatient appointments.

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As of October 2019, the total number of education, health and care plans (EHCPs) in place across Richmond was 1,492, which reflects a 9% increase over the last year. 2,494 children are being supported through special educational needs support.

This year also saw the development and embedding of Primary Care Networks (PCNs), with our GP Practices coming together to set up six PCNs to focus on prevention and tackling health inequalities. By working in PCNs, practices can reap the benefits of new technology, improve care for patients and better support our doctors and nurses.

The CCG has also continued to work with our colleagues in the Council, NHS providers, Healthwatch and the local voluntary sector through the Health and Wellbeing Board, as we build closer links across the borough to join up health and social care.

We launched our Richmond Health and Care Plan after talking to health and care frontline staff, local people and representatives from lots of different community organisations about what’s important in the borough of Richmond. The plan focuses on how we can work together to prevent ill health, keep people well and support local people to stay independent. Mental health was identified as a priority through these conversations. Already we have opened a recovery hub in each of the boroughs of Kingston and Richmond, as a safe, welcoming place where adults experiencing a mental health crisis or emotional distress can drop-in and see a team of support workers outside of normal working hours. It is hoped that these recovery hubs will help to reduce pressure on accident and emergency and 999 crews, and support people in a different setting to a hospital.

Our wider collaboration with colleagues across South West London (SWL) also continues. Examples of this collaboration include the SWL Health and Care Partnership’s Children and Young People’s programme which has brought in an additional £4.3m of investment for emotional wellbeing support to be made available in schools. Which has meant more young people are getting the right advice and support quickly.

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Like the NHS across the country, our work has been dominated by our system response to the COVID-19 pandemic in the last few months of 2020. In our South West London Health and Care Partnership role we became responsible for co- ordinating the South West London system response to COVID-19 and providing the link between our NHS providers, our SW London system and NHS England London. During February, we established an incident control room (ICR) to respond to the pandemic. We report directly into NHS England to support our NHS leaders to manage the incident in their organisations, and across South West London. At the time of writing we continue to support the local response to coronavirus, and we are enormously proud of the work of NHS health and staff across South West London who continue to do extraordinary things in the face of an extraordinary challenge.

As we look to the future, we will only build on this SWL-wide work, whilst still retaining focus on our local approach to deliver for the people of Richmond. We will do this through our Borough Committee which will ensure our approach remains clinically-led and retains the ability to engage with and consider the needs of local communities through our important relationships with local authorities, voluntary sector organisations, Healthwatch and other partners.

We’d like to thank all our members and staff and wider partners for their hard work and support since our organisation began, knowing we can count on their continued dedication to the people we serve as we move forward with our colleagues across South West London.

Best wishes,

Sarah Blow

Accountable Officer

South West London Clinical Commissioning Group

Date: 18th June 2020

Dr Andrew Murray, Clinical Chair

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Date: 18th June 2020

Dr Patrick Gibson, GP Borough Lead for Richmond

Date: 18th June 2020

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Performance overview

This section of the annual report gives an overview of the CCG’s corporate objectives, the health profile of its communities and a review of its activities during 2019/2020.

Richmond CCG’s (the CCG) vision is to deliver the best possible health and wellbeing outcomes for the local community, within the resources available. It does this via the Governing Body using the combined leadership of local GPs, a nurse and secondary care clinician, independent lay people, public health, local authority and NHS commissioning staff.

Richmond CCG works with patients, partners and member practices to commission safe, effective health services that continuously improve health outcomes, patient experience and reduce health inequalities. We strive to deliver cost effective, sustainable and integrated health services.

Richmond CCG worked in partnership with the other CCGs in South West London (Kingston, Merton, Wandsworth, Sutton and Croydon), as well as NHS England, NHS trusts and other providers, Richmond Health & Wellbeing Board, local authorities and the voluntary sector.

Corporate objectives Working together Richmond and Kingston CCGs have developed a shared set of corporate objectives for 2018 to 2020 which has guided our work and influenced our commissioning decisions. They are as follows: 1. Enable local people, patients, carers and stakeholders to have greater influence on the services we commission and keep the patient voice at the centre of what we do. 2. Improve the quality, safety and effectiveness of healthcare services and ensure that national performance targets are met and that people experience high quality care.

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3. Work in partnership with local health and care providers, commissioners and the voluntary sector to improve and transform services that achieve better health outcomes, are accessible and reduce inequalities. 4. Ensure the continued development of the CCG as a clinically-led and well governed organisation with strong leadership, and effective membership and staff engagement. 5. Achieve a financially sustainable health economy balancing the need for effective use of resources and better value for money with the need for innovation.

Statutory duties Deliver our statutory and organisational duties and ensure the CCG is a highly effective membership organisation.

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The Richmond Story

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See Richmond’s Strategic Needs Assessment for more information about local health and social care needs https://www.richmond.gov.uk/jsna

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Summary of achievements during 2019/20

Moving Forward Together

During 2019/20 we began our journey to merge the six CCGs (Croydon, Kingston, Merton, Richmond, Sutton and Wandsworth) across south west London to become NHS South West London CCG from 1st April 2020. In the first half of the year we discussed extensively the proposed merger with our GP member practices, the local medical committee (LMCs), staff, local authorities, provider trusts, Healthwatch and other stakeholders to design proposals that the six CCG Governing Bodies could consider and agree. The decision to merge was approved by NHS England in October 2019, following support of all six of our CCG Governing Bodies and GP membership votes in favour of the proposal.

We’re pleased that the majority of our 180+ member GPs voted in favour of merger, which was then approved by the Governing Bodies of all six CCGs.

NHS South West London CCG will be committed to retaining our borough focus to further support local partnerships bringing together health and care leaders to plan services locally. A single CCG will better support this ambition by enabling NHS organisations to collaborate, consider the needs of local communities and transform and improve services with partners to deliver local priorities. The SWL CCG will also play an active role as partner organisation within the South West London Health and Care Partnership, strengthening its ability to bring partners together to work on local issues in each borough and enabling focus on those initiatives which need collaboration across south west London as a whole.

Each borough will have a local committee which will be a sub-committee of the SWL CCG governing body known as the Borough Committee. It will remain clinically led and will engage with and consider the needs of local communities through our important relationships with local authorities, voluntary sector organisations, Healthwatch and other partners.

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The Chair of Richmond’s Borough Committee will be Dr Patrick Gibson, a local GP, who will also sit on the South West London CCG Governing Body. Each borough committee has taken formal responsibility for decision making, planning and commissioning of local community-based care. We are planning for the Borough Committees to have delegated responsibility of NHS commissioning budgets in each borough, based on the funding allocations for CCGs that have already been published. At the time of writing, as a result of the Covid-19 pandemic, a national decision has been taken to temporarily suspended the delegation of budgets as the NHS responds to this crisis through a command and control system. We also will continue to support further development of the local partnership board which bring together health and care partners across the borough to plan and deliver services.

As we come together, we will continue our work to ensure that we have robust patient and public engagement at the south west London and borough level. We are planning to strengthen our Patient and Public Engagement Steering Group (PPESG - comprised of local Healthwatch, voluntary service (CVS) and local patient reps) to have a key role advising on our approach to involvement. This forum will have early sight of significant matters requiring patient and public engagement and will shape our work to ensure that decisions are informed by local people. Two representatives from this group (one from Healthwatch and one from the voluntary service) will sit on the SWL CCG Governing Body as patient voices.

You can read more about the South West London Governing Body, our members and Governing Body meetings on our website at http://www.swlondonccg.nhs.uk/about/governance/our-governing-body/

Children and young people’s mental health

Our innovative work with schools to improve young people’s emotional resilience and wellbeing continued this year, as part of the south west London-wide Trailblazer programme. We were successful in bidding for a share of £4.3m awarded across the six south west London boroughs in July 2019, to support the rollout of school-based mental health support teams to around 150 schools.

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In Richmond the additional funding means a bigger team can be put in place across the schools involved and a new team working across further education colleges.

The programme also involves schools working to implement a ‘whole school approach’, providing support for young people, parents and teachers through a variety of different ways. The mental health support teams who work 1:1 with young people in secondary schools, and with children and parents in primary schools, as well as deliver whole-class sessions for example on techniques to manage anxiety. Other types of support include a new online service for the pupils of the schools involved, mental health first-aid training for teachers and a course for parents called Empowering Parents Empowering Communities.

South West London Health and Care Partnership

Responding to the COVID-19 pandemic

In our South West London Health and Care Partnership role we became responsible for co-ordinating the South West London system response to COVID-19 and providing the link between our NHS providers, our SW London system and NHS England London. During February, we established an incident control room (ICR) to respond to the pandemic. We report directly into NHS England to support our NHS leaders to manage the incident in their organisations, and across South West London. We established seven cells which report into and support the work of the Incident Control Room – clinical, acute, primary care, community, supply, HR and communications. The seven cells are made up of clinicians and managers across our NHS organisations in South West London.

In Richmond, we continue to support the South West London response for our borough. Working closely as part of the Local Resilience Forum we help coordinate and play a part in the health and care response for the people of Richmond. It is essential that each part of the system works together to support local people in their own homes, in GP practices, in care homes, hospices, pharmacies and across South West London. The media and public focus is quite rightly on intensive care treatment

NHS Richmond Clinical Commissioning Group Annual Report 2019/20 14 within hospitals, but we know that there are also pressures in our communities that are equally vital in our response to this virus.

Five Year Plan

Our partnership in Richmond also works with wider the South West London Health and Care Partnership (the Partnership) across key areas. This year the Partnership has published our collective response to the NHS Long Term Plan in the form of our Five Year Plan.

The foundation of the plan is all six borough health and care plans. The plan also sets out how this local work will be supported by the 20 south west London-wide work streams where it makes sense to work at scale or align approaches across boroughs.

Adult mental Cardiovascular Acute hospital care Cancer health disease and stroke Children and Enhanced health in Diabetes End of life care young people care homes Learning disability Medicines & autistic spectrum Maternity Outpatients optimisation disorder Personalised care Primary care Respiratory Social care Urgent and Digital Estates Workforce emergency care

The aims and actions of six of the key clinical work streams were developed at a conference in April 2019, which brought together around 250 health and social care professionals from all six boroughs to design the clinical vision for South West London.

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The full plan will be published in the coming months.

Key south west London achievements during 2019/20

You can read all about the South West London Health and Care Partnership’s (the Partnership) work and achievements on our website at www.swlondon.nhs.uk/ourwork - some highlights from 2019/20 are set out below.

 Improving children and young people’s mental health – as set out above the Partnership was successful in bidding for £4.3m of national funding this year to support the rollout of mental health support teams across our six boroughs.

 Suicide Prevention – the Partnership’s suicide prevention project supports NHS England’s ambition to reduce suicide amongst middle-aged men by 10% by 2021, through a range of outreach activities, training for organisations and individuals in the community, and recruiting Suicide Prevention champions. We have also set up a new Suicide Bereavement Liaison Service which aims to support individuals and families bereaved by suicide and link them to relevant services. A designated suicide bereavement liaison officer, who will receive referrals for support from police and/or health care professionals, proactively contacts anyone bereaved following suicide to offer a range of support.

 Improving diabetes care – we launched a new diabetes service this year called You and Type 2, after receiving over £500,000 funding from the NHS

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Test Bed programme. The service provides further education, support and resources, as well as enabling patients to develop their unique care plan with their healthcare professional. The service is supported by an app which allows patients to access and update their care plan when it suits them and receive personalised videos containing recent test results, which will prepare them for informed discussions with clinicians. The work is being piloted in 35 GP practices and expected to roll-out more widely later this year.

 Connecting Your Care – we have been working with NHS providers and local authorities to connect health and care records across our six boroughs into a single, shared view for the benefit of direct patient care. The first practices and acute hospitals went live on the system this year. We are also working with partners across London to develop our digital collaboration even further – with other NHS providers including London Ambulance Service, our other local authorities and even care homes.

 Workforce - we want to have the right staff, with the right skills, to provide the best possible care to our patients and residents, making South West London a Great Place to Work. We have developed a programme called Jobs That Care, in collaboration with Health Education England, to educate and encourage school leavers to think about a rewarding career in the care industry. The Partnership also worked to support health and social care organisations across south London to meet their 2.3% government apprenticeship targets and utilise levy funding by bringing providers together to work collaboratively to share good practice, innovation and success stories.

Special Educational Needs and Disabilities The Richmond special educational needs and disabilities (SEND) framework for joint commissioning of services to meet local needs has been established for 2019 -2022, with a shared vision that ensures that:

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Every child and young person belongs to a local, inclusive community that provides the education, health and social care support they need to develop their talents and skills for a happy and fulfilling life.

As of October 2019, the total number of education, health and care plans (EHCPs) in place across Richmond was 1,492, which reflects a 9% increase over the last year. 2,494 children are being supported through special educational needs support. A Designated Clinical Officer (DCO) for learning disabilities was recruited in the year and started in-post in September 2019

Work continues in the key workstreams:

Co-production, engagement and partner working - Significant development work continues across the system including cross system bimonthly quality assurance mechanism. The Richmond Parent Carer Forum is in development and will be launched in April 2020.

Joint commissioning - Agreement on CCG contribution to Therapies has been reached and as a result an implementation plan is being developed to mobilise the new Therapies model based on “The Balanced Model”.

Local provision - Local provision continues to develop including developing the outreach offer and agreement for 2 additional free schools. Waiting times for the Emotional Health Service and CAMHS continue to remain high and there is challenge around recruitment to some specific professional groups (including Clinical Psychology)

Early intervention and transition - This includes extending support packages for children with ASD in mainstream schools.

Assessment and planning - This includes reviewing processes around advice for Education, Health and Care Needs assessments. A series of multiagency workshops are to take place in March, in partnership with the Council for Disabled Children. The first around developing an outcomes-based framework for Children and Young

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People with SEND and the second on supporting advice givers in developing outcomes for plans.

Mental Health Recovery Hub

A recovery hub, which provides mental health support to people who feel emotionally distressed or are having a mental health crisis, has recently opened in each of the boroughs of Kingston and Richmond. They are both run by the charity Richmond Borough Mind (RB Mind) and funded by NHS Kingston and Richmond Clinical Commissioning Groups.

The Recovery Hubs provide a safe, welcoming place where adults can drop-in and see a team of experienced support workers, outside of normal working hours. It is hoped they will help to reduce pressure on existing NHS services, such as accident and emergency and 999 crews, who are often called to support people in distress.

For more information on the Recovery Hubs visit: rbmind.org/recoveryhub

Local multi-disciplinary teams Richmond locality teams have made great progress this year in establishing and embedding a way of working together as multi-disciplinary teams (MDT’s) to ensure they are serving the best interests of patients, particularly those with complex needs.

This means that GPs, together with their community colleagues, work with individuals to produce a personal care plan that is jointly designed to support an individual’s complex health care needs. As a result, growing numbers of people are avoiding unplanned admissions to hospital because the local health system and community are working together to support them in their own homes.

Care homes Richmond CCG has commissioned a care home support team providing rapid support and care to residents in care homes across Richmond borough. This has

NHS Richmond Clinical Commissioning Group Annual Report 2019/20 19 resulted in less people being admitted to hospital from care homes as compared to last year. We have worked across the SWL Health and Care Partnership to support the roll out of additional training for care home staff, covering leadership and the identification of early symptoms of deteriorating conditions.

Kingston & Richmond communications and engagement group We have created professional communities of borough-level communications and engagement steering groups that bring together the respective leads from local authorities, NHS trusts, CCGs, the voluntary sector and Healthwatch. The steering groups work on local joint projects, share knowledge, map stakeholders and coordinate plans for communicating with and involving local people. During 2019/20, the group delivered a joint engagement programme in each borough to shape local health and care plans, and delivered a coordinated winter communications campaign, focusing on flu vaccination uptake and directing people to use a community pharmacy for advice and treatment of minor illnesses.

Richmond Primary Eye Care Service From 1 January 2020, a community optometry service with 11 participating opticians across Richmond has been in place. Known as the Primary Eye Care Service (PECS) the purpose of this service is for patients to be assessed and receive treatment for routine and non-urgent eye conditions in local opticians (e.g. Specsavers) who agree to participate in the service. This would avoid patients attending GP appointments, attending A&E and subsequent hospital outpatient appointments.

Primary care We are committed to ensuring that people in Richmond receive the right care closer to home, so that they can live healthy and independent lives for as long as possible. Accessible primary care services that are co-ordinated with community and social care services are essential if we are to achieve this.

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There are 25 General Practices across Richmond. Our practices are working collaboratively across six Primary Care Networks and one General Practice federation, providing in excess of two million primary care appointments this year.

There are high quality primary care services in Richmond. At the end of the year, all 25 Richmond practices had received a “Good” or” Outstanding” rating from the Care Quality Commission.

Primary Care Networks

We have six Primary Care Networks (PCNs) across Richmond borough. The PCNs are delivering additional appointments to 100% of the borough population, and have developed and implemented quality improvement approaches across their community as part of Quality Outcomes Framework (QOF).

PCNs benefit patients, particularly those in protected groups, by offering improved access and extending the range of services available to them, and by helping to integrate primary care with wider health and community services.

There will be a significant transformation programme taking place over the next five year focused on additional roles and operational duties for networks.

Social prescribing

Following learning from pilots that have had a demonstrable positive impact for patients, we have worked with partners to expand the social prescribing programme in collaboration with PCNs. The CCG is working with PCNs to implement social prescribing link workers to help people access a range of local, non-clinical services.

Expanding digital services in primary care

There is a growing demand for practices to provide a greater range of digital services for people to improve access to clinicians, prescriptions, appointments and health advice. GP practices have been supported to enhance a digital offer to registered patients and online consultations. This is a positive step for many patient groups including those with a disability and those with mobility issues where attending a clinic in person may present a barrier to access.

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Locally Commissioned Services (LCS)

We have continued to commission services beyond the GP national contracts to ensure that we are able to: meet the changing needs of our local population; ensure services are available on a population-wide basis; deliver the best health outcomes for patients; and provide value for money.

Cancer This year we continued to work on a series of projects aimed at improving access to screening and increasing the number of people who are screened.

Bowel cancer screening reminder service

We worked with RM Partners to pilot the use of a bowel screening phone reminder service for practices in Richmond. Community Links were commissioned to work with the participating GP practices to identify appropriate patients and provided practices with health facilitators to speak with patients over the telephone

In Richmond, 7 GP practices participated, 1,149 patients were called, 748 patients were spoken to and of those 188 patients participated in the screening programme as a result of the intervention.

C the Signs

Using the latest National Institute for Health and Care Excellence (NICE) guidelines and pan-London referral guidance, C the Signs supports GPs to check combinations of signs, symptoms and risk factors. GPs can search by system, such as ‘chest’ or ‘head and neck’; or by sign, symptom or clinical information, such as ’thrombocytosis’ or 'weight loss’.

C the Signs can identify what cancer(s) a patient may be at risk of, and signpost to what test, investigation or referral they may need – in under 30 seconds. Information can be saved in electronic health records.

C the Signs is due to go live in Richmond in March 2020.

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Transforming diabetes care Recent national diabetes audit data shows an improvement in the percentage of diabetes patients being managed in line with all three clinical standards, for every borough in south west London, and a substantial improvement in the delivery of the eight recommended care processes for Type 2 diabetes in general practice. The SWL diabetes team has secured £120,000 of transformation funding for further work addressing unwarranted variation in the management of Type 2 diabetes across SWL.

End of life care During the year we continued to work with Kingston CCG and other local health and care partners including the voluntary sector, patients and carers to deliver our end of life care strategy.

Over 300 advance care plans have been created with people in Richmond with 69% of these being created in Primary Care with the rest being created at the hospital, in the community and with the Hospice. Hospital Consultants have taken a particular lead in positively encouraging staff and patients to have these important conversations to plan for the end of life.

Once plans are created and recorded on our online system ‘Coordinate my Care’ they can be viewed by urgent care services (111, GP out of Hours and ambulance) to help share decisions about care and follow patient preferences.

Data tells us that Richmond has significantly improved the numbers of people dying in their usual place of residence and deaths in Hospital have reduced. The coordinate my care website can be viewed here. https://www.coordinatemycare.co.uk/for-patients/

A new Care Home Support Team was started during the year and this can support patients and staff with providing the best in end of life care. The Team also works

NHS Richmond Clinical Commissioning Group Annual Report 2019/20 23 very closely with the Hospice and will provide training and advice to care Home staff when needed.

Funding healthcare in Richmond

This information serves as a summary of the CCG’s annual accounts including the controls assurance and auditor’s statements. Our performance against the key financial performance indicators is summarised below.

Income and expenditure target In 2018/19 the CCG ended the year with a deficit of £3.9m. For the 2019/20 financial year the CCG was set a surplus target of £0.1m by NHS England and the CCG closed the year with a surplus of £0.1m.

Expenditure by type The CCG was allocated a total of £284.2m to spend in 2019/20 and incurred £284.1m giving a surplus of £0.1m. Nearly half of this expenditure was acute services (£145.5m). The other significant areas of expenditure were mental health services £31.6m, community health services £23.5m, continuing care placements £21.4m and primary care prescribing costs £20.8m. The CCG spent £4.3m on the organisation’s running costs. An analysis of the CCG’s net expenditure in 2019/20 is set out below. Commissioning areas Expenditure 19/20 £m

Total Acute Commissioning 145.5

Mental Health 31.6

Continuing Care 21.4

Community 23.5

Prescribing 20.8

Primary Care 33.4

Other (including social care) 3.6

Running Costs 4.3

TOTAL 284.1

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Richmond CCG Expenditure in 2019/20

1% 2%

12% Total Acute Commissioning

7% Mental Health Continuing Care 8% 51% Community

8% Prescribing Primary Care 11% Other (including social care) Running Costs

Developments in 2019/20 The CCG has continued to invest in key areas to improve services and the long-term health of the population.

Better payment practice code The NHS executive requires that all trusts pay their creditors in accordance with the Confederation of British Industries (CBI) prompts payment code and government accounting rules; that is to pay their creditors within 30 days of receipt of invoice. The CCG’s performance against this target is provided within this report and action is being taken to improve performance in this area. We were not subject to any actions or interest charges from suppliers during the year due to late payments.

Value for money The CCG’s financial strategy is concerned with using our resources wisely, promoting value for money and having measures in place to promote economy, efficiency and effectiveness in using resources for the exercise of its functions. During the year, the CCG has focused on developing robust financial information and financial controls to ensure that best use is made of available resources. This has facilitated delivery of financial targets. Additionally, the CCG’s commissioning

NHS Richmond Clinical Commissioning Group Annual Report 2019/20 25 decisions are becoming increasingly informed by ‘value for money’ or ‘best value’ considerations using ‘health outcomes’ and ‘programme budgeting’ comparisons.

Going concern These accounts have been prepared on a going concern. Public sector bodies are assumed to be going concerns where the continuation of the provision of a service in the future is anticipated, as evidenced by inclusion of financial provision for that service in published documents.

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Performance analysis Improve quality Monitoring the quality of health services – and making improvements

Richmond CCG works to ensure good quality health services for its residents. The CCG monitors the quality of services by provider organisations by undertaking clinical quality reviews to measure performance against the quality standards we have set.

The CCG does this by monitoring achievement against an agreed set of outcomes including how the result of the treatment has improved their quality of life. The CCG also asks about the experience patients and their families have of services. The quality standards measured by the CCG also include ones focused on the training and support staff receive so they are able to provide the best care.

A member of the CCG team attends the community provider, Hounslow and Richmond Community Healthcare NHS Trust’s serious incident review process that supports early review of the root cause analysis and development of the actions plans. The clinical quality manager works with the provider to ensure that actions are targeted at improving quality and safety.

Along with the CCG’s monitoring, our providers, including general practices, are inspected by the Care Quality Commission (CQC). If the CQC highlights areas that need development or improvement the CCG supports the provider and monitors the action plans within CCG quality review groups to address any concerns which are raised. The CQC’s judgement of quality of care is based on a combination of what inspectors find during inspections and information provided by the provider, patients, the public and other organisations. Providers, again including general practices, are inspected by the Care Quality Commission (CQC) under five main domains – caring, effective, responsive, safe and well-led.

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Safeguarding

Richmond CCG is committed to working with stakeholders and commissioned services to ensure the health, safety and well-being of the local population. Protecting and supporting adults and children at risk is a key part of the approach to commissioning and working together with a continued focus on quality and patient experience.

The CCG approach to safeguarding is underpinned by Making Safeguarding Personal (MSP), close partnership and collaborative working and having contracting systems and processes that aim to reduce the risk of harm and respond quickly to any concerns.

As a commissioning organisation Richmond CCG is required to ensure that all health providers from whom it commissions services (both the public and independent sector) have comprehensive single and multi-agency policies and procedures in place. Richmond CCG fulfils its statutory responsibilities regarding safeguarding adults and children and report key achievements and any exceptions or risks. The CCG gains assurance regarding safeguarding across its commissioned services and highlights and identifies risks for the CCG to be aware of across the health economy.

The Director of Quality is a member of Kingston, and Richmond and Wandsworth Safeguarding Adults Board (SAB) and the safeguarding team are active members of the SAB sub-groups.

The CCG Safeguarding lead chairs the SAB’s communication and engagement group. One of the aims of these meetings is to hear the voice of the community.

This work involves collaborating with the Metropolitan Police, Trading Standards, the local authority, voluntary services and most importantly local residents. The CCG team delivers joint presentations at public events and to local groups. An ongoing concern for the residents of Richmond and Kingston is financial abuse through scams. It was recognised scammers pose as GP’s and pharmacists. Individuals who have been scammed are often affected in the long-term not only financially, but also psychologically by these crimes, which can in turn lead to physical health problems.

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Patient advice and liaison service (PALS) and complaints

During 2018/19 our complaints team and patient advice and liaison service handled 139 patient concerns, there were also further contacts requiring redirection and/or information. There were 17 formal complaints raised by patients and/or their families.

Richmond CCG continues to use the six principles of remedy to address concerns and complaints. (Parliamentary and Health Service Ombudsman report October 2007)

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

Members of the PALS team always listen carefully to the concerns being raised and provide advice or make recommendations, where possible, as to the best way forward for the patient or member of the public. It is not always possible to resolve a concern to the caller’s satisfaction; however, the PALS team can give information about support services and voluntary organisations that may be able to help.

Richmond CCG believes that a successful PALS service reduces the number of issues that go on to become formal complaints, however they recognise that complaints help to raise concerns that the CCG may not have been aware of and support continuous improvement.

Freedom of Information

Richmond CCG is committed to being open and transparent. The Freedom of Information Act (FOI) 2000 gives members of the public a right to request access to all types of recorded information held by public authorities. You can read more about this on our website: http://www.richmondccg.nhs.uk/contact/freedom-of-information

NHS Richmond Clinical Commissioning Group Annual Report 2019/20 29

Performance summary

The CCG meets with local providers regularly to understand the issues related to performance. The CCG scrutinises and tests action plans as needed, ensuring that the CCG understands the risks and uncertainty in continued achievement of the standards, as well as the timeline and trajectory for recovery. Performance against standards and other performance metrics are checked and reported within the governance framework of the CCG, are reported to the CCG board, and are included within the CCG risk register where there is a risk to non-compliance.

NHS England annual assessment of Richmond CCG

NHS England monitors performance of CCGs against the following constitutional standards:

1. Dementia diagnosis rate 2. Referral to treatment (18 weeks) and diagnostics 3. Access to cancer services 4. Mixed sex accommodation breaches 5. Mental health/ Improving Access to Psychological Therapies (IAPT) 6. Health outcome frameworks (MRSA and C Difficile breaches) 7. Urgent care (A&E and ambulance response times) 8. Cancelled operations 9. Health visitor numbers 10. Winterbourne View

A full scorecard, showing all the standards and CCG outcomes framework measures is available upon request to [email protected]

The table below shows the summary position against key measures since 2014/2015:

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Indicator Area 2014/15 2015/16 2016/17 2017/18 2018/19 2019/20

CCG Outcomes Indicators

1. Preventing people from dying prematurely G A G G G G 2. Enhancing quality of life for people with long-term conditions G G A G G G 3. Helping people to recover from episodes of ill health or following injury A G A G G A 4. Ensuring that people have a positive experience of care R G A A G G 5. Treating and caring for people in a safe environment and protecting them from avoidable A G A A A A harm

CCG National Measures

Acute Care A A A A A A Mental Health/ Non-Acute Care A G G G G G Supporting Activity Metrics G A R G A A Everyone Counts - Local Priorities G G G G G

CCG Local Measures

South West London and St Georges MHT G A A G G G Hounslow and Richmond Community Healthcare NHS Trust A G G G G G

CCG Internal Measures Organisational Indicators G G G G G G

As at 31 March 2020, Richmond CCG was showing an overall position of achieving 93 out of the 118 (78.8%) of the key indicators the CCG routinely reports performance against.

Whilst the CCG achieved 93 of the 118 metrics that make up the Richmond CCG

NHS Richmond Clinical Commissioning Group Annual Report 2019/20 31 performance scorecard, there were 9 indicators which were not achieved (red). These are:

 A&E waiting time less than 4 hours (Kingston Hospital) *  Incidence of healthcare associated infection: MRSA (zero tolerance) *  Incidence of healthcare associated infection: C-Difficile (zero tolerance) *  NHS 111: calls answered within 60 seconds *  Mixed sex accommodation (MSA) breaches (zero tolerance) *  Proportion of patients referred to first outpatient services via e-referral service  People with Serious Mental Illness (SMI) who have received the complete list of physical checks (NHS OF 1.12)  Annual Health Checks delivered by GPs for patients on the Learning Disability Register  Total General and Acute Referrals (Operating Plan Supporting Activity)

* Constitutional standards.

Measures relating to the CCG outcomes framework and other local standards and contractual measures are reviewed at the Integrated Quality Governance Committee.

Richmond CCG’s performance – performance analysis

Highlights of key achievements include:

 All diagnosis and treatment standards for cancer services have been achieved and Kingston Hospital have successfully implemented the 28-day faster diagnosis standard.  Effectively diagnosing dementia in the population aged 65 and above to meet the dementia diagnosis standard.  Increased people accessing phycological therapies through IAPT services, with more than half of those people recovering after their treatment.  Kept those people delayed in a hospital bed to a minimum and ensuring that appropriate community services are available.

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 Ensuring that people are seen within two weeks after experiencing a first episode of psychosis.  Increased the number of children and young people aged 0-18 with a mental health condition receiving treatment from NHS funded community services in 2019/20 by 8.5% compared to 2018/19.  Increased the number of personal health budgets available so that people care plan and manage their own care.  Ensuring that those people who have their elective operations cancelled by their hospital are rebooked quickly.  The monthly Friends and Family Test surveys show excellent outcomes reported for inpatients, outpatients, community care, A&E and maternity services.  There has been a reduction of 1,018 bed days for patients who have had their discharge from hospital delayed compared with 2019/20.  273 people received a personal health budget in 2019/20, compared to the 2019/20 plan of 195.

In addition, Richmond CCG has made improvements from the reported position in 2018/19 in the following areas:

 Inappropriate prescribing of antibiotics in primary care is reducing.  Increased percentage of the registered population able to access extended primary care services.

Key areas for improvement for Richmond CCG are:  There has been a great deal of work within Kingston Hospital and around the whole health and social care system to increase the proportion of people treated within the A&E four-hour waiting time standard.  Work is continuing to ensure that people are seen within the 18 weeks referral to treatment standard, and that people wait no more than 6 weeks for a diagnostic test.

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 The number of people with serious mental illness (SMI) who have received the complete list of physical checks in 2019/20 is not at the expected level. Work is continuing through locally commissioned services to improve the proportion of people to receive a comprehensive physical check.  The CCG has appointed a clinical lead to work with all relevant partners to increase the proportion of people with learning disabilities who have received a physical health check.

Performance on social matters, respect for human rights, anti-corruption and anti-bribery matters. Information about the CCG’s performance on social matters and human rights can be found in our public sector equality duty report, which is discussed later in this report.

Counter fraud arrangements are in place in the CCG to ensure compliance with standards set by the NHS Counter Fraud Authority. An accredited counter fraud specialist is contracted to undertake counter fraud work proportionate to identified risks. The CCG’s audit committee receives progress reports throughout the year and an annual report against each of the standards for commissioners.

There is executive support and direction for a proportionate proactive work plan to address identified risks. Regular fraud related communications are shared with CCG staff and training is available for all staff.

The local counter fraud specialist meets with the finance director and internal audit to agree tasks to be undertaken and produce the workplan. The local counter fraud specialist also has regular liaison with the finance director to discuss any concerns that come to light throughout the year.

A member of the executive team (the finance director) is proactively and demonstrably responsible for tackling fraud, bribery and corruption.

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There have been no assessments from the NHS Counter Fraud Authority but should one occur an action plan would be taken forward following any recommendation made.

Sustainability

What is meant by sustainability? Sustainability in this context is about the smart and efficient use of natural resources, to reduce both immediate and long term social, environmental and economic risks. The cost of all natural resources is rising and there are increasing health and wellbeing impacts from the social, economic and environmental costs of natural resource extraction and use. The most widely accepted definition for sustainable development comes from the 1992 Rio Earth summit, which defines it as “development that meets the needs of the present without compromising the ability of future generations to meet their own needs.”

Summary of performance Richmond CCG is committed to reducing its impact on the environment and moving towards a more environmentally friendly way of working. Leadership for sustainability within the CCG sits with the Director of Corporate Affairs and Governance.

While the CCG does not have a sustainable development management plan (SDMP) at present, we demonstrate commitment to reducing the impact the work we do has on the environment. For example, staff are encouraged to work from home to reduce the impact of travel, and use public transport for work related travel where possible. You can read more about the work we do to promote sustainability at work in Richmond CCG within the staff report.

As a part of the NHS, public health and social care system, it is our duty to contribute towards the level of ambition set in 2014 of reducing the carbon footprint of the NHS,

NHS Richmond Clinical Commissioning Group Annual Report 2019/20 35 public health and social care system by 34% (from a 1990 baseline) equivalent to a 28% reduction from a 2013 baseline by 2020.

Modelled carbon footprint Most of the environmental and social impacts are through the services we commission. Area Is sustainability considered? Commissioning (environmental) Yes Commissioning (social impact) Yes Suppliers’ impact Yes Business cases Yes Travel Yes

Other actions to encourage environmental sustainability: Since 23 March 2018 we have been co-located with Kingston CCG, in Thames House which is run by Hounslow and Richmond Community Healthcare (HRCH) NHS Trust. Our direct environmental impact arises mainly from our use of office accommodation, which sits under HRCH’s sustainability and environmental policy which is available on their website. The policy aims to ensure that energy consumption and waste products produced are minimised as much as practically possible through:  Staff awareness and good housekeeping  Energy efficiency and usage  Financial investment in innovation and technology  Effective energy procurement

Some of the actions taken under the HRCH policy are summarised below:

• We have a zero waste-to-landfill policy • We hold monthly waste management training sessions to ensure colleagues follow correct protocols • All domestic waste is burned to generate energy, enabling zero landfill; this energy is distributed to the National Grid • Public transport usage and agile working is encouraged

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• Continuous auditing and the introduction of ISO9001 processes, ensuring legal compliance and capturing any missed carbon and/or financial saving opportunities • Up-to-date reporting identifies trends in utility consumption and waste production and enables the estates team to take action to resolve issues

Utilities Electricity is hourly metered, so we can see daily peaks and troughs, enabling closer usage management. We have efficient gas boilers.

Water consumption has been tightly controlled, reducing stored water on site, and a more reliable water system of reducing leaks and water waste.

Waste The recycling rate for England (7/3/2019) was 45.2%. The rate for Thames House is currently at 68%.

Richmond CCG has also supported Richmond Council’s programme of work this year to improve air quality by reducing vehicle related emissions.

Procurement for social value and sustainability Social value is the recognition that social outcomes such as stronger communities, improved health and improved environments have a value to society. Commissioning of services and the procurement of products are very powerful levers to influence the delivery of sustainable services. Commissioners can develop and use criteria to stimulate more ambitious and innovative approaches to delivering care that costs less, creates less environmental harm and reduces inequalities. Equally, the significant procurement budget for goods and products used by the health and social care system provides multiple opportunities to maximise social, economic and environmental value. The CCG uses the Department of Health Standard NHS Contracts which have a requirement for all providers apart from small ones to demonstrate their progress on climate change adaptation, mitigation and sustainable development, including performance against carbon reduction management plans; they are also required to provide a summary of that progress in their annual report.

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Commissioners recognise that to expand, raise the quality of and increase the capability of community health and social care, ensuring its future sustainability, the landscape of providers may change. Commissioners in south west London are particularly interested in exploring outcomes-based commissioning and integrated service specifications, creating new opportunities for providers, including partnerships between health and social care providers. They aim to explore the collective impact of commissioning services differently and providing opportunities for providers to work together which will help to reduce organisational barriers.

The south west London CCG leaders recognise that the transformation of primary care in the local health economy is pivotal to achieving sustainability and improved clinical, public health and social care outcomes for the people of south west London.

Partnerships As a commissioning organisation, we will need effective contract mechanisms to deliver our ambitions for sustainable healthcare. The NHS policy framework sets the scene for commissioners and providers to operate in a sustainable manner. For us as a CCG, evidence of this commitment will need to be provided in part through contracting mechanisms. Providers must demonstrate progress on climate change adaptation, mitigation and sustainable development, including performance against carbon reduction management plans and must provide a summary of that progress in their annual report.

More information on these measures is available here: www.sduhealth.org.uk/policy- strategy/reporting/organisational-summaries.aspx

NHS Richmond Clinical Commissioning Group Annual Report 2019/20 38

Patient and public engagement

Patient and public engagement across south west London

We serve a large and diverse population across our six boroughs in South West London. A focus on what matters to our communities is at the heart of our approach to involvement. While developing services that respond to individual need, we must make sure that we respond to overall population needs, both now and for the future. We aim to involve people in decisions about how and what we prioritise; understanding people’s views on the quality and effectiveness of services they receive now, and their thoughts about the models and the range of services we will need for the future will, at a larger scale, ensure that our commissioning activity is informed by what matters to our communities.

We need to be flexible and steer away from a one-size fits all approach for engagement: different methods will be valuable for different purposes, for different groups and at different stages. Nobody knows more about how we can make things better than the people who use our services.

 Quality assurance and advice

Quality assurance is vital. We have a number of mechanisms to support good practice engagement across our work. We run a Patient and Public Engagement Steering Group (PPESG) comprising local Healthwatch organisations, CVSs and CCG lay representatives. They meet regularly to oversee public and patient engagement on the Health & Care Partnership, acting as a key strategic adviser to the Programme Board and the communications and engagement team on these matters. We also support the CCG PPE leads to meet as a network. Our patient and public engagement professionals from across south west London meet on a monthly basis to: discuss and advise on shared engagement work and challenges; progress professional development and offer peer support. We have been meeting since August 2018 and discussed, reviewed and refined a number of engagement activities – drawing from local learning and practise.

NHS Richmond Clinical Commissioning Group Annual Report 2019/20 39

We have three main strands to our engagement approach. Direct, wider and targeted.

 Direct engagement

We directly involve patient voices in our clinical work streams and decision making bodies. We are currently reviewing this across work streams to ensure it is effective and meaningful. Having taken advice from our PPESG and PPE Network we have strengthened patient voice at a governance level by inviting Healthwatch and CVSs to have a seat each. These representatives will be asked to champion patient voice and offer critical friend challenge at the Governing Body meetings.

 Wider engagement

In terms of wider engagement we have recently established a ‘People’s Panel’ made up of around 3,000 residents (representative of the local population) who take part in online surveys, sharing their views and feedback about plans, services and what matters most to them about health and care. Panel members are recruited to reflect the makeup of our local population. We will give panel members regular feedback on the results of surveys and how these are being used to influence developments. The first survey was conducted in December 2019 and informed our pharmacy campaign – supporting people to attend their local pharmacy, when relevant, rather than attend A&E. The second survey will be canvassing opinion on our digital work stream – finding out what people think about sharing their data across health and care organisations.

We also hold wide scale events to inform our planning and strategies. For example, in April 2019 we held a clinical conference which brought together almost 250 NHS clinicians, social care professionals, voluntary sector colleagues and other partners from across our six boroughs to design the clinical vision for South West London. Attendees took part in breakout sessions to share their experiences and expertise on six areas identified by the South West London Clinical Senate where we can make the greatest difference by working together across health and social care. Attendees shared the key challenges and opportunities they see in responding to the needs of

NHS Richmond Clinical Commissioning Group Annual Report 2019/20 40 diverse populations in a challenging environment. Colleagues from our six local Healthwatch organisations presented ‘what matters most’ to patients in living with each condition or illness, sharing insights from people with experience in these six areas. Each Healthwatch presentation was followed by a film of patients talking about what matters most to them, to bring these discussions to life.

 Targeted engagement

Sometimes we need to do specific pieces of work to shape local services – and we tailor our approach to the needs of each project: we may run a focus group or hold one to one interviews with people affected by a particular condition or service.

For example, as part of our children and young people trailblazer, we wanted to ensure that children understood what services were available to them. To help achieve this we set out to engage with young people around the language they use to describe mental health and emotional wellbeing, in order to develop effective communications.

Insight work with young people in all six boroughs was carried out in May and June 2019 through two rounds of focus groups, ten in total. The objective of the first sessions was to explore how young people understand mental health, how they deal with it and language they associate with it. Focus groups were held with year 5s, year 8s and one session with SEND young people from Carew Academy. We asked year 5s and SEND young people how they would define words like sad and happy, as well as worried or stressed and asked them to describe photos depicting young people in a variety of scenarios. We asked year 8s much broader questions about how they feel about the world around them and what ‘health’ and ‘mental health’ mean to them.

The application of this learning was to develop a campaign to encourage 11-18 year olds to use an online mental health services called Kooth through schools. We used the learning from the sessions with year 8s to develop messaging. We used the second round of focus groups to test these messages and design propositions for the campaign materials in the form of posters.

NHS Richmond Clinical Commissioning Group Annual Report 2019/20 41

The sessions were facilitated by CCG comms and engagement leads from the boroughs. The SWL programme comms and engagement leads commissioned a company which specialises in marketing for young people, Giraffe, to design the sessions, analyse the feedback and produce the attached report on our learnings. The report has been shared with our schools and those who shared their views. It was deigned to support children and young people to understand the findings.

We also supported our diabetes team to bring together patient representatives and carers who had experience of type 2 diabetes to inform the development of a new way to approach care planning. We ran two focus groups to gather feedback and comments on the app, the video and the preferred strapline for ‘You & Type 2’. The focus group also acted as a platform to build up a network of patient representatives and carers for future insight gathering and supported the development of a campaign. People were very positive about the app, and service as a whole, and thought it would be very helpful in supporting people when living with type 2 diabetes.

Lastly, we work closely with all our colleagues within the health and care partnership to tap into their existing channels of engagement – through doing this we try to ensure our activities are coordinated across the patch.

Patient and public engagement – Richmond

The CCG has discharged its duties under section 14Z2 Health Act 2012 (public involvement and consultation by clinical commissioning groups). We are committed to ensuring that the views and experiences of local people are at the heart of our plans, driving forward the changes needed to improve local services that reflect the needs of the people who use them.

Our latest patient and public engagement review provides an overview of our patient and public engagement for the year together with our forward plan.

In 2018/19 the CCG was rated as good for patient and public engagement against NHS England’s patient and public engagement indicator and await our rating for 2019/20. We have continued to make further improvements in this area of our work including how we work with local people to review and evaluate our engagement;

NHS Richmond Clinical Commissioning Group Annual Report 2019/20 42 developing our partnership approach for PPE with our local health and care partners, working with our providers to review involvement activity.

Our approach to engagement

An integrated approach to engagement and communications for the South West London Health and Care Partnership ensures consistency across the six boroughs of our Partnership and in our locally delivered engagement. A small central team provides support for us in the CCGs, facilitating knowledge sharing and collaboration, and coordinating activity that is best carried out at scale across the six boroughs in south west London.

The Kingston & Richmond communications and engagement group brings together professionals working in both boroughs across the NHS, councils, Healthwatch and the voluntary sector. The group meets monthly to work on local joint projects, share knowledge, map stakeholders and coordinate plans for involving local people During 2019/20 the group delivered a joint engagement programme to shape local health and care plans and delivered a coordinated winter communications campaign, focusing on flu vaccination uptake and pharmacy.

“Our partnerships with the CCG and with the SWL Health and Care Partnership have helped to enhance engagement and involvement; for example, through helping to build high quality involvement in local health and care plan development.” – local voluntary sector organisation

Local people and their representatives are involved in all areas of our work and that of the South West London Health and Care Partnership, from assessment of local need and development of strategy, in close collaboration with our partners, to monitoring of contracts with providers.

Locally we have several established channels to ensure regular engagement with our communities either directly with patients or via local voluntary and community sector organisations. These include working with our GP practice patient participation groups (PPGs) via our PPG network, specific interest groups via our community

NHS Richmond Clinical Commissioning Group Annual Report 2019/20 43 involvement group and holding CCG governing body and primary care commissioning committee meetings in public.

Our community involvement group acts as an engagement and equalities reference group for the CCG. The group is a valuable source of insight and input from key voluntary sector and community organisations on local patient and public engagement in commissioning. Membership is drawn from local organisations representing key local voluntary and community sector organisations, Richmond Council, Richmond Council for Voluntary Service (CVS) and Healthwatch Richmond. The PPG network is a forum for PPG representatives to come together and share information and ideas about their PPGs. It is also one of the ways the CCG ensures that the patient voice is shaping the CCG’s primary care programme. The network is represented on the primary care commissioning committee.

Richmond CVS coordinates several forums with local voluntary and community organisations and people with lived experience of services which the CCG takes part in to maintain ongoing engagement with local communities and patient groups. These include RCVS’ health and wellbeing network for local VCS; Richmond users and carers group and the health and social care co-production group.

For south west London programmes of work our engagement is overseen and constructively challenged by our SW London Patient and Public Engagement Steering Group (PPESG), an advisory sub-group to the South West London Health and Care Partnership Programme Board. The PPESG membership includes representatives from Healthwatch, south west London’s voluntary and community sector organisations, as well as CCG lay members from across the six boroughs.

Strategy - engaging local people in developing our health and care plan

The Richmond health and care plan 2019-2021 (HCP) describes our vision, priorities and actions to meet the health and care needs of local people and deliver improvements in their health and wellbeing. Engagement with local people and stakeholders continued during 2019 to hear from and test ideas at different stages in the development of the plan. In May 2019, we published a discussion document to sense check the HCP proposals with targeted groups who may be affected by or

NHS Richmond Clinical Commissioning Group Annual Report 2019/20 44 involved in this work. Working with our health and care partners we did this through a mix of face to face discussions, an online survey and direct feedback from individuals.

For more information on this programme of engagement, the feedback received and how this feedback informed the final plan can be found in the Richmond Health and Care Plan engagement report.

Decision-making - our direct engagement programme

Patient and public voice representatives, or PPVs, sit on several local and south west London clinical work streams including cancer and end of life care. Together with Healthwatch, PPVs bring insight and challenge to support more effective planning and decision-making. PPVs have an induction and ongoing support to enable them to fulfil their role. An example of this is the Macmillan Primary Care Nursing Project which has showcased the invaluable support patient partners have brought to the project on their Primary Care and Nursing Podcast. In one episode, they talk to patient partners who share tips on how to gain insights from patient partners, and how to incorporate them into project planning, and sharing learning.

Service and pathway design – our targeted engagement programme

Focused engagement influences and shapes strategy and service development in each of our work streams. Activities include focus groups, interviews and online channels such as surveys and the South West London People’s Panel. Depending on the project, this will either take place locally or at a south west London level on behalf of the local CCGs. An example includes:

Children and young people

Across South West London we have a high number of children who are self-harming, and we want both to address and prevent this by developing consistent wellbeing support and early intervention.

NHS Richmond Clinical Commissioning Group Annual Report 2019/20 45

We set out to engage with young people around the language they use to describe mental health and emotional wellbeing, to develop effective communication about mental health services and wider support available to them.

Insight work with young people was carried out in summer 2019 working with local school year 5s and 8s across south west London. In Richmond, we worked with Christ’s School in East Sheen and focused on year 8. We held two rounds of focus groups, the first to explore how young people understand mental health, how they deal with it and language they associate with it. We used the learning from these sessions to develop draft campaign materials. We then used the second round of focus groups to test the campaign materials.

This resulted in a campaign to promote and encourage 11-18 year olds to use if needed an online mental health service called Kooth through schools. A toolkit for teachers has now been distributed to all secondary schools across the borough.

On the benefits of an online service – ‘You don’t feel judged or intimidated by someone looking at you and writing stuff down. You can just tell them how you feel, and they give you advice’. - Year 8 student, Christ’s School

Reaching diverse communities – our community outreach programme

We regularly visit community groups and organisations to listen to people about their experiences of local services and give them the opportunity to shape future services. Through our outreach we can have meaningful conversations with local communities who do not always feel their voice is heard or face specific barriers to being involved in our work.

During the year, we visited 21 groups and heard from over 240 people. Local groups included Richmond Mencap, Alzheimer’s Society and Kingston and Richmond’s ME group. Visit our website to find out more about the organisations and groups we have visited.

NHS Richmond Clinical Commissioning Group Annual Report 2019/20 46

“Having the CCG visit us gave us an opportunity to tell them what we thought about local health services. We felt that we were listened to and our concerns were clearly documented” – Kingston and Richmond ME group.

Equalities

Our annual public sector equality duty (PSED) report brings together information and evidence which demonstrates how the CCG is meeting its statutory duties under the Equality Act 2010. During 2020/21 Richmond borough, working with Kingston borough, will build on a joint approach to equalities, as well as considering how equality and diversity will be further developed when we move to one SWL CCG in April 2020. Locally our areas of focus will include:  Review the process for non-QIPP commissioning projects to ensure equality analysis is undertaken for all commissioning programmes.  Ensure we collect robust demographic information so we know who we are engaging through the introduction of a revised evaluation form for engagement activities.  Review our community outreach programme to ensure our focus is on those who in our local population who face specific barriers accessing health services and/or to being involved in our work and whose specific needs must be considered.  Work with our health and care partners to identify priority equalities groups for targeted engagement, including people with a learning disability and those experiencing homelessness in the borough as advised by our Integrated Quality Governance Committee.

Our latest PSED report was published in January 2020 and is available on our website.

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Reducing health inequalities

Our role as a CCG is to reduce inequalities between patients in accessing the services we commission. A key area of focus is to support parity of esteem for mental health both in improving mental health outcomes and promoting the physical health of those with mental health needs.

To reduce health inequality and improve outcomes for all, we work with colleagues in the public health team at Richmond Council: they provide health intelligence - to inform commissioning, reduce inappropriate variation in the local area, identify vulnerable populations and marginalised groups, and support commissioning to meet their needs. Our work to reduce health inequalities is also reviewed by the local Health and Wellbeing Board. Key areas of health inequality in the borough are:

 Life expectancy at birth was about 2.6 years lower for women and 6.5 years lower for men in 2016-18 in the most deprived areas of Richmond, compared to the least deprived areas.1 (source: PHOF).  Similarly to 2015, 11% of Richmond residents live within the 50% most deprived LSOAs nationally in 2019, a smaller proportion than London where over 60% of the population live in the 50% most deprived LSOAs in England. Richmond had 1 LSOA that ranked amongst the 10% most deprived in London – this LSOA is home to 1,500 residents.2  The average IDACI (income deprivation affecting children index) scores indicate that 7% of children aged 0-15 years are affected by income deprivation2.  3 in 10 adults in routine and manual occupations (aged 18-64) (29.3%) smoke compared to 5.9% of the general Richmond population  There were 794 children in need as measured on 31st March 2019 a rate of 174/10,000 children aged under 18. This compared to 907 in Kingston (rate of

1 Public Health Outcome Framework 2 DataRich. Indices of Deprivation 2019

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233/10,000). The national rate in 2019 was 334/10,000 children aged under 18. It is projected that the numbers in Richmond will increase from 794 children aged under 18 years to 840 children in need by 2022. There were 96 children subject to the Child Protection Plan (2019). This equates to a rate of 21.1/10,000 within Richmond. This is less than the outer London rate of 37/10,000 and the national rate of 43.7/10,000. A lower proportion of children and young people in Richmond (15.9%) are subject to a plan for a second time than Kingston (25%) and nationally (20.8%)  An annual report by GLA presents information about people seen rough sleeping by outreach teams in London. Information in this report is derived from the Combined Homelessness and Information Network (CHAIN), a multi- agency database recording information about rough sleepers and the wider street population in London. In 2018/19, 128 people were seen sleeping rough in Richmond. This is an increase of 21 people compared to 2017/18 (107 people seen rough sleeping that year).3  There is a 67.2% gap in the employment rate for those in contact with secondary mental health services in Richmond and the overall employment rate. There is also an 8.5% gap in the employment rate between those with a long-term health condition and the overall employment rate which is lower than the London gap of 12.2%. (source: PHOF).  Adults with serious mental illness in Richmond are almost twice as likely to die prematurely than the general population.  People with disabilities are more likely to suffer a range of barriers and are at higher risk of other health problems. 21,447 (12%) people report that they have some form of disability or health problem that affects their day-to-day activities. This ranges from 2.3% (862) of children (0-15 year olds), to 79% (2,774) of people aged 85 and over.  Between October 2017 and September 2018, 3,800 (14.5%) of unemployed people aged 16-64 in Richmond were inactive due

3 London Data Store, Rough sleeping in London (CHAIN reports), 2014-2019, Data used: 2017-2019

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to long-term sickness or disability, compared to 17.1% in London and 22.4% in Great Britain (source: ONS, APS

Richmond Council’s data website DataRich hosts Health Needs Assessments for the nine protected characteristics of the Equality Act which provide further details of inequalities in health across the borough. DataRich also has dedicated Deprivation and Equalities pages where you can easily find information. The 2018 joint strategic needs assessment includes further details on the nine protected characteristics of the Equality Act which provides more information about health inequalities across the borough.

A quote from a local pharmacy: “What I most enjoy is that working closely with GPs, we strive to reduce the health inequalities that exist in our locality. As a pharmacy, we provide a wide-range of healthcare services, including: seasonal flu vaccinations, NHS health checks, chlamydia screening and treatment, and smoking cessation.” – community pharmacist

To help us respond to health inequalities in the population, equality impact needs assessments are carried out for all services we commission. We also review the uptake of services to ensure they are accessible to all and link in with public health colleagues for advice on steps to take when health inequalities are identified.

Healthy London Partnership NHS Richmond CCG, along with all of London’s 32 CCGs, Greater London Authority, London Councils, Public Health England and NHS England (London) contributed funding towards Healthy London Partnership (HLP) in 2019/20. The aim was to bring together the NHS and partners in London to work towards the common goals set out in Better Health for London, NHS Five Year Forward View and the devolution agreement.

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HLP is supporting the development of the refreshed shared vision for health and care to ensure all partners are clear about their role in making London the world’s healthiest city. The London Vision was launched at the London Health Board Conference in October 2019. It sets out shared priorities across 10 population health areas of focus and system enablers where it is recognised that partnership action is needed - London-wide together with local action working with Londoners.

Through successful partnership working across health and care in London, HLP has helped to deliver on a range of programmes, outputs and achievements spanning primary and community care, secondary care and mental health, as well as those focussed on integration of health and care and place-based care. All this work is part of the partnership’s collective aim to make London the world’s healthiest city.

You can explore HLP’s various programmes via its website or search the HLP resources section for publications or case studies.

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Health and wellbeing strategy

The Health and Social Care Act gives health and wellbeing boards statutory duties to encourage integrated working and to exercise the functions of a local authority and its partner clinical commissioning groups. In addition, the Act permits a local authority to arrange for a health and wellbeing board to exercise any functions that are exercisable by the authority. The Richmond Health and Wellbeing Board works collectively to ensure that people in the borough experience services of the highest quality and that promote their good health and wellbeing. The aims of the Health and Wellbeing Board are to:

 lead the development of the local authority’s role in integrating the commissioning of health, social care and other services

 lead the development of local partnerships for health and social care which share a common view about local need, priorities and service development

 ensure the engagement and involvement of local people in the development of the health and social care system locally

 work with regional and pan London bodies to ensure that the health and social care needs of local people are understood and taken account of in the commissioning of services at regional and pan London level

The ‘core’ membership of the Board is laid down in government regulations and consists of representatives of the Clinical Commissioning Group (CCG), who commission local health services and the Council, who commission a range of local services including social care, housing, environmental and cultural services, which support wellbeing. Local Healthwatch is the consumer champion for health and social care for residents and is also represented on the Board. A representative of NHS England, the body responsible for commissioning health services at a sub-regional and regional level, will also be a member of the Board. A list of the membership of Richmond Health and Wellbeing board is published on Richmond Council’s website.

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The responsibilities of the board are to:

 Produce a Joint Strategic Needs Assessment (JSNA) which will identify the priorities that will inform the commissioning decisions of the Council and the Clinical Commissioning Group (CCG).  Develop and agree a joint Health and Wellbeing Strategy, which the Council, CCG and the NHS England must have regard to when carrying out their functions, including the commissioning decisions they make.  To encourage and promote integrated working between health and social care commissioners and other local services, including housing and voluntary sector services.  To communicate and consult with stakeholders and the wider community on the work of the Health and Wellbeing Board and its priorities.

Our current Joint Health and Wellbeing Strategy (2016-2021) can be found here

https://www.richmond.gov.uk/media/10997/joint_health_and_wellbeing_strategy_20 16-21.pdf

It is based on the theme “Prevention and joined-up services throughout people’s lives, to enable all residents to start well, live well and age well.”

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ACCOUNTABILITY REPORT

Corporate governance report Members’ report Richmond CCG is a clinically led member organisation. This means that GPs make decisions about local health services by using their local knowledge to improve services and focus resources where there is greatest need. At the start of the year, the CCG was made up of 27 GP practices and this reduced to 25 GP practices by 31 March 2020. Richmond CCG is responsible for a budget of around £284 million. Together the GP practices have a registered population of 223,121 patients (1 March 2020). The membership is represented by a Governing Body of local GPs, a nurse representative, a secondary care doctor and lay members, supported by a management team. Richmond CCG’s work is overseen by an elected Governing Body which is chaired by Dr Graham Lewis, a GP at Hampton Medical Centre. Sarah Blow is the Accountable Officer for the six South West London CCGs, including Richmond CCG. All Governing Body members have specific areas of responsibility and sit on committees of the Governing Body. The members exercise their constitutional rights in respect of the CCG through a membership group. Each member practice has a representative on the membership group.

Member practices by locality Our member practices work across six primary care network (PCN) localities – East Twickenham PCN, Hampton PCN, Richmond PCN, Sheen, Kew and Barnes PCN, Teddington PCN, West Twickenham PCN as set out below.

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Our Governing Body Richmond CCG’s Governing Body was established following independent elections for the GP Governing Body members and an open recruitment process for the secondary care doctor and lay member roles. There are also representatives from London Borough of Richmond upon Thames and Healthwatch Richmond.

Richmond CCG’s Governing Body members lead on specific areas to ensure their knowledge and skills are effectively utilised to provide the best quality, safe care.

Our Governing Body meets in public every other month, and we encourage our community to join us to find out about the work we’re doing. Details of public Governing Body meetings, and meeting papers are published on the Richmond CCG website at this link.

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Governing Body: voting members

Dr Graham Lewis, GP Chair Graham is a partner at the Hampton Medical Centre. Graham was brought up and educated in the West Country and is of maritime heritage. He undertook his medical training in Leeds and trained as a GP in Croydon. He has worked as a GP in Richmond since 1983 and is the longest serving GP at his practice in Hampton. Graham helped form a Richmond based out of hours organisation (TedDoc) and chaired Harmoni for 3 years following their merger. He was a clinical lead with the National Primary Care Development Team. Graham has a continued desire to be involved in improving local health services. His focus is to encourage local GP practice involvement in the CCG and to develop GPs as the leaders for primary care. Graham has been Richmond CCG’s Chair for five years. In 2006, Graham was awarded an MBE for services to the NHS.

Sarah Blow, Accountable Officer Sarah was appointed Accountable Officer for the South West London Alliance of CCGs, taking full accountability for Kingston, Merton, Richmond and Wandsworth Clinical Commissioning Groups in April 2017; Sutton Clinical Commissioning Group in April 2018; and interim Accountable Officer for Croydon Clinical Commissioning Group in October 2019. Sarah is also the Senior Responsible Officer for the South West London Health and Care Partnership. All health and care organisations across South West London continue to work closely together through the South West London STP programme, known as the South West London Health and Care Partnership, and are supported by Sarah as the lead.

Prior to her role in south west London, Sarah led Bexley CCG, as Chief Officer, through authorisation and significant financial challenge to be a successful organisation with a strong collaborative approach. Sarah has held numerous senior management roles in the NHS; leading programmes across South East London STP and London, transformation and redesign in East Sussex and working widely across systems to improve services and deliver sustainability including joint posts with East

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Sussex County Council. Sarah has previously worked in operational roles and strategic roles within providers and the Department of Health.

Sarah is very familiar with south west London and has been a resident in south west London all her life, and has worked at Sutton and Merton PCT in the past. Sarah holds an MBA, PG Dip in healthcare systems management and a BA (Hons) in history and humanities.

Tonia Michaelides, Managing Director (Tonia is Managing Director for both Kingston and Richmond CCGs.)

Tonia has over 27 years of NHS management experience including in strategic leadership roles in both provider and commissioning organisations, including chief officer at Kingston CCG.

As managing director of Kingston and Richmond CCGs she is responsible for the delivery of the CCGs’ quality, finance and performance targets as well as working with leaders across the two boroughs to transform health and care services.

Tonia also leads on delivering transformation on a wider footprint as south west London senior responsible officer (SRO) for mental health. Tonia also operates at a London level, co-sponsoring the development of the London mental health dashboard and the implementation of the s136 pathway. Tonia’s interest and passion is the transformation of services and the integration of health and care to achieve the best possible outcomes for people.

James Murray, Chief Finance Officer James has been working within the NHS for over 25 years across a number of different NHS organisations at a senior level in provider and commissioning organisations and the civil service at a regional level.

He has held interim director roles at both NHS trust and commissioning organisations and worked on several major projects including system wide financial and services

NHS Richmond Clinical Commissioning Group Annual Report 2019/20 57 review, Foundation Trust development and acquisition and a wide variety of NHS business cases.

On 1st April 2018, James was successful in moving from Interim CFO for SWL Alliance CCGs to the substantive position of CFO for SWL Alliance CCGs.

Dr Kate Moore, Vice Clinical Chair Kate is a GP partner at Hampton Wick Surgery. Kate qualified from St George’s Hospital in 1992. She trained locally as a GP at West Middlesex Hospital and joined her current practice as a GP trainee in 1997. Kate’s focus is to commission high quality, excellent care for the population of Richmond. She would like to reduce inefficiencies by utilising technology to support and develop strategies to deliver out of hospital care and care closer to home.

Kate is also the governing body’s lead for primary care and is focussed on developing relationships at all levels across the borough.

Kate enjoys all aspects of general practice but her special interests include child health and immunisations, mental health problems and women’s health. She is married with 3 children and lives locally.

Dr Anne Dornhorst, Secondary Care Doctor Anne is a consultant physician and honorary senior lecturer in endocrinology and diabetes at Imperial College Hospital with an interest in all aspects of adult diabetes. She is the senior diabetes expert for Charing Cross and Hammersmith Hospitals. Anne received her doctorate of medicine from Oxford University and her clinical training from John Hopkins University in Maryland, USA and at St Mary's Hospital, London. She has published extensively in the field of diabetes in pregnancy and has been a member of the national guideline committees on the management of diabetes in pregnancy.

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Dr Nicola Bignell, GP Member Nicola is a GP partner at Thameside Medical Practice and the lead GP for planned care. She studied at Cambridge University and then the Royal London Hospital and has worked as a GP in Richmond ever since. Her main areas of interest are around referral management, outpatient transformation and pathway and service development.

Dr Branko Momic, GP Member Branko is a GP partner at the Acorn Group Practice in Twickenham. He studied at the University of Zagreb and completed his training at West Middlesex University Hospital. Branko is the CCG’s lead for urgent care and clinical governance lead for NHS 111. Branko is also a member of the Kingston A&E delivery board.

Dr Stavroula Lees-Karipoglou, GP member Stavroula is a Richmond borough GP and the CCG’s clinical lead for mental health. Stavroula studied in Berlin and began her career as a doctor in the UK in 1998. She has an MSc in Healthcare Commissioning at the HSMC of the University of Birmingham. Previously she was a hospital doctor specialising in surgery.

Stavroula has been Richmond CCG’s mental health lead since 2013 and has a particular interest in dementia. Her aim is to raise awareness of mental health issues and improve services for patients and carers and the public.

Dr Sylwia Ferguson, GP Member (up to end June 2019) Sylwia is a GP at Cross Deep Surgery. She graduated from Gdansk Medical University in Poland in 1997 and from St George’s University in London in 1999. Sylwia joined her current practice in January 2014 having worked at other local GP practices. She has broad medical interests which include caring for the ageing population, mental health and family planning.

Sylwia is also involved in training of medical students from St George’s University. Sylwia is Richmond CCG’s lead for prescribing, quality and safety.

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Dr Alireza Salehzadeh, GP Member Alireza is a GP partner at Glebe Road Surgery in Barnes. He qualified as a GP in August 2014 from the Kingston and Roehampton GP training programme. Before that he studied medicine at the University of Liverpool and studied for an intercalated bachelor’s degree in anatomy and human sciences at King’s College London.

Alireza has an interest in minor surgery and primary care IT. His aim is to make IT more user friendly and to increase the use of IT in primary care to improve efficiency and establish seamless communication between primary and secondary care. He also hopes to champion the transition of more services from secondary care to the community, making them more cost effective and more convenient for patients.

Alireza is the clinical lead for cardiology and respiratory care.

Dr Jayin Jacob (from June 2019) Dr Jacob is a GP at The Vineyard Surgery in Richmond and joined the governing body in June 2019.

He qualified in 2002 and completed his post graduate education in London. He has a keen interest in oncology and palliative medicine having worked in these specialties prior to becoming a GP. His special interests also include children's health, chronic disease management and sexual health.

Paul Gallagher, Lay Member for audit Paul is a chartered accountant, and a lay member on the governing body and chair of the CCG’s audit committee.

Following a career that began in local government, he has since worked in the private sector where he has held a number of senior leadership roles supplying IT, professional and support services to both private and public sector organisations.

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Paul currently works in management consulting and advises companies on finance transformation, strategy and operations. Paul is also a lay member on the governing body of Kingston CCG and chair of Kingston CCG’s audit committee.

Bob Armitage, Vice Chair and Lay Member for finance, remuneration, primary care and governance Bob worked for 18 years in the pharmaceutical industry in senior management positions ranging from country managing director to finance director. He retired from full-time employment but remains active in a variety of roles. His priorities for Richmond CCG are to ensure the achievement of appropriate quality standards, maintaining robust governance processes and financial strength.

Susan Smith, Lay Member for patient and public involvement

Susan has had extensive experience working in the voluntary and statutory sectors. Until recently Susan was the chief executive at Richmond Citizens Advice Bureau, a post she held for seven years. Prior to this, Susan worked as regional director for Save the Children UK. She is committed to ensuring that local health services are inclusive and service users from all groups of society, including excluded groups who often do not have a voice, are encouraged to participate in the commissioning and planning cycle.

Kathryn Yates, Nurse Member

Kathryn is a registered nurse, health visitor and nurse teacher and has worked across London in a variety of positions within health, education and social care.

Kathryn moved from Wales to London to train as a nurse, qualifying as a registered nurse in 1991. Her first post was at Kingston Hospital specialising in gynaecology and urology, followed by seven years working in the intensive care team at Atkinson Morley’s Hospital. Kathryn then studied psychology and

NHS Richmond Clinical Commissioning Group Annual Report 2019/20 61 trained as a counsellor before becoming a health visitor and then designated nurse for looked after children and young people in Southwark.

Kathryn later became a senior lecturer in public health, community and primary care, with specialist interests which include clinical supervision, public health, domestic abuse and pre-post-natal depression. Kathryn is a clinical supervisor, trainer and consultant and was a lead for practice learning at Kingston and St George’s University of London before taking up the Royal College of Nursing UK lead for primary, community and integrated care.

Kathryn is currently the director for primary care nursing, workforce transformation and innovation at Londonwide Local Medical Committees. Kathryn is an honorary lecturer at Kingston and St George’s, and a Royal Society of Medicine, general practice with primary healthcare section council member.

Governing body: non-voting members

Shannon Katiyo Interim Director of Public Health for the London Boroughs of Richmond Upon Thames and Wandsworth for the year 2019-20 Shannon Katiyo is a fully qualified public health specialist and a Fellow of the Faculty of Public Health, who has worked in senior local authority public health roles for over a decade and across a range of public sectors, including the United Nations, the voluntary sector, the National Health Service, Public Health England, and five local authorities. While at Public Health England, Shannon worked in its Centre for Infectious Disease Surveillance and Control, its Centre for Radiation, Chemicals and Environmental Hazards and its Field Epidemiology Service for the South East and London. He also led on the preparation and dissemination of the National Cold Weather Plan for England in 2015 and was the lead researcher and author of peer reviewed public health research on the epidemiology of non-typhoid Salmonella in

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England. On 8 April 2020, Richmond Council officially confirmed the permanent appointment of Shannon as Director of Public Health In a joint appointment for the two boroughs of Richmond and Wandsworth.

John Anderson Healthwatch Richmond (from Nov 2019) John is a former civil servant who has lived in Richmond for over 25 years. He worked in a variety of policy roles in the Department of Health including in primary care and has had responsibilities for negotiating with nurses, midwives and professions allied to medicine.

He also worked at a senior level for Ealing Council including the social services department where he worked with NHS colleagues on the primary care trust and Health and Well Being Board. He has been Chair of the Environment Trust for a number of years, and active in areas affecting the local voluntary sector including encouraging interest in social enterprise.

The Governing Body met in public five times during 2019/20. Membership and attendance is shown in the table below:

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Governing Body No. of meetings attended

Dr Graham Lewis CCG Chair 4

Sarah Blow Accountable Officer 4

Tonia Michaelides Managing Director 5

Paul Gallagher Lay Member for Audit 3

Dr Kate Moore Vice Clinical Chair 5

Bob Armitage Lay member for Finance, Remuneration, 5 Primary Care and Governance

Susan Smith Lay Member for patient and public engagement 3

James Murray Chief Finance Officer 5

Dr Nicola Bignell GP Member 1

Dr Branko Momic GP Member 3

Dr Alireza Salehzadeh GP Member 5

Dr Stavroula Lees- GP Member 4 Karipoglou

Dr Jayin Jacob (from GP Member 4 July 2019) (since July 2019)

Dr Sylwia Ferguson (up GP Member 1 to end June 2019) (up to end June 2019)

Kathryn Yates Nurse Member 2

Dr Anne Dornhorst Secondary Care Consultant 5

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The Governing Body meeting agenda, papers and minutes are available on the CCG’s website at this link

The Governing Body also receives a report from the Audit Committee Chair as appropriate. Recommendations from the Remuneration Committee and its minutes are taken to the Governing Body at its part two private meetings.

Committees of the Governing Body

The Governing Body has established several committees of the Governing Body and these are described below. The extent of authority to act of these committees depends on the powers delegated to them by the CCG, as set out in its scheme of reservation and delegation (appendix D of the CCG’s constitution), and in their terms of reference.

The CCG’s scheme of reservation and delegation sets out:

 Decisions that are reserved to the membership as a whole  Decisions delegated to the Governing Body and its committees  Decisions delegated to individual members and employees

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

In discharging their delegated responsibilities, the Governing Body and its committees are required to:

 Comply with the principles of good governance  Operate in accordance with the CCG’s Scheme of Reservation and Delegation  Comply with the CCG’s Standing Orders  Comply with the CCG’s arrangements for discharging its statutory duties  Where appropriate, ensure that members have had the opportunity to contribute to the CCG’s decision-making process through the membership group

When discharging their delegated functions, the Governing Body and committees operate in accordance with their approved terms of reference.

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Primary Care Commissioning Committee (meeting in public)

The Primary Care Commissioning Committee enables its members to make collective decisions on the review, planning and procurement of primary care services in Richmond under delegated authority from NHS England. The committee acts as a sub-committee of the Governing Body.

The functions of the committee are undertaken in the context of a desire to promote increased co-commissioning to maximise quality, efficiency, productivity and value for money and to remove administrative barriers. The role of the committee shall be to carry out the functions relating to the commissioning of primary medical services under section 83 of the NHS Act.

Membership of the Primary Care Commissioning Committee includes representation from:

 Public Health, London Borough of Richmond upon Thames  Healthwatch Richmond  Surrey and Sussex Local Medical Committee  NHS England  Local Pharmaceutical Committee  Patient Participation Group

The Primary Care Commissioning Committee met 6 times in 2019-20.

Primary Care Commissioning Committee

(Voting members)

Bob Armitage (Chair), Lay member for Finance, Remuneration, Primary Care and Governance

Susan Smith (Vice Chair), Lay Member for Patient and Public Engagement

Tonia Michaelides Managing Director

Neil Ferrelly Interim Director of Finance

Kathryn Yates Nurse Member

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Dr Anne Secondary Care Doctor Dornhorst

Gareth Hull Independent GP Advisor, Richmond CCG

Dr Pete Smith (up Independent GP Advisor, Richmond CCG to end August 2019)

Non-voting members

Paul Gallagher Audit Chair and Lay Member

Dr Graham Lewis Chair of Richmond CCG

Dr Kate Moore Vice Clinical Chair and GP Member

Dr Nicola Bignell GP Member

Dr Alireza GP Member Salehzadeh

Dr Branko Momic GP Member

Dr Stavroula Lees GP Member

Dr Jayin Jacob GP Member (from July 2019)

Dr Sylwia GP Member Ferguson (up to end June 2019)

Fergus Keegan Director of Quality

Martin Ellis (from Interim Director of Transformation November 2019)

Omid Gilanshah Interim Deputy Director of Primary Care

Shannon Katiyo Public Health, London Borough of Richmond upon Thames

John Anderson Healthwatch Richmond representative

Dr Julius Parker Surrey and Sussex Local Medical Committee

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William NHS England representative Cunningham- Davis

Terry Silverstone CEO, Local Pharmaceutical Committee LPC) (up to June 2019)

Mike Keen (from CEO, Local Pharmaceutical Committee LPC) August 2019)

Maggie Ennis Patient Participation Group (PPG) representative

Bonnie Green Patient Participation Group (PPG) representative

Audit Committee The Audit Committee is responsible for reviewing the establishment and maintenance of an effective system of governance, risk management and internal control, across the whole of the CCG’s activities that support the achievement of its objectives.

The Audit Committee met 6 times during 2019-20, one of which was a virtual meeting. Membership is shown below:

Audit Committee Paul Gallagher (Chair) and Lay Member David Knowles Vice Chair, Lay Member for Governance, Kingston CCG Jim Smyllie Lay Member for Patient and Public Engagement, Kingston CCG Bob Armitage Lay member for Finance, Remuneration, Primary Care and Governance, Richmond CCG Dr Annette Pautz GP member, Kingston CCG Dr Naeem Iqbal GP member, Kingston CCG

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Dr Phil Moore GP member, Kingston CCG

Dr Alireza Salehzadeh GP member, Richmond CCG Sarah Blow Accountable Officer James Murray Chief Finance Officer

In addition, there are a number of regular attendees including auditors and other CCG officers.

The committee has reviewed the adequacy and effectiveness of:

 All risk and control related disclosure statements (in particular the annual governance statement) together with any appropriate independent assurances, prior to endorsement by the CCG  The underlying assurance processes that indicate the degree of achievement of CCG objectives, the effectiveness of the management of principal risks and the appropriateness of the above disclosure statements  The policies for ensuring compliance with relevant regulatory, legal and code of conduct requirements and related reporting and self-certification  The policies and procedures for all work related to fraud and corruption as set out in Secretary of State Directions and as required by the NHS Counter Fraud Authority

In carrying out this work the Audit Committee primarily utilises the work of internal audit, external audit and other assurance functions, but is not limited to these sources. It also seeks reports and assurances from the Accountable Officer, executive management team and managers as appropriate focusing on the over- arching systems of governance, risk management and internal control, together with indicators of their effectiveness.

Integrated Quality Governance Committee The committee is responsible for overseeing, understanding, reviewing and ensuring action is taken for all issues in relation to the quality of services commissioned by the CCG. The committee is responsible for ensuring the appropriate governance

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systems and processes are in place to commission, monitor and ensure the delivery of high quality and safe patient care in commissioned services, primary care and the nursing home sector in line with the CCG’s vision.

The committee provides oversight and scrutiny of arrangements for supporting NHS England in relation to securing continuous improvement in the quality for primary medical services. The committee approves arrangements for handling CCG Patient Advice and Liaison Service contacts (PALS) and complaints, and provides oversight and scrutiny on arrangements for business continuity and emergency planning.

The Integrated Quality Governance Committee held 10 meetings during 2019-20. Membership is shown below:

Integrated Quality Governance Committee Dr Phil Moore (Joint chair), GP, CCG Deputy Chair (Clinical), Kingston CCG Dr Graham Lewis (Joint chair), GP and CCG Chair, Richmond CCG

Fergus Keegan (Joint deputy-chair), Director of Quality

Dr Jayin Jacob (from July 2019) (Joint deputy-chair), GP Member, Richmond CCG

Dr Sylwia Ferguson (up to May (Joint deputy-chair), GP Member, Richmond CCG 2019)

Dr Naz Jivani GP and CCG Chair, Kingston CCG

David Knowles CCG Vice Chair, Lay Member for Governance, Kingston CCG

Bob Armitage Lay member for Finance, Remuneration, Primary Care and Governance, Richmond CCG

Paul Gallagher Lay Member for Audit and Finance

Jim Smyllie Lay Member for Patient and Public Engagement, Kingston CCG

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Susan Smith Lay Member for Patient and Public Engagement, Richmond CCG

Kathryn Yates Nurse Member

Nadeem Nayeem Secondary Care Doctor, Kingston CCG

Dr Anne Dornhorst Secondary Care Doctor, Richmond CCG

Dr Pete Smith (up to end August GP Member, Kingston CCG 2019)

Dr Naeem Iqbal GP Member & Caldicott Guardian, Kingston CCG Dr Branko Momic GP Member, Richmond CCG

Julia Travers (up to end October Director of Commissioning 2019)

Martin Ellis (from November Interim Director of Transformation 2019)

Finance Committee The Finance Committee is responsible for providing assurance on key financial indicators, ensuring that the organisation is meeting its financial duties. The finance committee held 11 meetings during 2019-20. Membership is shown below:

Finance committee

David Knowles (Chair), Vice Chair, Lay Member for Governance, Kingston CCG

Bob Armitage Lay member for Finance, Remuneration, Primary Care and Governance, Richmond CCG

Paul Gallagher Lay Member for Audit

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Jim Smyllie Lay Member for Patient and Public Engagement, Kingston CCG

James Murray Chief Finance Officer

Neil Ferrelly Interim Director of Finance

Dr Naz Jivani GP and CCG Chair, Kingston CCG

Dr Graham Lewis GP and CCG Chair, Richmond CCG

Dr Phil Moore GP (Deputy Chair, clinical), Kingston CCG

Dr Kate Moore Vice Clinical Chair and GP Member, Richmond CCG

Tonia Michaelides Managing Director

Dr Annette Pautz GP Representative, Kingston CCG

Dr Branko Momic GP Representative, Richmond CCG

Jenny Sinnott Head of Finance, Kingston CCG

Liam Bayly Head of Finance, Richmond CCG

Julia Travers (up to end October Director of Commissioning 2019)

Executive Management Team The Executive Management team supports the Governing Body and the Managing Director in discharging their functions. It assists the Governing Body in its duties to promote a comprehensive health service, reduce inequalities and promote innovation. The remit of the executive management team is to acquire, manage and develop the resources, infrastructure, systems and business processes required to enable the discharge of the CCG’s functions and the delivery of the CCG’s strategy.

During 2019-20 there were 6 meetings held. Membership is shown below:

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Executive Management Team

Tonia Michaelides Managing Director

Dr Naz Jivani (NJ) Kingston GB Chair

Dr Graham Lewis (GL) Richmond GB Chair

Dr Phil Moore (PM) Kingston Deputy Chair, Clinical

Dr Kate Moore (KM) Richmond Vice Clinical Chair

Vicki Harvey-Piper (VHP) Director of Corporate Affairs & Governance Fergus Keegan (FK) Director of Quality

Neil Ferrelly Interim Director of Finance

Martin Ellis (from November 2019) Interim Director of Transformation

Julia Travers (up to end October 2019) Director of Commissioning

Clinical Executive Team The Clinical Executive Team fulfils the clinical leadership function of the CCG, supporting the Governing Body and the Accountable Officer in discharging their functions. It assists the Governing Body in its duties to promote a comprehensive health service, reduce inequalities and promote innovation. The remit includes the development and implementation of plans for commissioning services and in the championing of transformational change, the development of pathways of care for local clinical delivery, and ensuring that the group’s vision and strategy are translated into annual priorities including the provision of a plan for local out of hospital services which improves clinical outcomes, service quality and coherence for Richmond residents.

The Clinical Executive Team met 6 times, and membership of the committee is shown below.

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Clinical Executive Team Dr Kate Moore (Chair), Vice Clinical Chair Dr Graham Lewis CCG Chair Neil Ferrelly Interim Director of Finance

Martin Ellis (from November 2019) Interim Director of Transformation Dr Patrick Gibson Network Lead (R&B) Heather Bryan Network Lead (TTH) Shannon Katiyo Acting Director of Public Health, London Borough of Richmond upon Thames Dr Nicola Bignell GP Member Dr Branko Momic GP Member Dr Stavroula Lees GP Member Dr Alireza Salehzadeh GP Member Dr Jayin Jacob (from July 2019) GP Member Dr Sylwia Ferguson (up to end June 2019) GP Member

The South West London ‘Committees in Common’ The South West London Clinical Commissioning Groups have agreed the establishment of Committees in Common (CiC) for the purpose of strategic decision making, with particular reference to the South West London Five Year Forward Plan or any successor strategy as agreed by the CCGs.

The role of a CiC is to take decisions on behalf of the CCGs as set out in the Establishment Agreement. Decisions will be taken by the representatives of each CCG on behalf of their individual CCG and will be taken only after consideration of the issues by the CCG Governing Body and the engagement of CCG membership. The meeting convenor (a pre-agreed SWL CCG Lay Member) chairs the meetings on a quarterly basis.

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Management of Conflicts of Interest The CCG operates a robust policy for the management of Conflicts of Interest for CCG members, Governing Body members, office holders, employees and contractors working on behalf of Richmond CCG. It applies to all the CCG’s business but is particularly relevant considering the CCG’s decision to take on a role in the co-commissioning of primary care with NHS England and in preparation for full delegated commissioning from April 2016.

Register of interests

A summary of the Governing Body’s register of interest 2019/20 is available to view on our website. This includes details of company directorships and other significant interests held by members of the Governing Body.

Personal data related incidents There have been no serious internal incidents or Information Governance issues relating to data security breaches that have been reported to the Information Commissioner.

Statement of disclosures to auditors

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

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

Modern Slavery Act Richmond CCG fully supports the Government’s objectives to eradicate modern slavery and human trafficking but does not meet the requirements for producing an

NHS Richmond Clinical Commissioning Group Annual Report 2019/20 75 annual Slavery and Human Trafficking Statement as set out in the Modern Slavery Act 2015.

Statement of Accountable Officer’s responsibilities

The National Health Service Act 2006 (as amended) states that each Clinical Commissioning Group shall have an Accountable Officer and that officer shall be appointed by the NHS Commissioning Board (NHS England). The Accountable Officer for CCGs in south west London including Richmond CCG is Sarah Blow.

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

 The propriety and regularity of the public finances for which the Accountable Officer is answerable  For keeping proper accounting records (which disclose with reasonable accuracy at any time the financial position of the Clinical Commissioning Group and enable them to ensure that the accounts comply with the requirements of the Accounts Direction)  For safeguarding the Clinical Commissioning Group’s assets (and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities).  The relevant responsibilities of Accounting Officers under Managing Public Money  Ensuring the CCG exercises its functions effectively, efficiently and economically (in accordance with Section 14Q of the National Health Service Act 2006 (as amended) and with a view to securing continuous improvement in the quality of services (in accordance with Section14R of the National Health Service Act 2006 (as amended)  Ensuring that the CCG complies with its financial duties under Sections 223H to 223J of the National Health Service Act 2006 (as amended)

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Under the National Health Service Act 2006 (as amended), NHS England has directed each Clinical Commissioning Group to prepare for each financial year a statement of accounts in the form and on the basis set out in the Accounts Direction. The accounts are prepared on an accruals basis and must give a true and fair view of the state of affairs of the Clinical Commissioning Group and of its income and expenditure, statement of financial position and cash flows for the financial year.

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

 Observe the Accounts Direction issued by NHS England, including the relevant accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis  Make judgements and estimates on a reasonable basis  State whether applicable accounting standards as set out in the Government Financial Reporting Manual have been followed, and disclose and explain any material departures in the accounts; and  Prepare the accounts on a going concern basis

To the best of my knowledge and belief, and subject to the disclosures set out below, I have properly discharged the responsibilities set out under the National Health Service Act 2006 (as amended), Managing Public Money and in my Clinical Commissioning Group Accountable Officer Appointment Letter.

I also confirm that:

 as far as I am aware, there is no relevant audit information of which the CCG’s auditors are unaware, and that as Accountable Officer, I have taken all the steps that I ought to have taken to make myself aware of any relevant audit information and to establish that the CCG’s auditors are aware of that information.

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

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Sarah Blow

Accountable Officer

South West London Clinical Commissioning Group

Date: 18th June 2020

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Governance statement

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

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

As at 1 April 2019, the Clinical Commissioning Group is not subject to any directions from NHS England issued under Section 14Z21 of the National Health Service Act 2006.

Scope of responsibility

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

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

Governance arrangements and effectiveness The main function of the Governing Body is to ensure that the group has made appropriate arrangements for ensuring that it exercises its functions effectively,

NHS Richmond Clinical Commissioning Group Annual Report 2019/20 79 efficiently and economically and complies with such generally accepted principles of good governance as are relevant to it.

Richmond CCG’s constitution sets out how it shall fulfil its statutory duties and the primary governance rules for the CCG. It complies with the Act and relevant guidance issued by NHS England. The CCG is a clinically led membership organisation and is accountable for exercising the statutory functions of the CCG. It grants authority to act on its behalf to its:  Membership group  Governing Body  Employees; and  Committees of the Governing Body, namely an Audit Committee, a Finance Committee, a Remuneration Committee, an Integrated Quality Governance Committee, a clinical executive team and an executive management team. A summary of the role of each committee can be found in our constitution

The members exercise their constitutional rights in respect of the CCG through the membership group which met four times in 2019-20. Each member practice has a representative on the membership group.

Two clinical networks enable the membership to drive clinical commissioning at a locality and practice level. The clinical networks met six times in 2019-20. The networks report into the clinical executive team (CET). The CET has a formal reporting line to the Governing Body and takes commissioning recommendations to the Governing Body for approval. The CET also produces a quarterly report for the membership group, summarising the work of the clinical networks.

The CCG’s Governing Body has most statutory and business functions delegated to it including the powers and authority to lead the CCG and set its strategic direction.

The Governing Body comprises:  7 GPs (one of whom is the CCG chair and one the vice clinical chair)  One registered nurse  One secondary care specialist doctor  Three lay members:

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- Finance, remuneration and governance - Patient and Public Involvement - Audit and Conflicts of Interest guardian  The Accountable Officer  The Chief Finance Officer  Managing Director

Committees of the Governing Body and membership of each are described within the Corporate Governance report section (pages 54-74)

Discharge of statutory functions During establishment, the arrangements put in place by the CCG and explained within the corporate governance framework were developed with extensive expert external legal input, to ensure compliance with the all relevant legislation. That legal advice also informed the matters reserved for membership group and Governing Body decision and the scheme of delegation.

In light of recommendations of the 2013 Harris review, the CCG has reviewed all the statutory duties and powers conferred on it by the National Health Service Act 2006 (as amended) and other associated legislative and regulations. Thus, I can confirm that the CCG is clear about the legislative requirements associated with each of the statutory functions for which it is responsible, including any restrictions on delegation of those functions.

Responsibility for each duty and power has been clearly allocated to members of the executive team who ensure the necessary capability and capacity to undertake all of the CCG’s statutory duties.

UK Corporate Governance Code

We are 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

NHS Richmond Clinical Commissioning Group Annual Report 2019/20 81 and the Corporate Governance in Central Government Departments: Code of Good Practice 2011 (HM Treasury and Cabinet Office) that we consider to be relevant to the CCG. These are especially reflected in this report in describing review of Governing Body effectiveness and the CCG’s risk management arrangements

Risk management arrangements and effectiveness

The CCG has a robust internal control mechanism to allow it to prevent, manage and mitigate risks. The Internal Control Framework section below describes the governance structure of the CCG, while the risk assessment section (described over the following pages) describes our approach to risk management and appetite for risk, explaining the key components of the internal control structure. Combined, these arrangements underpin the CCG’s ability to control risk through a combination of:

 Prevention – the CCG’s structures, governance arrangements, policies, procedures, and training minimise the likelihood of risks crystallising.  Deterrence – staff are made aware that failure to comply with key policies and procedures, such as the Standards of Business Conduct Policy or the Fraud, Bribery and Corruption Policy, will be taken seriously by the CCG and could lead to disciplinary action, or dismissal.  Management of risk – once risks are identified the arrangements for ongoing monitoring and reporting of progress through the Committee structure to the Governing Body ensure appropriate action is taken to manage risks.

The Capacity to handle risk section describes the range of systems and processes in place to embed risk management more broadly in the CCG’s activities including the requirement for equality impact assessments to accompany papers to the Governing Body.

The CCG is fully committed to complying with the public sector equality duty set out in the Equality Act 2010, both as an employer and a commissioner of health services

NHS Richmond Clinical Commissioning Group Annual Report 2019/20 82 for the borough and publishes these arrangements on our website. The Lay Member for patient and public involvement ensures the profile of this work at the Governing Body. The Lay Member, PPI oversees the arrangements that help the Governing Body to ensure public stakeholders can influence the work of the CCG and therefore be involved in managing the risks which impact on them. This is assisted by Healthwatch who attend meetings of the Governing Body. Members of the public are also able to attend meetings of the Governing Body and Primary Care Commissioning Committee.

Board assurance and risk management framework The Board Assurance Framework (BAF) provides assurance to the Governing Body on the delivery of its corporate objectives.

The corporate objectives are achieved through the delivery of a number of priority programmes which are identified and risk assessed in the BAF document.

The BAF has been designed to provide assurance on the delivery and impact of the priority programmes as well as the risks threatening delivery and therefore impact on corporate objectives being achieved. It sets out mitigating actions for the risks and timescales in respect of these actions being completed.

Various priority areas are managed under the CCG’s strategic objectives:

 Enable local people, patients, carers and stakeholders to have greater influence on the services we commission and keep the patient voice at the centre of what we do

 Improve the quality, safety and effectiveness of healthcare services and ensure that national performance targets are met and that people experience high quality care

 Work in partnership with local health and care providers, commissioners and the voluntary sector to improve and transform services that achieve better health outcomes, are accessible and reduce inequalities

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 Ensure the continued development of the CCG as a clinically-led and well governed organisation with strong leadership, and effective membership & staff engagement

 Achieve a financially sustainable health economy balancing the need for effective use of resources and better value for money with the need for innovation

Capacity to handle risk

The responsibilities of Directors and committees are set out in the CCG Constitution and the accompanying Scheme of Delegation, as well as the governance reporting lines. Timely and accurate information to assess risk and ensure compliance with the CCGs statutory obligations, is submitted in line with the CCGs annual plan of committee work. The Governing Body has rigorous oversight of the performance of the CCG, via formal Governing Body meetings, seminars and through assurances received from committees and audits.

The overall responsibility for the management of risk lies with the Chief Officer as Accountable Officer. The Governing Body collectively ensures that robust systems of internal control and management are in place. These arrangements, and the enhancements that have been made to them during 2019/20, are described in in the Risk Assessment section of this report.

Risk management capacity has been developed across the CCG in a number of ways during the year. The statutory and mandatory training programme includes numerous elements relevant to risk management, including information governance, health and safety, fire safety, safeguarding adults and children and counter fraud. Incident reporting systems supporting these areas are now well established. Governing Body and Committee reporting arrangements prompt authors to confirm that key aspects of potential risk – financial, contractual, quality, equality and diversity, have been considered and addressed.

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Risk assessment in relation to governance, risk management and internal control

 The executive management team is the designated committee responsible for oversight of the risk management process and at its monthly meetings reviews the full BAF and has oversight of all residual risks (after mitigation). It evaluates the status of risks, identifies new risks and monitors effectiveness of the CCG’s board assurance and risk management control systems. Individual members of the executive management team lead on each of the priority areas and are ultimately accountable for their delivery  The CET focuses on high or extreme risk priority areas with a clinical focus, and the primary care commissioning committee those relating to primary care  The Audit Committee provides scrutiny and independent assurance to the Governing Body on the effectiveness of the CCG’s board assurance and risk management processes  The Governing Body reviews the content of the BAF twice a year as a means of assessing the current level and receives summary BAF reports in the intervening months  All other sub committees of the Governing Body review those risks specific to their corporate objective area and are made aware of significant changes to the risk register at each meeting

Operational management of the BAF is provided by the CCG’s corporate affairs and governance team. Regular meetings are held with manager leads to review progress and performance of each of the priority areas and associated risks.

The BAF summary reflects the risk status of the CCG’s strategic risks. It identifies the target score, the current score and any movement from the previous month. The detail sitting within the overall BAF describes the individual programme, its outcome measures, risks to delivery, controls in place, how the Governing Body is assured and actions to address gaps in control or assurance including timelines for completion.

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The areas of high risk for Richmond CCG are as follows:

- Failure to delivery financial recovery plan implementation to achieve operating plan target - Failing to meet some of the national performance targets based on previous performance - Failure to deliver year on year QIPP targets

The CCG views risk management as key to the successful delivery of its business and remains committed to ensuring staff are equipped to assess, manage, escalate and report risks. The BAF and Corporate Risk Register are currently managed using 4Risk software. This ensures a comprehensive overview of all the risks affecting the organisation and facilitates decision making about those risks that need immediate treatment and those that the organisation can tolerate for a specified amount of time.

Considering incidents and risks in this way enables such events to be graded into one of four categories: low, medium, high, and very high. Grading in this way allows:

 The appropriate level of investigation and causal analysis to be carried out

 Identification of the level at which the risk will be managed, the assigning of priorities for remedial action and determination of whether the risk will be accepted

The CCG Risk Matrix (multiplying scores for impact and likelihood from 1-5) ranges from 1-25. Risks scoring 15+ are not tolerated and require formal action plans mitigating the level of risk and adding to the Corporate Risk Register that is reported to the Governing Body. The risk will continue managed at Director level with oversight by the Committee relevant to the risk as well as oversight from the Audit Committees in common.

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Incident reporting

We also encourage people to report incidents and to discuss learning from these with their line manager and within teams. Staff are encouraged to approach any manager or HR within the organisation with any concerns, in the knowledge that and all incidents and concerns are taken seriously. Feedback is always given to staff following any incident reported.

Other sources of assurance

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

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

Our governance structures are used to ensure effective oversight of operational and strategic decisions and compliance with the NHS regulatory environment. Details of the Governing Body responsibilities and those of its committees are described above.

Ensuring effective risk management, financial management and compliance with statutory duties is high on the list of our priorities. We have implemented policies, systems and processes to reduce exposure in these areas and to ensure that we are legally compliant. Each committee and group oversees risks and policies relating to their area of responsibility. Clinicians and management work in partnership through the commissioning cycle, adding value and delivering outcomes, to ensure the procurement of quality services that are tailored to local needs and deliver sustainable outcomes and value for money.

The CCG has established an effective organisational structure with clear lines of authority and accountability which guards against inappropriate decision making and

NHS Richmond Clinical Commissioning Group Annual Report 2019/20 87 delegation of authorities enabling us to meet our statutory duties and follow best practice guidelines. Work to ensure that we promote and demonstrate the principles and values of good governance and the review of governance related risks takes place at Senior Management Team meetings and assurance is provided by the Audit Committees in Common (meeting in common across SW London) to the Governing Body with insight from Internal Audit. The Committee also ensures that, in non- financial and non-clinical areas that fall within the remit of its terms of reference, appropriate standards are set and compliance with them is monitored. We have considered the effectiveness of our governance framework and processes and raised no significant concerns on governance related matters this year.

The system of internal control is based on an ongoing process designed to identify and prioritise the risks to the achievement of the policies, aims and objectives of the CCG, 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 has been in place in the CCG for the year ended 31 March 2020 and up to the date of approval of the annual report and accounts.

Annual audit of Conflicts of Interest management The revised statutory guidance on managing Conflicts of Interest for CCGs (published June 2016 and further updated in June 2017) requires CCGs to undertake an annual internal audit of Conflicts of Interest management. To support CCGs to undertake this task, NHS England has published a template audit framework.

An internal audit review was carried out in November 2019 on the Conflicts of Interest processes set in place within the CCG. The outcome of the review noted that the CCG can take reasonable assurance that the controls upon which the organisation relies to manage the identified risk(s) are suitably designed, consistently applied and operating effectively.

Data quality The Governing Body regularly receive reports that cover financial, governance, compliance, performance and quality matters for the CCG.

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The CCG has a business intelligence and performance function which monitors how local providers are performing against key performance indicators. This information is reported to the Governing Body on a regular basis.

The data contained in the reports is subject to significant scrutiny and review, both by management and by Governing Body committees. The quality of information received to direct decision making is also assured through the service level specification arrangements with the North East London Commissioning Support Unit (NELCSU) and the use of contractual arrangements with the commissioned providers. The Governing Body are confident that the information they are presented with has been through appropriate review and scrutiny, and that it continues to develop with organisational needs.

Information Governance The NHS Information Governance Framework sets the processes and procedures by which the NHS handles information about patients and employees, in particular personal identifiable information. The NHS Information Governance Framework is supported by the Data Security and Protection Toolkit and the annual submission process provides assurances to the Clinical Commissioning Group, other organisations and to individuals that personal information is dealt with legally, securely, efficiently and effectively.

The Data Security and Protection Toolkit (DSPT) came into force for the 2018-19 financial year and replaces the Information Governance toolkit. The DSPT toolkit is now the recognised standard for cyber and data security within the NHS. The toolkit requires the CCG to demonstrate compliance with ten data security standards along with demonstrable compliance with the General Data Protection Regulations (GDPR).

We have been working with our Information Governance team from North East London Commissioning Support Unit (NELCSU), in respect of submission of the Data Security and Protection Toolkit (DSPT). The DSPT is based on the 10 National Data Guardian (NDG) standards. Richmond CCG completed all 106 mandatory assertions,

NHS Richmond Clinical Commissioning Group Annual Report 2019/20 89 and 44 of the 48 non-mandatory assertions. The CCG published the 2019-20 submission with ‘Standards Met’ on the 25th March 2020.

The CCG places high importance on ensuring there are robust Information Governance systems and processes in place to protect patient and corporate information. We have an Information Governance management framework, including Information Governance processes and procedures in line with the DSPT. We have ensured all staff undertake annual Information Governance training. There are processes in place for incident reporting and investigation of serious incidents. We continue to develop information risk assessment and management procedures and a programme is in place to fully embed an information risk culture throughout the organisations against identified risks.

How we look after information securely The Senior Information Risk Owner (SIRO) for Richmond CCG is the Director of Corporate Affairs and Governance; she is a member of the senior executive team and attends Governing Body meetings.

Business critical models The CCG confirms that no business critical models have been identified that would require information about quality assurance processes for those models to be provided to the Analytical Oversight Committee, chaired by the Chief Analyst in the Department of Health.

Third party assurances The CCG relies on a number of third party providers (such as NHS SBS, NHS BSA, NEL CSU) to provide a range of transactional processing services ranging from finance to data processing. Our requirements for the assurance provided by these organisations are reviewed every year. Appropriate formal assurances are obtained to supplement routine customer/supplier performance oversight arrangements.

Control Issues No significant control issues have been identified at the CCG during 2019/20.

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Review of economy, efficiency & effectiveness of the use of resources The Governing Body through its meetings retains primary oversight of the appropriateness of arrangements in pace within the organisation to exercise its functions in an effective, economic and efficient manner. It is my role as Accountable Officer to retain overall executive responsibility for the use of our resources.

The organisation has a number of key processes and internal mechanisms that provide assurance that we are operating within our statutory authority:

 Within our constitution there are clearly defined standards for conducting business, Standing Orders, Scheme of Reservation and Delegation along with Prime Financial Policies that ensure the effective management and protection of assets and public funds  Key policies are in operation in respect of contract management and procurement that ensure effective operational and financial performance whilst ensuring we operate within regulatory frameworks and reduce the likelihood and impact of risk  There is a clearly defined process for the consideration of business cases and saving opportunities to ensure transparency and value for money is upheld. The Financial Delivery Group evaluate the robustness of proposed business cases before these are then considered by the Finance Committee  The Finance Committee and the Integrated Quality Governance Committee are accountable for overseeing a robust, organisation-wide system of quality, performance and financial management.  The Finance Committee ensures that the finances of the CCG are scrutinised to ensure budgets are managed in an appropriate and timely manner. It will ensure that the Governing Body is fully aware of any financial risks which may materialise throughout the year. It works alongside the Audit Committee to ensure financial probity in the organisation.

These committees have, on behalf of the Governing Body, an overview of all aspects of finances (including capital spend and cash management).

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Counter fraud arrangements Counter fraud arrangements are in place in the CCG to ensure compliance with standards set by the NHS Counter Fraud Authority Standards for Commissioners: Fraud, Bribery and Corruption.

 An accredited counter fraud specialist is contracted to undertake counter fraud work proportionate to identified risks.  The CCG’s audit committee receives progress reports throughout the year and an annual report against each of the standards for commissioners.  There is executive support and direction for a proportionate proactive work plan to address identified risks.  Regular fraud related communications are shared with CCG staff and training is delivered to all staff.  The local counter fraud specialist meets with the local director of finance and internal audit to agree tasks to be undertaken as part of the workplan.  The local counter fraud specialist also has regular liaison with the local director of finance to discuss any concerns that come to light throughout the year.  A member of the executive team (the local director of finance) is proactively and demonstrably responsible for tackling fraud, bribery and corruption.

There have been no assessments from the NHS Counter Fraud Authority but should one occur an action plan would be taken forward following any recommendation made.

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HEAD OF INTERNAL AUDIT OPINION

In accordance with Public Sector Internal Audit Standards, the head of internal audit is required to provide an annual opinion, based upon and limited to the work performed, on the overall adequacy and effectiveness of the organisation’s risk management, control and governance processes. The opinion should contribute to the organisation's annual governance statement.

1.1 The head of internal audit opinion

For the 12 months ended 31 March 2020, our head of internal audit opinion for NHS Richmond Clinical Commissioning Group is as follows:

Head of internal audit opinion 2019/20

1.2 Scope and limitations of our work

The formation of our opinion is achieved through a risk-based plan of work, agreed with management and approved by the audit committee. Our opinion is subject to inherent limitations, as detailed below:

 the opinion does not imply that internal audit has reviewed all risks and assurances relating to the organisation;  the opinion is substantially derived from the conduct of risk-based plans generated from a robust and organisation-led assurance framework. As such, the assurance framework is one component that the Governing Body takes into account in making its annual governance statement (AGS);  the opinion is based on the findings and conclusions from the work undertaken, the scope of which has been agreed with management / lead individual;

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 the opinion is based on the testing we have undertaken, which was limited to the area being audited, as detailed in the agreed audit scope;  where strong levels of control have been identified, there are still instances where these may not always be effective. This may be due to human error, incorrect management judgement, management override, controls being by- passed or a reduction in compliance;  due to the limited scope of our audits, there may be weaknesses in the control system which we are not aware of, or which were not brought to our attention; and  it remains management’s responsibility to develop and maintain a sound system of risk management, internal control and governance, and for the prevention and detection of material errors, loss or fraud. The work of internal audit should not be seen as a substitute for management’s responsibilities around the design and effective operation of these systems;  Our internal audit work for 2019/20 was completed prior to the advent of the substantial operational disruptions caused by the Covid-19 pandemic. As such our audit work and annual opinion does not reflect the situation which has arisen in the final weeks of the year. We do, however, recognise that there has been a significant impact on both the operations or the organisation and its risk profile.

1.3 Factors and findings which have informed our draft opinion Based on the work undertaken in 2019/20, there is a generally sound system of internal control, designed to meet the CCG’s objectives, and controls are generally being applied consistently.

We have provided either a substantial or reasonable level of assurance in the areas reviewed, with the exception of a partial assurance opinion assigned to Quality, Innovation, Productivity and Prevention (QIPP) review, 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 risk.

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Quality, Innovation, Productivity and Prevention (QIPP) At the time of the review the Richmond CCG target still contained £2.1m of unidentified QIPP, which the CCG had phased over the last 3 months of the year but was still to be converted in to realistic schemes. Richmond and Kingston share joint schemes for QIPP achieved and work closely together. Richmond CCG was forecasting missing the target by £2.1M.

We highlighted the need for the CCG to revisit the phasing of the expected QIPP savings to ensure there was an accurate reflection of savings across the year and that unidentified QIPP was taken account of and a plan put in place to address the shortfall. Despite acknowledging the impetus from the Regulator to sign off the plan, the Governing Body should consider whether there is sufficient evidence in place to agree the plan with a shortfall in the realistic achievable target. It is noted however that through the introduction of the new block contract with the main provider, management are currently introducing a change in culture around the plan, particularly looking at moving away from it being seen as an annual and shorter-term cycle towards it being embedded as a longer-term plan.

However, after the completion of the audit, we revisited and found that at month 8 the CCG was reporting to achieve the planned surplus of £0.1m. The CCG identified £1.9m across three additional QIPP schemes in Month 7 against the previous £2.1m unidentified QIPP. The CCG have included the remaining £0.2m in the risk position. At month 8 the QIPP position is £7.5m against a budget of £8.1m and a forecast outturn of £14.7m against a plan of £14.1m and has been risk rated as ‘Green’.

We have also issued the following reports for individual reviews undertaken during the year from which the CCG can take:

Substantial Assurance  Commissioning of Acute Service  Primary Care Delegated Commissioning

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 Provider Quality Management

Reasonable Assurance  Continuing Healthcare  Conflicts of Interest  Board Assurance & Risk Management

Advisory South West London CCG Single Ledger Project – RSM has represented the CCGs in SW London on a monthly basis at the SW London Single Ledger Project Board and provided updates to the Audit Committee. No major issues or concerns have been noted to date. After the Project Board agreed to proceed, the ledger has gone live.

Balance Sheet Cleansing – We have conducted desk top reviews on a monthly basis to ensure the process for cleansing existing balance sheet items in legacy CCGs has been reviewed and balances cleared where appropriate prior to transfer to the single CCG progressing. The project proceeded to plan with the workstream rated as green, on the RAG system and no major issues or concerns noted or raised when the system went “Live”

Data Security Protection Toolkit No significant issues were found with only 1 Medium priority action identified.

Follow up of Management Actions During the year we have followed up on the implementation of management actions with progress reported to each Audit Committee and to the Audit Committee in Common. We conclude that generally there has been good progress overall with only one Medium priority action overdue in its implementation at the time of preparing this opinion. Some joint actions across the SW London CCGs, pertaining to the management of IT across South West London are still being implemented.

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1.4 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 within the Quality, Innovation, Productivity and Prevention (QIPP) review, assigned a partial assurance opinion, as set out above. The CCG may wish to consider whether any other issues have arisen, as well as recognising the challenging financial environment within which the CCG is operating, including the results of any external reviews, when determining whether anything should be highlighted within the Annual Governance Statement.

Service Auditor reports We reviewed the Service Auditor Report for NEL Commissioning Support Unit (CSU) for the year ended 31 March 2020. Exceptions were noted on the testing in relation to six of the controls for which the CCG relies upon the CSU. None of these were sufficiently significant to impact our Opinion, although we would advocate Management following up with the CSU to confirm the amendments to process enacted to decrease the likelihood of control failings recurring.

We reviewed the Service Auditor Report from the internal auditors of NHS Shared Business Services who, provide services to the CCG via a contract held with NHS England. No exceptions were noted and there is therefore no negative impact on the control environment.

We reviewed the Service Auditor Report from the internal auditors for NHS Digital in regard to GP Payments. Testing for one of the controls identified an exception but there was no significant impact for the CCG on its overall control environment.

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We reviewed the Service Auditor Report from the internal auditors for NHS Business Services Authority in regard to prescription payments. Exceptions were identified on testing for three of the controls although there was no significant impact for the CCG on its overall control environment.

We have not yet received the Service Auditor Report in relation to Capita and therefore cannot place any reliance on the controls operated on behalf of the CCG.

Review of the effectiveness of governance, risk management and internal control

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

Our assurance framework provides me with evidence that the effectiveness of controls that manage risks to the Clinical Commissioning Group achieving its principle objectives have been reviewed.

I have been advised on the implications of the result of this review by:

 The Governing Body  The Quality, Safety & Performance committee  The Audit Committee  The Executive Management Team  Internal audit

Conclusion

Internal Audit has not identified any significant issues that need to be flagged as significant control issues within the Annual Governance Statement

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Sarah Blow

Accountable Officer South West London Clinical Commissioning Group Date: 18th June 2020

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Remuneration and Staff Report

Under the Government Financial Reporting Manual NHS bodies are required to prepare a remuneration report that is published as part of their annual report and financial accounts. This report must contain information about the remuneration of (pay received by) senior managers.

Senior managers are defined as people in senior positions having authority or responsibility for directing or controlling the major activities of the Clinical Commissioning Group. This means those who influence the decisions of the CCG as a whole rather than the decisions of individual directorates or departments.

To ensure remuneration is in line with national guidance, current good practice and ensures value for public money, the CCG has set up a remuneration committee.

The committee, which is accountable to the Governing Body, makes recommendations on the remuneration, fees and other allowances for employees and for people who provide services to the CCG. This includes advising on salaries for the CCG’s most senior staff (known as Very Senior Managers). It would also make recommendations on allowances under any pension scheme that the CCG may establish as an alternative to the NHS pension scheme.

Remuneration committee report (not subject to audit)

The local Remuneration Committee did not meet during 2019/20. Instead the business of this meeting was discussed at a south west London level, as described below.

SWL Remuneration Committees in Common

In respect of Alliance wide roles, the Remuneration Committee meets as a committee in common to agree a unanimous basis for decision making. This committee provides advice and recommends decisions to each Governing Body in determining remuneration, fees and allowances payable to employees and other persons providing services as well as determining allowances payable under pension schemes established by the CCG.

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Remuneration Committee Members:

Bob Armitage (Chair) Lay Member (Finance, Remuneration, Primary care & Governance) Susan Smith Lay Member (Patient & Public Involvement) Paul Gallagher Lay Member (Audit and Conflicts of Interest Guardian)

Remuneration policy (not subject to audit)

Remuneration for Governing Body members, including the Accountable Officer and Chief Finance Officer, is determined on the basis of reports to the Remuneration Committee, taking into account national guidance on pay rates, any independent evaluation of the post and national and market rates.

All other managers are covered by terms and conditions set out in the national NHS Agenda for Change arrangements. Individual staff performance is assessed as part of the staff appraisal process, which includes objective setting and annual reviews with line managers. In line with national guidance and the Agenda for Change programme, staff progress through an incremental pay scale if their performance during the year has been in line with agreed targets and objectives.

Senior managers’ performance related pay The CCG does not have a policy of performance related pay for senior managers.

Senior managers’ service contracts (not subject to audit) The CCG’s policy concerning permanent senior managers’ contracts is that they have no end date, with a notice period of 6 months.

Payments to past senior managers (not subject to audit) The CCG has not made any payments to past senior managers.

Senior manager remuneration (subject to audit) The table below discloses salaries and allowances paid by the CCG to Directors of significant influence in 2019/20.

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Name and title Salary Taxable Annual Long-term All TOTAL and/or benefits performance performance pension fees related related related (rounded bonuses bonuses benefits to the (bands of nearest (bands of (bands of (bands of (bands of £5,000) £100) £5,000) £5,000) £2,500) £5,000)

£000 £ £000 £000 £000 £000 Graham Lewis, CCG Chair 55-60 0 0 0 0 55-60

Kate Moore, Vice Chair 55-60 0 0 0 0 55-60

Sarah Blow, Accountable 25-30 0 0 0 5-7.5 35-40 Officer (1)

James Murray, Chief Finance 25-30 0 0 0 0 25-30 Officer (2)

Jonathan Bates, Director of 20-25 0 0 0 2.5-5 25-30 Commissioning Operations, SWL Alliance (3)

Charlotte Gawne, Director of 20-25 0 0 0 2.5-5 25-30 Communications, SWL Alliance (4)

Tonia Michaelides, Managing 60-65 0 0 0 12.5-15 70-75 Director (5)

Kathryn Yates, Registered 5-10 0 0 0 27.5-30 35-40 Nurse

Nicola Bignell, GP Member 40-45 0 0 0 0 40-45

Alireza Salehzadeh, GP 25-30 0 0 0 0 25-30 Member

Anne Dornhurst, Secondary 10-15 0 0 0 0 10-15 Care Doctor

Stavroula Lees-Karipoglou, 40-45 0 0 0 0 40-45 GP Member

Branko Momic, GP Member 25-30 0 0 0 0 25-30

Sylwia Ferguson, GP Member 5-10 0 0 0 0 5-10 (to 30th June 2019)

Jayin Jacob, GP Member 20-25 0 0 0 0 20-25 (from 1st July 2019)

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Bob Armitage, Lay Member 10-15 0 0 0 0 10-15 (Finance, Remuneration, Primary care & Governance)

Susan Smith, Lay Member 10-15 0 0 0 0 10-15 (Patient & Public Involvement)

Paul Gallagher, Lay Member 0 0 0 0 0 0 (Audit and Conflicts of Interest Guardian) (6)

Notes

1: Sarah Blow is the Accountable Officer for South West London Alliance, and is on Wandsworth CCG’s payroll; her total salary is in the range £146k-£150k. Richmond CCG is responsible for 20% of her costs.

2: James Murray is Chief Financial Officer for South West London Alliance and is on Wandsworth CCG’s payroll; his total salary is in the range £140-£145k. Richmond CCG is responsible for 20% of his costs. The CCG does not make any employer’s pension contribution in respect of James Murray.

3: Jonathan Bates is Director of Commissioning Operations for South West London Alliance and is on Wandsworth CCG’s payroll; his total salary is in the range £120-£125k. Richmond CCG is responsible for 20% of his costs.

4: Charlotte Gawne is Director of Communications for South West London Alliance and is on Wandsworth CCG’s payroll; her total cost is in the range £115-£120k. Richmond CCG is responsible for 20% of her costs.

5. Tonia Michaelides is Managing Director for Kingston & Richmond CCGs and is on Kingston CCG’s payroll; her total cost is in the range £120-£125k. Richmond CCG is responsible for 50% of her costs.

6. Paul Gallagher is the Lay Member for Audit and Conflicts of Interest Guardian. He fulfils the same role in Kingston CCG and is remunerated by them.

The table below gives the equivalent information for 2018/19.

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Name and title Salary Taxable Annual Long-term All TOTAL and/or benefits performance performance pension fees related related related (rounded bonuses bonuses benefits to the (bands of nearest (bands of (bands of (bands of (bands of £5,000) £100) £5,000) £5,000) £2,500) £5,000)

£000 £ £000 £000 £000 £000 Graham Lewis, CCG Chair 55-60 0 0 0 0 55-60

Kate Moore, Vice Chair 55-60 0 0 0 0 55-60

Sarah Blow, Accountable 25-30 0 0 0 5-7.5 30-35 Officer

James Murray, Chief Finance 25-30 0 0 0 0 25-30 Officer

Jonathan Bates, Director of 20-25 0 0 0 2.5-5 25-30 Commissioning Operations, SWL Alliance

Charlotte Gawne, Director of 20-25 0 0 0 5-7.5 30-35 Communications, SWL Alliance

Tonia Michaelides, Managing 55-60 0 0 0 10-12.5 70-75 Director

Fergus Keegan, Registered 45-50 0 0 0 0 45-50 Nurse (to 1st October 2018)

Kathryn Yates, Registered 0-5 0 0 0 0 0-5 Nurse (from 2nd October 2018)

Nicola Bignell, GP Member 40-45 0 0 0 0 40-45

Alireza Salehzadeh, GP 25-30 0 0 0 0 25-30 Member

Anne Dornhurst, Secondary 10-15 0 0 0 0 10-15 Care Doctor

Stavroula Lees-Karipoglou, 40-45 0 0 0 0 40-45 GP Member

Branko Momic, GP Member 25-30 0 0 0 0 25-30

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Zehra Rashid, GP Member (to 5-10 0 0 0 0 5-10 19th June 2018)

Sylwia Ferguson, GP Member 20-25 0 0 0 0 20-25 (from 1st September 2018)

Bob Armitage, Lay Member 10-15 0 0 0 0 10-15 (Finance, Remuneration, Primary care & Governance)

Susan Smith, Lay Member 5-10 0 0 0 0 5-10 (Patient & Public Involvement)

Paul Gallagher, Lay Member 0 0 0 0 0 0 (Audit and Conflicts of Interest Guardian)

Pensions entitlement table (This section is subject to audit).

Where the CCG contributed to pension schemes for senior managers, the benefits are shown in the table below:

Name and title Real Real Total Lump sum Cash Cash Real Employer’s increase increase in accrued at age 60 equivalent equivalent increase in contributio in pension pension at related to transfer transfer cash n to pension lump sum pension accrued value at value at equivalent stakeholder at age 60 at aged 60 age at 31 pension at 31 March 31 March transfer s pension March 31 March 2020 2019 value 2020 2019

(bands of (bands of £5,000) £5,000) (bands (bands of of £2,500) £2,500)

£000 £000 £000 £000 £000 £000 £000 £000

Sarah Blow, Accountable Officer (1) 2.5 to 5 0 40 to 45 85 to 90 797 731 27 0

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James Murray, CFO (2) n/a n/a n/a n/a n/a n/a n/a n/a

Jonathan Bates, Director of Commissioning 0 to 2.5 0 40 to 45 90 to 95 732 678 20 0 Operations, SWL Alliance (3)

Charlotte Gawne, Director of 0 to 2.5 0 35 to 40 70 to 75 602 554 18 0 Communications, SWL Alliance (4)

Tonia Michaelides, 0 to 2.5 0 35 to 40 75 to 80 670 615 22 0 Managing Director (5)

Kathryn Yates, 2.5 to 5 5 to 7.5 5 to 10 20 to 25 175 165 5 0 Registered Nurse

Notes

1: Sarah Blow is the Accountable Officer for South West London Alliance on Wandsworth CCG’s payroll. Richmond CCG is responsible for 20% of her costs, but we are showing the full costs.

2: James Murray is Chief Financial Officer for South West London Alliance and is on Wandsworth CCG’s payroll. Wandsworth CCG does not make any employer’s pensions contribution in respect of James Murray.

3: Jonathan Bates is Director of Commissioning Operations for South West London Alliance on Wandsworth CCG’s payroll. Richmond CCG is responsible for 20% of his costs, but we are showing the full costs.

4. Charlotte Gawne is Director of Director of Communications for South West London Alliance on Wandsworth CCG’s payroll. Richmond CCG is responsible for 20% of her costs, but we are showing the full costs.

5: Tonia Michaelides is on Kingston CCG’s payroll: Richmond CCG is responsible for 50% of her costs. We are showing her full pension costs.

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

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

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

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

Compensation on early retirement or for loss of office

This is not applicable for Richmond CCG during 2019/20.

Payments to past members

This is not applicable for Richmond CCG during 2019/20.

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Pay multiples (This section is subject to audit).

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

The banded remuneration of the highest paid governing body member in the financial year 2019/20 was £150k-£155k per annum. This was 2.3 times the median remuneration of the workforce, which was £66k. The workforce includes both permanent staff and excludes off payroll engagements.

The banded remuneration of the highest paid governing body member in the financial year 2018/19 was £150k-£155k per annum. This was 2.6 times the median remuneration of the workforce, which was £59k. The workforce includes both permanent staff and off payroll engagements.

In 2019/20, one employee received remuneration in excess of the highest-paid director/Member (2018/19 was one). Remuneration ranged from £25k to £179k (In 2018/19 remuneration ranged from £18k to £168k). Total remuneration includes salary, non-consolidated performance-related pay, benefits-in-kind, but not severance payments. It does not include employer pension contributions and the cash equivalent transfer value of pensions.

Staff Report

Keeping our staff informed and engaged

During the year, we have built on the progress we made last year to further develop staff communication and organisational development activities. This is important so that CCG and Health and Care Partnership staff understand the shared work objectives across south west London, and are engaged in them, as well as local CCG priorities. The staff engagement group with representation from all CCGs in

NHS Richmond Clinical Commissioning Group Annual Report 2019/20 108 south west London has been set up to steer organisational development and internal communications activities to ensure that staff engagement remains an area of focus.

Highlights this year included:

 Holding our third staff conference for all CCG and South West London Health and Care Partnership staff in South West London in June 2019.

 Setting up a Leadership Forum for senior leaders across the six CCGs and the South West London Health and Care Partnership (HCP) to come together and shape how we collectively lead the CCGs and the HCP.  Holding monthly staff briefings – ‘Team Talk’ – to ensure there is consistency in our approach to staff communications. Each monthly briefing contains key messages from the senior management team and are localised with updates on initiatives from the local delivery unit’s managing director. Feedback from staff from these briefings is collated and shared with the senior management team.  In March 2020 we held our second Staff Awards. The South West London Alliance Awards for Making a Difference, or the “SAMs” for short, recognises the work and contributions of both individuals and teams who have ‘made a difference’ to the people, patients and staff across South West London throughout the year.  Reinvigorating our Staff Partnership Forum with Trade Union colleagues. The staff forum provides a framework for consultation and local collective bargaining and ensures that matters affecting employee relations are dealt with effectively and speedily.  Involving staff in our Moving Forward Together programme to guide the merger of the six CCGs. Senior Staff from across the CCGs and the South West London Health and Care Partnership came together to review all CCG/HCP functions and develop staff structures for a future single CCG; informal conversations with staff were undertaken so that they could feedback and help shape staffing structures prior to formal consultation; staff were invited to give feedback during the formal consultation process on future

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staffing structures. At every stage of the development of staffing structures, changes were made as a result of the feedback staff gave.

Staff engagement activities in Richmond CCG

The results of the annual national staff survey form the basis of the action plan which continues to evolve to address the concerns that staff have raised. The ways of working group is responsible for developing and implementing initiatives to improve the working lives of our staff.

Throughout the year we have continued our focus on healthy workplace initiatives (both physical and mental health) including signing up for the ‘Global Walking Challenge’ for the fourth year in a row and continuing to run weekly mindfulness sessions at lunchtimes. We also held a mental health awareness session for staff to help with their own mental health and to help colleagues if they appear to be struggling. Line managers were also trained to recognise the signs of mental ill health in their staff and how to manage it. During the year as part of the ‘Time to Change’ programme, we trained 15 members of staff to be mental health champions. The role of the champion is to listen, promote and support conversations about mental health. This has been supplemented by giving staff the opportunity to take time out on a regular basis to focus on themselves which could include accessing digital wellbeing services or participating in lunchtime games sessions.

In recognition of our commitment to staff health and wellbeing, Vicki Harvey-Piper, director of corporate affairs and governance, was recognised with the London region Parliamentary award for wellbeing at work.

Another area of focus for this year was to enhance engagement of staff across the organisation. This was important against the backdrop of the Moving Forward Together programme which impacted every member of staff. To ensure senior managers felt more engaged and able to contribute to discussions before decisions were made, the leadership team meeting was extended once a month to include directors’ direct reports.

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This year, instead of running another mid-year online survey we held several staff focus groups which were run by an external facilitator. Obtaining anonymised staff feedback in this way gave us a richer source of information mid-way through the year to ‘test the temperature’ of the organisation and utilise in our action plan initiatives. We also held our third annual local staff conference which brought together the whole organisation and focused on personal resilience to help staff manage change both in and out of work.

A further key area of focus this year based on the results of the staff survey was training and development. During the year we held several south west London-wide training sessions. This included workshops on navigating conflict at work which focused on developing a culture where conflicts are effectively managed and creating an improved work environment. We also held IT training sessions to enable staff to get the most out of their IT equipment and software and ensure that they were able to work smarter in different locations outside of the office environment. During the year, we developed and implemented line management ‘back to basics’ training with the aim that every line manager has the same training to ensure consistency in approach to managing staff across the organisation. In addition, each team has attended a development day to enable them to identify their priorities, objectives and enhance working relationships within their teams.

As part of our continued commitment to make South West London a great place to work we have, for the second year running, run the South West London Alliance Awards for Making a Difference (The SAMs). This is an annual reward and recognition programme for staff. Reward and recognition is a key element of staff engagement. Awards can help to support the recognition of the good work that staff undertake, the contribution they make as well as making them feel more valued. There are six award categories ranging from quality improvement, leadership and unsung hero. A judging panel consisting of the Accountable Officer, a CCG chair and a lay member make the final decision.

Staff policies and other information

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We have statutory and mandatory training requirements and reporting procedures in place. This training is provided both on line via e-learning and in house.

We have an annual appraisal system to support staff and set personal development plans. Training is available to staff to support personal development and career progression.

Employee consultation is covered by an agreed CCG-wide organisational change policy.

Staff who have a disability are protected under the terms of the Equality Act 2010. The sickness absence policy states: ‘If an employee is disabled or becomes disabled, the CCG is legally required under the Equality Act 2010 to make reasonable adjustments to enable the employee to continue working – for example, providing an ergonomic chair or a power-assisted piece of equipment. The CCG must ensure the individual is not disadvantaged because of their disability. If their absence is related to disability, records should be kept separate from other sickness absence’.

Candidates who apply to the CCG and who declare they have a disability are given full and fair consideration for employment and are not discriminated against on the ground of their disability at any stage of the recruitment process. For example, candidates are asked if any adjustments are needed in order for them to attend interview and / or undertake assessments, and any reasonable adjustments to enable a disabled person to take up a role would also be given consideration.

The CCG has an organisational development plan which includes plans for the development of all staff in the organisation.

The majority of roles in the CCG are paid in accordance with the national Agenda for Change payscales.

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Number of senior managers Band Number in March 2019 Very Senior Manager 0 Band 9 1 Band 8D 2 Total 3

These figures include only staff employed directly through Richmond CCG’s payroll.

Staff numbers and costs (subject to audit)

Permanently Other staff Total employed staff Category Cost, Average Cost, Average Cost, Average £000 WTE £000 WTE £000 WTE A: Ambulance staff 0 0.0 0 0.0 0 0.0 G: Administration and 2,932 37.91 495 4.30 3,427 42.21 estates staff H: Healthcare Assistants 0 0.0 0 0.0 0 0.0 and other support staff M: Medical and Dental 62 0.37 0 0.0 62 0.37 staff N: Nursing, Midwifery 232 2.92 148 2.88 380 5.79 and health visiting staff P: Nursing, midwifery and health visiting 0 0.0 0 0.0 0 0.0 learners

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S: Scientific, therapeutic 513 6.69 13 0.09 526 6.78 and technical staff U: Healthcare science 0 0.0 0 0.0 0 0.0 Total 3,738 47.89 657 7.26 4,395 55.15

Staff composition Female Male Total Directors 0 0 0 Senior managers 3 1 4 Employees 44 14 58 Total 47 15 62

Equalities for staff

An equalities breakdown of staff by six categories in line with guidance is available and key areas are presented regularly to the CCG in the form of workforce reports. Tables do not include Governing Body members and clinical leads. Monitoring will continue to identify any priority areas to address.

As at 31 March 2020 The following tables are a profile of the CCG relating to the main protected characteristics.

Tables do not include Governing Body members/clinical leads.

Disability

Disability Headcount Percentage FTE No 45 97.83% 42.13 Prefer Not To Answer 1 2.17% 1.00 Grand Total 46 100% 43.13

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Disability 120.00%

100.00%

80.00%

60.00%

40.00%

20.00%

0.00% No Prefer Not To Answer

Ethnic origin

Ethnic Origin Headcount Percentage FTE A White - British 24 52.17% 22.42 B White - Irish 1 2.17% 1.00 C White - Any other White background 4 8.70% 3.40 D Mixed - White & Black Caribbean 1 2.17% 0.91 G Mixed - Any other mixed background 2 4.35% 2.00 H Asian or Asian British - Indian 2 4.35% 2.00 J Asian or Asian British - Pakistani 1 2.17% 0.60 L Asian or Asian British - Any other Asian background 1 2.17% 1.00 LB Asian Punjabi 1 2.17% 1.00 M Black or Black British - Caribbean 3 6.52% 3.00 N Black or Black British - African 2 4.35% 2.00 P Black or Black British - Any other Black background 1 2.17% 1.00 S Any Other Ethnic Group 2 4.35% 2.00 Z Not Stated 1 2.17% 0.80 Grand Total 46 100% 43.13

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Sexual orientation Sexual Orientation Headcount Percentage FTE Heterosexual or Straight 37 80.43% 35.14 Not stated (person asked but declined to provide a response) 9 19.57% 7.99 Grand Total 46 100% 43.13

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Religious Belief

Religious Belief Headcount Percentage FTE Atheism 5 10.87% 4.69 Christianity 22 47.83% 20.85 Hinduism 1 2.17% 1.00 I do not wish to disclose my religion/belief 12 26.09% 10.99 Islam 1 2.17% 0.60 Other 3 6.52% 3.00 Sikhism 2 4.35% 2.00 Grand Total 46 100% 43.13

Religious Belief

6.52% 4.35% Atheism 2.17% 10.87% Christianity 26.09% Hinduism 47.83% I do not wish to disclose my religion/belief Islam

2.17% Other

Age Range

Age Band Headcount Percentage FTE 26-30 5 10.87% 5.00 31-35 1 2.17% 1.00 36-40 3 6.52% 2.80 41-45 9 19.57% 7.59 46-50 10 21.74% 10.00 51-55 10 21.74% 9.34 56-60 6 13.04% 5.80 61-65 2 4.35% 1.60 Grand Total 46 100% 43.13

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AGE BAND

21.74% 21.74%

19.57%

13.04%

10.87%

6.52%

4.35% 2.17%

26- 30 31- 35 36- 40 41- 45 46- 50 51- 55 56- 60 61- 65

Employee Category Headcount FTE Full Time 35 35.00 Part Time 27 11.36 Grand Total 62 46.36

Gender

The following figures exclude directors and staff on the payrolls of other CCGs who are part- recharged to Richmond CCG.

Gender Headcount Percentage FTE Female 37 80.43% 34.13 Male 9 19.57% 9.00 Grand Total 46 100% 43.13

Sickness absence data

The CCG sickness absence percentage rate is presented regularly to the CCG in the form of workforce reports. Individual sickness absence cases are managed by the line manager with advice and support from HR.

An occupational health (OH) service is available to provide professional medical advice to the CCG. Staff can access OH for a self-referral.

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The CCG also has access to an employee assistance programme which offers confidential access to emotional and practical support, including legal and financial advice.

Number of days lost 455.99 Total staff years 45.10 Average working days lost 10.11

Consultancy

The reported expenditure on consultancy was £55k in 2019/20 (-£6k in 2018/19).

Off-payroll engagements (not subject to audit) Table 1: Off-payroll engagements longer than 6 months

For all off-payroll engagements as of 31 March 2020, for more than £245 per day and that lasted longer than six months were as follows:

Number Number of existing arrangements as of 31 March 2020. 6

Of which, the number that have existed: for less than one year at the time of reporting 1 for between one and two years at the time of reporting 2 for between 2 and 3 years at the time of reporting 2 for between 3 and 4 years at the time of reporting 0 for between 4 or more years at the time of reporting 1

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

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Table 2: New off-payroll engagements

Where the reformed public sector rules apply, entities must complete Table 2 for all new off-payroll engagements, or those that reached six months in duration, between 1 April 2019 and 31 March 2020, for more than £245 per day and that last for longer than 6 months:

Number

Number of new engagements or those that reached six months in 3 duration between 1 April 2019 and 31 March 2020.

Of which… Number assessed as caught by IR35 0 Number assessed as not caught by IR35 3

Number engaged directly (via PSC contracted to the entity) and are on 0 the departmental payroll Number of engagements reassessed for consistency / assurance 0 purposes during the year Number of engagements that saw a change to IR35 status following the 0 consistency review.

Table 3: Off-payroll engagements / senior official engagements

For any off-payroll engagements of board members, and/or, senior officials with significant financial responsibility, between 1 April 2019 and 31 March 2020

Number Number of off-payroll engagements of board members, and/or senior 0 officers with significant financial responsibility, during the financial year

Number of individuals that have been deemed Governing Body 18 members, and/or senior officers with significant financial responsibility during the financial year. This figure includes both off-payroll and on- payroll engagements.

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Exit packages, including special (non-contractual) payments (subject to audit) During 2019-20 there were no exit packages at Richmond CCG.

Sarah Blow Accountable Officer Date: 18th June 2020

Parliamentary Accountability and Audit Report

Richmond CCG is not required to produce a Parliamentary Accountability and Audit Report. Disclosures on remote contingent liabilities, losses and special payments, gifts, and fees and charges are included as notes in the Financial Statements of this report at. An audit certificate and report is also included in this Annual Report.

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Entity name: Richmond CCG This year 2019-20 Last year 2018-19 This year ended 31-March-2020 This year commencing: 01-April-2019 Richmond CCG - Annual Accounts 2019-20

CONTENTS Page Number

The Primary Statements:

Statement of Comprehensive Net Expenditure for the year ended 31st March 2020 3 Statement of Financial Position as at 31st March 2020 4 Statement of Changes in Taxpayers' Equity for the year ended 31st March 2020 5 Statement of Cash Flows for the year ended 31st March 2020 6

Notes to the Accounts Accounting policies 7-10 Other operating revenue 11 Employee benefits and staff numbers 12-14 Operating expenses 15 Better payment practice code 16 Operating leases 17 Property, plant and equipment 18 Trade and other receivables 19 Cash and cash equivalents 20 Trade and other payables 21 Provisions 22 Financial instruments 23-24 Operating segments 24 Related party transactions 25 Events after the end of the reporting period 26 Pooled Budget 26 Financial performance targets 26

2 Richmond CCG - Annual Accounts 2019-20

Statement of Comprehensive Net Expenditure for the year ended 31 March 2020

2019-20 2018-19 Note £'000 £'000

Other operating income 2 (1,709) (2,688) Total operating income (1,709) (2,688)

Staff costs 3 4,395 3,931 Purchase of goods and services 4 282,219 272,714 Depreciation and impairment charges 4 79 79 Provision expense 4 126 849 Other Operating Expenditure 4 (1,037) 1,478 Total operating expenditure 285,782 279,051

Total Net Expenditure for the Financial Year 284,073 276,363

Comprehensive Expenditure for the year 284,073 276,363

3 Richmond CCG - Annual Accounts 2019-20

Statement of Financial Position as at 31 March 2020 2019-20 2018-19

Note £'000 £'000 Non-current assets: Property, plant and equipment 7 79 157 Total non-current assets 79 157 Current assets: Trade and other receivables 8 2,022 2,849 Cash and cash equivalents 9 157 174 Total current assets 2,179 3,023

Total assets 2,258 3,180

Current liabilities Trade and other payables 10 (23,867) (31,483) Provisions 11 (904) (849) Total current liabilities (24,771) (32,332)

Non-Current Assets plus/less Net Current Assets/Liabilities (22,513) (29,152)

Assets less Liabilities (22,513) (29,152)

Financed by Taxpayers’ Equity General fund (22,513) (29,152) Total taxpayers' equity: (22,513) (29,152)

The notes on pages 7 to 26 form part of this statement

The financial statements on pages 3 to 6 were approved by the Audit Committee on 27th May and signed on its behalf by:

Sarah Blow Chief Accountable Officer

4 31 March 2020 Total General fund reserves £'000 £'000 Changes in taxpayers’ equity for 2019-20

Balance at 01 April 2019 (29,152) (29,152) Transfer between reserves in respect of assets transferred from closed NHS bodies 0 0 Adjusted NHS Clinical Commissioning Group balance at 31 March 2020 (29,152) (29,152)

Changes in NHS Clinical Commissioning Group taxpayers’ equity for 2019-20 Net operating expenditure for the financial year (284,073) (284,073)

Net Recognised NHS Clinical Commissioning Group Expenditure for the Financial Year (284,073) (284,073) Net funding 290,712 290,712 Balance at 31 March 2020 (22,513) (22,513)

Total General fund reserves £'000 £'000 Changes in taxpayers’ equity for 2018-19

Balance at 01 April 2018 (27,529) (27,529) Transfer of assets and liabilities from closed NHS bodies 0 0 Adjusted NHS Clinical Commissioning Group balance at 31 March 2019 (27,529) (27,529)

Changes in NHS Clinical Commissioning Group taxpayers’ equity for 2018-19 Impact of applying IFRS 9 to Opening Balances (4) (4) Net operating costs for the financial year (276,363) (276,363)

Net Recognised NHS Clinical Commissioning Group Expenditure for the Financial Year (276,367) (276,367) Net funding 274,744 274,744 Balance at 31 March 2019 (29,152) (29,152)

The notes on pages 7 to 26 form part of this statement

5 Richmond CCG - Annual Accounts 2019-20

Statement of Cash Flows for the year ended 31 March 2020 2019-20 2018-19 Note £'000 £'000 Cash Flows from Operating Activities Net operating expenditure for the financial year (284,073) (276,363) Depreciation and amortisation 4 79 79 Non-cash movements arising on application of new accounting standards 0 (3) (Increase)/decrease in trade & other receivables 8 827 2,856 Increase/(decrease) in trade & other payables 10 (7,616) (2,067) Provisions utilised 11 (71) (183) Increase/(decrease) in provisions 11 126 849 Net Cash Inflow (Outflow) from Operating Activities (290,728) (274,832)

Net Cash Inflow (Outflow) before Financing (290,728) (274,832)

Cash Flows from Financing Activities Grant in Aid Funding Received 290,711 274,743 Net Cash Inflow (Outflow) from Financing Activities 290,711 274,743

Net Increase (Decrease) in Cash & Cash Equivalents 9 (17) (89)

Cash & Cash Equivalents at the Beginning of the Financial Year 174 263 Effect of exchange rate changes on the balance of cash and cash equivalents held in foreign currencies 0 0 Cash & Cash Equivalents (including bank overdrafts) at the End of the Financial Year 157 174

The notes on pages 7 to 26 form part of this statement

6 Richmond CCG - Annual Accounts 2019-20 Notes to the financial statements

1 Accounting Policies

NHS England has directed that the financial statements of clinical commissioning groups shall meet the accounting requirements of the Group Accounting Manual issued by the Department of Health and Social Care. Consequently, the following financial statements have been prepared in accordance with the Group Accounting Manual 2019-20 issued by the Department of Health and Social Care. The accounting policies contained in the Group Accounting Manual follow International Financial Reporting Standards to the extent that they are meaningful and appropriate to clinical commissioning groups, as determined by HM Treasury, which is advised by the Financial Reporting Advisory Board. Where the Group Accounting Manual permits a choice of accounting policy, the accounting policy which is judged to be most appropriate to the particular circumstances of the clinical commissioning group for the purpose of giving a true and fair view has been selected. The particular policies adopted by the clinical commissioning group are described below. They have been applied consistently in dealing with items considered material in relation to the accounts. 1.1 Going Concern These accounts have been prepared on a going concern basis. Public sector bodies are assumed to be going concerns where the continuation of the provision of a service in the future is anticipated, as evidenced by inclusion of financial provision for that service in published documents. The following is evidence that it is appropriate for Richmond CCG to prepare its annual accounts on a going concern basis: • Richmond CCG has agreed and is operating to, its constitution to govern its activities. • The CCG has been allocated funds from NHS England for 2020/21, however these have subsequently been included within the SWL allocation • The CCG was allocated a control total of £1.5m for 2020/21, however this has now been subsumed within the SWL control total.

On 1st April 2020, Richmond CCG merged with the other five CCGs in South West London to become South West London CCG. This is a non- adjusting event.

On 17th March 2020, NHSE issued a letter from Simon Stevens which set out amended financial arrangements for the NHS for the period between 1 April and 31st July to enable the NHS to respond to COVID-19. This set out the suspension of the operational planning process for 2020/21. Commissioner allocations for 2020/21 have already been notified as part of operational planning and will not be changed. In addition, NHS Commissioners were allocated £1.3bn nationally to cover the cost of COVID-19 hospital discharges and out of hospital work which applies from 19th March 2020. Other costs of COVID-19 will be claimed monthly under the financial arrangements set out in the 17th March 2020 letter. 1.2 Accounting Convention These accounts have been prepared under the historical cost convention modified to account for the revaluation of property, plant and equipment, intangible assets, inventories and certain financial assets and financial liabilities. 1.3 Pooled Budgets The clinical commissioning group has entered into a pooled budget arrangement with London Borough of Richmond in accordance with section 75 of the NHS Act 2006. Under the arrangement, funds are pooled for commissioning out of hospital services and a note to the accounts provides details of the income and expenditure. 1.4 Operating Segments Richmond CCG reports as one operating segment. 1.5 Revenue In the application of IFRS 15 a number of practical expedients offered in the Standard have been employed. These are as follows; • As per paragraph 121 of the Standard the clinical commissioning group will not disclose information regarding performance obligations part of a contract that has an original expected duration of one year or less, • The clinical commissioning group is to similarly not disclose information where revenue is recognised in line with the practical expedient offered in paragraph B16 of the Standard where the right to consideration corresponds directly with value of the performance completed to date. • The FReM has mandated the exercise of the practical expedient offered in C7(a) of the Standard that requires the clinical commissioning group to reflect the aggregate effect of all contracts modified before the date of initial application. The main source of funding for the Clinical Commissioning Group is from NHS England. This is drawn down and credited to the general fund. Funding is recognised in the period in which it is received. Revenue in respect of services provided is recognised when (or as) performance obligations are satisfied by transferring promised services to the customer, and is measured at the amount of the transaction price allocated to that performance obligation. Where income is received for a specific performance obligation that is to be satisfied in the following year, that income is deferred. Payment terms are standard reflecting cross government principles. 1.6 Employee Benefits 1.6.1 Short-term Employee Benefits Salaries, wages and employment-related payments, including payments arising from the apprenticeship levy, are recognised in the period in which the service is received from employees, including bonuses earned but not yet taken. The cost of leave earned but not taken by employees at the end of the period is recognised in the financial statements to the extent that employees are permitted to carry forward leave into the following period.

1.6.2 Retirement Benefit Costs Past and present employees are covered by the provisions of the NHS Pensions Schemes. These schemes are unfunded, defined benefit schemes that cover NHS employers, General Practices and other bodies allowed under the direction of the Secretary of State in England and Wales. The schemes are not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities. Therefore, the schemes are accounted for as though they were defined contribution schemes: the cost to the clinical commissioning group of participating in a scheme is taken as equal to the contributions payable to the scheme for the accounting period. For early retirements other than those due to ill health the additional pension liabilities are not funded by the scheme. The full amount of the liability for the additional costs is charged to expenditure at the time the clinical commissioning group commits itself to the retirement, regardless of the method of payment. The schemes are subject to a full actuarial valuation every four years and an accounting valuation every year. 1.7 Other Expenses Other operating expenses are recognised when, and to the extent that, the goods or services have been received. They are measured at the fair value of the consideration payable. 1.8 Grants Payable Where grant funding is not intended to be directly related to activity undertaken by a grant recipient in a specific period, the clinical commissioning group recognises the expenditure in the period in which the grant is paid. All other grants are accounted for on an accruals basis.

7 Richmond CCG - Annual Accounts 2019-20 Notes to the financial statements

1.9 Property, Plant & Equipment 1.9.1 Recognition Property, plant and equipment is capitalised if: · It is held for use in delivering services or for administrative purposes; · It is probable that future economic benefits will flow to, or service potential will be supplied to the clinical commissioning group; · It is expected to be used for more than one financial year; · The cost of the item can be measured reliably; and, · The item has a cost of at least £5,000; or, · Collectively, a number of items have a cost of at least £5,000 and individually have a cost of more than £250, where the assets are functionally interdependent, they had broadly simultaneous purchase dates, are anticipated to have simultaneous disposal dates and are under single managerial control; or, · Items form part of the initial equipping and setting-up cost of a new building, ward or unit, irrespective of their individual or collective cost. Where a large asset, for example a building, includes a number of components with significantly different asset lives, the components are treated as separate assets and depreciated over their own useful economic lives. 1.9.2 Measurement All property, plant and equipment is measured initially at cost, representing the cost directly attributable to acquiring or constructing the asset and bringing it to the location and condition necessary for it to be capable of operating in the manner intended by management. Assets that are held for their service potential and are in use are measured subsequently at their current value in existing use. Assets that were most recently held for their service potential but are surplus are measured at fair value where there are no restrictions preventing access to the market at the reporting date Revaluations are performed with sufficient regularity to ensure that carrying amounts are not materially different from those that would be determined at the end of the reporting period. Current values in existing use are determined as follows: · Land and non-specialised buildings – market value for existing use; and, · Specialised buildings – depreciated replacement cost.

Properties in the course of construction for service or administration purposes are carried at cost, less any impairment loss. Cost includes professional fees but not borrowing costs, which are recognised as expenses immediately, as allowed by IAS 23 for assets held at fair value. Assets are re-valued and depreciation commences when they are brought into use. IT equipment, transport equipment, furniture and fittings, and plant and machinery that are held for operational use are valued at depreciated historic cost where these assets have short useful economic lives or low values or both, as this is not considered to be materially different from current value in existing use. An increase arising on revaluation is taken to the revaluation reserve except when it reverses an impairment for the same asset previously recognised in expenditure, in which case it is credited to expenditure to the extent of the decrease previously charged there. A revaluation decrease that does not result from a loss of economic value or service potential is recognised as an impairment charged to the revaluation reserve to the extent that there is a balance on the reserve for the asset and, thereafter, to expenditure. Impairment losses that arise from a clear consumption of economic benefit are taken to expenditure. Gains and losses recognised in the revaluation reserve are reported as other comprehensive income in the Statement of Comprehensive Net Expenditure. 1.9.3 Subsequent Expenditure Where subsequent expenditure enhances an asset beyond its original specification, the directly attributable cost is capitalised. Where subsequent expenditure restores the asset to its original specification, the expenditure is capitalised and any existing carrying value of the item replaced is written- out and charged to operating expenses. 1.10 Leases Leases are classified as finance leases when substantially all the risks and rewards of ownership are transferred to the lessee. All other leases are classified as operating leases. 1.10.1 The Clinical Commissioning Group as Lessee Property, plant and equipment held under finance leases are initially recognised, at the inception of the lease, at fair value or, if lower, at the present value of the minimum lease payments, with a matching liability for the lease obligation to the lessor. Lease payments are apportioned between finance charges and reduction of the lease obligation so as to achieve a constant rate on interest on the remaining balance of the liability. Finance charges are recognised in calculating the clinical commissioning group’s surplus/deficit. Operating lease payments are recognised as an expense on a straight-line basis over the lease term. Lease incentives are recognised initially as a liability and subsequently as a reduction of rentals on a straight-line basis over the lease term. Contingent rentals are recognised as an expense in the period in which they are incurred. Where a lease is for land and buildings, the land and building components are separated and individually assessed as to whether they are operating or finance leases. 1.11 Cash & Cash Equivalents Cash is cash in hand and deposits with any financial institution repayable without penalty on notice of not more than 24 hours. Cash equivalents are investments that mature in 3 months or less from the date of acquisition and that are readily convertible to known amounts of cash with insignificant risk of change in value. In the Statement of Cash Flows, cash and cash equivalents are shown net of bank overdrafts that are repayable on demand and that form an integral part of the clinical commissioning group’s cash management. 1.12 Provisions Provisions are recognised when the clinical commissioning group has a present legal or constructive obligation as a result of a past event, it is probable that the clinical commissioning group will be required to settle the obligation, and a reliable estimate can be made of the amount of the obligation. The amount recognised as a provision is the best estimate of the expenditure required to settle the obligation at the end of the reporting period, taking into account the risks and uncertainties. Where a provision is measured using the cash flows estimated to settle the obligation, its carrying amount is the present value of those cash flows using HM Treasury’s discount rate . A restructuring provision is recognised when the clinical commissioning group has developed a detailed formal plan for the restructuring and has raised a valid expectation in those affected that it will carry out the restructuring by starting to implement the plan or announcing its main features to those affected by it. The measurement of a restructuring provision includes only the direct expenditures arising from the restructuring, which are those amounts that are both necessarily entailed by the restructuring and not associated with on-going activities of the entity. 1.13 Clinical Negligence Costs NHS Resolution operates a risk pooling scheme under which the clinical commissioning group pays an annual contribution to NHS Resolution, which in return settles all clinical negligence claims. The contribution is charged to expenditure. Although NHS Resolution is administratively responsible for all clinical negligence cases, the legal liability remains with clinical commissioning group.

8 Richmond CCG - Annual Accounts 2019-20 Notes to the financial statements

1.14 Non-clinical Risk Pooling The clinical commissioning group participates in the Property Expenses Scheme and the Liabilities to Third Parties Scheme. Both are risk pooling schemes under which the clinical commissioning group pays an annual contribution to the NHS Resolution and, in return, receives assistance with the costs of claims arising. The annual membership contributions, and any excesses payable in respect of particular claims are charged to operating expenses as and when they become due. 1.15 Contingent liabilities and contingent assets A contingent liability is a possible obligation that arises from past events and whose existence will be confirmed only by the occurrence or non- occurrence of one or more uncertain future events not wholly within the control of the clinical commissioning group, or a present obligation that is not recognised because it is not probable that a payment will be required to settle the obligation or the amount of the obligation cannot be measured sufficiently reliably. A contingent liability is disclosed unless the possibility of a payment is remote. A contingent asset is a possible asset that arises from past events and whose existence will be confirmed by the occurrence or non-occurrence of one or more uncertain future events not wholly within the control of the clinical commissioning group. A contingent asset is disclosed where an inflow of economic benefits is probable. Where the time value of money is material, contingent liabilities and contingent assets are disclosed at their present value. 1.16 Financial Assets Financial assets are recognised when the clinical commissioning group becomes party to the financial instrument contract or, in the case of trade receivables, when the goods or services have been delivered. Financial assets are derecognised when the contractual rights have expired or the asset has been transferred. Financial assets are classified into the following categories: · Financial assets at amortised cost; · Financial assets at fair value through other comprehensive income and ; · Financial assets at fair value through profit and loss. The classification is determined by the cash flow and business model characteristics of the financial assets, as set out in IFRS 9, and is determined at the time of initial recognition. 1.16.1 Financial Assets at Amortised cost Financial assets measured at amortised cost are those held within a business model whose objective is achieved by collecting contractual cash flows and where the cash flows are solely payments of principal and interest. This includes most trade receivables and other simple debt instruments. After initial recognition these financial assets are measured at amortised cost using the effective interest method less any impairment. The effective interest rate is the rate that exactly discounts estimated future cash receipts through the life of the financial asset to the gross carrying amount of the financial asset. 1.16.2 Financial assets at fair value through other comprehensive income Financial assets held at fair value through other comprehensive income are those held within a business model whose objective is achieved by both collecting contractual cash flows and selling financial assets and where the cash flows are solely payments of principal and interest. 1.16.3 Financial assets at fair value through profit and loss Financial assets measure at fair value through profit and loss are those that are not otherwise measured at amortised cost or fair value through other comprehensive income. This includes derivatives and financial assets acquired principally for the purpose of selling in the short term. 1.16.4 Impairment For all financial assets measured at amortised cost or at fair value through other comprehensive income (except equity instruments designated at fair value through other comprehensive income), lease receivables and contract assets, the clinical commissioning group recognises a loss allowance representing the expected credit losses on the financial asset. The clinical commissioning group adopts the simplified approach to impairment in accordance with IFRS 9, and measures the loss allowance for trade receivables, lease receivables and contract assets at an amount equal to lifetime expected credit losses. For other financial assets, the loss allowance is measured at an amount equal to lifetime expected credit losses if the credit risk on the financial instrument has increased significantly since initial recognition (stage 2) and otherwise at an amount equal to 12 month expected credit losses (stage 1).

HM Treasury has ruled that central government bodies may not recognise stage 1 or stage 2 impairments against other government departments, their executive agencies, the Bank of England, Exchequer Funds and Exchequer Funds assets where repayment is ensured by primary legislation. The clinical commissioning group therefore does not recognise loss allowances for stage 1 or stage 2 impairments against these bodies. Additionally Department of Health and Social Care provides a guarantee of last resort against the debts of its arm's lengths bodies and NHS bodies and the clinical commissioning group does not recognise allowances for stage 1 or stage 2 impairments against these bodies. For financial assets that have become credit impaired since initial recognition (stage 3), expected credit losses at the reporting date are measured as the difference between the asset's gross carrying amount and the present value of the estimated future cash flows discounted at the financial asset's original effective interest rate. Any adjustment is recognised in profit or loss as an impairment gain or loss. 1.17 Financial Liabilities Financial liabilities are recognised on the statement of financial position when the clinical commissioning group becomes party to the contractual provisions of the financial instrument or, in the case of trade payables, when the goods or services have been received. Financial liabilities are de- recognised when the liability has been discharged, that is, the liability has been paid or has expired. 1.17.1 Financial Guarantee Contract Liabilities Financial guarantee contract liabilities are subsequently measured at the higher of: · The premium received (or imputed) for entering into the guarantee less cumulative amortisation; and, · The amount of the obligation under the contract, as determined in accordance with IAS 37: Provisions, Contingent Liabilities and Contingent Assets. 1.17.2 Financial Liabilities at Fair Value Through Profit and Loss

Embedded derivatives that have different risks and characteristics to their host contracts, and contracts with embedded derivatives whose separate value cannot be ascertained, are treated as financial liabilities at fair value through profit and loss. They are held at fair value, with any resultant gain or loss recognised in the clinical commissioning group’s surplus/deficit. The net gain or loss incorporates any interest payable on the financial liability. 1.17.3 Other Financial Liabilities After initial recognition, all other financial liabilities are measured at amortised cost using the effective interest method, except for loans from Department of Health and Social Care, which are carried at historic cost. The effective interest rate is the rate that exactly discounts estimated future cash payments through the life of the asset, to the net carrying amount of the financial liability. Interest is recognised using the effective interest method. 1.18 Value Added Tax Most of the activities of the clinical commissioning group are outside the scope of VAT and, in general, output tax does not apply and input tax on purchases is not recoverable. Irrecoverable VAT is charged to the relevant expenditure category or included in the capitalised purchase cost of fixed assets. Where output tax is charged or input VAT is recoverable, the amounts are stated net of VAT.

9 Richmond CCG - Annual Accounts 2019-20 Notes to the financial statements

1.19 Foreign Currencies The clinical commissioning group’s functional currency and presentational currency is pounds sterling and amounts are presented in thousands of pounds unless expressly stated otherwise. Transactions denominated in a foreign currency are translated into sterling at the exchange rate ruling on the dates of the transactions. At the end of the reporting period, monetary items denominated in foreign currencies are retranslated at the spot exchange rate on 31 March. Resulting exchange gains and losses for either of these are recognised in the clinical commissioning group’s surplus/deficit in the period in which they arise. 1.20 Third Party Assets Assets belonging to third parties (such as money held on behalf of patients) are not recognised in the accounts since the clinical commissioning group has no beneficial interest in them. 1.21 Losses & Special Payments Losses and special payments are items that Parliament would not have contemplated when it agreed funds for the health service or passed legislation. By their nature they are items that ideally should not arise. They are therefore subject to special control procedures compared with the generality of payments. They are divided into different categories, which govern the way that individual cases are handled. Losses and special payments are charged to the relevant functional headings in expenditure on an accruals basis, including losses which would have been made good through insurance cover had the clinical commissioning group not been bearing its own risks (with insurance premiums then being included as normal revenue expenditure). 1.22 Critical accounting judgements and key sources of estimation uncertainty In the application of the clinical commissioning group's accounting policies, management is required to make various judgements, estimates and assumptions. These are regularly reviewed. 1.22.1 Critical accounting judgements in applying accounting policies Apart from those involving estimations (see below), there are no critical judgements that management has made in the process of applying the clinical commissioning group’s accounting policies that have a significant effect on the amounts recognised in the financial statements. 1.22.2 Sources of estimation uncertainty The following are assumptions about the future and other major sources of estimation uncertainty that have a significant risk of resulting in a material adjustment to the carrying amounts of assets and liabilities within the next financial year. - Estimates of the final two months prescribing expenditure have been conservatively based on historical expenditure patterns - Estimates of continuing care expenditure in the final three months have been based on invoices received during the financial year. 1.23 Gifts Gifts are items that are voluntarily donated, with no preconditions and without the expectation of any return. Gifts include all transactions economically equivalent to free and unremunerated transfers, such as the loan of an asset for its expected useful life, and the sale or lease of assets at below market value.

1.24 Accounting Standards That Have Been Issued But Have Not Yet Been Adopted The Department of Health and Social Care GAM does not require the following IFRS Standards and Interpretations to be applied in 2019-20. These Standards are still subject to HM Treasury FReM adoption, with IFRS 16 being for implementation in 2021-22, and the government implementation date for IFRS 17 still subject to HM Treasury consideration.

● IFRS 16 Leases – The Standard is effective 1 April 2021 as adapted and interpreted by the FReM. When the standard comes in force the impact on South West London CCG to which Richmond CCG will be merged into from 1st April 2020 will be; the lease payments for rental of the 2nd floor of Thames House, will be accounted for as an increase in the right of use of asset as a non current assest , offset by the financial liabilty over the expected term of the lease on the financial position statement. This transaction is currently treated as a operating lease for 2019-20 and expensed via statement of comprehensive net expenditure. The impact of adopting the standard is not expected to have a material impact on the CCG. ● IFRS 17 Insurance Contracts – Application required for accounting periods beginning on or after 1 January 2023, but not yet adopted by the FReM: early adoption is not therefore permitted. The impact of adopting the standard is not expected to have a material impact on the CCG.

10 Richmond CCG - Annual Accounts 2019-20

2 Other Operating Revenue 2019-20 2018-19 Total Total £'000 £'000

Other operating income Charitable and other contributions to revenue expenditure: non-NHS - 6 Other non contract revenue 1,709 2,682 Total Other operating income 1,709 2,688

Total Operating Income 1,709 2,688

Note The CCG did not receive any contract income so no disaggregation of income required

11 Richmond CCG - Annual Accounts 2019-20

3. Employee benefits and staff numbers

3.1.1 Employee benefits Total 2019-20

Permanent Employees Other Total £'000 £'000 £'000 Employee Benefits Salaries and wages 2,996 657 3,653 Social security costs 273 - 273 Employer Contributions to NHS Pension scheme 469 - 469 Gross employee benefits expenditure 3,738 657 4,395

Less: Employee costs capitalised - - - Net employee benefits excluding capitalised costs 3,738 657 4,395

3.1.1 Employee benefits Total 2018-19

Permanent Employees Other Total £'000 £'000 £'000 Employee Benefits Salaries and wages 2,692 647 3,339 Social security costs 269 - 269 Employer Contributions to NHS Pension scheme 323 - 323 Gross employee benefits expenditure 3,284 647 3,931

Less: Employee costs capitalised - - - Net employee benefits excluding capitalised costs 3,284 647 3,931

12 Richmond CCG - Annual Accounts 2019-20

3.2 Average number of people employed 2019-20 2018-19 Permanently Permanently employed Other Total employed Other Total Number Number Number Number Number Number

Total 48 7 55 53 8 61

3.3 Exit packages agreed in the financial year There have been no compulsory redundancies or other agreed departures in 2019-20. (2018-19, Nil).

13 Richmond CCG - Annual Accounts 2019-20

3.4 Pension costs

Past and present employees are covered by the provisions of the two NHS Pension Schemes. Details of the benefits payable and rules of the Schemes can be found on the NHS Pensions website at www.nhsbsa.nhs.uk/pensions.

These schemes are unfunded, defined benefit schemes that cover NHS employers, General Practices and other bodies allowed under the direction of the Secretary of State in England and Wales. The schemes are not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities.

Therefore, the schemes are accounted for as though they were defined contribution schemes: the cost to the clinical commissioning group of participating in a scheme is taken as equal to the contributions payable to the scheme for the accounting period.

The schemes are subject to a full actuarial valuation every four years and an accounting valuation every year.

The employer contribution rate for NHS Pensions increased from 14.3% to 20.6% from 1st April 2019. For 2019/20, NHS CCGs continued to pay over contributions at the former rate with the additional amount being paid by NHS England on CCGs behalf. The full cost and related funding has been recognised in these accounts.

3.4.1 Accounting valuation

A valuation of scheme liability is carried out annually by the scheme actuary (currently the Government Actuary’s Department) as at the end of the reporting period. This utilises an actuarial assessment for the previous accounting period in conjunction with updated membership and financial data for the current reporting period, and is accepted as providing suitably robust figures for financial reporting purposes. The valuation of the scheme liability as at 31 March 2019, is based on valuation data as 31 March 2018 updated to 31 March 2019 with summary global member and accounting data. In undertaking this actuarial assessment, the methodology prescribed in IAS 19, relevant FReM interpretations, and the discount rate prescribed by HM Treasury have also been used.

The latest assessment of the liabilities of the scheme is contained in the report of the scheme actuary, which forms part of the annual NHS Pension Scheme Accounts. These accounts can be viewed on the NHS Pensions website and are published annually. Copies can also be obtained from The Stationery Office.

3.4.2 Full actuarial (funding) valuation

The purpose of this valuation is to assess the level of liability in respect of the benefits due under the schemes (taking into account recent demographic experience), and to recommend contribution rates payable by employees and employers.

The last published actuarial valuation undertaken for the NHS Pension Scheme was completed for the year ending 31 March 2016. The results of this valuation set the employer contribution rate payable from April 2019. The Department of Health and Social Care have recently laid Scheme Regulations confirming that the employer contribution rate will increase to 20.6% of pensionable pay from this date.

The 2016 funding valuation was also expected to test the cost of the Scheme relative to the employer cost cap set following the 2012 valuation. Following a judgment from the Court of Appeal in December 2018 Government announced a pause to that part of the valuation process pending conclusion of the continuing legal process.

14 Richmond CCG - Annual Accounts 2019-20

4. Operating expenses 2019-20 2018-19 Total Total £'000 £'000

Purchase of goods and services Services from other CCGs and NHS England 3,604 4,264 Services from foundation trusts 126,431 118,750 Services from other NHS trusts 61,905 61,617 Services from Other WGA bodies 157 45 Purchase of healthcare from non-NHS bodies 36,772 36,724 Prescribing costs 20,533 19,850 GPMS/APMS and PCTMS 30,896 29,723 Supplies and services – clinical 391 385 Supplies and services – general 752 70 Consultancy services 55 (6) Establishment (78) 809 Transport 160 137 Premises 350 219 Audit fees 39 39 Other professional fees 173 32 Legal fees 52 28 Education, training and conferences 27 28 Total Purchase of goods and services 282,219 272,714

Depreciation and impairment charges Depreciation 79 79 Total Depreciation and impairment charges 79 79

Provision expense Provisions 126 849 Total Provision expense 126 849

Other Operating Expenditure Chair and Non Executive Members 383 367 Expected credit loss on receivables (1,420) 1,111 Total Other Operating Expenditure (1,037) 1,478

Total operating expenditure 281,387 275,120

Note 1. Audit fees of £39k (£39k 2018/19) represent full cost including non-reclaimable VAT. Actual Audit Fees paid to Grant Thornton were £32k (£32k 2018/19).

4.1 Limitation on auditor's liability In accordance with the terms of engagement with the clinical commissioning group's external auditors, Grant Thornton UK LLP, its members, partners and staff (whether contract, negligence or otherwise) in respect of services provided in connection with or arising out of the audit shall in no circumstances exceed £2million in the aggregate in respect of all such services.

15 Richmond CCG - Annual Accounts 2019-20

5.1 Better Payment Practice Code

Measure of compliance 2019-20 2019-20 2018-19 2018-19 Number £'000 Number £'000 Non-NHS Payables Total Non-NHS Trade invoices paid in the Year 9,377 73,954 9,895 69,761 Total Non-NHS Trade Invoices paid within target 9,294 73,272 9,744 68,668 Percentage of Non-NHS Trade invoices paid within target 99.11% 99.08% 98.47% 98.43%

NHS Payables Total NHS Trade Invoices Paid in the Year 3,276 197,824 3,140 186,911 Total NHS Trade Invoices Paid within target 3,199 196,862 3,025 186,443 Percentage of NHS Trade Invoices paid within target 97.65% 99.51% 96.34% 99.75%

5.2 The Late Payment of Commercial Debts (Interest) Act 1998 2019-20 2018-19 £'000 £'000

Amounts included in finance costs from claims made under this legislation - - Compensation paid to cover debt recovery costs under this legislation - - Total - -

16 Richmond CCG - Annual Accounts 2019-20

6 Operating Leases

6.1 As lessee

The CCG occupies space at Thames House for use as its headquarters. Currently, there is no signed lease with Hounslow and Richmond Community Healthcare trust for the use of Thames House, a Heads of Terms is in the process of being agreed. The lease will transfer to South West London CCG from the 1st April 2020 following the merger of the 6 CCGs. 6.1.1 Payments recognised as an Expense 2019-20 2018-19 Land Buildings Other Total Land Buildings Other Total £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 Payments recognised as an expense Minimum lease payments - 193 - 193 - 150 - 150 Contingent rents ------Sub-lease payments ------Total - 193 - 193 - 150 - 150

12.1.2 Future minimum lease payments 2019-20 2018-19 Land Buildings Other Total Land Buildings Other Total £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 Payable: No later than one year - 193 - 193 - - - - Between one and five years - 608 - 608 - - - - After five years ------Total - 801 - 801 - - - -

17 Richmond CCG - Annual Accounts 2019-20

7 Property, plant and equipment

Information 2019-20 technology Total £'000 £'000 Cost or valuation at 01 April 2019 236 236

Cost/Valuation at 31 March 2020 236 236

Depreciation 01 April 2019 79 79

Charged during the year 79 79 Depreciation at 31 March 2020 157 157

Net Book Value at 31 March 2020 79 79

Purchased 79 79 Total at 31 March 2020 79 79

Asset financing:

Owned 79 79

Total at 31 March 2020 79 79

Information 2018-19 technology Total £'000 £'000 Cost or valuation at 01 April 2018 236 236

Cost/Valuation at 31 March 2019 236 236

Depreciation 01 April 2018 - -

Charged during the year 79 79 Depreciation at 31 March 2019 79 79

Net Book Value at 31 March 2019 157 157

Purchased 157 157 Total at 31 March 2019 157 157

Asset financing:

Owned 157 157

Total at 31 March 2019 157 157

18 Richmond CCG - Annual Accounts 2019-20

8.1 Trade and other receivables Current Non-current Current Non-current 2019-20 2019-20 2018-19 2018-19 £'000 £'000 £'000 £'000

NHS receivables: Revenue 1,685 - 3,486 - NHS prepayments 776 - 773 - Non-NHS and Other WGA receivables: Revenue 319 - 972 - Non-NHS and Other WGA prepayments 214 - - - Non-NHS and Other WGA accrued income 26 - 32 - Non-NHS and Other WGA Contract Receivable not yet invoiced/non-invoice - - 6 - Expected credit loss allowance-receivables (1,010) - (2,431) - VAT 1 - 9 - Other receivables and accruals 11 - 2 - Total Trade & other receivables 2,022 - 2,849 -

Total current and non current 2,022 2,849

Included above: Prepaid pensions contributions - -

8.2 Receivables past their due date but not impaired 2019-20 2019-20 2018-19 2018-19 DHSC Group Non DHSC DHSC Group Non DHSC Bodies Group Bodies Bodies Group Bodies £'000 £'000 £'000 £'000 By up to three months 204 108 658 - By three to six months - 43 - - By more than six months 1,007 8 2,563 - Total 1,211 159 3,221 -

19 Richmond CCG - Annual Accounts 2019-20

9 Cash and cash equivalents

2019-20 2018-19 £'000 £'000 Balance at 01 April 2019 174 263 Net change in year (17) (89) Balance at 31 March 2020 157 174

Made up of: Cash with the Government Banking Service 157 174 Cash and cash equivalents as in statement of financial position 157 174

Total bank overdrafts - -

Balance at 31 March 2020 157 174

20 Richmond CCG - Annual Accounts 2019-20

Current Non-current Current Non-current 10 Trade and other payables 2019-20 2019-20 2018-19 2018-19 £'000 £'000 £'000 £'000

NHS payables: Revenue 1,986 - 6,611 - NHS accruals 3,305 - 2,293 - Non-NHS and Other WGA payables: Revenue 3,184 - 8,552 - Non-NHS and Other WGA accruals 13,233 - 11,516 - Social security costs 45 - 43 - Tax 41 - 41 - Other payables and accruals 2,073 - 2,427 - Total Trade & Other Payables 23,867 - 31,483 -

Total current and non-current 23,867 31,483

Other payables include £303,830 outstanding pension contributions at 31 March 2020

21 Richmond CCG - Annual Accounts 2019-20

11 Provisions Current Non-current Current Non-current 2019-20 2019-20 2018-19 2018-19 £'000 £'000 £'000 £'000 Pensions relating to former directors - - - - Pensions relating to other staff - - - - Restructuring - - - - Redundancy - - - - Agenda for change - - - - Equal pay - - - - Legal claims - - - - Continuing care 904 - 849 - Other - - - - Total 904 - 849 -

Total current and non-current 904 849

Pensions Relating to Pensions Former Relating to Agenda for Continuing Directors Other Staff Restructuring Redundancy Change Equal Pay Legal Claims Care Other Total £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Balance at 01 April 2019 ------849 - 849

Arising during the year ------525 - 525 Utilised during the year ------(71) - (71) Reversed unused ------(399) - (399) Unwinding of discount ------Change in discount rate ------Transfer (to) from other public sector body ------Transfer (to) from other public sector body under absorption ------Balance at 31 March 2020 ------904 - 904

Expected timing of cash flows: Within one year ------904 - 904 Between one and five years ------After five years ------Balance at 31 March 2020 ------904 - 904

The Continuing Care Provision relates to retrospective cases where the eligibty to CHC is still to be determined.

22 Richmond CCG - Annual Accounts 2019-20

12 Financial instruments

12.1 Financial risk management

Financial reporting standard IFRS 7 requires disclosure of the role that financial instruments have had during the period in creating or changing the risks a body faces in undertaking its activities.

Because NHS Richmond Clinical Commissioning Group is financed through parliamentary funding, it is not exposed to the degree of financial risk faced by business entities. Also, financial instruments play a much more limited role in creating or changing risk than would be typical of listed companies, to which the financial reporting standards mainly apply. The clinical commissioning group has limited powers to borrow or invest surplus funds and financial assets and liabilities are generated by day-to-day operational activities rather than being held to change the risks facing the clinical commissioning group in undertaking its activities.

Treasury management operations are carried out by the finance department, within parameters defined formally within the NHS clinical commissioning group standing financial instructions and policies agreed by the Governing Body. Treasury activity is subject to review by the NHS clinical commissioning group and internal auditors.

12.1.1 Currency risk

NHS Richmond Clinical Commissioning Group is principally a domestic organisation with the great majority of transactions, assets and liabilities being in the UK and sterling based. NHS Richmond Clinical Gommissioning Group has no overseas operations and therefore has low exposure to currency rate fluctuations.

12.1.2 Interest rate risk

NHS Richmond Clinical Commissioning Group borrows from government for capital expenditure, subject to affordability as confirmed by NHS England. The borrowings are for 1 to 25 years, in line with the life of the associated assets, and interest is charged at the National Loans Fund rate, fixed for the life of the loan. The clinical commissioning group therefore has low exposure to interest rate fluctuations.

12.1.3 Credit risk

Because the majority of the NHS Richmond Clinical Commissioning Group revenue comes from parliamentary funding, NHS Richmond Clinical Commissioning Group has low exposure to credit risk. The maximum exposures as at the end of the financial year are in receivables from customers, as disclosed in the trade and other receivables note.

12.1.4 Liquidity risk

NHS Richmond Clinical Commissioning Group is required to operate within revenue and capital resource limits, which are financed from resources voted annually by Parliament. NHS Richmond Clinical Commissioning Group draws down cash to cover expenditure, as the need arises. NHS Richmond Clinical Commissioning Group is not, therefore, exposed to significant liquidity risks.

23 Richmond CCG - Annual Accounts 2019-20

12 Financial instruments cont'd

12.2 Financial assets

Financial Assets measured at amortised cost Total 2019-20 2019-20 £'000 £'000

Trade and other receivables with NHSE bodies 1,507 1,507 Trade and other receivables with other DHSC group bodies 205 205 Trade and other receivables with external bodies 330 330 Cash and cash equivalents 157 157 Total at 31 March 2020 2,199 2,199

Financial Assets measured at amortised cost Total 2018-19 2018-19 £'000 £'000

Trade and other receivables with NHSE bodies 3,483 3,483 Trade and other receivables with other DHSC group bodies 907 907 Trade and other receivables with external bodies 106 106 Other financial assets 2 2 Cash and cash equivalents 174 174 Total at 31 March 2019 4,672 4,672

12.3 Financial liabilities

Financial Liabilities measured at amortised cost Total 2019-20 2019-20 £'000 £'000

Trade and other payables with NHSE bodies 457 457 Trade and other payables with other DHSC group bodies 8,312 8,312 Trade and other payables with external bodies 15,012 15,012 Total at 31 March 2020 23,781 23,781

Financial Liabilities measured at amortised cost Total 2018-19 2018-19 £'000 £'000

Trade and other payables with NHSE bodies 1,522 1,522 Trade and other payables with other DHSC group bodies 10,963 10,963 Trade and other payables with external bodies 16,487 16,487 Other financial liabilities 2,427 2,427 Total at 31 March 2019 31,399 31,399

13 Operating segments Richmond CCG reports as one operating segment.

24 Richmond CCG - Annual Accounts 2019-20

14 Related party transactions

Details of related party transactions with individuals are as follows:

2019-20 2018-19 Receipts Amounts Amounts Receipts Amounts Amounts from owed to due from Payments from owed to due from Payments to Related Related Related to Related Related Related Related Table 1. Governing Body Related Party Transactions Related Party Party Party Party Party Party Party Party £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Glebe Road Surgery (Y01206) 1,181 0 88 0 1,186 0 102 0 Thameside Medical Practice (H84059) 763 0 68 0 594 0 137 0 The Acorn Group Practice (H84007) 1,029 0 67 0 1,225 0 47 0 The Hampton Medical Centre (H84040) 1,351 0 110 0 1,542 0 102 0 Hampton Wick Surgery (H84032) 1,209 0 68 0 1,291 0 66 0 The Vineyard Surgery (H84041)* 504 0 24 0 Kingston Hospital NHS Foundation Trust 53,864 0 643 0 51,187 0 243 0 Chelsea and Westminster Hospital NHS Foundation Trust 39,673 0 463 0 38,257 0 836 0 Barts Health NHS Trust 297 0 (55) 0 336 0 87 0 Your Healthcare CIC 1,513 0 20 0 1,740 0 24 0 Richmond General Practice Alliance 1,901 0 306 0 1,211 0 160 0

Table 2. Material Related Party Transactions St George's Healthcare NHS Trust 12,401 0 10 0 15,209 0 (1,443) 0 Epsom & St Helier NHS Trust 2,287 0 505 0 2,768 0 (281) 0 South West London & St George's Mental Health NHS Trust 16,571 0 233 0 15,657 0 528 0 London Ambulance NHS Trust 6,121 0 44 0 6,346 0 (214) 0 Richmond upon Thames Borough Council 7,972 (125) 551 0 10,178 (85) 2,290 0 NHS England 21 (323) 4 0 3 (166) 24 0 Imperial College HC Foundation Trust 11,536 0 (1,446) 0 10,518 0 454 0 Houslow and Richmond Community Healthcare NHS Trust 23,495 0 183 0 22,246 (124) 387 0 East London NHS Foundation Trust 3,569 0 85 0 3,060 0 1 0

*There is no 2018/19 comparative figure for The Vineyard Surgery (H84041) as this was not considered a related party transaction in 2017/18

The Department of Health is regarded as a related party. During the year the clinical commissioning group has had a significant number of material transactions

In addition, the clinical commissioning group has had a number of material transactions with other government departments and other central and local government bodies. Most of these transactions have been with the Richmond upon Thames Borough Council

Table 1 - Disclosure is made when a Governing Body member has an interest in an organisation that has material transactions with the clinical commissioning group. This disclosure applies to all GP governing body members. The materiality level set for Table 1 is £50k

Table 2 - Disclosure is made for the six NHS organisations with which the clinical commissioning group spends most of its resources. Houslow and Richmond Community Healthcare is disclosed as the clinical commissioning group provides approximately 33% of Houslow and Richmond Community Healthcare income. Richmond upon Thames Borough Council has also been included as the clinical commissioning group has material balances with the borough. The materiality level set for Table 2 is £2.6m

25 Richmond CCG - Annual Accounts 2019-20

15 Events after the end of the reporting period

On 1st April 2020, Richmond CCG merged with the other five CCGs in South West London to become South West London CCG. This is a non-adjusting event.

16 Pooled Budget

NHS Richmond CCG has a pooled budget arrangement with the London Borough of Richmond upon Thames in respect of the Better Care Fund. The income and expenditure handled by the pooled budget in the financial year were:

2019-20 2018-19 £'000 £'000 Income 14,281 13,185 Expenditure 14,281 13,185

17 Financial performance targets

NHS Clinical Commissioning Group have a number of financial duties under the NHS Act 2006 (as amended). NHS Clinical Commissioning Group performance against those duties was as follows:

2019-20 2019-20 Duty 2018-19 2018-19 Duty Target Performance Achieved? Target Performance Achieved? Expenditure not to exceed income 285,897 285,783 Yes 275,194 279,051 No Capital resource use does not exceed the amount specified in Directions - - Yes - - Yes Revenue resource use does not exceed the amount specified in Directions 284,188 284,073 Yes 272,506 276,363 No Capital resource use on specified matter(s) does not exceed the amount specified in Directions - - Yes - - Yes Revenue resource use on specified matter(s) does not exceed the amount specified in Directions - - Yes - - Yes Revenue administration resource use does not exceed the amount specified in Directions 4,486 4,344 Yes 4,373 4,041 Yes

26

Independent auditor's report to the members of the Governing Body of NHS South West London Clinical Commissioning Group in respect of NHS Richmond Clinical Commissioning Group

Report on the Audit of the Financial Statements

Opinion We have audited the financial statements of NHS Richmond Clinical Commissioning Group (the ‘CCG’) for the year ended 31 March 2020, which comprise the Statement of Comprehensive Net Expenditure, the Statement of Financial Position, the Statement of Changes in Taxpayers’ Equity, the Statement of Cash Flows and notes to the financial statements, including a summary of significant accounting policies. The financial reporting framework that has been applied in their preparation is applicable law and International Financial Reporting Standards (IFRSs) as adopted by the European Union, and as interpreted and adapted by the Department of Health and Social Care Group Accounting Manual 2019 to 2020. In our opinion, the financial statements:

 give a true and fair view of the financial position of the CCG as at 31 March 2020 and of its expenditure and income for the year then ended; and

 have been properly prepared in accordance with International Financial Reporting Standards (IFRSs) as adopted by the European Union, as interpreted and adapted by the Department of Health and Social Care Group Accounting Manual 2019 to 2020; and

 have been prepared in accordance with the requirements of the Health and Social Care Act 2012.

Basis for opinion We conducted our audit in accordance with International Standards on Auditing (UK) (ISAs (UK)) and applicable law. Our responsibilities under those standards are further described in the ‘Auditor’s responsibilities for the audit of the financial statements’ section of our report. We are independent of the CCG in accordance with the ethical requirements that are relevant to our audit of the financial statements in the UK, including the FRC’s Ethical Standard, and we have fulfilled our other ethical responsibilities in accordance with these requirements. We believe that the audit evidence we have obtained is sufficient and appropriate to provide a basis for our opinion.

The impact of macro-economic uncertainties on our audit Our audit of the financial statements requires us to obtain an understanding of all relevant uncertainties, including those arising as a consequence of the effects of macro-economic uncertainties such as Covid-19 and Brexit. All audits assess and challenge the reasonableness of estimates made by the Accountable Officer and the related disclosures and the appropriateness of the going concern basis of preparation of the financial statements. All of these depend on assessments of the future economic environment and the CCG’s future operational arrangements. Covid-19 and Brexit are amongst the most significant economic events currently faced by the UK, and at the date of this report their effects are subject to unprecedented levels of uncertainty, with the full range of possible outcomes and their impacts unknown. We applied a standardised firm-wide approach in response to these uncertainties when assessing the CCG’s future operational arrangements. However, no audit should be expected to predict the unknowable factors or all possible future implications for an entity associated with these particular events.

Conclusions relating to going concern We have nothing to report in respect of the following matters in relation to which the ISAs (UK) require us to report to you where:

 the Accountable Officer’s use of the going concern basis of accounting in the preparation of the financial statements is not appropriate; or

 the Accountable Officer has not disclosed in the financial statements any identified material uncertainties that may cast significant doubt about the CCG’s ability to continue to adopt the going concern basis of accounting for a period of at least twelve months from the date when the financial statements are authorised for issue. In our evaluation of the Accountable Officer’s conclusions, and in accordance with the expectation set out within the Department of Health and Social Care Group Accounting Manual 2019 to 2020 that the CCG’s financial statements shall be prepared on a going concern basis, we considered the risks associated with the CCG’s operating activities, including effects arising from macro-economic uncertainties such as Covid-19 and Brexit. We analysed how those risks might affect the

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CCG’s financial resources or ability to continue operations over the period of at least twelve months from the date when the financial statements are authorised for issue. In accordance with the above, we have nothing to report in these respects. However, as we cannot predict all future events or conditions and as subsequent events may result in outcomes that are inconsistent with judgements that were reasonable at the time they were made, the absence of reference to a material uncertainty in this auditor's report is not a guarantee that the CCG will continue in operation.

Emphasis of matter – Demise of the organisation In forming our opinion on the financial statements, which is not modified, we draw attention to note 15 in the financial statements, which indicates that NHS Richmond CCG merged with the other five CCGs to become NHS South West London CCG with effect from 1 April 2020.

Other information The Accountable Officer is responsible for the other information. The other information comprises the information included in the Annual Report, other than the financial statements and our auditor’s report thereon. Our opinion on the financial statements does not cover the other information and, except to the extent otherwise explicitly stated in our report, we do not express any form of assurance conclusion thereon. In connection with our audit of the financial statements, our responsibility is to read the other information and, in doing so, consider whether the other information is materially inconsistent with the financial statements or our knowledge obtained in the audit or otherwise appears to be materially misstated. If we identify such material inconsistencies or apparent material misstatements, we are required to determine whether there is a material misstatement in the financial statements or a material misstatement of the other information. If, based on the work we have performed, we conclude that there is a material misstatement of the other information, we are required to report that fact. We have nothing to report in this regard.

Other information we are required to report on by exception under the Code of Audit Practice Under the Code of Audit Practice published by the National Audit Office in April 2015 on behalf of the Comptroller and Auditor General (the Code of Audit Practice) we are required to consider whether the Governance Statement does not comply with the guidance issued by the NHS Commissioning Board or is misleading or inconsistent with the information of which we are aware from our audit. We are not required to consider whether the Governance Statement addresses all risks and controls or that risks are satisfactorily addressed by internal controls. We have nothing to report in this regard.

Opinion on other matters required by the Code of Audit Practice In our opinion:

 the parts of the Remuneration and Staff Report to be audited have been properly prepared in accordance with IFRSs as adopted by the European Union, as interpreted and adapted by the Department of Health and Social Care Group Accounting Manual 2019 to 2020 and the requirements of the Health and Social Care Act 2012, and

 based on the work undertaken in the course of the audit of the financial statements and our knowledge of the CCG gained through our work in relation to the CCG’s arrangements for securing economy, efficiency and effectiveness in its use of resources, the other information published together with the financial statements in the Annual Report for the financial year for which the financial statements are prepared is consistent with the financial statements.

Opinion on regularity required by the Code of Audit Practice 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 in the financial statements conform to the authorities which govern them.

Matters on which we are required to report by exception Under the Code of Audit Practice, we are required to report to you if:

 we issue a report in the public interest under Section 24 of the Local Audit and Accountability Act 2014 in the course of, or at the conclusion of the audit; or

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

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 we make a written recommendation to the CCG under Section 24 of the Local Audit and Accountability Act 2014 in the course of, or at the conclusion of the audit. We have nothing to report in respect of the above matters.

Responsibilities of the Accountable Officer and Those Charged with Governance for the financial statements As explained more fully in the Statement of Accountable Officer's responsibilities, the Accountable Officer, is responsible for the preparation of the financial statements in the form and on the basis set out in the Accounts Directions, for being satisfied that they give a true and fair view, and for such internal control as the Accountable Officer determines is necessary to enable the preparation of financial statements that are free from material misstatement, whether due to fraud or error. In preparing the financial statements, the Accountable Officer is responsible for assessing the CCG’s ability to continue as a going concern, disclosing, as applicable, matters related to going concern and using the going concern basis of accounting unless they have been informed by the relevant national body of the intention to dissolve the CCG without the transfer of its services to another public sector entity. The Accountable Officer is responsible for ensuring the regularity of expenditure and income in the financial statements. The NHS South West London CCG Audit Committee is Those Charged with Governance. Those Charged with Governance are responsible for overseeing the CCG’s financial reporting process.

Auditor’s responsibilities for the audit of the financial statements Our objectives are to obtain reasonable assurance about whether the financial statements as a whole are free from material misstatement, whether due to fraud or error, and to issue an auditor’s report that includes our opinion. Reasonable assurance is a high level of assurance, but is not a guarantee that an audit conducted in accordance with ISAs (UK) will always detect a material misstatement when it exists. Misstatements can arise from fraud or error and are considered material if, individually or in the aggregate, they could reasonably be expected to influence the economic decisions of users taken on the basis of these financial statements. A further description of our responsibilities for the audit of the financial statements is located on the Financial Reporting Council’s website at: www.frc.org.uk/auditorsresponsibilities. This description forms part of our auditor’s report. We are also responsible for giving an opinion on the regularity of expenditure and income in the financial statements in accordance with the Code of Audit Practice.

Report on other legal and regulatory requirements – Conclusion on the CCG’s arrangements for securing economy, efficiency and effectiveness in its use of resources

Matter on which we are required to report by exception - 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, in our opinion we have not been able to satisfy ourselves that the CCG has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources for the year ended 31 March 2020. We have nothing to report in respect of the above matter.

Responsibilities of the Accountable Officer As explained in the Governance Statement, the Accountable Officer is responsible for putting in place proper arrangements for securing economy, efficiency and effectiveness in the use of the CCG's resources.

Auditor’s responsibilities for the review of the CCG’s arrangements for securing economy, efficiency and effectiveness in its use of resources We are required under Section 21(1)(c) and Schedule 13 paragraph 10(a) of the Local Audit and Accountability Act 2014 to be satisfied that the CCG has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources and to report where we have not been able to satisfy ourselves that it has done so. We are not required to consider, nor have we considered, whether all aspects of the CCG's arrangements for securing economy, efficiency and effectiveness in its use of resources are operating effectively. We have undertaken our review in accordance with the Code of Audit Practice, having regard to the guidance on the specified criterion issued by the Comptroller and Auditor General in April 2020, as to whether in all significant respects, the CCG had proper arrangements to ensure it took properly informed decisions and deployed resources to achieve planned and sustainable outcomes for taxpayers and local people. The Comptroller and Auditor General determined this criterion as

Grant Thornton UK LLP. 3 that necessary for us to consider under the Code of Audit Practice in satisfying ourselves whether the CCG put in place proper arrangements for securing economy, efficiency and effectiveness in its use of resources for the year ended 31 March 2020, and to report by exception where we are not satisfied. We planned our work in accordance with the Code of Audit Practice. Based on our risk assessment, we undertook such work as we considered necessary to be satisfied that the CCG has put in place proper arrangements for securing economy, efficiency and effectiveness in its use of resources.

Report on other legal and regulatory requirements – Certificate We certify that we have completed the audit of the financial statements of NHS Richmond CCG in accordance with the requirements of the Local Audit and Accountability Act 2014 and the Code of Audit Practice.

Use of our report This report is made solely to the members of the Governing Body of the CCG, as a body, in accordance with Part 5 of the Local Audit and Accountability Act 2014. Our audit work has been undertaken so that we might state to the members of the Governing Body of the CCG those matters we are required to state to them in an auditor’s report and for no other purpose. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the CCG and the members of the Governing Body of the CCG, as a body, for our audit work, for this report, or for the opinions we have formed.

Sarah L Ironmonger Sarah Ironmonger, Key Audit Partner for and on behalf of Grant Thornton UK LLP, Local Auditor

London 25 June 2020

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