NHS North West Surrey Clinical Commissioning Group

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1 NHS North West Surrey Clinical Commissioning Group Annual Report and Accounts 2016/17

2 North West Surrey CCG Annual Report

3 Table of Contents 1. Introduction 5 About us 8 2. Performance Report - Overview 11 Chief Executive s introduction 11 Our vision and strategy 14 Our Operating Plan for 2016/17 16 Delivering our plan 20 Future plans looking ahead Performance Report - Analysis 24 Measuring delivery of services 24 Financial performance 29 CCG improvement and assessment framework 32 Ensuring Quality and Patient Safety 33 Our key priorities 35 Listening to our community 55 Partnership working 58 Equality and diversity report 59 Sustainable development Accountability Report 62 Corporate Governance report 62 Statement of Accountable Officer s responsibilities 69 Annual Governance Statement 71 CCG Risk Management Framework 87 North West Surrey CCG Annual Report

4 Table of Contents Workforce and staff report Independent Auditor s Report to the Members of NHS North West Surrey CCG Financial Accounts 113 Forward to Financial Statements 113 Financial Statements 114 Notes to the Financial Statements Remuneration Report 160 North West Surrey CCG Annual Report

5 1. Introduction Introduction from Dr Charlotte Canniff, Clinical Chair Welcome to the NHS North West Surrey Clinical Commissioning Group s (CCG s) Annual Report and Accounts 2016/17. Within the context of continuing challenge for the NHS nationally, North West Surrey CCG has been able to celebrate a number of important successes this year and continues to move forward as an innovative and successful commissioning organisation. As a member of the wider Surrey Heartlands partnership, we are also demonstrating our ability and commitment to work collectively with others across traditional boundaries in new and dynamic ways. Of particular note this year was our success in being shortlisted as CCG of the Year at the national HSJ Awards in November. Being a finalist is a significant achievement and is testament to the dedication of our staff who work hard to design and commission services that are responsive to people s needs, ensuring our population continues to receive high quality local healthcare. This year we have continued the development of our locality hub programme, which provides a proactive and integrated service for older people all in one place. Building on the Bedser Hub at Woking Community Hospital, which opened last year, we are now developing similar services in Ashford and Weybridge. Initial feedback from the Bedser Hub has been extremely positive and importantly we are seeing a reduction in attendances at A&E and in hospital admissions for patients within the service. Also part of the Royal College of Physicians Future Hospital Programme, the hub has helped put us on the national platform, and we ve taken the opportunity to present our learning at a number of national events including the annual RCP conference in March. Our vision to ensure local residents have the best possible healthcare is dependent on developing and commissioning the right services. This year we have concluded a number of major procurement programmes to improve both quality and efficiency of local healthcare. These include a new integrated musculoskeletal service awarded to Ashford and St Peter s Hospitals NHS Foundation Trust, and the new contract for adult community services awarded to CSH Surrey from 1 April An enormous North West Surrey CCG Annual Report

6 amount of work has gone into developing these new contracts both of which represent a significant shift in service design, providing more integrated and holistic services that will really benefit patients. We also led a major procurement of a new Non-Emergency Patient Transport Service on behalf of the Surrey CCGs (excluding Surrey Downs CCG), which was awarded to South Central Ambulance Service NHS Foundation Trust, again from 1 April We are now looking forward to working closely with our new providers and to further improvements for local patients. Across Surrey we are members of the Surrey Collaborative working closely with other Surrey CCGs on a range of priorities, although the focus of the collaborative is changing with the development of the Surrey Heartlands STP. One of the pieces of work undertaken by the collaborative was the Surrey-wide review of stroke services and we are now finishing a public consultation on proposals to improve and consolidate services across West Surrey (see more on p.48). A final decision following the consultation will take place this summer with full implementation expected from October Pressure on local NHS emergency services has grown again this year and we have continued to work positively with our system partners in particular Ashford and St Peter s Hospitals, Virgin Care Services Limited and Surrey County Council. Together we are proactively managing demand to ensure local people continue to have timely access to the services they need at the busiest times. We are also working closely with South East Coast Ambulance NHS Foundation Trust (SECAmb) and the regulators to support the Trust through a number of challenges particular to the ambulance service. We continue to work collaboratively with our member practices, engaging them in leading and developing new pathways of care across North West Surrey CCG. We are particularly grateful to our Clinical and Locality Leads who represent our Members at Governing Body and Clinical Executive level and on our work programmes. From 1 April 2016 we took on delegated commissioning for primary care from NHS England, which is an exciting new development and is helping us support practices in continuing to improve services for patients. Looking forward there is no doubt 2017/18 will be another challenging year. Collaboration is becoming increasingly important and I have no doubt the Surrey Heartlands partnership, which has developed so successfully this year, will go from strength to strength. Working across both health and social care is essential if we are to see the kind of transformation we need to ensure health and care services remain sustainable into the future. Our collective ambition for devolution is particularly exciting and will give us greater local accountability, helping us realise our vision for residents across Surrey Heartlands much more quickly. North West Surrey CCG Annual Report

7 Towards the end of this financial year Julia Ross, who has led this organisation since its inception in 2012, announced her intention to move on to take up another exciting role leading Bristol, North Somerset and South Gloucestershire CCGs I would like to take this opportunity to thank Julia for the enormous contribution she has made to North West Surrey CCG, for her personal commitment and drive in leading this organisation and for the many achievements she has helped develop on behalf of local residents. In turn, we look forward to welcoming Matthew Tait who will be taking up the reigns working as Joint Accountable Officer across the three CCGs within our STP footprint. Finally, on behalf of our Council of Members, I would like to thank all colleagues and partners across North West Surrey CCG who have worked so hard over this last year on behalf of patients, their families and carers. Finally, I would like to thank everyone who has supported me in my first year as Clinical Chair. We all have a lot to be proud of. Dr Charlotte Canniff Clinical Chair North West Surrey CCG Annual Report

8 About us our history and background NHS North West Surrey Clinical Commissioning Group (NHS North West Surrey CCG) was formally established without conditions on 1 April 2013, in line with changes to the commissioning structure of the NHS introduced by the Health and Social Care Act The CCG is responsible for commissioning healthcare services for a population of 350,000 across the boroughs of Elmbridge (West), Runnymede, Spelthorne and Woking, as well as the very small number of our population who live in Guildford and Surrey Heath. The CCG is a membership organisation, comprised of practices that provide primary medical services to the population within the geographic boundaries of the CCG. The CCG now has 41 member practices working across three localities: Thames Medical (Runnymede and West of Elmbridge) Stanwell, Ashford, Staines, Shepperton and Egham (SASSE) Woking This structure allows us to commission the services that our patients need at a local level, develop services that are tailored to the specific needs of each of our diverse communities, and provides a rich understanding of how our initiatives improve patients experiences of health services. The CCG s localities are aligned with the borough councils shown in purple on the map, below. Geography of NHS North West Surrey CCG North West Surrey CCG Annual Report

9 Our providers We commission healthcare services in North West Surrey CCG from a variety of providers; the main ones are listed here: Acute hospital services Ashford and St Peter s Hospitals NHS Foundation Trust provides services across two sites: St Peter s Hospital, which delivers urgent care, including A&E, maternity, intensive care and other specialist services; and Ashford Hospital, which focuses on outpatient, elective services and planned care. The CCG also commissions acute hospital services from other providers, including: Royal Surrey County Hospital NHS Foundation Trust Frimley Health NHS Foundation Trust St. George s Healthcare NHS Trust Local independent sector hospitals Community health services Virgin Care Services Limited provided the majority of community services for North West Surrey CCG in 2016/17; this included community hospitals, community nursing, children s services and prison healthcare. Virgin Care Services Limited was also responsible for two of the local NHS Walk-in Centres at Woking and Weybridge. The contract with Virgin Care Services Limited expired at the end of the financial year (31 March 2017). After a robust procurement process the contract for adult community services across North West Surrey CCG was awarded to CSH Surrey. CSH took over services from 1 April The contract for children s community services across Surrey (commissioned on behalf of Surrey CCGs by Guildford and Waverley CCG) was awarded to Children and Family Health Surrey, a partnership of Surrey and Borders Partnership Foundation Trust, CSH Surrey, and First Community Healthcare, from 1 April Mental health services Under Surrey s collaborative commissioning arrangements, Surrey and Borders Partnership NHS Foundation Trust (SABP) is commissioned on our behalf by Guildford and Waverley CCG to provide mental health services to our local population. North West Surrey CCG Annual Report

10 The Trust is the leading provider of specialist mental health and learning disability services for people of all ages in Surrey and North East Hampshire. It also provides psychiatric liaison at Ashford and St Peter s Hospitals and community mental health input to the virtual ward teams within the community. In addition a number of providers now offer Improved Access to Psychological Therapies services (IAPT) on our behalf for those suffering with mild to moderate mental health conditions such as stress, anxiety and low mood (see p.44). Ambulance and patient transport services From 1 April 2014, North West Surrey CCG has been the lead commissioner for ambulance, patient transport and NHS 111 contracts on behalf of all Surrey CCGs. From 1 April 2015, changes to the 999 contract meant that there are now separate contracts for Kent, Surrey and Sussex. Emergency ambulance, non-emergency patient transport and NHS 111 services in Surrey have been provided by South East Coast Ambulance Service NHS Foundation Trust (SECAmb) during 2016/17; 111 is delivered in partnership with Care UK. Following an extensive procurement exercise, a new contract for patient transport services was awarded to South Central Ambulance Service NHS Foundation Trust from 1 April 2017, to cover North West Surrey, East Surrey, Guildford and Waverley, North East Hants and Farnham and Surrey Heath CCGs. The existing NHS111 contract is due to expire in March 2018 and North West Surrey is currently leading a procurement process for a new contract in partnership with Surrey Downs and Guildford and Waverley CCGs. North West Surrey CCG Annual Report

11 2. Performance Report Overview Chief Executive s Introduction This has been another challenging year for local health services but overall North West Surrey CCG has performed well and we have seen many improvements for local patients. Financially, we ended the year having achieved a 1% surplus ( million), a testament to the hard work of teams across the local health economy. With increasing financial pressure being felt by all health and social care organisations, the effectiveness of work such as our QIPP programmes (Quality, Improvement, Productivity, Prevention) and new and innovative procurements is imperative to our continuing success. Our close working relationship with partners is also an important contributory factor and will become increasingly so as we move forward. With increasing demand, we are working hard to support all providers across North West Surrey CCG to improve access to services for patients. Responding to the publication of the GP Five Year Forward View, our new primary care strategy will help to facilitate an improvement in access to general practice as we look at more innovative ways to support practices, particularly around evening and weekend appointments. Our decision to take on delegated commissioning for GP contracts, which has been successful in 2016/17, will also help us offer even more support to practices over time. Our main acute provider, Ashford and St Peter s Hospitals is meeting the 18 week referral to treatment (RTT) target for planned care, and the majority of its cancer waiting targets. Concerns remain around the 62 day target, which has not been achieved for most of the year, however. To address this, the Trust has developed a comprehensive Cancer Recovery Action Plan and we are working proactively with them to support improvement moving forward. The Trust continues to struggle to meet the four hour A&E waiting target, although the system as a whole is performing well compared to others, both regionally and nationally, with excellent recovery capability at times of severe demand. This is a direct result of positive partnership working across the system. North West Surrey CCG Annual Report

12 We continue to improve access to mental health services and have supported the reprocurement of IAPT (Improving Access to Psychological services), which now makes it easier for both patients and professionals to refer into. We have also extended the pilot of the new Safe Haven service (in Woking), an informal environment where those experiencing a more immediate mental health crisis can find expert support. And we continue to work closely with our mental health partners at Surrey and Borders Partnership NHS Foundation Trust, to ensure local patients have access to the right mental health services when they need them. 2016/17 has been another challenging year for our ambulance provider, South East Coast Ambulance Service NHS Foundation Trust (SECAmb), as they have struggled to deliver against national performance standards for most of the year. Due to a number of quality and performance issues, SECAmb was placed into special measures by the Care Quality Commission and NHS Improvement. Changes in staff at senior level, continued recruitment issues and increasing demand have all contributed to a particularly difficult picture. As lead commissioners for the service for Surrey, the CCG working closely with commissioners in Sussex and Kent and the national bodies involved has engaged with the Trust throughout the year to continue to seek assurance around delivery of key improvement actions. We recognise that there has been growing public concern about the ambulance Trust s performance and we have engaged with stakeholders to offer assurance of the work we are doing to monitor and manage the contract and to offer support. This work continues. We continue to manage performance of our key providers through our contractual performance and quality meetings with positive relationships across the local health system with acute, community, mental health and social care colleagues and with primary care and our general practice colleagues. This year we have also been working towards a change in provider for two of our major contracts; adult community services provided by Virgin Care Services Limited, and non-emergency patient transport, which was provided by SECAmb. New contracts with CSH Surrey and South Central Ambulance Service began on 1 April Any change in provider at this scale requires a lot of hard work on all sides to ensure a seamless transition for both staff and patients and I would particularly like to applaud our contracting teams for a successful transition. Importantly this year has seen the further development of the Surrey Heartlands Sustainability and Transformation Plan (STP), within which we are a key partner. Wider collaboration is the only way we can secure the additional scale to make the transformational change we know is needed and the STP is a real opportunity to improve services for patients. Surrey Heartlands has been recognised by NHS England and others as having an ambitious and credible plan and our workstreams are starting to gather pace. This next year will be a critical one for its success but there is a genuine will from all partners to work together to deliver the plan. North West Surrey CCG Annual Report

13 Our move towards devolution of health and social care budgets will also be another important factor. There is no doubt we have another challenging year ahead of us; however, the positive relationships we are developing, coupled with the skill and commitment of both our internal team and GP members, means we are well equipped to continue improving healthcare for the population of North West Surrey CCG. Karen Thorburn Acting Chief Executive North West Surrey CCG Annual Report

14 Our vision and strategy Our vision and purpose Our vision is to enable all people in North West Surrey CCG to enjoy the best possible health. Our Strategic Commissioning Plan, which is available in full on the CCG s website ( sets out how we intend to realise this vision by focusing on the following key objectives: 1. Prevent people from dying prematurely 2. Improve quality of life and promote independence 3. Optimise the integration, quality and effectiveness of services 4. Help people recover from ill-health 5. Target spend for greatest gain and eliminate waste. In order to deliver these objectives, we listen to our communities and work with local people and clinicians to plan and improve healthcare services in line with people s needs. We award contracts for the delivery of healthcare services and by measuring performance against those contracts, make sure that services meet the required standards. With clinical leaders and managers working in partnership, we empower our member practices, GPs and local residents to shape the healthcare expenditure we are responsible for by: Considering the needs of patients and the local population Deciding on how and where to invest in order to ensure effective services and treatments Leading the local health economy to make sure health and other care providers work effectively together to deliver safe, seamless, high quality services in the best interests of patients. Our operating ethos We aim to deliver patient-centred, clinically-led commissioning and planning of healthcare services. We do this by operating as one organisation with one vision and by supporting our member practices to work as one entity through our three localities. By combining strong clinical leadership with excellent management and working with partners across health and social care, we now have a significant presence as North West Surrey CCG Annual Report

15 leaders of the local health economy and as a collaborative partner across Surrey Heartlands and the wider Surrey footprint. This gives us the foundation to achieve essential transformation and sustainable change. The CCG promotes good governance and proper stewardship of public resources in the pursuit of its goals and in meeting its statutory duties. Our values In 2016/17 following extensive consultation with our staff and other stakeholders we updated the CCG s values statement. The values at the heart of the CCG are: Collaboration Achievement Respect Excellence Ensuring good corporate governance is embedded within the CCG s operating model. Health needs in North West Surrey Clinical Commissioning Group We are fortunate to enjoy better health than much of Britain. People in North West Surrey CCG live longer than the national average and our healthcare services achieve better results for people across a wide range of conditions than in many other parts of the country. We also serve an ageing population, which has important implications for our healthcare planning. Conditions such as cancer and dementia are becoming more widespread as people live longer, leading to a greater demand for long-term care. Strokes are more common and require urgent treatment to minimise lasting brain damage. Also an increase in people living with serious health conditions is placing pressure on services that were designed to deliver urgent care in a crisis, rather than managing people s care over the longer term. We also know that unhealthy weight is an increasing issue for both children and adults - often linked to areas of deprivation. Excess weight can raise the risk of major disease such as diabetes, heart disease and cancer. While North West Surrey is largely an affluent area, there are pockets of deprivation in all our boroughs, particularly Maybury and Sheerwater in Woking and Stanwell in Spelthorne. North Walton in Elmbridge and parts of Chertsey and Addlestone in Runnymede are other areas where life expectancy can be up to six years lower than in the more prosperous parts of North West Surrey. North West Surrey CCG Annual Report

16 Around 32,000 people provide unpaid care in North West Surrey (one in eleven residents); 40% of carers are found to suffer from mental distress increasing with the amount of time spent in caring activities. Our Operating Plan for 2016/17 Our Operating Plan for 2016/17 was developed within the context of our Strategic Commissioning Plan and the wider Surrey Heartlands Sustainability and Transformation Plan (STP). Our plan sets out our core priorities for this year (see below) and how we intend to progress our transformation vision for the wider system. This year s Operating Plan set out three key objectives: Model of Care working towards our vision for the development of a comprehensive and fully integrated model of health and care provision for our local population. This focuses on the creation of an organised and coordinated out of hospital provider environment as the main conduit for meeting a person s health and social care needs, with General Practice at the heart of the system (see diagram below). In particular this included the following priorities: Progressing the system prevention plan Procurement of new community services contract Increased clinical collaboration Working towards more seven day services Enhancing access to primary care Targeted clinical priorities including dementia, learning disabilities, cancer, maternity, diabetes, musculoskeletal services and elective and emergency pathways. North West Surrey CCG Annual Report

17 Our new Model of Care 2. Improving access standards in order to ensure better health, better care and the sustainability of services across North West Surrey the maintenance of access standards set out in the NHS Constitution is essential. In particular we wanted to see system wide collaboration on meeting and maintaining the following: 4 hour A&E waiting time standard Cancer access times for 62 day waits Stroke access standards Mental health access standards Referral to Treatment access standard for colorectal and urology services and; Improving access to psychological therapies (IAPT) 3. Primary Care Development building on work already completed during 2015/16, and using the opportunities delegated primary care commissioning (which we took on from 1 April 2016) affords us, we set out the following priorities: Supporting GP practices to manage pressures on their capacity and workload Linking with the estates strategy to optimise premises and developing the primary care workforce through education, training and succession planning Developing and mobilising future visioning including a new primary care strategy, governance and standard protocols. North West Surrey CCG Annual Report

18 Our plan also seeks to address the three gaps identified nationally (health and wellbeing; care and quality; and finance and efficiency), working closely with our strategic planning partners (via the STP) and across our local system. Our Annual Operating Plan is summarised in our plan on a page (overleaf). North West Surrey CCG Annual Report

19 Our 2016/17 Plan on a Page

20 Delivering our plan Local Leadership North West Surrey CCG has developed a strong leadership role within the local health economy, with robust partnerships with the wider health and social care system. These partnerships are integral to the successful delivery of our ambitious plans including robust clinical, patient and wider stakeholder engagement; ensuring services are planned and developed with both those using and delivering them. Delivering our plan requires significant transformation of services, changing the local health and social care landscape in such a way to ensure high quality, joined up services that are both clinically and financially sustainable into the long term. As system leaders, the CCG chairs the North West Surrey Cabinet with senior leadership at Chief Executive level from Ashford and St Peter s Hospitals, Adult Social Care and Community Services to ensure pressures in the local system are managed collectively, in a timely and responsive way. The CCG has also agreed a Joint Delivery Programme with Ashford and St Peter s Hospitals to jointly manage activity and streamline pathways of care, both acute and in the community, to ensure sustainability and best outcomes for patients. We are also members of the Surrey Health and Wellbeing Board and the wider Surrey Transformation Board looking at wider transformation of services across the Surrey Heartlands footprint more detail on the STP is on p.22. We have also developed strong partnerships between clinicians and our internal programme teams, ensuring we have the right skills and expertise in place to ensure delivery. Working with NHS England The CCG works in partnership with NHS England s Surrey and Sussex Area Team, which commissions a number of services for the wider population, including primary care specialised services, offender health and military health. Key issues and risks we face A number of key risks were identified during 2016/17: Sustained failure to meet the four hour A&E waiting time standard by our main acute provider, Ashford and St Peter s Hospitals NHS FT more detail on how we are managing this is given on p.25. North West Surrey CCG Annual Report

21 Lack of assurance on SECAmb s Governance Framework and failure of key standards more detail on how we are managing this is given on p.26. Inability to deliver our financial control total due to non-achievement of QIPP programme this risk was effectively mitigated and we delivered our financial control total. Progress against key standards and local priorities Overall the CCG has performed well this year making good progress against the local priorities set out within our strategic programmes, and meeting the majority of statutory and key NHS standards. More detail on our performance is given in the Performance Analysis starting on p. 24. Future plans looking ahead This year the CCG has made many positive achievements for local residents, particularly through our transformation work both at local and system level, and we will continue to build on this. However, the whole local system continues to face significant financial and performance challenges. Our population s need for services continues to grow at a faster rate than available funding, meaning that we have to innovate and transform the way we deliver high quality services at an even greater scale to remain within the resources available. Looking ahead, system transformation at the level required can only be achieved through further collaboration and wider system partnership in particular between commissioners, providers and other colleagues within health, social care, primary care, general practice, public health and the voluntary and charitable sector. We have now set out a clear operational plan for the next two years which aligns with both local partners and the wider Surrey Heartlands Sustainability and Transformation Plan; it is only by working collaboratively at this level that we will achieve the transformation we need to keep and continue to develop the right high quality services for our population. As a system, we are working with our partners to prioritise carefully where preventative action can reduce pressure on care services and better manage complexity across pathways. We aim to ensure that the provision of out of hospital services is appropriately balanced, and are developing a primary care strategy that will ensure GP services are sustainably at the heart of the out of hospital system. North West Surrey CCG Annual Report

22 The Surrey Heartlands Sustainability and Transformation Plan As part of the national response to delivering the NHS Five Year Forward View, in early 2016 local NHS organisations and their partners were asked to work together in larger geographical areas to commission and plan on a wider strategic footprint. North West Surrey CCG is part of the Surrey Heartlands footprint which also includes the areas covered by Guildford and Waverley and Surrey Downs CCGs (see map). Together we are supporting important Surrey-wide relationships and patient flows such as the emergency care network and stroke pathway. Surrey Heartlands operates as a partnership and comprises the following 11 local organisations who together have developed an ambitious plan to improve health and care services for local residents. Ashford and St Peter s Hospitals NHS Foundation Trust (acute hospital services) CSH Surrey (community services) Epsom and St Helier University Hospitals NHS Trust (acute hospital services) Guildford and Waverley Clinical Commissioning Group North West Surrey Clinical Commissioning Group Royal Surrey County Hospital NHS Foundation Trust (acute hospital services) South East Coast Ambulance NHS Foundation Trust (ambulance services) Surrey and Borders Partnership NHS Foundation Trust (delivering mental health services across Surrey) Surrey County Council (adult and children s social care services) Surrey Downs Clinical Commissioning Group Virgin Care Services Limited (community services) As with the other 44 STP areas, the full plan for Surrey Heartlands developed in partnership across the 11 participating organisations - was submitted to NHS England at the end of October and was approved at a meeting held in public demonstrating transparency. The plan has received favourable feedback from the national bodies and is aimed at delivering a number of key benefits to local people: North West Surrey CCG Annual Report

23 Improving the quality of services with better outcomes lower mortality rates, reducing the impact of long-term disease on people s lives and improving patient experience of health and care services Enhanced well-being local people experiencing better physical and mental health Improved access to healthcare shorter waiting times and services closer to home. Six clinical workstreams have been established (see below), with prevention playing a key role throughout, alongside a range of supporting workstreams including workforce, digital, citizen-led communications and engagement, out of hospital and primary care. Urgent and emergency care Women and children s services Cardiovascular Musculoskeletal services Cancer Mental health The STP has developed a Clinical Academy, a virtual network of clinicians to tackle unwarranted variation so that any patient, no matter where they live in Surrey Heartlands, will receive the same levels of care and outcomes. The Academy will also identify and spread best practice and play a key role in ensuring local citizens and staff are genuinely involved in service development and transformation, using well established co-design methodology. This work will be informed by a robust deliberative research programme undertaken with a statistically representative sample of the local population, to understand more about how citizens feel about health and care services and what their priorities are. Together with Surrey County Council, the CCGs in Surrey Heartlands are working on a devolution proposal, an agreement with the Department of Health, NHS England and NHS Improvement, as well as other national health bodies, that would enable the devolution of health responsibilities from a national/regional level to Surrey Heartlands. This will be a key enabler in helping us achieve our ambitions and plans more quickly by giving us greater accountability and a faster decision-making process particularly around the integration of health and social care. Many colleagues across North West Surrey CCG are engaged in the work of the STP, as clinical and strategy leads and/or members of the individual programmes and workstreams. The programme itself is run through a Transformation Board, where all partner organisations are represented, chaired by the Chief Executive of Surrey County Council. Julia Ross is currently the Senior Responsible Officer for the STP. A small programme team supports the Transformation Board. More information on the Surrey Heartlands STP is available at: North West Surrey CCG Annual Report

24 3. Performance Report Analysis Introduction This section expands on the performance overview above. It describes how the CCG measures itself against key performance indicators for the delivery of services to its resident population. It also provides further information on the development and performance of the CCG as a whole during the year, with reference to NHS England s CCG Improvement and Assessment Framework for 2016/17 and progress against our key strategic programmes. Improving performance and delivery This has been another challenging and successful year for the CCG, as we continue to address issues across our local health system and start to realise some key components of our vision. In this section we look at the work the CCG has undertaken to embed structures and processes to improve performance and delivery, and how we have worked with our providers to ensure they are delivering the best possible care for our population. We continue to develop a robust approach to commissioning. This includes establishing new models that promote integration and innovation and incentivising a move towards more care out of hospital in the community. Importantly our approach focuses on quality improvement and maximising efficiency, both key elements in developing the kind of transformational change we need to make. Measuring delivery of services Maximum 18 week wait from referral to treatment (RTT) 6 Performance against this standard is demonstrated by tracking the percentage of patients who started consultant-led treatment within 18 weeks of being referred. Incomplete Pathway (target 92%) Our YTD performance against this national standard is currently 92.9%. 6 Data Source: UNIFY Consultant-led Referral to Treatment Waiting Times (09/03/2017) North West Surrey CCG Annual Report

25 18 weeks - Incomplete Q1 Q2 Q3 Q4 YTD Total Activity 68,225 69,446 65,273 64, ,405 Performance against standard 93.7% 92.8% 92.8% 92.4% 92.9% Target 92% 92% 92% 92% 92% Variance +1.7% +0.8% +0.8% +0.4% +0.9% Incomplete pathways were not a concern during 2016/17. The CCG is working with the Trust to ensure that continual improvement activity actions and interventions across three at risk specialties (General Surgery, Urology and Oral Surgery) are maintained to ensure compliance is sustained. Maximum 4 hour wait in A&E departments 7 Performance against this standard is demonstrated by tracking the percentage of patients who are assessed within four hours of attending A&E. Combined Measure: Type 1 and Type 3 A&E attendances at St Peter s and Ashford Health Centre (target 95%) From April 2016/17 the contractual measure included the Type 3 attendances from Ashford Health Centre. A&E <4hr wait (combined) Types 1 & 3 at St Peters plus Ashford Health Centre Q1 Q2 Q3 Q4 YTD (Type 3) Total Activity 39,195 38,001 40,275 38, ,806 Performance against standard 90.6% 93.0% 90.9% 88.1% 90.6% Target 95% 95% 95% 95% 95% Variance -4.4% -2.0% -4.1% -6.9% -4.4% Compliance was not achieved against the four hour A&E target during 2016/17. However, the North West Surrey system continues to perform comparatively well regionally and nationally, with excellent recovery capability and demonstrably better discharge flow from the acute system via partner agencies. Performance against this metric is overseen by the Local A&E Delivery Board (LAEDB) which meets fortnightly. Current priorities are to enhance and re-align the whole system Recovery Action Plan to deliver the revised 2017/18 trajectory in line with NHS Improvement s intention for 95% compliance nationally by March This includes continued working in collaboration with all providers (ASPH, CSH, Social Services, CHC, SECAmb and SABP) on acute and non-acute led improvement actions. Maximum 62 day wait for urgent cancer treatment 8 Performance against this standard is monitored by measuring the percentage of patients receiving first definitive treatment for cancer within 62 days of an urgent referral from a GP. 7 Data Source: UNIFY A&E 4 hr Waiting Time Compliance (09/03/2017) 8 Data Source: OPEN EXETER Cancer Waiting Times 09/03/17 North West Surrey CCG Annual Report

26 Cancer wait (62 days - Urgent GP Referral) Q1 Q2 Q3 Q4 YTD Total Activity Performance against standard 81.4% 79.2% 84.4% 80.8% 81.5% Target 85% 85% 85% 85% 85% Variance -3.6% -5.8% -0.6% -4.2% -3.5% The national standard for 2016/17 year to date has not been met, with our YTD result at 81.5%. The reasons behind non-compliance are varied and include increases in demand as a result of more two week referrals (driven by changes to NICE guidelines), patients choosing to have their appointments at a later date, and complex pathways due to multiple diagnostic tests at tertiary centres (e.g. Royal Surrey County Hospital). The Trust has developed a comprehensive Cancer Recovery Action Plan and this incorporates a number of recommendations as a result of a diagnostic review of systems and processes by the Intensive Support Team in July Implementation of the plan is being proactively managed through the Joint Cancer Performance and Quality Group to drive recovery and enable sustainable delivery of the 62 day pathway performance. In addition, wider cancer alliance work is continuing across Surrey Heartlands (including NWS CCG, G&W CCG, ASPH, and RSCH) to improve cancer wait standards by monitoring remedial action plans and complex tertiary pathways (e.g. prostate pathway). The new Surrey & Sussex Cancer Alliance should also support continued improvement in key cancer standards over the next year and beyond. Maximum 8 minute response for ambulance calls Performance against this standard is tracked by measuring the percentage of Category A (Red 1) ambulance calls responded to within 8 minutes. South East Coast Ambulance (SECAmb) is the main provider in North West Surrey and also provides ambulance services across the South East Coast. Service provided across South East Coast: (target 75%) 9 Official data relates to performance across the South East Coast. To date the national standard has not been met since April 2016/17. Category A (R1 calls) SECamb Ambulance Q1 Q2 Q3 Q4 YTD Total Activity 4,022 3,974 5,025 4,912 17,933 Performance against standard 65.3% 63.1% 64.5% 66.1% 64.8% Target 75% 75% 75% 75% 75% Variance -9.7% -11.9% -10.5% -8.9% -10.2% Service provided within North West Surrey: (target 75%) 10 Un-validated data for NHS North West Surrey CCG has been provided by SECAmb. To date, the national standard has not been met since April 2016/17. 9 Data Source: UNIFY Ambulance Quality Indicators 09/03/17 10 Data Source: SECamb Performance Report M11 6 Data Source: UNIFY Diagnostics 09/03/ Data Source: HSCIC web site 27/03/2017 North West Surrey CCG Annual Report

27 Category A (R1 calls) North West Surrey CCG Q1 Q2 Q3 Q4 YTD Total Activity ,103 Performance against standard 61.2% 57.2% 62.9% 65.7% 61.9% Target 75% 75% 75% 75% 75% Variance -13.8% -17.8% -12.1% -9.3% -13.1% A wide range of actions have taken place or are underway to drive recovery. This includes restructuring at both a senior executive and operational level to ensure appropriate levels of supervisory managers are in place 24/7 to support staff and deal with incidents throughout the day. The CQC and NHS Improvement (NHSI) placed the Trust in quality special measures earlier in the year. Commissioners have engaged with SECAmb throughout the year; North West Surrey CCG is working closely with the other commissioners in Kent and Sussex and with the national bodies (CQC, NHSI) to seek assurance around delivery of actions both within the Unified Recovery Plan (URP) and the CQC action plan. In particular revised improvement trajectories have been agreed and included within the contract with a stronger focus on handover delays. A Commissioners Forum has been established including commissioning and quality representatives from associate CCGs. Regular briefings have also been set up for associate CCGs in between monthly contract reports when required. Monthly catch-up telephone conversations are also taking place with Surrey Healthwatch. The CQC has recently announced their follow-up inspection which is due in May. The Strategic Partnership Group (SPG) continues to oversee the implementation of the URP and this is now being channelled through the PMO process to ensure there is appropriate governance and to minimise risk by strengthening oversight. Diagnostics 6 Performance against this standard is monitored by measuring the percentage of patients waiting 6 weeks or longer for a diagnostic test. Diagnostic waits >6 weeks Q1 Q2 Q3 Q4 YTD Total Waiting List Size 16,091 16,737 16,535 17,214 66,577 Performance against standard 1.1% 1.1% 0.6% 0.8% 0.9% Target 0.9% 0.9% 0.9% 0.9% 0.9% Variance +0.2% +0.2% -0.3% 0.1% 0.0% The CCG has recovered from a non-compliant position in September 2015 and sustained good performance for most of 2016/17. This achievement was the result of strong delivery of a recovery plan focused on short, medium and long term actions; the plan was further enhanced by the CCG s patient engagement awareness campaigns and the implementation of a new endoscopy pathway through the Referral Support Service (RSS). North West Surrey CCG Annual Report

28 Dementia 7 Performance against this standard is monitored by estimating the dementia diagnosis rate and comparing the dementia register with expected prevalence. Dementia (Diagnosis Rate) Q1 Q2 Q3 Q4 YTD Number of people diagnosed 8,536 8,541 8,550 8,418 34,045 Performance against standard 66.0% 66.1% 66.2% 65.1% 65.9% Target 67.0% 67.0% 67.0% 67.0% 67.0% Variance -1.0% -0.9% -0.8% -1.9% -1.1% The CCG is continuing to work closely with both general practice and care homes to improve the dementia diagnosis rate and ensure individuals living with dementia and their families/carers receive the best possible support and care. The CCG has been one of the top performers in the Surrey and Sussex region since March 2015 and sustained good level of performance for most of the current financial year. NHS Outcomes Framework Indicators in the NHS Outcomes Framework focus on five domains, setting out high level national outcomes that the NHS should aim to improve. There are a small number of overarching indicators for each domain. These are followed by a number of improvement areas, which focus on improving health and reducing health inequalities. Domain 1: Preventing people from dying prematurely Domain 2: Enhancing quality of life for people with long term conditions Domain 3: Helping people to recover from episodes of ill health or following injury Domain 4: Ensuring that people have a positive experience of care Domain 5: Treating and caring for people in a safe environment and protecting them from avoidable harm Performance against the framework is improving in the majority of domains, as evidenced by the NHS Outcomes Tool, which supports effective commissioning for value. These outcome indicators show that NHS North West Surrey CCG achieves many good outcomes, in some cases in the top 25% nationally. The table below illustrates examples of the CCG s performance per domain in comparison with the cluster and England mean for 2016/17: North West Surrey CCG Annual Report

29 Domains Indicators CCG Cluster England CCG Rating Mean Mean 1.10 One-year survival from all cancers Performs Well One-year survival from breast, lung and colorectal cancers 1.19 Record of lung cancer stage at decision to treat Performs Well Needs Improvement Health-related quality of life for people with long-term conditions 2.11b Percentage of referrals to Improving Access to Psychological Therapies (IAPT) services which indicated a reliable improvement following completion of treatment 2.15 Health-related quality of life for carers, aged 18 and above Performs Well Performs Well Performs Well Elective groin hernia procedures - patient reported outcomes measures (PROMS) 3.6 People who have had an acute stroke who receive thrombolysis 3.7 People with stroke who are discharged from hospital with a joint health and social care plan Needs Improvement Performs Well Performs Well Patient experience of hospital care Performs Well 4.5 Responsiveness to Inpatients personal needs Needs Improvement Incidence of Healthcare Associated Infection (HCAI) Methicillin-resistant Staphylococcus aureus (MRSA) 5.4 Incidence of Healthcare Associated Infection (HCAI) C. difficile Performs Well Performs Well Financial performance North West Surrey CCG in common with all other CCG s is required to meet a number of statutory financial duties. The main duty is to remain within its revenue allocation, plus further duties on remaining within the allocated cash limit and the running costs allowance. A summary of the CCG financial performance is detailed below; Summary of Financial Performance Target Actual Remain within the resource limit 471, ,950 Rating Remain within the cash limit 465, ,247 Remain within the running costs allocation 7,649 7,319 North West Surrey CCG Annual Report

30 Resource Limit The CCG as part of its financial planning for 2016/17 was required to plan for the delivery of a surplus of 4.288m (1% of allocation). The CCG set a prudent plan to achieve this target, which recognised a number of risks to delivery. At Month 5, some of these risks materialised and together with new cost pressures resulted in a change to the CCG s plan to breakeven. As set out in the 2016/17 NHS Planning Guidance, CCGs were required to hold a 1 percent reserve uncommitted from the start of the year, created by setting aside the monies that CCGs were otherwise required to spend non-recurrently. This was intended to be released for investment in Five Year Forward View transformation priorities to the extent that evidence emerged of risks not arising or being effectively mitigated through other means. In the event, the national position across the provider sector has been such that NHS England has been unable to allow CCGs 1% non-recurrent monies to be spent. Therefore, to comply with this requirement, NHS North West Surrey CCG has released its 1% reserve to the bottom line, resulting in an additional surplus for the year of 4.567m. This additional surplus will be offset against other cost pressures from the current financial year. The CCG has delivered a surplus of 4.591m made up as follows; 2016/ / Total Spend 466, ,357 Revenue Resource Limit 471, ,615 Over (Under) spend (4,591) (4,258) Cash In 2016/17 the CCG had a requirement to ensure that its cash balance at the end of the financial year was less than 463k The CCG s performance is detailed below; 2016/ / Total Cash Expenditure 465, ,534 Cash Allocation 465, ,574 Over (Under) spend (85) (40) North West Surrey CCG Annual Report

31 Running Costs Allowance The CCG received an allocation for running costs of 7.606m ( per head of population (2015/ per head). Quality premium payments were allocated to running costs in 2015/16 but this has been changed to programme costs in 2016/17. In year the CCG received an additional allocation due to the move to market rent for premises of 43k. The CCG is not permitted to overspend against this allocation. Although the CCG has had to use a number of interim and agency staff, it has managed to remain within the allocation and generate an underspend of 0.330m (2015/ m) as follows; 2016/ / Running Costs Expenditure 7,319 7,373 Running Costs Allocation 7,649 8,067 Over (Under) spend (330) (694) Better Payments Practice Code CCGs are expected to meet the requirements of the Better Payments Practice Code, to achieve a target of payment of invoices within 30 days of receipt of goods or a valid invoice. The target is 95% of invoices paid within creditor terms. The CCG paid 88.73% (2015/ %) of all valid invoices by the due date or within 30 days of a receipt of a valid invoice in 2016/17. QIPP Financial plans for 2016/17 for the CCG included a savings requirement for QIPP totalling m (2015/ m). By the end of the financial year the CCG had achieved 72% of this QIPP target through delivery of schemes. The QIPP schemes have focussed on reducing demand in acute hospitals, MSK procurement and a reduction in medicines management. North West Surrey CCG Annual Report

32 Other key outcomes from the CCG Improvement and Assessment Framework This year NHS England has introduced a new CCG Improvement and Assessment Framework to replace the previous CCG Assurance Framework and CCG Performance Dashboard. Quality of leadership The CCG has been rated Green for Quality of Leadership for the first half of 2016/17. In particular NHS England has acknowledged: The strength of the Governing Body and the Executive Team in terms of robust leadership, both within the CCG and to the local health economy. The assessment also acknowledged strong evidence of the clinical and nonclinical leadership role the CCG has played in the development of Surrey Heartlands STP. The success of the CCG is being shortlisted as CCG of the Year at the HSJ Awards, recognised as an indication of the quality of leadership and positive culture in North West Surrey. The Quality work the CCG is undertaking with SECAmb in the light of the CQC report and with Ashford and St Peter s to improve elective pathways. In terms of Governance, the CCG has demonstrated an effective grip on its financial position albeit with acknowledged challenges regarding the 2017/18 position. Positive engagement with community and system partners, particularly evidenced via the STP, with an integrated approach to planning and contracting with providers. Successful joint delivery programme with Ashford and St Peter s, which is starting to deliver results. Quality of engagement with member practices around delegated primary care co-commissioning. Success of the first locality hub (the Bedser Hub in Woking), as an example of positive joint working with the reduction of A&E attendances for patients over 75 from the Woking area. Use of Right Care to support the joint delivery programme with Ashford and St Peter s, with success in tackling frequent attenders to A&E and improvements to the MSK pathway (with an expected 3m savings). North West Surrey CCG Annual Report

33 Recognition that although Ashford and St Peter s is still not achieving the improvement trajectory for the A&E 4 hour target, the LAEDB is working well with all system partners to improve the non-elective pathways. Ensuring Quality and Patient Safety One of the most important tasks that the CCG performs is to make sure that our population is able to obtain timely, safe and good quality care when they need it from the NHS providers in North West Surrey. This covers not only community and hospital services but also mental health, ambulance, independent providers, out of hours and primary care. Key achievements this year include: System HCAI process - In 2016 the CCG set up the North West Surrey System Wide Health Care Acquired Infection (HCAI) Review Panel with the purpose of bringing together different parts of the system to review all acute cases of Clostridium Difficile (Cdiff). Through the panels we identify any lapses in care, including those which may have a contractual sanction, acknowledge notable practice and identify areas for improvement. The panels provide an opportunity for an open and transparent discussion and learning from the panel is shared across the system. Harms forums - as part of the Quality meetings we held with Virgin Care Services Limited our community services provider, we undertook to host two system wide harms forums, one focused on children s services and one on adult services. The adult forum focused on the safe transfer and discharge of patients across the system. The children s forum explored the provision of specialised equipment. Both forums were well received and the findings are feeding into local work groups to address specific concerns in line with the wider work of the Patient Safety Collaborative. Nursing and Serious Incident Learning Event - In April 2016 the Surrey CCGs hosted a nursing and serious incident learning conference. Overall there was really positive feedback and it was a good networking opportunity for all who attended. The presentations on resilience, human factors and patient safety were all particularly well received and used to reflect and review how our own local serious incident process, while robust and effective, can be further improved. New dashboard and reporting schedule - The quality team reviewed quality reporting to Governing Body and developed a new dashboard approach that enables us to easily triangulate quality metrics. This sits alongside our more qualitative patient safety and patient experience reports, and a schedule of in depth reviews. Altogether these enable us to assure the Governing Body on our providers care delivery or highlight issues of concern. North West Surrey CCG Annual Report

34 Care home and safeguarding - During the last year we have made significant improvements in how we work collaboratively with the care home sector around adult safeguarding. In particular, the care home team (made up of a community matron, dietician, CCG pharmacist and geriatrician) have worked hard with care homes ensuring positive partnership working with both social care and with the CQC around monitoring. In the last month we have also held a high level strategy meeting to look at the future management of the care homes system in North West Surrey. We look forward to collaborative working between Surrey Social Care, Ashford and St Peter s, primary care and ourselves in the future. From a children s safeguarding perspective, the CCG undertook the Surrey Safeguarding Board s Section 11 children s safeguarding audit. The Safeguarding Board has now published its findings and no areas of concern were identified in the CCG s safeguarding process. North West Surrey CCG Annual Report

35 How we ve performed against our key priorities Our key priorities are summarised in the following strategic programmes*: Targeted communities in particular looking at active outreach and prevention in targeted areas Urgent care looking at our urgent care pathway, and meeting the four hour waiting target for A&E Planned care including musculoskeletal services, cardiovascular, cancer and diabetes Frailty including the frail elderly, stroke, end of life, neurology and dementia Children and young people focusing on the paediatric urgent care pathway and emotional and behavioural support Mental health and learning disabilities. Medicines optimisation and primary care are incorporated through the work of all programmes. Our priority programmes continue to progress work across the system to improve patient pathways for residents in North West Surrey. Unplanned care The challenges facing unplanned care services are well documented throughout the media. Increased demand on NHS services, both nationally and locally, has put pressure on the provision of urgent care and achieving the 95% four-hour standard. North West Surrey has managed well over the winter period in spite of these challenges, due to robust planning and preparation undertaken by all system partners prior to the winter period, drawing on the learning from the previous two years. Although not achieving the 95% standard, resilience has been demonstrated. We aim to support our population, who need urgent care, to access the right care, in the right place in a timely way. Our work this year particularly focused on improving pathways, both at the front door and on discharge, to ensure efficient flow through the whole urgent care pathway, and provision of a resilient system over the winter period. Key achievements include: North West Surrey CCG Annual Report

36 System-wide information system - North West Surrey has continued to work with Alamac in the development of an information system to support greater understanding of whole system activity and performance. Alamac is a specialist company who partner with NHS organisations to support the delivery of efficient, high quality urgent care services. Measures are collected daily and discussed on daily system calls to understand performance challenges and success factors, also supporting more transparency with partners in respect of performance and delivery. Through this improved collaboration, underpinned by objective performance metrics, we have been able to take much more timely action together to improve daily working and experience for patients. Surge and Escalation Planning - North West Surrey is successfully working as a system in the planning and preparation for periods of expected surge, such as the winter period. The Local A&E Delivery Board (LAEDB), previously the System Resilience Group (SRG), has worked well together this year to review and develop system escalation plans so that when periods of surge and escalation are experienced, the agreed set of actions can be successfully implemented. Winter resilience initiatives - we successfully implemented resilience initiatives over the winter, based on learning from previous years. This included enhancing walk-in centres at weekends with GP and X-ray provision, extending the hours of Rapid Response In-Reach in A&E to evening and weekends, and providing GP support to community hospital rehabilitation wards at weekends. Discharge to Assess - a significant achievement this year has been the implementation of the Discharge to Assess (D2A) programme which aims to enable people who are medically fit to leave hospital to be discharged in a safe and timely way, with the support of an integrated health and social care team and without having to wait for longer term support options to become available. The programme also aims to maximise post-acute recovery at home whenever possible. Provider partners in North West Surrey s Adult Social Care Team, Virgin Care Services Limited and Ashford and St Peter s Hospitals came together last September to form an Integrated Care Bureau (ICB), providing intermediate care options for those needing supported discharge post an acute hospital admission. The service model has three discharge pathways: Pathway 1: Support at home: for patients on a hospital ward (acute or community) who can return home with additional support Pathway 2: Bedded rehabilitation/reablement: for patients who cannot be discharged home, but who may return there with additional bedded rehabilitation/reablement North West Surrey CCG Annual Report

37 Pathway 3: 24/7 care: for patients likely to need on-going care in either a residential or nursing home setting, who may or may not be eligible for continuing healthcare funding. The Supported Discharge Team consists of nurses, physiotherapists, occupational therapists and rehabilitation/reablement support workers. Urgent and Emergency Care Network (UECN) - the UECN operates on the same footprint as Surrey Heartlands, and was re-established this year to facilitate the delivery of the national Urgent and Emergency Care Review, Surrey Heartlands Sustainability and Transformation Plan (STP) and the national strategy set out in Safer, Faster, Better. Communicating the right use of services - to support the urgent care system over the winter, we launched a communications campaign to support patients in making the most appropriate choice to meet their urgent health needs. This year the campaign included targeted social media advertising, provision of leaflets to GP practices and services across North West Surrey, as well as a series of adverts in the local media. NHS the existing NHS111 contract was due to expire in March 2016 but an extension was agreed to March North West Surrey is currently leading a procurement process for a new contract in partnership with Surrey Downs and Guildford and Waverley CCGs. The service will incorporate the new national requirements to integrate GP out of hours, as outlined in recent Department of Health Guidance. The procurement programme will launch an extensive engagement plan in summer 2017, consulting with system partners and patient groups to support the development of the service specification, as well as involvement from the voluntary sectors and the wider public. The new service is due to go live in April 2019 and will include many enhanced features to the already good existing service. North West Surrey CCG is leading this procurement process on behalf of Surrey Heartlands CCGs (Surrey Downs CCG and Guildford & Waverley CCG). Planned care Planned care is a term given for services and treatments which are not carried out in an emergency, and for which patients are usually referred by their GP. Key achievements this year have included: Our Referral Support Service The national electronic referral service (e-rs) has been successfully rolled out across North West Surrey GP practices, with relevant training of all practice staff North West Surrey CCG Annual Report

38 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 completed. The system supports safe and effective processing of patient referrals, and promotes patient choice of hospital provider. Our GP triage team has seen a significant increase in the number of referrals processed by the team. 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 Total Referrals The advice was received very quickly.and provided useful advice such as changes in medication, enabling the GP to manage the patient promptly. In addition to providing referral support, the RSS team has implemented a process for GPs to access specialist advice and guidance from consultants based at Ashford and St Peter s Hospitals NHS Foundation Trust to avoid unnecessary outpatient visits. The Advice & Guidance project was launched in July 2016 and has been received very positively. Our new Integrated Musculoskeletal Service (imsk) Following a robust procurement process, the new imsk contract was awarded to Ashford and St Peter s Hospitals. The service began on 1 October 2016 and includes physiotherapy, hand therapy, rheumatology, pain management and orthopaedic care. It provides comprehensive and integrated musculoskeletal (MSK) assessments and treatments including diagnostics, such as X-rays, ensuring that patients are seen by the right person for their condition as quickly as possible. The service includes: Extended scope practitioners (highly trained physiotherapists who have undertaken additional specialist training to be able to assess and treat MSK conditions) Physiotherapy and hand therapy Senior nurses Consultants in pain management, rheumatology or orthopaedics Range of other clinicians all who are trained in specialist areas The service considers the patient s whole health and wellbeing, providing up to date advice and information to enable their involvement in all decisions regarding options North West Surrey CCG Annual Report

39 for treatment. Information and guidance on self-management on a wide number of MSK conditions is available through a new innovative website: On the new service: I was treated with great understanding for my issues and a solution was given. I am very pleased everything was very professional. I would highly recommend this unit. The new service commissioned by the CCG represents an improved and more efficient pathway of care for patients, helping to avoid unnecessary surgery and achieve optimum improvement in their condition. The service gives patients better understanding of their condition and access to excellent tools to support their selfmanagement. The service is also expected to save in the region of 3m/year. Community ophthalmology service the CCG has worked jointly with Ashford and St Peter s Hospitals to redesign the ophthalmology service, now providing a wide range of treatments within a community setting. From 1 April 2016, a number of local clinics opened with experienced optometrists and consultants in West Byfleet, Addlestone and Woking. Arrhythmia and chest pain pathways we have worked jointly with Ashford and St Peter s Hospitals to redesign the arrhythmia pathways, speeding up test results and also resulting in earlier diagnosis by GPs. From June 2016, GPs have been able to access specialist advice and guidance from a GP with a special interest in cardiology. This has helped to free up capacity in the acute hospital to see patients with greater need and more complex conditions. Further collaborative work with the Trust has resulted in the redesign of the chest pain pathway to help avoid unnecessary invasive procedures. The revised pathway was launched in April Dermatology - dermatoscopes, which allow GPs to analyse skin conditions in greater detail, were rolled out across GP practices this year. Images can now be captured and sent remotely to consultant specialists for triage and review. We anticipate this will lead to at least 25% of patients being redirected/managed remotely avoiding unnecessary hospital appointments. Cancer - there have been a number of key achievements this year: A joint Clinical Audit, funded by NHS England, was carried out in collaboration with Ashford and St Peter s Hospitals to review the journey for patients diagnosed with cancer following emergency care presentations. The audit identified some key learning that will be shared across the Surrey & North West Surrey CCG Annual Report

40 Sussex Cancer Alliance to facilitate improvements in earlier diagnosis of cancer by GPs and cancer services in hospital. The second annual Joint Cancer Health & Wellbeing Event was held in collaboration with Ashford and St Peter s Hospitals, aimed at supporting patients living with, and beyond cancer as outlined in the national cancer strategy s recovery package (see diagram). Around 120 cancer patients and carers attended the event, which received very positive feedback. Of particular interest were topics that addressed key consequences of a cancer diagnosis, ranging from body image issues, medical, emotional, work, and financial aspects that can affect a person with cancer. What our patients have said: The amount of different areas which were covered was very helpful as was being able to talk to experts at their stands.. Relieved to know that even after treatment ends, we can still be helped and supported. Very informativehad an insight of what my wife has been going through Well organised, helpful staff, informative presentations and excellent The Surrey and Sussex Cancer Alliance, supported by Macmillan Cancer Support and Cancer Research UK, also worked with us and Ashford and St Peter s Hospitals to roll out the electronic health needs assessment forms for cancer patients across Surrey and Sussex. North West Surrey CCG Annual Report

41 Through St Luke s Cancer Alliance, we actively participated in the development and roll out of the new NICE guidance referral forms. Gastroenterology we worked in partnership with Ashford and St Peter s gastroenterology clinical team to redesign pathways to help reduce the number (and associated costs) of unnecessary invasive diagnostic procedures and improve GP referral protocols, helping to reduce variation in referrals. Redesigned pathways are also helping to reduce unnecessary follow-ups in secondary care for the management of stable chronic conditions. Redesigned pathways include: Irritable Bowel Syndrome to facilitate more diagnostics in primary care before referral to hospital. More significantly, a FODMAP pathway was developed to support patients to self-manage their condition through specific dietary advice and use of a low FODMAP diet. This will be launched later this year. FODMAP stands for Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols which are a collection of poorly absorbed simple and complex sugars found in a variety of fruits and vegetables, milk and wheat. We are also working in collaboration with the Trust and the relevant STP workstream to begin to develop a clear pathway for patients with Irritable Bowel Disease. Children and young people Supported by our GP clinical leads, we have close clinical partnerships with all our local maternity, paediatric and health visiting services, as well as Children s Centres and other local partners. Our priorities continue to focus on the paediatric urgent care pathway and on emotional and behavioural support. Key achievements include: Child and Adolescent Mental Health Services (CAMHS) and Behavioural services - we identified a need for a new behavioural service and worked with Surrey County Council and CCGs across Surrey to agree additional investment. We successfully procured a primary provider for a range of CAMHS services who are now supporting children with their mental health and emotional wellbeing. Key improvements with the new expanded CAMHS service since 1 April 2016 include: A single CAMHS Referral and Information Centre which offers a no wrong door approach to help children, young people and families to find the right help at the right time North West Surrey CCG Annual Report

42 The threshold criteria has been lowered and, as a result, the number of children being helped by CAMHS has increased significantly Expanded operating hours during the week, and improved access at weekends Services provided in more accessible and user friendly locations and online Automated clinical scheduling ensures capacity, appointments and room availability are managed effectively A new BEN pathway (Behavioural Education and Neurodisability) for children with ADHD (attention deficit hyperactivity disorder) and ASD (autism spectrum disorder) The work continues with CAMHS youth advisors and development of an employment pathway for young people. Children s Community Health Procurement - recognising the need for closer integration between children s services, we worked in partnership with the Surrey CCGs, Surrey County Council and NHS England to develop a joint specification for the re-procurement of Children s Community Health Services across Surrey. Children Family Health Services (CFHS) has been appointed as the provider and has been delivering the service since 1 April CAMHS Transformation Fund - promoting emotional wellbeing and good mental health is one of the five priorities of Surrey s Health and Wellbeing Board. We recognise that improving children s health and wellbeing is essential to give every child the best start in life and support them in achieving the best outcomes possible. North West Surrey and all Surrey CCGs were ranked in the top 20 CCGs nationally for this. Supporting the paediatric urgent care pathway - we have continued to support parents with education and information on how to look after their child s health and when to seek help, with the aim to reduce unnecessary A&E attendances. Despite a number of successful initiatives, A&E paediatric attendances remain high locally. We are continuing to work on our innovative schools programme to promote a better understanding of the NHS. This is a unique project working with local secondary schools to help students understand the variety of services offered by the NHS and aimed at influencing their own behaviour, now and in the future. We have also commissioned a paediatric app (to be launched in June 2017) to give up-to-date advice about common childhood illnesses and how to treat them, when and how to ask for help, and what to expect when the child is being assessed which will also help reduce unnecessary A&E attendances. North West Surrey CCG Annual Report

43 Supporting high quality maternity services - initiatives this year include: Saving Babies Lives : the still birth care bundle, to help spot signs of foetal growth retardation, has now been fully implemented by Ashford and St Peter s Hospitals, along with a training session for GPs hosted by the CCG. This includes a section on prescribing for mental health in pregnancy and breastfeeding. We were part of a successful joint bid, led by Guildford and Waverley CCG, to the Better Births fund on behalf of the Surrey Heartlands partnership. Surrey Heartlands will now be one of seven local areas selected to take forward recommendations to improve maternity services set out in the NHS Maternity Transformation Programme with a funding allocation of x. Improvements will include: o A shared community midwifery service across the geography, enabling midwives to work across organisational boundaries supported by mobile technology and electronic patient records o Service provision from community hubs, where a variety of services can be delivered to pregnant women and families o A Surrey Heartlands-wide home-birthing team ensuring local women have access to a full range of birth choices o A dedicated maternity line to ensure that women have easy access to consistent advice and information when they need it. This is a great early success for Surrey Heartlands and demonstrates the value of working in partnership to benefit local people. Children and Young People with special educational needs or disabilities - we have published joint commissioning principles for speech and language and occupational therapies to improve access and earlier support. We are also working closely with Surrey County Council to develop a new strategy that places positive user experience at the heart of service planning and change, for children with special educational needs or disabilities. Looked After Children - we have improved planning and co-ordination for children who are looked after, through investment and co-location of staff in health and social care, and we will continue to prioritise health assessments and intervention. Mental health services North West Surrey Clinical Commissioning Group has supported several improvements to services for people with mental ill health this year. Our achievements include: North West Surrey CCG Annual Report

44 Save Haven - the Safe Haven launched in Woking in December 2015 and has been very successful, with visitor numbers continuing to increase. It provides care and support to people experiencing a mental health crisis through a café-style drop-in centre, which offers a place of safety. Feedback from users has been overwhelmingly positive, with many indicating that it has been life-saving. The new premises at The Prop in Woking have been well received, with both staff and visitors commenting it is a significant improvement. The service is also having a positive effect on the numbers of people with mental ill health attending A&E. Based on these clearly positive outcomes, the CCG took the decision to continue commissioning the service after the pilot ended on 31 March IAPT services - the IAPT (Improving Access to Psychological services) service was re-procured in spring 2016, with all existing providers re-accredited to continue to deliver services. The procurement exercise offered the opportunity to reshape and simplify the service model and it is now easier for both patients and professionals to refer into. We also saw the addition of a fifth provider, offering more choice to patients in North West Surrey. We have established valuable links with the mental health midwife at Ashford and St Peter s Hospitals and the community health visitors team, to emphasise the benefits of IAPT for perinatal mental health support. We have also raised awareness of the service with Borough Council colleagues, sending leaflets through Meals on Wheels to reach older people who, we know, have very good recovery rates when they access the service. GP education - we have been working to provide education events to help GPs improve the support they give to people with mental health problems. Events have focused on topics including suicide prevention, perinatal mental health, and support for people with long-term conditions and dementia. We also partnered with Public Health to provide training for GPs on how to identify high-risk drinkers, including the use of Information and Brief Advice (IBA). Improved working with providers - we have formed a close working relationship with Surrey & Borders Partnership NHS Foundation Trust, helping to improve the communication between GPs and their Community Mental Health Recovery Service (CMHRS), establishing regular interface meetings between GP clinical leads, CMHRS staff and clinicians. We have jointly developed referral guidance documents and a new referral form that will help to streamline and simplify the process and should help to reduce the numbers of referrals requiring follow-up. Community Connections - we partnered with Surrey County Council to re-procure the valuable voluntary sector mental health support service known as Community Connections. The service was re-designed to have one lead provider across the North West Surrey CCG Annual Report

45 whole of North West Surrey, which now provides improved clarity for GPs when they are referring patients. Frailty and integrated care We are committed to providing a fully integrated health and care system that delivers more joined-up services, putting patients at the centre. We have made considerable progress this year in a number of areas: Frequent attenders - people who frequently attend A&E often have complex needs, which demand a multi-disciplinary approach. We reviewed the top 70 frequent attenders and established the Frequent Attenders project. Through this project patients needs are met by a multi-disciplinary team outside A&E. Care Homes the CCG has worked in partnership with Surrey County Council, Ashford and St. Peter s Hospitals and the voluntary sector to establish a combined approach to providing support for care homes with key achievements including: A joint forum for care homes which offers support from peers and tailored training from health and care professionals A multi-disciplinary team, led by a consultant geriatrician, to provide care homes with intensive support, including links to a wide range of professionals across health and social care. This is now specified as an on-going service in the new community contract. Dementia the CCG has developed a new 5-year Dementia Strategy in partnership with Surrey County Council and neighbouring CCGs, based on research and feedback gained through extensive discussions with people living with dementia, their carers and professionals across health and social care. The strategy is based on the Living well within dementia-friendly communities model which underlines the need to have coordinated care across health and care for people with dementia as shown in the diagram below. North West Surrey CCG Annual Report

46 Diabetes - diabetes is one of six clinical priority areas under the CCG s Improvement & Assessment Framework. We are part of the National Diabetes Prevention Programme, a nationally funded initiative that provides education on healthy eating and lifestyle, weight loss support and physical exercise programmes for people who are pre-diabetic. We have also been supporting GP practices to increase submissions to the National Diabetes Audit 15/16, which resulted in a 66% increase in submissions this year. We will continue to work with practices with the aim to further increase participation to 100%. We have significantly expanded the provision of structured patient education through commissioning the X-PERT programme, designed for people with type 2 diabetes and offered through Self-Management UK. The average number of participants within North West Surrey is significantly higher than the national average, with patients demonstrating significant improvements in their ability to self-manage their condition after completion. The acute diabetic team continues to deliver the STEPH educational course for people with type 1 diabetes. We continue to work with stakeholders to enhance the model of care for diabetes. A joint bid across the Surrey Heartlands STP footprint has been submitted to secure funding towards further improving services, following the agreement that approximately 40m per year will be made available nationally to promote access to evidence-based interventions. Locality Hubs - The Bedser Hub opened at Woking Community Hospital in 2015, combining community, social, mental health, primary, voluntary and acute care sectors to deliver a single-site, one-stop shop, integrated care model for older people Patients are allocated a Wellbeing Coordinator as their named key worker on referral to the Hub. Wellbeing Co-ordinators support patients and their carers, including with scheduling of appointments, timetables, organising transport, and providing general information/sign posting to services available in the wider North West Surrey CCG Annual Report

47 community. The Wellbeing Co-ordinator supports the patient and their family throughout their connection with the Hub, and maintains regular, at least monthly contact. Every patient who attends the Hub receives a comprehensive multidisciplinary team assessment. Community matrons carry out initial assessments, followed by a medication review with the Hub pharmacist. Patients also have a medical review with a GP, with onward referral to other services within the Hub if appropriate. A social services practitioner is on hand when any specific social care needs are identified.. More than 1800 patients have benefited from the service to date and we have seen significant improvements including: The proportion of older people receiving planned and coordinated care has increased, with fewer unpredictable exacerbations of need. We are eliminating duplication with more efficient and effective use of resources across health and social care. Partnership working between health and social care and the voluntary sectors has streamlined the service and reduced waiting times. Emergency services have access to Hub patients care plans through the ambulance service s IBIS system and through this we have seen fewer older people taken unnecessarily to hospital. We have seen a reduction overall in the number of people over 75 from Woking being admitted to St Peter s Hospital. People and their families and carers tell us the service better meets their needs, and their confidence levels have risen as a result. Clinicians have welcomed the service and that people s needs are now met within a community setting rather than often unnecessary attendance at A&E. Great to have it all under one roof. There is less anxiety at the Bedser Hub and my husband is much more relaxed. When there was a problem, he was able to have an X-ray along the corridor and be back with the doctor, looking at the results on the screen, within half an hour. Community Services - we have successfully completed a comprehensive procurement exercise to award a new contract for the delivery of adult community health services across North West Surrey. This process included the complete redesign of the service specification to enable and develop multi-disciplinary teams to work across the GP localities. These teams will allow doctors, community nurses, North West Surrey CCG Annual Report

48 physiotherapists, speech and language therapists, dieticians, mental health professionals, and many more, to work as part of a single team with a much closer working relationship with GPs and colleagues in hospital. This significant change in approach will improve quality and responsiveness, and make it easier for patients to access and benefit from the right services at the right time according to their needs. The contract has been awarded to CSH Surrey, a social enterprise with a strong track record of high quality care in the local area. CSH Surrey has taken over the community service provision from Virgin Care Services Limited from 1 April Dermatology - we have begun a redesign and procurement process for specialist dermatology services in North West Surrey. Working with clinicians across the area, commissioners have set out a new approach to accessing dermatological care including: Greater access to services in the community Expanded use of technology allowing consultants to review pictures of skin lesions, taken by local GPs, to ensure prompt diagnosis and triage Significantly reduced waiting times. This new model of care is expected to begin from October Stroke over the past two years an extensive stroke review has taken place across Surrey as clinical evidence suggested outcomes and patient experience of stroke care in Surrey was not as good as other areas of the country where reconfiguration had taken place. The review engaged widely with patients, carers, clinicians and other staff involved in stroke care and the voluntary sector particularly the Stroke Association. As a result, and with advice from the South East Coast Clinical Senate and national experts, proposals to improve stroke care across Surrey were put forward. This included the recommendation to have three co-located hyper-acute/acute stroke units (where patients receive urgent treatment for up to seven days after experiencing a stroke) across the County, with more consolidated specialist rehabilitation services and more people being cared for at home after their stay in hospital via the Early Supported Discharge teams. We know larger specialist units lead to improved outcomes, lower mortality and reduced disability as they are able to provide specialist stroke care 24/7 with the right specialist staffing levels, and are more attractive in terms of recruiting staff. Because different localities are at different stages, it was decided to consult on proposals in West Surrey this year. A 12 week public consultation is currently underway which closes on 30 April. The consultation is being led by Guildford and Waverley CCG, in partnership with North West Surrey and a number of public events have taken place across this area. Key proposals include: North West Surrey CCG Annual Report

49 Co-locating hyper-acute/acute stroke services at St Peter s Hospital (this would mean stroke services would no longer be provided at Royal Surrey County Hospital in Guildford) Specialist inpatient rehabilitation services provided at either Ashford Hospital and/or Woking Community Hospital (for North West Surrey patients) An increase from 20% up to 45% of patients going directly home from hospital with support from the Early Supported Discharge team, as we know patients recover more quickly in their own surroundings Six weekly and six monthly reviews for all patients New stroke navigator role to help signpost patients, carers and their families to available services and additional support Guildford and Waverley and North West Surrey CCGs will make a final decision on stroke services for West Surrey once the consultation concludes. We expect new services to be up and running by October this year. Targeted Communities Working with our public health, social care and wider colleagues we continue to progress a number of key initiatives including: Working with young carers to provide support, advice and guidance to improve the health and wellbeing of those caring for others through the Surrey Carers Strategy. Prevention action joint work with the CCG, local boroughs and Surrey County Council Public Health to deliver the Prevention Plan aiming to improve health and reduce health inequalities for people living in North West Surrey. This has included: Smoking: COPD o Increase the provision of Stop Smoking Services in primary care by summer 2016 o Increase Stop Smoking Services in priority groups o Systematic case finding of patients in specific general practice cohort. Physical Activity o Increase physical activity levels amongst groups identified as inactive or with a condition that would benefit from exercise o Improve adoption of Workforce Wellbeing Charter which encourages physical activity and healthy eating as part of a healthier workforce North West Surrey CCG Annual Report

50 Healthy Weight o Raising the issue of weight o Increasing the number of people referred to diabetes prevention programme Alcohol o Improving early identification of alcohol misuse among general population o Improving effective management of people who misuse alcohol NHS Health Checks o Increase the number of General Practices that offer NHS Health Checks o Increase the number of pharmacies that offer NHS Health Checks. Specific work on the Prevention Plan relating to children is included in the Improving Children's Health and Wellbeing section on p.41. People with Learning Disabilities - on-going dialogue with primary care to identify and address training and development priorities that will enable more GP Practices to offer people with learning disabilities annual health checks, to identify and support patients at risk of developing long term health conditions and co-morbidities, such as diabetes and hypertension. The Prevention Plan sits as part of the Joint Operational Group that reports to the Local Joint Commissioning Group for North West Surrey. This group involves representatives from all partner organisations. Through the latter part of 2016/17 the priorities for the Prevention Plan have been refined and now reflect the following high-level priorities: Preventing disease and promoting wellbeing - to include the promotion of healthy lifestyles across the life-course such as smoking, alcohol, healthy weight and emotional wellbeing Earlier diagnosis of Long term conditions linked to QIPP priorities and SH STP with a focus on hypertension, diabetes and cancer Promoting Independence including action to reduce social isolation, to promote winter wellbeing and prevent falls The CCG is working in partnership with Surrey County Council Public Health, Adult Social Care, and the borough and district councils on an action plan to address these priorities. North West Surrey CCG Annual Report

51 Working with primary care Our primary care strategy has been developed over the course of 2016 with wide consultation from our Members and stakeholders. The strategy begins to address the significant challenges that general practice is facing, including a growing and aging population with often complex multiple health conditions, as well as an increase in workload. In April 2016 we saw the launch of the General Practice Forward View (GPFV), which is aligned with our local strategy and contains specific, practical and funded steps to drive efficiencies in the delivery of general practice. We are using both local and national investment streams to fund a variety of initiatives to support these transformational projects. The GPFV has highlighted 10 actions that practices and Clinical Commissioning Groups can implement to release capacity. Changes have already been implemented that will bring about the shift of administrative workload from clinical teams to appropriately trained administrative staff. This will release time for patients. The strategy known as the Locality Transformation Scheme - has three main requirements: to develop a locality vehicle to work at scale and interface effectively with other North West Surrey providers and the Surrey Heartlands STP; work in partnership with CSH Surrey (incoming community provider) to ensure we achieve maximum value and effectiveness from the implementation of the new contract in the best interest of patients and that primary and community services work in an integrated way, and the development of a business case to secure additional transformation funding for enhanced primary care, including extended access. This approach has been overwhelmingly supported in a vote of the 41 practices within North West Surrey. Access to General Practice We have commenced work with our three localities on how they can work together to provide access to their population during the evenings and weekends by April This will enable patients to access routine and more urgent appointments locally, delivered by local clinicians who will have direct access to their full medical records to improve safety and efficiency. Along with initiatives we are currently developing, we will support the demand on General Practice and improve the overall patient experience. Access is not just about appointments; it is also about infrastructure and technology. We have successfully bid for the Estates and Technology Transformation Fund in 2016 which will support further improvements including: Upgrading or replacement of network connections to improve speed North West Surrey CCG Annual Report

52 Implementing mobile working to support practices in recording care home and home visits more efficiently Enabling a mobile phone texting service to remind patients about appointments or provide results. Enable patients to record feedback on their appointment through the Friends and Family Test. Engagement & Leadership We continue to have strong engagement with our member practices through a range of activities including monthly locality meetings, led by our clinical leaders and supported by our practice managers. The Locality Development Team works with the localities and have supported the implementation of many new schemes across the year including the NHS e-referral Service. This is a secure and reliable method of booking a hospital appointment, and patients can choose the date and time of their appointment. To ensure we build upon the success of our clinical and management teams, we have launched a leadership programme to support the development of clinical and non-clinical members. This will ensure that we have the leaders that we need to help shape future delivery of services for our population. Delegated Primary Care Commissioning From 1 April 2016 the CCG assumed responsibility for aspects of general practice commissioning from NHS England, which effectively means we have delegated responsibility for managing most elements of GP contracts. Responsibility for this lies with our new Primary Care Commissioning Committee (PCCC), which meets in public most months. This year the contract held for Ashford Health Centre was due to expire on 31 March 2017; having assumed delegated responsibility for primary care commissioning this meant the CCG was responsible for running a public consultation on the future of the Health Centre. Following a robust process, a final decision was made to disperse the list at the end of the financial year (March 2017) by the new PCCC. The dispersal of Ashford Health Centre GP Practice In 2010, Greenbrook Healthcare was awarded the contract to deliver both GP and Walk-In-Centre services at Ashford Health Centre for five years. In 2015, the contract was extended for 18 months until 31 March As this contract could not be extended further (for legal reasons), in July 2016 the CCG began a public consultation to help make a decision on whether to re-tender the contract for the GP service or disperse the registered list. The Walk-In-Centre service continues under the new community services contract. North West Surrey CCG Annual Report

53 The consultation ran for 10 weeks during the summer of 2016 and included two public meetings, a number of drop-in sessions and a survey (online and paper) for people to provide feedback. A dedicated address and telephone number were provided, with further information on the CCG s website. The consultation ended on 11 September. On 23 September, our Primary Care Commissioning Committee, after reviewing the options available and taking into account all the feedback including an equality impact assessment, unanimously made the decision to disperse the registered list and to close the GP practice on 31 March The CCG supported patients in re-registering at nearby practices and held a number of registration events over the winter period. Neighbouring GP practices provided copies of their practice leaflets and registration boundary maps which were displayed in the waiting room of the surgery, allowing all patients access to information on how and where to re-register. In March the CCG proactively allocated any remaining vulnerable patients at Ashford Health Centre to their nearest GP practice. Any remaining patients were informed by letter that Ashford Health Centre GP practice was closed and that they were no longer registered with a GP. Any complaints or issues were fed back to the Primary Care Commissioning Committee throughout the whole process to ensure there was oversight of the programme and to address any concerns or problems. Throughout the whole process, the CCG worked closely with Greenbrook Healthcare. Regular weekly contractual and operational meetings and monthly exit meetings took place to ensure a smooth dispersal for all parties. Communication was discussed at all meetings to ensure that patients were kept informed throughout the process. Medicines Optimisation The Medicines Optimisation Team has continued to drive the focus on better use of medicines for patients in North West Surrey. Many of the successes over the past year have been achieved through effective clinical engagement and decision making across the wider health economy. This has been done in collaboration with eight other CCGs in the Prescribing Clinical Network and therefore helps remove the post code lottery. It is vital that the resources available to the NHS are directed towards those interventions that are evidence based and demonstrably improve outcomes for patients. Within medicines optimisation there is a constantly changing evidence base that may require changes to the way that drugs or appliances are North West Surrey CCG Annual Report

54 utilised. Addressing the whole care pathway rather than individual aspects of care linked with a specific disease ensures that high quality, cost effective patient care is delivered. Amongst the successes of 2016/17 are the following highlights: Antibacterial prescribing - antibacterial resistance and antibiotic prescribing are inextricably linked; overuse and incorrect use of antibiotics are major drivers of resistance. This year we have achieved the national target for Quality Premium, maintaining a low volume of antibiotics prescribed and reducing use of those antibiotics that have been associated with resistant strains of bacteria (see previous Quality section). Biologic switching - biologics are a type of medicine derived from living organisms (as opposed to chemical drugs) used to treat a wide range of conditions and are expensive. North West Surrey CCG was one of the first Surrey CCGs to commission and successfully switch all their patients on certain biologics (infliximab and etanercept) to equivalent biosimilar (a copy of an original product which does the same thing), which are 33% cheaper. This has helped us realise around 150k worth of savings, with close working with acute trust clinicians. The savings realised by the acute trust were re-invested into improving its gastroenterology service. QIPP target - through positive engagement with local GPs and secondary care clinicians, we have continued to maintain good financial management of the prescribing budget this year, achieving a 1million saving. Safety reporting - research shows that organisations which regularly report more patient safety incidents usually have a stronger learning culture. By improving reporting we can build the foundations for driving improvement in the safety of care received by our patients. Currently, primary care providers contribute only a fraction of the patient safety incident reports received by the National Reporting and Learning System (NRLS). In 2016/17, we encouraged primary care prescribers to report any safety incidents by the NRLS. Since then the number of incidents reported has risen - nationally, Surrey is now one of the highest recorders of safety incidents. All incidents were anonymised, reviewed regularly and a report with learning points was shared across the CCG, which will lead to improvements in safety. Medicines reconciliation - evidence suggests that the transfer of information regarding medicines between hospitals and primary care is far from optimal, with 10,000 safety incidents relating to discharge being recorded. We have now carried out medicine reconciliation audits in all North West Surrey practices and have taken part in a national audit that will inform a larger piece of improvement work. The learning from the audits will be shared this summer with stakeholders to help improve discharge processes in secondary care and improve medicines reconciliation throughout the healthcare system. North West Surrey CCG Annual Report

55 Listening to our community and working in partnership We continue to work in partnership with the community and our wider partners, listening to, engaging and working proactively with patients, local residents and other stakeholders to help plan and commission the right services that meet the needs and aspirations of local people. Engaging patients and the public As part of our engagement strategy we have established a number of routes to engage patients and local residents. These include: Patient and Public Engagement Forum (PPEF) our over-arching forum for engaging patients and the public. The group meets four times a year and tasks itself with monitoring the CCG s engagement work, holding it to account where necessary and acting as a conduit for patient and public feedback to the CCG, helping to shape commissioning decisions and making recommendations where appropriate to the Governing Body. Forum members include: Representatives from GP practice Patient Participation Groups Representatives from current CCG Patient Advisory Groups which are aligned to specific commissioning activity (e.g. patient transport services, community services) Statutory bodies, including Public Health Agency, Surrey County Council, Surrey Healthwatch Local voluntary and community groups, which aims to include seldom heard demographic groups During the year, the Forum has had the opportunity to discuss issues such as SECAmb 999 performance, the Surrey Heartlands STP, and the West Surrey stroke consultation. The group has also commented on the engagement process for our major procurement programmes such as Community Services, Patient Transport Services and imsk. We have also engaged the group on our RSS communication material and the group is currently reviewing our wider engagement agenda. North West Surrey CCG Annual Report

56 Patient Advisory Groups - the CCG has set up a number of Patient Advisory Groups to ensure robust patient engagement within its major procurement programmes including: Patient Transport Services (PTS) involving service users from the start of the procurement process ensured people felt truly engaged and feedback from the Patient Advisory Group (PAG) has been extremely positive. The PAG was particularly helpful in reviewing the eligibility criteria for patient transport and ensuring it was fit for purpose, in light of concern expressed at the start of the process. Community services a Patient Advisory Group for the community services procurement was set up in March The PAG played an active role with bidders, having both the opportunity to present the patient perspective at one of the market events, and to listen and feedback on presentations from the final two bidders towards the end of the procurement process. MSK (musculoskeletal) the PAG played an active role during the procurement process including attendance at the final presentation session from bidders. The group also gave feedback on the service communication material once the contract had been awarded. NHS 111 a PAG has been set up to support the NHS 111 procurement. Patient and public engagement will play a pivotal role in developing the specification for the new, enhanced NHS111 service, procurement of which will commence over summer Patients will be invited to provide early feedback on both the existing service and the new proposed service model to help develop and influence the final service specification. Patient Participation Groups we continue to support practices to engage patients via their Patient Participation Groups (PPGs) where we can, and endeavour to secure involvement from the PPGs in our range of engagement meetings and events. Responding to feedback from PPG representatives who attended the locality stakeholder meetings (see below); we are now in the process of reviewing how we engage at this local level. Local PPG representatives felt that a dedicated meeting with the CCG on a quarterly basis with agreed speakers was the right approach. We have therefore established a wider PPG group for which we are in the process of agreeing Terms of Reference.. Locality Stakeholder Meetings bringing together patient representatives, GPs, local boroughs, community and voluntary representation in each of our three localities. Following feedback from Patient Participation Group members the CCG is now reviewing how best to engage people at locality level as described above. North West Surrey CCG Annual Report

57 Wider engagement during the year we have continued to attend a variety of community and stakeholder events for example the AGM for the Coalition of Disabled People, local Disability Alliance Network meetings and Valuing People meetings. Our local stakeholders are also engaged in the work of the STP through a Surrey Heartlands wide Stakeholder Reference Group. Informing our community our newsletter Connect is sent out to all local stakeholders on a bi-monthly basis. This is an electronic newsletter to keep people informed about the work of the CCG and offering opportunities to get more involved. How many have we distributed and what has happened as a result Consulting with the public in meeting our statutory obligation to consult on major service changes we ran a 10 week consultation on the future of Ashford Health Centre (see p.52) and are currently in consultation on proposed changes to stroke services across West Surrey (see p.48). Working with local community representatives We continue to work proactively to build and maintain good relationships with a range of patient and community representatives and wider stakeholders, including; Healthwatch Surrey Surrey Wellbeing and Scrutiny Committee MPs and elected representatives Borough and district councils Voluntary sector We continue to work closely with the voluntary sector, with Age UK playing an important role in our Locality Hub programme for example. We have also engaged the voluntary sector widely through a series of engagement events, with strong representation on our Patient and Public Engagement Forum. We have worked proactively with the voluntary sector where appropriate for example with the Stroke Association - throughout the Surrey Stroke Review and subsequent public consultation. Through the Surrey Heartlands STP we are engaging the voluntary sector through a series of stakeholder reference meetings, working in partnership with Surrey Downs and Guildford and Waverley CCGs. North West Surrey CCG Annual Report

58 Partnership Working As leaders of the local health system partnership working is at the heart of how we carry out our business. In addition to our main providers, there are a number of other key relationships in our day to day business. Surrey Health and Wellbeing Board The Surrey Health and Wellbeing Board includes representatives from the NHS, Public Health, adult and children s social care, local councillors, Surrey Police, borough and district councils and Healthwatch Surrey. These organisations work collectively to improve the health and wellbeing of the people of Surrey. The Surrey Health and Wellbeing Board developed the Surrey Joint Health and Wellbeing Strategy in collaboration with Surrey residents, partner organisations and key stakeholders. They agreed a number of key priority areas where the Board will work together, which are reflected in the CCG s overall work programme. These priority areas include: Improving older adults health and wellbeing (through our Frailty programme) Promoting emotional wellbeing and mental health (through our Mental Health and Learning Disabilities programme) Developing a preventative approach (through our Targeted Communities programme, working closely with Public Health) Safeguarding (through our Quality team) The CCG has consulted the Surrey Health and Wellbeing Board on its contribution to the Joint Health and Wellbeing Strategy via a detailed self-assessment table which was discussed with the Board at their March meeting. Working with Public Health The CCG works closely with the Public Health Team at Surrey County Council to target specific communities (see p.49). The Public Health team provides technical expertise to support the CCG s commissioning, including developing the Joint Strategic Needs Assessment and delivering public health intelligence, research and stakeholder engagement. The CCG works jointly with the Public Health Team to deliver health improvement, health protection and healthcare quality and evaluation. The Deputy Director, a consultant in public health, sits on the CCG s Clinical Executive Committee. North West Surrey CCG Annual Report

59 Equality and diversity report We are committed to meeting our duties under the Equality Act 2010 by embedding equality in the contracts for the services that we commission and in the recruitment and development of our people. Our aim is to reduce inequalities in health for local people by meeting the diverse needs of our population and workforce, based on the Joint Strategic Needs Assessment. We want to ensure that no one is placed at a disadvantage due to their protected characteristics. We are committed to providing a consistently high standard of commissioning and recognise that the establishment of a supportive, open culture which ensures equality and values diversity and human rights is essential to achieving this goal. Equality, diversity and human rights are key to the way we commission services and support our staff. During the year we have continued to make progress with the equality objectives that we set ourselves in Objective 1: To understand the health needs of our local people and ensure that services commissioned reference the Joint Strategic Needs Assessment and reduce health inequalities Objective 2: To ensure that equality is at the heart of the commissioning process, ensuring services are commissioned, procured, designed and delivered to meet the health needs of local communities Objective 3: To provide a working environment where staff feel valued and are supported in their training and development needs In June we arranged a whole team training session on equality, diversity and human rights. We have continued to focus this year on ensuring equality analysis is fundamental to all aspects of our work ensuring that equality is business as usual and informs our decision making as a commissioner of services and as an employer. Further equality analysis training workshops have been held to help our staff understand the importance of this and how it supports good decision making. We have continued with regular one to one sessions with programme leads to support this work, and to make sure that equality and diversity, quality of services and patient experience are integral to these programmes of work. We have carried out equality analysis on a number of procurement exercises this year including Patient Transport Services, imsk and Community Services, and also North West Surrey CCG Annual Report

60 the work to review the GP practice at Ashford Health Centre, ensuring extensive engagement and consultation with patients and the public. The Prevention Plan for North West Surrey has been updated by our public health team building on existing equality work to target those communities with the poorest health. Equality analysis has been completed on a number of service changes such as mental health, sexual health and 0-19 services. The Joint Strategic Needs Assessment has been updated and links to the protected characteristic groups which will be included on the intranet site for staff. We have continued to ensure equality analysis is undertaken for new policies and as part of any policy review. The equality and diversity information on our website has been updated to include information about the Accessible Information Standard (AIS) and we have reviewed all information that we send to the public to ensure that people can request information in alternative formats if needed. We will be recording details of all requests for alternative formats. We have also incorporated requirements of the AIS and the Workforce Race Equality Standard into the commissioning and contracting process. On-going monitoring and follow up on non-compliance is managed through the Clinical Quality Review Meetings and 6 monthly Workforce Assurance Review Meetings with providers. Sustainable development North West Surrey CCG is committed to developing its commissioning role to support sustainable development. It recognises the contribution CCGs can make to help shape a more sustainable NHS by: Developing a whole systems approach to commissioning Understanding our role in improving the sustainability of healthcare Using the commissioning cycle to implement the NHS Carbon Reduction strategy. The CCG will work towards a sustainability policy that can also factor in additional priorities to: Set objective sustainability measures and targets for providers in contracts Assess provider sustainability performance at performance management meetings North West Surrey CCG Annual Report

61 Consider providers sustainability credentials as part of the tendering process Maintain oversight of local health system carbon emissions Work with local authorities, providers and health and wellbeing boards to reduce health system carbon emissions. The CCG will monitor the performance of providers who are required by the standard NHS contract to report performance against their carbon reduction management plan. The CCG will also ensure that sustainable procurement is gradually embedded into tender and contract management especially for areas such as energy, waste, water and transport. It will work with partners to develop key performance indicators for sustainable procurement monitoring across the supply chain. This year, as part of the procurement for a new non-emergency patient transport service, there have been many sustainability features outlined within the service specification which will be embedded in the new service from April These are outlined below: The Provider is required to ensure that the service is Green and must take action to reduce the carbon footprint of patient journeys wherever possible for example more efficient planning, not leaving engines running, speed limiters and so on. New vehicles should have the latest/lowest possible CO2 emission rating and the Provider must provide any equipment required to accurately record and measure the service standards for journey times, arrival and collection times, total mileage and other performance measures such as carbon footprint. The Provider must have a sustainability policy which underpins their service design. This will include annual assessment of the carbon emissions associated with the service and a plan to minimise them. In accordance with the NHS and North West Surrey CCG s commitment to promoting carbon reduction initiatives, the Provider should specify, where possible, that vehicles use current technologies such as low-emission models, hybrid vehicles, electric vehicles, automatic stop/start, speed limiters, leanburn engines, green-optimised models and LPG dual fuel to assist in the reduction of the carbon footprint of the service. In order to support the above, we have also strengthened this requirement within the quality targets set for the new contract and the Provider is required to report their levels of alternatively fuelled vehicles. North West Surrey CCG Annual Report

62 4. Accountability Report Corporate Governance Report Members Report Introduction The member practices CCG member practices are detailed in the table below. The Council of Members consists of a lead GP from each of the member practices and meets quarterly. The Council of Members has the highest level of authority within the CCG and holds the Governing Body to account both for adherence to the CCG s constitution and for progress against objectives. Member practices and representatives as at March 2017: Practice Representative Knowle Green Medical Dr Vineet Thapar M Shepperton Medical Practice Dr Joanne Turvey F Staines Health Group Dr Zoe Griffiths F Stanwell Road Surgery Dr Diljit Bhatia M Staines and Thameside Medical Dr Seda Boghossian-Tighe F Orchard Surgery Dr Andeep Kaur F Studholme Medical Practice Dr Gillian McFarlane F The Grove Medical Centre Dr Peter Warwicker M Hythe Medical Centre Dr Mobin Salahuddin M St David's Health Centre Dr Paul Sodhi M Fordbridge Medical Practice Dr Sharzhad Ghaderi M Upper Halliford Medical Centre Dr George Kamil M North West Surrey CCG Annual Report

63 St John s Health Centre Dr Ulla Anderson F Madeira Medical Dr Sundeep Soin M Goldsworth Park Medical Centre Dr Chrissie Clayton F Parishes Bridge Practice Dr Joanne Horgan F Hillview Medical Practice Dr Deborah Shiel F Pirbright Surgery Dr Alexandra Henderson F Heathcot Medical Practice Dr Linda Roberts F Maybury Surgery Dr Nazura Khan F College Road Surgery Dr Ash Kapoor M Southview Surgery Dr Caroline Baker F Greenfields Surgery Dr Ulla Anderson F Wey Family Practice Dr Natalie Jesshop F Chobham and West End Practice Dr Vanessa Preece F Sunny Meed Surgery Dr Sarah Gil Rivas F Sheerwater Health Centre Dr Munira Mohamed F Walton Health Centre - Red Practice Dr Helen Tilly F Hersham Surgery Dr Asha Pillai F Church Street Practice Dr Graeme Wilding M The Bridge Practice Dr Christine Canty F Ashford Health Centre (closed 31 March 2017) Dr Rebecca Gaster F Sunbury Health Centre Dr Neeta Bilagi F The Abbey Practice Dr Khalid Wyne M Rowan Tree Practice Dr Sarah Scott F Ottershaw Surgery Dr Andrew Harris M Walton Health Centre - Yellow Practice Dr Saba Khan F Packers Dr Sahar Hassan M Fort House Practice Dr Timothy Bates M Crouch Oak Practice Dr Mohan Kanagasundaram M North West Surrey CCG Annual Report

64 Ashley Medical Practice Dr Layth Delaimy M Walton Health Centre - White Practice Dr Samy Morcos M The Chair, Chief Executive and Directors The names of the Chair, Chief Executive and Executive Directors are identified below. Name Position Dr Charlotte Canniff Chair F Julia Ross Chief Executive F Jonathan Molyneux Mark Baker Anthony Shipley Steven Emerton Sumona Chatterjee Interim Director of Finance from (from 22 February 2016 to 29 July 2016) Director of Finance (from 1 August 2016) Acting Director of Corporate Development and Assurance (from 1 June 2016; previously Acting Director of Corporate Development and Assurance) Director of Strategic Commissioning (to 8 July 2016) Acting Director of Strategic Commissioning (from 11 July 2016) Director of Commissioning (from 10 February 2017) M M M M F Clare Stone Chief Nurse F Karen Thorburn Director of System Redesign (from 1 June 2016, previously Director of Quality and System Redesign) F North West Surrey CCG Annual Report

65 The Governing Body The Governing Body is the main strategic decision making body of the CCG. The Members delegate authority to the Governing Body to provide leadership and direction for the organisation. Voting members comprise: nine locality leads, the Chair, Chief Executive and Director of Finance, and four independent members (two lay members, a registered nurse and a secondary care doctor). Individuals were members of the Governing Body for the full year 2016/17 unless otherwise indicated. Organisation/role Member Clinical Members Clinical Chair of Governing Body Dr Charlotte Canniff F SASSE Locality Lead Dr Diljit Bhatia M SASSE Locality Clinical Director and Chair of Clinical Executive Dr Jagjit Rai M SASSE Locality Lead Dr Arrthy Ramachandran (to 3 October 2016) F Clinical Chief of Innovation and Quality Dr Richard Barnett M Thames Medical Locality Lead Dr Layth Delaimy M Thames Medical Locality Clinical Director Dr Asha Pillai F Woking Locality Lead Dr Alexandra Henderson F Woking Locality Clinical Director and Clinical Chief of Contracts & Performance Dr Deborah Shiel F Woking Locality Lead Dr Christine Clayton F Executive Members Chief Executive Julia Ross F North West Surrey CCG Annual Report

66 Director of Finance Jonathan Molyneux (interim from 22 February 2016 to 29 July 2016) Mark Baker (substantive from 1 August 2016) M M Independent Members Independent Member (Governance) Paul Hopper M Independent Member (Patient and Public Engagement) William McKee M Registered Nurse (Clinical Member) Sally Bassett (to 21 July 2016) Julia Dutchman-Bailey (from 22 August 2016) F F Secondary Care Specialist Doctor (Clinical Member) Non-Voting Members Dr Naila Kamal F Steve McCarthy PPE Forum Representative M Anthony Shipley Steven Emerton Sumona Chatterjee Karen Thorburn Director of Corporate Development and Assurance (from 1 June 2016; previously Acting Director of Corporate Development and Assurance) Director of Strategic Commissioning (to 8 July 2016) Director of Commissioning (from 10 February 2017; previously Acting Director of Strategic Commissioning from 11 July 2016) Director of System Redesign (from 1 June 2016; previously Director of Quality and System Redesign) M M F F Clare Stone Chief Nurse F Please see the Remuneration Report pages164 to170 for profiles of the CCG s Governing Body. North West Surrey CCG Annual Report

67 Gender distribution The gender distribution for North West Surrey CCG is as follows: Body Females Males Council of Members Governing Body (including non-voting) 11 9 Audit and Risk Committee Further information about the Audit and Risk Committee and its work during the course of the year is provided in the Governance Statement. The committee consists of independent members of the Governing Body: Lay member (governance): Lay member: Paul Hopper William McKee Independent Registered Nurse Sally Bassett (to 21 July 2016) Julia Dutchman-Bailey (from 22 August 2016) Independent Secondary Care Doctor: Dr Naila Kamal In addition, the Director of Finance and the Director of Corporate Development and Assurance were in attendance at the committee. The Clinical Chair and the Chief Executive attended as required. Register of Interests NHS England issued proposals for consultation during 2016 relating to Standards of Business Conduct and Conflicts of Interest Policy, including Receipt of Gifts, Hospitality and Inducements/Commercial Sponsorship and Joint Working with the Pharmaceuticals Industry. The Governing Body and the Primary Care Commissioning Committee received reports summarising the requirements of the new guidance. The Governing Body also considered issues arising from the new guidance at a seminar held on 22 August The Audit and Risk Committee considered in September 2016 and agreed the approach to the publication of the staff register at Band 8A and above. North West Surrey CCG Annual Report

68 The report submitted to the Governing Body summarised the current position in respect of implementing NHS England guidance on conflicts of interest, and provided a draft policy for discussion and comment. The draft policy has been circulated for further comments and will then be finalised for agreement at the April meeting of the Governing Body. Once finalised the Register of Interests for voting and non-voting members of the Governing Body will be available to be seen at: In the meantime, the register is included with each set of Governing Body papers. Personal Data Related Incidents There have been no personal data incidents reported to the Information Commissioner s office. Directors Statement Each Governing Body Member knows of no information which would be relevant to the auditors for the purposes of their audit report, and of which the auditors are not aware, and has taken all the steps that he or she ought to have taken to make himself or herself aware of any such information and to establish that the auditors are aware of it. North West Surrey CCG Annual Report

69 Statement of Accountable Officer s responsibilities The National Health Service Act 2006 (as amended) states that each Clinical Commissioning Group shall have an Accountable Officer and that Officer shall be appointed by the NHS Commissioning Board (NHS England). NHS England has appointed the Chief Executive to be the Accountable Officer of the Clinical Commissioning Group. The responsibilities of an Accountable Officer, include responsibilities for the propriety and regularity of the public finances for which the Accountable Officer is answerable, keeping proper accounting records (which disclose with reasonable accuracy at any time the financial position of the Clinical Commissioning Group and enable them to ensure that the accounts comply with the requirements of the Accounts Direction) and safeguarding the Clinical Commissioning Group s assets (and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities). These responsibilities are set out in the Clinical Commissioning Group Accountable Officer Appointment Letter. Under the National Health Service Act 2006 (as amended), NHS England has directed each Clinical Commissioning Group to prepare for each financial year financial statements in the form and on the basis set out in the Accounts Direction. The financial statements are prepared on an accruals basis and must give a true and fair view of the state of affairs of the Clinical Commissioning Group and of its net expenditure, changes in taxpayers equity and cash flows for the financial year. In preparing the financial statements, the Accountable Officer is required to comply with the requirements of the Group Accounting Manual issued by the Department of Health and in particular to: Observe the Accounts Direction issued by NHS England, including the relevant accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis Make judgements and estimates on a reasonable basis State whether applicable accounting standards, as set out in the Group Accounting Manual, issued by the Department of Health have been followed, and disclose and explain any material departures in the financial statements Prepare the financial statements on a going concern basis. North West Surrey CCG Annual Report

70 As the Accountable Officer, I know of no information additional to that contained in this report which would be relevant to the auditors for the purposes of their report, and of which the auditors are not aware, and have taken all the steps that I should have taken to make myself aware of any such information and to establish that the auditors are aware of it. I confirm that the Annual Report and Accounts as a whole are fair balanced and understandable, and that I take personal responsibility for the Annual Report and Accounts and the judgements required for determining that it is fair, balanced and reasonable. To the best of my knowledge and belief, I have properly discharged the responsibilities set out in my Clinical Commissioning Group Accountable Officer Appointment Letter. Signed: Karen Thorburn Acting Chief Executive Date North West Surrey CCG Annual Report

71 Annual Governance Statement Introduction and context North West Surrey CCG (CCG) was licensed from 1 April 2013 under provisions enacted in the Health and Social Care Act 2012, which amended the National Health Service Act The licence was granted by NHS England. The CCG received its formal Authorisation (without any restrictions or covenants) on 23 January 2013 from NHS England and on 1 April 2013, the CCG was licensed without conditions. As at 1 April 2015, the clinical commissioning group was licensed without conditions. During 2015/16 the CCG has operated as a legal entity under the terms of its licence and legal and regulatory framework and has continued to exercise its statutory duties and ensure that key internal controls were in place. North West Surrey CCG is a membership organisation of GP practices who from 1 April 2013 inherited a range of functions, duties and responsibilities from the former NHS Surrey Primary Care Trust. The CCG is clinically led with a GP majority membership on the Governing Body. The CCG commissions services for the population in North West Surrey. Services commissioned include acute services from acute NHS Trusts, mental health services, and community services from a range of NHS providers and other providers. Services commissioned include: Acute services Ambulance services Community services Mental health and learning disability services Children s services and children and adolescent mental health services The CCG also works in collaboration with neighbouring CCGs, and with Surrey County Council in the commissioning of some of these services. Scope of responsibility As Accounting Officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of the clinical commissioning group s policies, aims and objectives, whilst safeguarding the public funds and assets for North West Surrey CCG Annual Report

72 which I am personally responsible, in accordance with the responsibilities assigned to me in Managing Public Money. I also acknowledge my responsibilities as set out in my Clinical Commissioning Group Accountable Officer Appointment Letter. 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. Compliance with the UK Corporate Governance Code Whilst the detailed provisions of the UK Corporate Governance Code are not mandatory for public sector bodies, compliance is considered to be good practice. This Governance Statement is intended to demonstrate the CCG s compliance with the principles set out in the Code. The UK Corporate Governance Code sets out principles for leadership, effectiveness, accountability, remuneration and relations with shareholders. The performance and accountability sections of this report set out the arrangements put in place to ensure the effective governance and management of the organisation. It notes that the performance of the CCG has been rated as good by NHS England. The accountability principles require the board to present a fair, balanced and understandable assessment of the organisation s prospects. This is represented by this annual report. The principles also refer to establishing formal and transparent arrangements for corporate reporting, risk management and internal control. These arrangements are all set out in the risk management section of the report, which highlight key risks to the organisation and concludes with the Head of Internal Audit opinion and a level of assurance of significant with minor improvement opportunities for the organisation. The remuneration report satisfies the requirements of NHS England. Relations with stakeholders in the sense of member practices are set out in the members report. The sections in this report on Listening to our Community and Partnership Working set out the CCGs work in engaging with partner organisations and the wider community. For the financial year ended 31 March 2017, and up to the date of signing this statement, we complied with the provisions set out in the Code, and applied the principles of the Code except as follows: The requirement for re-election of Directors at regular intervals (in the CCG context the re-election of directors by shareholders does not apply); and For Executive Directors pay to be aligned to underlying CCG performance (As noted in the remuneration report, directors and senior managers pay set by the very senior managers framework consists of three elements: basic pay, additional payments and an annual performance bonus scheme. As at 31 March 2017 entitlement to this payment for had yet to be determined). North West Surrey CCG Annual Report

73 The Clinical Commissioning Group Governance Framework The National Health Service Act 2006 (as amended), at paragraph 14L(2)(b) states: The main function of the governing body is to ensure that the group has made appropriate arrangements for ensuring that it complies with such generally accepted principles of good governance as are relevant to it. The governance framework of the CCG is illustrated below, and further information about how this structure functions and has performed during the year is provide in the following sections. North West Surrey CCG Annual Report

74 Council of Members The Council of Members approved the CCG s governance model. It also approved the overall strategic direction of the CCG, its Constitution and mission. The Governing Body provides assurance to the Council of Members that the CCG s objectives are being achieved and that it meets its statutory and legal obligations. The Council of Members holds the Governing Body to account via the Clinical Chair for delivery and for ensuring the CCG is clinically led and effectively engages with its members. It also receives an annual report of the Governing Body s effectiveness. The Governing Body The Governing Body has responsibility for: The Governing Body consists of: The Clinical Chair (who is always a local GP) Ten Locality Leads (who are currently GPs but may be other Healthcare Professionals) two of which are currently vacant North West Surrey CCG Annual Report

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