Governing Body Agenda. Thursday 13 July 2017, 10:30-13:00 Riverside Centre, The Quay, Newport, Isle of Wight PO30 2QR

Transcription

1 Governing Body Agenda Thursday 13 July 2017, 10:30-13:00 Riverside Centre, The Quay, Newport, Isle of Wight PO30 2QR

2 Governing Body AGENDA Thursday 13 July 2017, 10:30-13:00 Riverside Centre, The Quay, Newport, Isle of Wight PO30 2QR Apologies for absence: Melanie Rogers ML 10: Declaration of Interests ML GB Confirmation that the Meeting is Quorate ML 2. Minutes of the last Governing Body Meeting 25 May 2017 ML GB Matters Arising from the Minutes 3.1 Schedule of Actions from the 25 May 2017 ML GB :35 4. Chair / Chief Officer Report HS/ML Verbal 10:40 5. Items for Assurance /Approval 5.1 Performance Report Performance Quality Commissioning LO LO LK CM GB : Finance Report LO GB : Annual Report and Accounts HS GB : Governing Body Assurance Framework HS GB : Risk Register Summary HS GB : Better Care Fund (BCF) GB GB : IFR Highlight Report HS GB : Local Delivery System Report HS GB : Day Working Update HS GB : Summary and Action Plan HS GB :35 6. Minutes to Receive 6.1 Clinical Executive Minutes June 2017 HS GB : Quality and Patient Safety Committee Minutes May 2017 IR GB Audit Committee Minutes May 2017 MD GB Any Other Urgent Business ML 12:55

3 8. Motion to exclude the Press and Public that representatives of the press, and other members of the public, be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest, (Section 1 (2), Public Bodies (Admission to Meetings) Act I960) ML 13:00 9. Date of Next Meeting Thursday 7 July 2017, 10:30 to 13:00hrs, Northwood House, Ward Avenue, Cowes, Isle of Wight, PO31 8AZ Circulation: Members In attendance: For Information (Agenda): Gillian Baker Deputy Chief Officer Martyn Davies Governing Body Lay Member Governance (Deputy Chair) Dr Michele Legg CCG Chair Loretta Outhwaite Chief Finance Officer Dr Ian Reckless Secondary Care Doctor Melanie Rogers Director of Quality and Clinical Services Helen Shields Chief Officer Laurence Taylor Governing Body Lay Member- Independent Carole Truman Governing Body Lay Member Patient and Public Involvement Lindsay Voss Governing Body Nurse Dr Timothy Whelan Clinical Executive Caroline Morris, Assistant Director of Primary Care and Corporate Business Rebecca Berryman, Governance Support Officer (Minutes) Invited: For Information (Minutes): Cath Love, Acting Head of Quality Linda Rann, Sue Lightfoot, Eleanor Roddick - Heads of Commissioning, Tracy Savage, Assistant Director of Medicines Management, Rebecca Wastall Deputy Chief Finance Officer Phil Hartwell, Head of Corporate Governance Andrew Heyes, Head of Performance and Contracting Lucy Long, Information Governance Manager

4 Governing Body Declaration of Governing Body Members Interests Sponsor: Summary of issue: Helen Shields, Chief Officer This paper sets out the relevant and material interests of the members of the CCG Governing Body. It represents the Register of Interests as required by the Standing Orders in accordance with the NHS Code of Accountability. This paper supports the CCG Governing Body to fulfil its Standing Orders in accordance with the NHS Code of Accountability. The CCG Governing Body is being asked: Action required / recommendation: Principle risk(s) relating to this paper: Other committees where this has been considered: Financial / resource implications: Legal implications / impact: Public involvement /action taken: Equality and diversity impact: Author of Paper: To receive and note the register of interests of members and ensure that members play no part in discussion or decision where a conflict of interest is established. To receive any oral updates on the interests of members. There are no risks relating to this paper. This paper has not been considered at any other committee. There are no financial or resource implications arising from this paper. There are no legal implications arising from this paper. There has been no public involvement or action taken. This paper does not request decisions that impact on equality and diversity Rebecca Berryman, Governance Support Officer Date of Paper: April 2017 Date of Meeting: 13 July 017 Agenda Item: 1.2 Paper number: GB

5 Declaration of Interest 1. Introduction 1.1 The NHS Code of Accountability requires the Governing Body to declare interests which are relevant and material to the Governing Body of which they are a member. 1.2 Interests which should be regarded as relevant and material are: Directorships, including non-executive directorships held in private companies or PLCs (with the exception of those of dormant companies); Ownership or part-ownership of private companies, businesses or consultancies likely or possibly seeking to do business with the NHS; Majority or controlling share-holdings in organisations likely or possible seeking to do business with the NHS; A position of authority in a charity or voluntary organisation in the field of health or social care; Any connection with a voluntary or other organisation contracting for NHS services; Research funding/grants that be received by an individual or their department; Interests in pooled funds that are under separate management (any relevant company included in this fund that has a potential relationship with the CCG must be declared); 1.3 Any Governing Body Member who comes to know that the CCG Governing Body has entered into or proposed to enter into a contract in which he/she or any person connected with him/her (as defined in the Standing Orders) has any pecuniary interest, direct or indirect, the Governing Body member shall declare his/her interest by giving notice in writing of such fact to the CCG Governing Body as soon as practicable. 1.4 The Chief Officer will ensure that a Register of Interests is established to record formally declarations of interests of Governing Body Members. Interests will be declared at Governing Body meetings to ensure they are known to the public. 2

6 2. Register of Interests Name Gillian BAKER Deputy Chief Officer Martyn DAVIES Governing Body Lay Member Governance (Deputy Chair) Michele Legg Chair Relevant and Material Interests Gillian s has no interests to declare. Last Updated/Noted: July 2016 Martyn has no declarations of interests. Last Updated/Noted: November 2016 Michele is: GP Partner at Tower House Surgery. Commercial partnership Island Clinical Academic services. School Governor of Ryde School. President of IOW Osteoporosis society. Michele s partner is a GP on the Isle of Wight Caroline MORRIS Assistant Director of Primary Care and Corporate Business Loretta OUTHWAITE Chief Finance Officer All GP Practices will potentially be receiving funding through My Life A Full Life. Last Updated / Noted: February 2017 Caroline is: Parent Governor of Christ the King College. Last Updated/Noted: June 2016 Loretta: has a Directorship at the Island Free School (This is the Island Community School (Companies House Registration)) is Governor The Island Free School; Director; retrospectively registered to 22 July 2015; Dr Ian RECKLESS Secondary Care Doctor she has no financial interest, this is on a voluntary basis. Last Updated / Noted: March 2017 Ian is: Employed as Medical Director and Consultant Physician by Milton Keynes University Hospital NHS Foundation Trust. He is Honorary Consultant Stroke Physician at Oxford University Hospitals NHS Foundation Trust and Honorary Senior Clinical Lecturer, Oxford University. Ian undertakes ad hoc work with the Care Quality Commission and the Parliamentary and Health Service Ombudsman. He receives occasional royalties from Oxford University Press and Blackwell-Wiley in respect of 3

7 Melanie ROGERS Director of Quality and Clinical Services Helen SHIELDS Chief Officer Laurence TAYLOR Governing Body Lay Member Carole TRUMAN Governing Body Lay Member Patient and Public Involvement Lindsay VOSS Governing Body Nurse prior publications. Last Updated / Noted: October 2016 Melanie is: A CQC Specialist Advisor Last Updated /Noted: April 2017 Helen s husband is Head of Podiatry and MPTT at IOW NHS Trust. Last Updated / Noted: February 2017 Laurence is: Director of Bembridge Airport Ltd and Bembridge Farm Ltd. He is employed by EU & FT Taylor Ltd Last Updated /Noted: February 2017 Carole has no declaration of interests. Last Updated / Noted: May 2017 Lindsay is: Lay member for National Catholic Safeguarding Commission Lindsay s husband is employed in Pharmaceutical industry (Eli Lilly and Company) Dr Timothy Whelan Deputy Clinical Chair Lindsay is commissioned by NHS England (Wessex) to undertake project work relating to Safeguarding children and adults. Last Updated / Noted: February 2017 Timothy is: A GP Partner at The Dower House Surgery with ownership of land or rental property (accommodation used by the CCG) of The Dower House Surgery, 27 Pyle Street, Newport, Isle of Wight, PO30 1JW RCGP Regional Ambassador for Hampshire and the Isle of Wight (average 1 or 2 sessions per month since July 2016). Timothy holds nominal 1 Shares with Lighthouse Medical Timothy works occasional (2/month) shifts at the Urgent Care Services, St Marys Hospital (OOH GP Service) All GP Practices will potentially be receiving funding through My Life A Full Life. Last Updated / Noted: March

8 Governing Body Minutes of the Governing Body 25 May 2017 Sponsor: Helen Shields, Chief Officer Summary of issue: Minutes of the previous Governing Body Meeting held on 25 May Action required/ recommendation: To approve the minutes of the Governing Body 25 May Principle risks: Other committees where this has been considered: Financial /resource implications: Legal implications/ impact: Public involvement /action taken: Equality and diversity impact: There are no risks relating to this paper. This paper has not been considered at any other committees. There are no financial or resource implications. These minutes form a formal public record of the previous meeting. The Governing Body was held in public. There is no equality and diversity impact relating to this paper. Author of paper: Rebecca Berryman, Governance Support Officer Date of Paper: 26 May 2017 Date of Meeting: 13 July 2017 Agenda Item: 3 Paper number: GB Page 1 of 10

9 NHS Isle of Wight Clinical Commissioning Group: Governing Body Minutes of Part 1 of the CCG Governing Body held on Thursday 25 May 2017 at 10:30 hrs Northwood House, Ward Avenue, Cowes, Isle of Wight PO31 8AZ. PRESENT: IN ATTENDANCE: MINUTED BY: Gillian Baker (GB) Deputy Chief Officer Martyn Davies (MD) Governing Body Lay Member Governance Dr Michele Legg (ML) CCG Chair Loretta Outhwaite (LO) Chief Finance Officer Ian Reckless (IR) Secondary Care Doctor Melanie Rogers (MR) Director of Quality, Safeguarding and Clinical Services Helen Shields (HS) Chief Officer Laurence Taylor (LT) Governing Body Lay Member- Independent Lindsay Voss (LV) Governing Body Nurse Dr Timothy Whelan (TW) Deputy Clinical Chair Andy Heyes (AH) Head of Performance and Contracting Caroline Morris (CM) Assistant Director of Primary Care and Corporate Business Tracy Savage (TS) Associate Director of Medicines Management Rebecca Berryman (RB) Governance Support Officer 1. Apologies for Absence Apologies for absence were received from Carole Truman, Lay Member PPI. 1.1 Declarations of Interest The Governing Body received and noted paper GB Declaration of Interests. The were no new declarations made or any declarations made in relation to any of the agenda items. The Governing Body noted the Declaration of Interest. 1.2 Confirmation the Meeting is Quorate Confirmed. 2. Minutes of the Last Governing Body Meeting 30 March The Governing Body received paper GB Minutes of the last Governing Body Meeting 30 March The minutes were approved as a true and accurate record. The Governing Body approved the Governing Body Minutes of the 30 March Schedule of Actions The Governing Body received and noted paper GB Schedule of Actions from 30 March 201.The following actions were discussed: WISR Document Figures Action closed, it was agreed that this would be taken forward with the proposals relating to the Acute Services Review. Page 2 of 10

10 Rehabilitation Consultation Action closed, the Clinical Executive as delegated by the Governing Body agreed to The Clinical Executive approved option 4 for the CCG to undertake a separate community rehabilitation beds tender and work collaboratively with the Isle of Wight NHS Trust (IOWNHST) to implement the community rehabilitation teams. The Governing Body received the Schedule of Actions. 4. Chair / Chief Officer Report The Governing Body received a verbal Chair/Chief Officer Report from HS/ML. Chair ML thanked the CCG for giving her a warm welcome, specifically the Senior Team, Liz Elliott, and RB for their support. She also welcomed Dr Timothy Whelan, Deputy Clinical Chair to the Governing Body. It was noted that Carole Truman is the new Lay Member for Patient and Public Involvement; however she sent her apologies to this meeting. As a result of Purdah the Annual Report and Accounts are not able to be discussed in part I of the Governing Body. They would be approved in part II of the meeting and published after the General Election on 10 June Chief Officer HS informed the Governing Body that the Clinical Executive had reviewed the Clinical Funding Authorisation Policy, specifically in relation to the appeals panel. The appeals panel has been amended to consist of 3 members and will include a Governing Body and a Clinical Executive member. The Clinical Executive recommended this for approval to the Governing Body. IR queried where the visibility of the IFR process was. It was confirmed an Annual Report is presented to the Clinical Executive. It was agreed that a highlight report would be presented at the next Governing Body meeting. HS highlighted that she and ML had attended an Isle of Wight Scenario planning meeting with the STP. This meeting was to discuss and understand the challenges facing the Isle of Wight and how mainland providers can help support the future of services on the Island. Paul Sly has been appointed as the System Director to support the development of the Single Plan between the CCG, IOWNHST and Local Authority. The Governing Body noted the Chair / Chief Officer Report. The Governing Body approved the IFR Policy and Appeals Panel. ACTION: IFR highlight report to be presented to the July 2017 Governing Body meeting. HS 5. Items for Approval Page 3 of 10

11 5.1 Annual Report and Accounts To be discussed in part II as a result of Purdah. 5.2 External Audit Report To be discussed in part II as a result of Purdah. 5.3 Governing Body Assurance Framework Objectives and Critical Success Factors The Governing Body received paper GB Governing Body Assurance Framework, presented by CM. The Governing Body Assurance Framework (GBAF) identifies the organisation s annual objectives and identifies key risks. The Governing Body were asked to discuss the risks and critical success factors (CSF), amend and approve the contents of the paper. The following discussion took place: GB felt that in relation to Objective 1, CSF 1 to add ensuring delivery of all plans the CCG has agreed to take a lead in. She also felt that there should be an additional CSF under Objective 1 that relates to improving outcomes within the CCG Assurance Framework. This was agreed but felt it should sit under Objective 3 in relation to Quality. It was agreed that a separate bullet point for Objective 1 should state to complete the Acute Services Redesign. TW suggested the Objective 1 should articulate who the CCG is co-producing with. It was discussed and agreed that Objective 2 should include reference to the CCG working with the National Team in relation to the CCG funding formula for 2019/20. With regard to Objective 3, it was felt that the specifics of what needed to be delivered in terms of quality should be highlighted. Discussion took place regarding the engagement of stakeholders and CCG staff. GB commented that the CCG had engaged more than ever in the past year. The difficulty relates to how the CCG is identified when working in a more integrated way. The Governing Body approved the Governing Body Assurance Framework subject to the above ammendments and considerations. 5.4 Weight Management The Governing Body received paper GB Weight Management, presented by GB. The Clinical Executive recommended to the Governing Body on the 20 th April 2017 that the Individual Funding Request activity in relation to weight management to be monitored for 6 months and amend the policy statement if this was considered necessary. It was noted that the CCG adheres to the current policy, but this relates to exceptionalities. The CCG needs to understand the exceptions in order to establish whether the policy statement needs to change. Page 4 of 10

12 It was highlighted that the Equality and Diversity section on the front sheet of the paper is misleading as it implies that the policy is different from the Island when it is the same as the rest of Hampshire. The Governing Body approved for the IFR activity relating to tier 3 and 4 weight management treatment to be monitored for 6 months and an amended policy statement be considered if necessary. 5.5 High Cost Drugs Policy The Governing Body received paper GB High Cost Drugs policy presented by TS. The Clinical Executive recommended this policy for approval to the Governing Body on the 18 May There is a significant spend against the primary care drugs bill on medicines that should not be transferred to GPs and should remain the responsibility of the Secondary Care Consultant. The policy provides clarity over where prescribing responsibility and associated costs should remain. It was confirmed the policy will be implemented via support given by the Medicines Management Team via Script Switch and Newsletters. LT asked for clarity with regard to the high cost limit. It was confirmed to be ML commented that this was a welcome policy. The Governing Body approved the High Cost Drugs Policy and Process. 5.6 Working with Industry Policy The Governing Body received paper GB Working with Industry Policy, presented by TS. The Audit Committee recommended this policy for approval to the Governing Body on the 24 May IR commented that it was a welcome policy. It was noted there has been an increase in the number of pharmaceutical companies offering rebates on drugs used in primary care. The CCG has a duty to ensure all involvement with the pharmaceutical industry is transparent, ethical and exists only to improve the quality of patient care. The policy has been reviewed by the Local Counter Fraud Specialist and is in line with the work plan of the STP. The policy clearly outlines the authority and processes required when considering engagement with the pharmaceutical industry. The only scheme the CCG would engage in would be a price discount, where the CCG would control the billing for discounts and robust mechanisms with the finance team are in place for this. The Governing Body approved the Working with Industry Policy. Page 5 of 10

13 5.7 Drugs of Limited Clinical Value The Governing Body reviewed paper GB Drugs of Limited Clinical Value, presented by TS. The Clinical Executive recommended this policy for approval at the Governing Body on the 18 th May Prescribing of Drugs of Limited Clinical Value (DoLCV) place an increased financial burden on CCG resources. In common with other primary care organisations, the CCG is proposing an inclusive approach to decision making about drugs and preparations that are not suitable to be prescribed at NHS expense. The policy proposes a framework for decision making that approaches the issue in a fair and transparent way via the Primary Care Prescribing Committee. It was noted that this policy is in line with the STP falling under the Medicines Optimisation Workstream. IR queried whether there was a shared formulary with the IOWNHST. It was confirmed that there is, however this is not always effective. In addition not all prescriptions come from the IOWNHST. TS highlighted the policy offers support to GPs who can explain to patients why some drugs are not prescribed. The Governing Body approved Drugs of Limited Clinical Value. 6. Care Quality Commission (CQC) Inspection Report The Governing Body received paper GB CQC Inspection Report, presented by MR. The paper was taken as read. MR informed the Governing Body that the CCG Quality Team were undertaking a Gap Analysis in terms of the CCG s assurance. The Gap Analysis will be presented to the Quality and Patient Safety Committee. The Governing Body noted the CQC presentation Cyber Attack The Governing Body a verbal update from LO on the recent Cyber Attack. LO confirmed that the CCG and IOWNHST has not been affected by the Cyber Attack on the 12 May 2017, but that 4 out of 16 (25%) GP Practices on the Island were affected. There are a number of lessons to be learnt from the attack, particularly with regard to staff education and ensuring equipment is updated. MD informed the Governing Body that the Audit Committee had discussed Cyber Security with the IT Team at the Trust and had gained assurance from them that the correct systems and processes were in place and being reviewed and strengthened where necessary. It was noted however there is some concern regarding IT in Primary Care, steps are in place with the Commissioning Support Unit (CSU), however the Audit Committee will be following this up. LO also highlighted that the CCG has an IT Specialist working 2 days a week to ensure Page 6 of 10

14 plans are in place. The Governing Body noted the Cyber Attack Update. 8. Items for Assurance 8.1 Performance Report The Governing Body received paper GB Performance Report, presented by AH, GB and MR. The report highlighted the following: Performance A&E 4 Hour Waits - ended the year at 85.41% against a national target of 95% 12 Hour Trolley Waits -68 were reported for 16/17 compared with 46 for 15/16 Readmission rates have increased compared to the same 6 months last year Ambulance Targets the 3 ambulance call out targets continued to fail throughout the year 111 c94% calls answered in 60 seconds against 95% target. 18 week RTT target ended the year at just below 88% against the national target of 92% Cancer 62 day urgent referral to treatment target was c82% overall Diagnostics remains above the constitutional target of 99% Quality Serious Incidents Requiring Investigation (SIRIs) although there were no SIRIs for April 2017, there have been 8 SIRIs reported in the past month, there are no specific themes. MR highlighted concern regarding the quality of SIRI reports and as a result the learning that is achieved from the SIRIs. The CCG have offered to help support the IOWNHST with this process. Mixed Sex Accommodation reports will now be received in relation to the number of ICU Mixed Sex Accommodation breaches. Looked After Children Reviews are not being completed in a timely manner. This has been raised at the Safeguarding Children s Board. This has also been discussed at the Quality and Patient Safety Committee. Commissioning The Clinical Executive have considered options with regard to Shackleton Ward at the IOWNHST. A decision was not made as further options have now been proposed by the Trust. Urgent Care Service there is still concern regarding Out of Hours Service, particularly in filling the GP rotas. Options are being considered for this service. Acute Services Redesign is currently at the end of the phase reviewing individual specialities. There is some challenges regarding the engagement of mainland partners. The costing still need to be worked through for the options but this is challenging due to the cost base review still not being complete. Learning Disabilities the action plan is nearing completion. The Governing Body noted the Performance Report. Page 7 of 10

15 8.2 Finance Report The Governing Body received and noted paper GB Finance Report, presented by LO. The report highlighted the following (subject to final audit): The CCG met its statutory financial targets for 2016/17 and spend stayed within the running cost allocation. The CCG was required to hold a 1% reserve uncommitted from the start of the year. This was intended to be release for investment in the Five Year Forward View transformation priorities, however this did not materialise. However the national position across the provider sector has been such that NHS England has been unable to allow CCG s 1% non-recurrent monies to be spent. Therefore to comply with this requirement, the CCG has released its 1% reserve to the bottom line resulting in an additional surplus of 2.2.m. The CCG has to make significant savings of 12.9m for 2017/18. The Governing Body expressed their thanks to the finance team for all their hard work over the year. The Governing Body noted the Finance Report. 9. Minutes to Receive 9.1 Clinical Executive Minutes 20 April The Governing Body received and noted paper GB Clinical Executive Minutes 20 April The Governing Body received the Clinical Executive Minutes. 9.2 Quality and Patient Safety Committee Minutes 23 March The Governing Body received and noted paper GB Quality and Patient Safety Committee Minutes 23 March IR highlighted that NHS England had observed the meeting, the feedback received was regarding the lack of Primary Care quality data and information. The Governing Body received the Quality and Patient Safety Committee Minutes. 9.3 Audit Committee Minutes 23 March The Governing Body received and noted paper GB Audit Committee Minutes 23 March The Governing Body received the Audit Committee minutes. 10. Any Other Urgent Business There was no any other urgent business. 11. Motion to exclude the Press and Public. Page 8 of 10

16 MR read the following statement: that representatives of the press, and other members of the public, be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest, (Section 1 (2), Public Bodies (Admission to Meetings) 12. Date of Next Meeting: Thursday 13 July 2017, Riverside Centre, The Quay, Newport, Isle of Wight Page 9 of 10

17 Circulation: Members In attendance: For Information (Agenda): Gillian Baker Deputy Chief Officer Martyn Davies Governing Body Lay Member Governance (Deputy Chair) Dr Michele Legg CCG Chair Loretta Outhwaite Chief Finance Officer Dr Ian Reckless Secondary Care Doctor Melanie Rogers Director Quality, Safeguarding and Clinical Services Helen Shields Chief Officer Laurence Taylor Governing Body Lay Member- Independent Carole Truman Governing Body Lay Member - PPI Lindsay Voss Governing Body Nurse Dr Timothy Whelan Deputy Clinical Chair Caroline Morris, Assistant Director of Primary Care and Corporate Business Rebecca Berryman, Governance Support Officer (Minutes) Invited: For Information (Minutes): Karen Morgan, Head of Quality Linda Rann, Sue Lightfoot, Rachael Hayes, Eleanor Roddick - Heads of Commissioning, Tracy Savage, Assistant Director of Medicines Management, Rebecca Wastall Deputy Chief Finance Officer Lucy Long, Information Governance Manager Page 10 of 10

18 Governing Body Matters arising: Schedule of Actions Part 1 Sponsor: Helen Shields, Chief Officer Summary of issue: Action required/ recommendation: Actions identified from previous meeting together with updates on progress to date and expected completion dates To gain assurance that the actions requested by the Governing Body are in train Principle risks: Other committees where this has been considered: Financial /resource implications: Legal implications/ impact: Public involvement /action taken: Equality and diversity impact: There are no risks associated with this paper. This paper has not been considered at any other committee. There are no financial or resource implications in relation to this paper. There are no legal implications or impact relating to this paper. There has been no public involvement in this paper. There is no equality and diversity impact relating to this paper. Author of paper: Rebecca Berryman, Governance Support Officer Date of Paper: 26 May 2017 Date of Meeting: 13 July 2017 Agenda Item: 3.1 Paper number: GB

19 Isle of Wight Clinical Commissioning Group: Governing Body SCHEDULE OF ACTIONS TAKEN FROM THE MINUTES: 25 May 2017 Date of Meeting Minute No Action Lead Update Due Date Status IFR highlight report to be presented to the Governing Body in July 2017 HS On July agenda. July 2017 Closed 2

20 Governing Body: Performance Report July 2017 Sponsor: Summary of issues: Action required/ recommendation: Principle risks: Other committees where this has been considered: Financial /resource implications: Legal implications/ impact: Public involvement /action taken: Equality and diversity impact: Author of Paper: Loretta Outhwaite, Chief Finance Officer 1. The Governing Body is presented with a CCG Performance Report in a format that seeks to provide assurance on key performance indicators associated with Quality; NHS Constitution and CCG Outcomes Framework to note and comment upon. The Governing Body is invited to: Note and comment on the content of the Performance Report. Key Risks for the Performance Report include: Complexity and wide range of metrics and indicators with differing measurement for different purposes (eg COF, Quality Premium, CCG Assurance process) systems in development and embedding risk of missing vital information on all indicators continuously. Availability of data due to Health & Social Care Act compliance with Patient Identifiable Data for CCGs. New systems not yet agreed at NHS England level. Information contained in the report has been considered at: Clinical Executive Quality & Patient Safety Committee Contract Review Meetings Internal Performance Review Meetings Over-performance on contract activity could result in financial pressure where contracts are PBR based. There are no significant legal issues within the Report. Report is publicly available and provides patients and public with information on the CCG s financial position and use of resources. Requirement of providers and CCG to ensure all patients are treated in line with rights set out the in the NHS Constitution. Andrew Heyes, Head of Performance and Contracts Date of Paper: 3 July 2017 Date of Meeting: 13 July 2017 Agenda Item: 5.1 Paper number: GB17-020

21 Governing Body Summary Performance Report July 2017 (Performance Information up to April 2017)

22 Page 1

23 Part One Provider Performance Page 2

24 Part 1 Provider Performance - Summary A&E Performance for the IWCCG in April was reported to have been 86.53%, up on the 84.24% reported for March, but remaining below the constitutional target rate of 95%. 18 week RTT Performance rates for Incompletes (the principle measure of performance being applied by NHS England) demonstrated some marginal improvement in performance April compared with the result for March, rising to a reported rate of 87.98% at the end of April However, this rate continues to fall short of the target rate of 92%. o There were two cases in April of individuals having had to wait 52 weeks or more for treatment to be completed. Both were Incompletes (2 x Urology) one of which had rolled into April due to the treatment date given of 30 May The other patient had been delayed as a result of hospital cancellation and patient choice to delay, with a revised date for treatment of 9 May Performance for Ambulance Category A calls achieved each of the three targets applied in April. There had been a total of seven breaches for Mixed Sex Accommodation assigned to IWCCG for April These all occurred in the ITU unit at the IWNHST where patients had become suitable for transfer to a ward but with no bed being available. Cancer pathways were achieved in April for all nine of the treatment pathways reported on in month. This included the 62 day standard, which remains the single pathway for focus on by NHS England. Mental Health CPA Performance in April was a reported rate of 100%, a marked improvement on the rate achieved in March and achieving the target rate of 95%. Diagnostics performance continued to achieve the target of <1% in April, with a reported rate of 99.59% representing six breaches in month, occurring across three Trusts (IWNHST (2): UHS (2) and PHT (2)). Page 3

25 Part 1 Performance Outcomes NHS Constitution Dashboard Page 4

26 Part 1 Provider Performance - Commentary A&E <4 hour wait for admission, treatment or discharge National target 95% IWCCG Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD 2016/ % 92.49% 85.42% 87.34% 87.47% 85.84% 82.88% 83.57% 86.10% 81.45% 85.31% 84.24% 85.74% A&E <4 hour wait 2017/ % 86.53% No Attending 16/17 4,174 4,684 4,606 5,271 5,395 4,635 4,227 3,792 4,270 3,900 3,609 4,417 52,979 No Attending 17/ Breaches 16/ ,557 Breaches 17/ IWNHST Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD A&E <4 hour 2016/ % 92.49% 85.42% 87.34% 87.47% 85.84% 82.88% 83.57% 86.10% 81.42% 85.31% 84.24% 85.87% wait 2017/ % 80.14% 86.53% A&E 4hr waits data is collected as provider totals and allocated to CCGs based on providers, whereby the proportion is 1% or more. The 86.53% reported for the Trust in April represented a total of 5,149 patients attending A&E with a total of 694 breaches (5,000 / 788 in March; 2016/17 average 4,997 / 713). The constitutional target rate of 95% continued to be missed. Whilst the IW Health System was at Opel 2 (Amber Alert)for almost the whole of the month, the Trust were at Opel 3 (Red Alert) for eight days in the month, and Opel 2 (Amber Alert) for ten days and Opel 1 (Green Alert) for the remainder of that month (12 days). For a half of the month (14 days), occupancy of General and Acute beds had been reported as being above 95%. Provisional results from the Trust for performance in May suggest a performance rate of 80.14%, down on the previous month s results while continuing to miss the constitutional target rate for a further month. In that month the Trust were at Opel 3 (Red Alert) for twenty days of the month, with eleven days at Opel 2 (Amber Alert). Page 5

27 Part 1 Provider Performance - Commentary continued % Attendances within 4 hours February March April YTD 09D NHS Brighton And Hove CCG 81.02% 84.99% 85.80% 85.80% 09G NHS Coastal West Sussex CCG 93.56% 95.38% 94.65% 94.65% 10K NHS Fareham And Gosport CCG 77.52% 79.90% 80.84% 80.84% 10L NHS Isle Of Wight CCG 85.31% 84.24% 86.53% 86.53% 99M NHS North East Hampshire And Farnham CCG 91.35% 91.73% 92.61% 92.61% 10J NHS North Hampshire CCG 88.86% 96.18% 95.78% 95.78% 10R NHS Portsmouth CCG 87.16% 88.17% 88.79% 88.79% 10V NHS South Eastern Hampshire CCG 84.30% 86.01% 86.83% 86.83% 10X NHS Southampton CCG 88.81% 93.16% 93.52% 93.52% 10C NHS Surrey Heath CCG 91.29% 91.62% 92.48% 92.48% 11A NHS West Hampshire CCG 88.63% 94.09% 94.23% 94.23% DATA SOURCE: UNIFY and DH published percentages provider splits by CCG (via CSU Performance Portal) Action: The A&E performance recovery trajectories were revised and re-submitted in March 2017 to NHS England and NHS Improvement. The revised trajectories model a return to the national standard at 95% by March 2018, with an interim milestone of 90% achieved by September Performance improvements are aimed to be as a result of developments in the following areas: Acute Frailty model Recruitment and role development Stabilisation of the Ambulatory Emergency Care service in A-Bay Expansion of Ambulatory Emergency Care to a 14 chaired/bedded resource Improved inter-professional standards In addition, a number of other actions within the A&E Improvement plans aim to sustain improved patient flow and support maintaining improved A&E performance. In February 2017, Emergency Care Improvement Programme (ECIP) undertook a detailed review of Emergency and Urgent Care at the Isle of Wight Trust. Feedback has been received and specific actions are being taken forward. 12 hour trolley waits National target zero 2017/18 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD Trolley waits in A&E 0 0 For April, there have currently been no reported cases of individuals waiting for 12 hours or longer to be admitted. Page 6

28 Part 1 Provider Performance Commentary continued 18 week Referral to Treatment: National Targets: Admitted 90%; Non-Admitted 95%; Incompletes 92% IWCCG IWNHST UHS PHT Salisbury Admitted Non-Adm Incompletes Admitted Non-Adm Incompletes Admitted Non-Adm Incompletes Admitted Non-Adm Incompletes Admitted Non-Adm Incompletes May 64.02% 93.48% 89.78% 62.65% 93.84% 90.47% 70.91% 85.19% 89.69% 71.43% 92.00% 86.44% 100% 100% 92.00% June 64.26% 93.90% 89.28% 61.71% 94.62% 90.21% 66.04% 82.48% 78.74% 81.48% 94.74% 86.25% 100% 100% 85.19% July 59.03% 91.11% 89.55% 58.94% 92.41% 90.29% 64.06% 74.44% 81.72% 79.17% 81.97% 87.81% 100% 100% 79.31% August 65.54% 88.00% 88.64% 65.23% 88.39% 89.17% 70.97% 83.53% 85.04% 83.64% 92.06% 85.12% - 100% 82.76% September 64.12% 88.04% 87.77% 64.36% 88.89% 88.16% 65.28% 79.17% 85.86% 84.09% 86.84% 85.16% 50.00% 100% 90.32% October 65.93% 89.69% 87.86% 65.44% 90.42% 88.14% 69.23% 84.62% 87.00% 71.43% 80.65% 85.57% 0% 100% 75.86% November 65.40% 89.36% 86.49% 63.69% 90.71% 86.86% 80.85% 68.66% 85.97% 69.57% 91.67% 79.59% December 62.60% 92.22% 84.35% 60.11% 93.30% 84.78% 61.70% 80.70% 80.82% 80.00% 83.02% 80.81% % 76.47% January 54.64% 87.23% 83.44% 48.39% 89.23% 83.96% 72.22% 66.14% 82.62% 80.43% 79.07% 78.03% 100% 100% 71.88% February 48.24% 87.26% 85.41% 43.40% 88.65% 85.93% 62.32% 62.28% 83.91% 78.26% 92.54% 79.05% % March 58.07% 86.74% 87.29% 54.43% 88.19% 88.35% 71.83% 65.00% 80.21% 73.33% 89.61% % % April 57.70% 88.34% 87.98% 54.69% 89.56% 88.65% 69.39% 76.67% 80.21% 69.39% 86.96% 80.32% - 100% 85.71% 382/ / / / / / /49 92/ /758 34/49 60/69 200/249-2/2 42/49 RED Target missed; AMBER Performance achieved within 5% of meeting target; GREEN Target achieved. Performance for Incompletes in April demonstrated a further improvement in performance, but the reported outcome continued to miss the overall constitutional target of 92%. Other than for Salisbury, for the other principal Trusts monitiored, performance rates showed no improvement or deteriorated in that month. o Provisional performance in month reported by the IWNHST: (Admitted 52.02% (258/496); Non-Admitted 88.84% (1,751/1971) and Incompletes 88.27% (6,088/6,897)). In addition and for the treatment of Island patients: o UHS (Incompletes: 80.21% (655/758)). o PHT (Incompletes: 80.32% (200/249)). o Salisbury- (Incompletes: 85.71% (42/49)). o Southampton NHS Treatment Centre (Incompletes: 92.86% (130/140)) o University College London Hospitals (Incompletes: 80.95% (17/21)) o Spire Southampton Hospital (Incompletes: 96.23% (51/53)) o Spire Portsmouth Hospital (Incompletes: 100% (5/5)). Page 7

29 Part 1 Provider Performance - Commentary continued Patients waiting >52 weeks National Target: Zero There were two reported breaches in April of individuals waiting 52 weeks plus for treatment, one of which had carried over from March into April due to the treatment dates applied. Both were Urology cases and categorised as Incompletes and both are likely to carry over to May s reporting. - Carried over from March, the delay in treatment resulted from multiple cancellations due both to the patient and hospital together, with multiple occasions where the patient Did Not Attend (DNA). The waiting list was cancelled on 4 April 2017 and the individual had an outpatient appointment for 30 May The Patient breached 15 April 2017 at 53 weeks, with the reasons unknown for the delay between being added to the waiting list and first To Come In (TCI) date. The hospital cancelled one TCI due to a more urgent case and the patient subsequently cancelled. New TCI date 9 May Actions: Performance Recovery Trajectories for 2016/17 have been resubmitted with a trajectory for achieving 92% (Incompletes) RTT by March The trajectories were submitted to NHS England and NHS Improvement in March 2017 by the CCG. The trajectory was met in April Key issues: Effective application of policy managing pathways and scheduling. Impact of non elective demand and delayed transfers ofcare. Resourcing inc Senior consultants in certain specialities Key Actions: Implement SRG plans supporting patient flow and non elective impact. Bed reconfiguration based on capacity plans. Improve scheduling - booking efficiency and theatre utilisation Improve focus on performance management Recruitment plans Improve patient information and validations Review underperforming services Promoting patient choice. The CCG is continuing to encourage GPs to offer choice to patients at the Mainland ISP providers. Mainland Trusts: Commissioners continue to liaise with the Lead Commissioner and Trusts to highlight patient waiting times and resolve any issues relating to specific specialities. Page 8

30 Part 1 Provider Performance - Commentary continued Category A Ambulance Calls: National targets: Red 1 and Red 2 75%; 19 minutes 95% Category A Red 1 75% Category A Red 2 75% Category A 19 min 95% Target April May June July Aug Sept Oct Nov Dec Jan Feb Mar YTD 2016/ % 66.67% 58.97% 69.70% 56.41% 71.05% 66.67% 67.57% 52.50% 75.68% 50.00% 68.29% 63.16% 2017/ % 77.78% Numbers 36/28 36/ / % 75.33% 73.68% 63.29% 68.06% 72.68% 70.32% 75.19% 67.94% 67.49% 66.85% 68.26% 70.03% 2017/ % 77.83% Numbers 609/ / / % 95.70% 94.92% 88.57% 88.07% 93.02% 92.81% 95.84% 90.65% 89.16% 89.46% 92.46% 91.87% 2017/ % 95.35% Numbers 645/ /615 Performance in April resulted in the Constitutional target for all three measures being achieved. The key issues facing the Service are its ability to provide a high quality of care against a back drop of system wide pressures and flow of patients through the hospital setting, leading to delays in response times, and a similar situation is being experienced for ambulance services across the country. Action: The Ambulance performance recovery trajectories were revised and submitted on 27 February 2017 to the CCG, NHS England and NHS Improvement for approval. The revised trajectories model a return to the national standard by March 2018 for the Red 1 target and September 2017 for the Red 2 target and 19 minutes. The trajectory was bettered with performance achieved in April Performance improvements are aimed to be as a result of developments in the following areas: Improved hospital handover (Turnaround) dependant on better overall hospital flow Efficient use of Community First Responders Workforce Rotas re-design Recruitment and role development Implementation of Nature of Call (NoC) and Dispatch on Disposition (DoD) initiatives A number of these actions are outlined within the Ambulance response programme and included within the Urgent and Emergency Care Delivery Plan. Page 9

31 Part 1 Provider Performance - Commentary continued Ambulance Handover: National Target 100% for Handovers and Crew Green-Up time Against a reduced number for total trips undertaken in April there was an improvement registered in the rate for transfers completed within 15 minutes. The reported rate of 56.42% followed a third successive month of improvement although not as high as the rate registered in December 2017 of 57.87%. These outcomes remain below the overall target rate of 100%. January / 891 (56.90%); February / 793 (54.48%); March / 875 (54.97%); April 444 / 787 (56.42%). Waits of over 120 minutes had fallen to zero following a review of the timings posted, with the rates for transfers of greater than 60 minutes having also demonstrated some reduction (target rate for each being 0%). Against each of these outcomes, it should be noted that for transfers reported for up to 15 minutes and between 15 minutes and up to 90 minutes, the report received from the Trusts indicates that these have NOT been subject to review. Page 10

32 Part 1 Provider Performance - Commentary continued Cancer: Nine National Targets RED Target missed; AMBER Performance achieved within 5% of meeting target; GREEN Target achieved. IWCCG 2016/17 Target Q4 16/17 Jan 17 Feb 17 Mar 17 Apr 17 Year to Date Seen within 2 weeks of referral 93% 97.53% 95.88% 98.47% 97.93% 97.63% 412/ % Seen within 2 weeks of referral - Breast Symptoms 93% 93.94% 100% 94.44% 90.67% 98.00% 49/ % Treated in <31 days of diagnosis 96% 100% 100% 100% 100% 98.33% 59/ % Treated in <31 days - Surgery 94% 97.22% 94.74% 96.00% 100% 100% 12/12 100% Treated in <31 days - Drug Treatment 98% 99.14% 97.56% 97.56% 100% 100% 27/27 100% Treated in <31 days - Radiotherapy 94% 97.62% 100% 96.88% 96.67% 100% 22/22 100% Treated in <62 days - urgent referral to treatment 85% 84.30% 82.86% 80.56% 87.76% 89.19% 33/ % Treated in <62 days - Consultant upgrade 86% 50.00% 0% 0% 100% 100% 1/1 100% Treated in <62 days - Screening service 90% 96.15% 100% 87.50% 100% 100% 3/3 100% IWNHST 2016/17 Target Q4 16/17 Jan 17 Feb 17 Mar 17 Apr 17 Year to Date Seen within 2 weeks of referral 93% 97.58% 96.15% 98.45% 97.90% 97.62% 410/ % Seen within 2 weeks of referral - Breast Symptoms 93% 93.83% 100% 94.34% 90.54% 98.00% 49/ % Treated in <31 days of diagnosis 96% 100% 100% 100% 100% 100% 49/49 100% Treated in <31 days - Surgery 94% 97.67% 90.00% 100% 100% 100% 8/8 100% Treated in <31 days - Drug Treatment 98% 99.10% 97.50% 100% 100% 100% 27/27 100% Treated in <31 days - Radiotherapy 94% <N/a> <<N/a>> <N/a> <<N/a>> <<N/a>> <N/a> <<N/a>> Treated in <62 days - urgent referral to treatment 85% 85.00% 85.94% 78.79% 88.76% 92.54% 31/ % Treated in <62 days - Consultant upgrade 86% 57.14% 0.0% 0.0% 100% 100% 1/1 100% Treated in <62 days - Screening service 90% 97.92% 100% 92.86% 100% 100% 3/3 100% Mainland Trusts performance for island registered patients 2016/17 Q4 16/17 UHS Feb 17 Mar 17 Apr 17 Page 11 Year To Date Q4 16/17 PHT Feb 17 Mar 17 Apr 17 Seen within 2 weeks of referral 88.89% 100% 100% 100% 2/2 100% 100% 100% 100% <N/a> <N/a> <N/a> Seen within 2 weeks of referral - Breast Symptoms <N/a> <N/a> <N/a> <N/a> <N/a> <N/a> 100% 100% <N/a> <N/a> <N/a> <N/a> Treated in <31 days of diagnosis 100% 100% 100% 100% 5/5 100% 100% 100% 100% 80.00% 1/ % Treated in <31 days - Surgery 100% 100% 100% 100% 2/2 100% 88.89% 50.00% 100% 100% 2/2 100% Treated in <31 days - Drug Treatment 80.00% 66.67% 100% <N/a> <N/a> <N/a> <N/a> <N/a> <N/a> <N/a> <N/a> <N/a> Treated in <31 days - Radiotherapy 100% 100% 100% 100% 13/13 100% 93.55% 92.86% 87.50% 100% 8/8 100% Treated in <62 days - urgent referral to treatment 80.00% 100% 83.33% 60.00% 1.0/ % 71.43% 100% 66.67% 50.00% 0.5/ % Treated in <62 days - Consultant upgrade <N/a> <N/a> <N/a> <N/a> <N/a> <N/a> 0.00% 50.00% <N/a> <N/a> <N/a> <N/a> Treated in <62 days Screening service <N/a> <N/a> <N/a> <N/a> <N/a> <N/a> 75.00% <N/a> <N/a> <N/a> <N/a> <N/a> Year To Date

33 Part 1 Provider Performance - Commentary continued Performance in April saw the achievement of target across all nine of the pathways monitored, with a rate of 100% reported for five of these. With reference to the attached Breach Report, it can be seen that there is still an issue with the numbers of cancellations resulting from patient choice, particularly with the initial two week target period for being seen: o o Seen within 2 weeks of referral nine from ten, and Seen within 2 weeks of referral - Breast Symptoms the one breach was due to the patient being on holiday. In the case of Treated in <62 days - urgent referral to treatment, which remains a focus for performance by NHS England, the target rate was achieved for April with a total of four breaches from 37 referrals, one of which appears to have again been from patient choice. Actions: Performance monitoring continues on a monthly basis. The IOW Trust (Cancer Unit), continues to work with tertiary Cancer Centres (University Hospitals Southampton and Portsmouth Hospitals Trust) to improve treatment pathways and patient experience. Weekly tracking via validated Patient tracking Lists continues. Both the IWCCG and IWNHST attend the Wessex Cancer Alliance meetings and work with the Alliance to develop transformation opportunities/bids as they occur. In June the focus on 62 day treatment has been prioritised as a transformation opportunity, and bids against this, are being led by the Wessex Cancer Alliance. Page 12

34 Part 1 Provider Performance - Commentary continued Breach Report: Seen within 2 weeks of referral (IWNHST): Tumour type: 2 x Suspected breast cancer Wait 19 days Patient unavailable 15 days Patient on holiday 34 days Patient unavailable Tumour type: 3x Suspected lower gastrointestinal cancer Wait 20 days Patient unwell 17 days Patient cancelled on day - no reason given Tumour type: 2 x Suspected skin cancer Wait 16 days Patient unavailable 15 days Patient unavailable Tumour type:1 x Suspected upper gastrointestinal cancer Wait 21 days Patient unavailable Tumour type: 2 x Suspected urological malignancies (excluding testicular) Wait 21 days Patient on holiday 15 days Patient choice Seen within 2 weeks of referral - Breast Symptoms (IWNHST): Tumour type: 1 x Exhibited (non-cancer) breast symptoms - Wait 21 days Patient on holiday cancer not initially suspected Treated in <31 days of diagnosis Admitted (PHT): Tumour type : Urological Wait 43 days Treated in <62 days urgent referral to treatment Admitted: First seen IWNHST Tumour type: Urological (excluding testicular) PHT Wait 97 days Other reason - ITR Day 42 Treated in <62 days urgent referral to treatment Non-Admitted: First seen IWNHST Elective capacity inadequate (patient unable to be scheduled for treatment within standard time Tumour type: 1 x Urological (Excluding testicular) IWNHST Wait 68 days Patient cancelled post MDT outpatient appointment Tumour type: 2 x Urological (Excluding testicular) UHS Wait 75 days Received day 36. Needed PET to clarify nodal status and if bone met 71 days Referred day 51 Page 13

35 Part 1 Provider Performance - Commentary continued Other Key Metrics Diagnostics National Target: >99% Performance in April achieved a rate that was within the target of >99%. For April there were a total of six patients that had been waiting more than six weeks (achieving a rate of 99.59%), the breaches having been spread equally (two at each) across three Trusts of IWNHST; University Hospitals Trust Southampton and Portsmouth Hospitals Trust.. Action: Performance Trajectories for 2017/18 are aimed at the sustained achievement of the Constitutional target throughout the year. Performance will be subject to on-going monitoring and review. Cancelled Operations National Targets: 100% / Zero A 100% performance was achieved in April 2017 in respect of cancelled operations not being re-booked within 28 days at the IWNHST. (NB: Adjustments to reported occurrences may be made in subsequent months following investigation and review of occurrences). In addition, there had been no reported cases of a cancelled operation being cancelled for a second time for a further month. Mixed Sex Accommodation National Target: Zero There were seven breaches reported for April, all of these having occurred at the IWNHST, where the patient was able to be returned to ordinary level care and personal care facilities were not of the standard required. Mental Health Care Programme Approach National Target: 95% The target rate of 95% was achieved in April with a rate of 100% (38/38). Page 14

36 Part 1 Provider Performance - Commentary continued Contract Query notices The following Contract Query Notices are currently in place: University Hospital Southampton (UHS) Emergency Department (on-going) Commissioning Support Unit (CSU) IT Performance Notice (on-going) PHT RTT - Failure to agree Remedial Action Plan (on-going) PHT Cancer - Failure to agree RAP (on-going) PHT A&E (on-going) Salisbury Mixed Sex Accommodation (on-going) IWNHST A&E Performance (on-going) IWNHST RTT 18 Weeks Incompletes (on-going) IWNHST Cancer 62 day Urgent referral to treatment (on-going) IWNHST Ambulance Handovers (on-going) IWNHST Ambulance Performance, Red 1 and Red 2 (on-going) IWNHST Quality of Mental Health Services (on-going) IWNHST Emergency Preparedness, Resilience and Response (EPRR) (on-going) Page 15

37 Part Two Quality and Safeguarding Page 16

38 Part 2 Quality and Safeguarding - Summary CQC update on progress Following the inspection of the IOW NHS Trust on November 2016 the Care Quality Commission (CQC) issued a rating for the IOW NHS trust of inadequate. In addition the CQC imposed conditions on the Trusts registration under section 31 of the Health and Social Care Act 2008 in relation to Mental Health, and issued a Regulation 17 letter concerning a number of regulatory breaches. The Trust has appointed an interim Chief Executive Officer, Maggie Oldham, who took up post on 2 May With experience in the acute, ambulance, community and mental health sectors, Maggie is particularly experienced at supporting NHS Trusts that face significant challenges. The Trust also has an Improvement Director working with them to support the change required. The Trust had been operating with many single issue action plans and without a framework through which to drive the delivery of improvements, or to monitor their effectiveness in resolving problems. Since the publication of the CQC findings the Trust has developed an Integrated Improvement Framework (IIF) that captures all activity into a single programme delivery methodology supported by a dedicated programme management team. Within the IIF is a significant subset of activity described as the Trust s Quality Improvement Plan (QIP). The QIP brings together the actions within the IIF which the Trust believe are of greatest significance in delivering the short term goal of an overall Trust CQC rating of at least Requires Improvement by March 2018 and the longer term ambition of an overall Trust rating of Good by June The CCG has supported the Trust in a number of ways including external auditing of the robustness of actions taken in response to the section 31 notice, training and support regarding Serious Incident investigations, and in the review of a number of processes including incident management. Governance and assurance A Quality Improvement Plan Oversight Group (QIPOG) has been established and is meeting monthly to oversee and support the implementation of the Trust s Quality Improvement Plan. The CCG, along with CQC, NHSE and NHSI are attending the monthly Quality Improvement Plan Oversight Group. The CCG is a member of the Mental Health Improvement Group which meets fortnightly to monitor progress being made in response to the section 31 and regulation 17 notices. Page 17

39 Part 2 Quality and Safeguarding - Summary The CCG Quality Team reviews the quality indicators on a monthly basis to understand and create actions where appropriate for exceptions in performance. The indicators for April 2017 (M01) show the following exceptions: Isle of Wight NHS Trust: Trustwide SIRIs 0 reported for April, however, ongoing concerns regarding the quality of investigations. Actions are underway to support the Trust in improving quality and timeliness of investigations. HCAI 1 case of C. Difficile and 0 cases of MRSA. The CCG are working with Provider on reviewing all cases to identify whether there are any lapses in care and any learning to be taken. Acute / Hospital Services Mixed Sex Accommodation breaches 7 breaches in April. These relate to ITU and patients becoming suitable for transfer to a ward but no bed being available. Agreement had been reached between CCG and Provider that these breaches were to be reported from April 2017 in line with national guidance. Emergency Care 4 hour standard performance for April 2017 of 87% against national target of 95%. A Performance trajectory is in place to achieve the national standard by March Actions are captured and will be monitored within the Integrated Improvement Framework (IIF) and CCG seek assurance over care and treatment of patients who are subject to an extended wait within the department. Ambulance Service All Category A targets were achieved for April, which is an improvement on recent months NHS111 targets and Ambulance re-contact targets failed to achieve due to capacity issues. Impact on the patient, and actions to improve are discussed and monitored at the Officer Level Meeting. Recruitment is underway for 111 service. Community Services Quality Team at CCG are linking with commissioners to undertake a series of assurance visits to community services to understand the quality performance and suitability of commissioned services, this work will be used to support the Transforming Community Services work streams. Mental Health Services Whilst many indicators continue to achieve, CCG recognise is not always consistent with the quality and safety of the service. CCG is monitoring improvement work required in response to the CQC findings and attends the Quality Improvement Plan Oversight Group and Mental Health Improvement Group. Performance of all indicators is monitored via Officer Level Meetings. Isle of Wight CCG HCAI 5 cases of C. Difficile associated with the IWCCG, one of which is indicated to have occurred at the Isle of Wight NHS Trust, with the other four occurring in the wider CCG community. Page 18

40 Part 2 Quality and Safeguarding - Commentary Performance Summary Quality Dashboard The dashboard provides a summary of outcomes by month, Year to Date and Trend (May 2016 April 2017). Page 19

41 Part 2 Quality and Safeguarding Commentary continued Serious Incidents Requiring Investigation Isle of Wight NHS Trust In May, nine SIRIs were reported by the IOW NHS Trust. Seven related to unexpected/potentially avoidable death or injury and two SIRIs reported relating to information governance breaches. Further detail around the nature of each SIRI is included in the paper for the Clinical Executive Seminar which follows the Clinical Executive meeting. Whilst SIRIs continue to be reported onto the STEIS system within the required two days, there remains a delay in reviewing incidents prior to the decision that the incident is SIRI reportable. Page 20

42 Part 2 Quality and Safeguarding Commentary continued To date there are nine outstanding SIRIs awaiting closure from the previous year; RCAs have been received but closure has not been recommended for five cases and the CCG SIRI Review Panel are awaiting further assurances, two cases were returned to the Trust following initial screening of the RCA investigation report and the CCG are awaiting revised RCA reports. One RCA report is overdue and awaited and the CCG has recommended an external review for one case. CCG assurance: The CCG Interim Associate Director of Quality has met with Lead for SEE and Deputy Director of IPC regarding streamlining the SIRI process so that learning is established and embedded and that the National SI framework is complied with. The CCG Interim Associate Director of Quality will also be providing Root Cause Analysis training to ensure the robustness of SIRI investigations. Isle of Wight CCG There have been no SIRIs reported for the CCG in May. CCG assurance: Investigations in to the two cases reported in April are underway and are on schedule to be concluded within time. Page 21

43 Part 2 Quality and Safeguarding Commentary continued Complaints and Concerns Complaints (A Formal complaint made and responded to in writing): Complaints 2017/18 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD IWCCG IWNHST 23 tbc 23 Concerns (An informal process, commenting verbally, with the response given by phone): Concerns 2017/18 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD IWCCG IWNHST 78 tbc 78 Complaints to the Ombudsman Nos referred to Ombudsman Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep YTD IWCCG No. awarded in favour of complainant IWNHST No. awarded in favour of Not complainant Pending Pending - Pending Upheld - - Friends and Family Test IWNHST Jan Feb Mar Apr A&E Inpatients Maternity Question 2: Birth Q1 16/17 Average Q2 16/17 Average Q3 16/17 Average Q4 16/17 Average Response rate 5.25% 3.61% 7.75% 3.42% 4.17% 4.89% 5.28% 5.68% Total Eligible/Responses 2341 / 123 2,273 / / / 80 7,868 / / / / 418 % Recommending 91.87% 89.02% 91.55% 88.75% 95.04% 86.16% 83.81% 91.15% - % Not recommending 2.44% 4.88% 1.88% 7.50% 1.56% 3.34% 3.09% 2.64% - Response rate 25.11% 29.12% 30.19% 34.01% 18.52% 22.99% 27.76% 28.40% Total Eligible/Responses 1123 / / / / / / / / 1125 % Recommending 95.74% 96.34% 94.36% 95.63% 96.25% 95.21% 95.20% 95.38% - % Not recommending 0.35% 0.79% 1.30% 0.92% 0.67% 0.77% 0.30% 0.89% - Response rate 12.17% 5.68% 12.71% 15.22% 17.49% 0.0% 7.40% 10.60% Total Eligible/Responses 115 / / / / / / / / 34 % Recommending 100% 100% 100% 100% % 0.0% 85.72% 100% - % Not recommending 0% 0% 0% 0% 2.18% 0.0% 0.0% 0.0% - Trend Page 22

44 Part 2 Quality and Safeguarding Commentary continued Pressure Ulcers Total numbers for reported Pressure Ulcers for April in a hospital setting had reduced compared to the adjusted total numbers for March, particularly with reported numbers of Grade 2 PUs. There were no reported cases of Grades 3 or 4 PUs in month. In a Community setting the numbers of Grade 2 PUs had increased on the revised number reported for March but again there were no Grades 3 or 4 PUs reported in month. At the end of April, the combined total number for Grade 2 PUs in that month was fewer than the total number being reported for the same month in the preceding year. Target Apr 16 May 16 Jun 16 Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17 YTD Total Reduction in Pressure Ulcers Hospital setting (including community wards) Grade 2 Pressure Ulcer Grade 3 Pressure Ulcer Grade 4 Pressure Ulcer 2016/17 Total /18 30% reduction 11 monthly /17 Total /18 50% reduction 0.17 monthly /17 Total /18 80% reduction 0.03 monthly Ungradable not 2017/18 N/a 0 0 yet assigned Overall Rate of newly 2016/ developed per 100,000 Occupied Bed Days N/a (updated retrospectively as data 2017/ available) Reduction in Pressure Ulcers Community setting (external to hospital) Grade 2 Pressure Ulcer Grade 3 Pressure Ulcer Grade 4 Pressure Ulcer Ungradable not yet assigned 2016/17 Total /18 30% reduction 9 monthly /17 Total /18 50% reduction 1 monthly /17 Total /18 50% reduction 1 monthly /18 N/a 0 Annual Target N.B. Figures for previous months will continue to change as validation occurs during the process of investigation. Page 23

45 Part 2 Quality and Safeguarding Commentary continued Within a Hospital setting: The Pressure Ulcer Collaborative has continued to review on a weekly basis, all pressure ulcers that occurred in the IWNHS care. This has helped to focus further attention on this issue and helped to raise awareness in the Business Units. Whilst there had been a rise in the overall reporting, this had been mainly in the area of Grade 1 and 2 pressure ulcers, while there remained a number of ungradable pressure ulcers that were still under review. A recent trial undertaken by the Trust with hand held Tissue Scanners has demonstrated early detection of tissue damage up to 10 days prior to development of a visual lesion. This has indicated that the majority of ulcers developed within 10 days of admission have already passed the preventable stage prior to arrival on the wards and has proved a more reliable indicator than the current system scoring of risk. Scanners have been purchased for trial on two wards following positive initial evaluation and it is anticipated that greater awareness of incipient tissue damage and rapid measurement of effectiveness of interventions will lead to a reduction of PU development. Within a Community Setting: The Pressure Ulcer collaborative has also been looking at the community. The trend overall remains encouraging with reviews now focussing on the root cause analysis and cluster review, of Grade 2 pressure ulcers as there is an intended target for 2016/17 of reducing the occurrence of this grade of pressure ulcer by 50%. Overall the trend continues to decrease. Reviews are now focussing on the root cause analysis and cluster review of grade 2 ulcers. CCG assurance: Pressure Ulcers continue to be monitored on a monthly basis with discussion either at Officer Level Meetings or CQRM where there is cause for concern. Pressure Ulcers remain as a key indicator within the contractual Local Quality Indicators schedule and the CCG receives quarterly cluster review reports demonstrating the number of cases reviewed and the learning identified. Page 24

46 Part 2 Quality and Safeguarding Commentary continued Benchmarking: The following table has been produced using numbers published via NHS Digital safety thermometer outcome report (all Wards & Teams/All settings/all Services/All Ages/All Sexes) The Trusts included for comparison are all indicated to be Small Acute Trusts and are offered as a geographic distribution across England: Page 25

47 Part 2 Quality and Safeguarding Commentary continued Page 26

48 Part 2 Quality and Safeguarding Commentary continued HCAI: C.Difficile IWNHST and IWCCG There were five cases reported in April for the CCG, one of which was indicated to have occurred at the IWNHST, the other four having occurred in the wider community. The total number was higher than in April 2016 when there were zero cases but similar to the year before when there were four cases (45 cases for the year 2015/16). IOWNHS Trust trajectory for the year 2017/18 remains as it was in 2016/17 at seven. CCG assurance: A member of the CCG Quality team, who is a registered nurse and a member of the medicines optimisation team, attends all Trust C Difficile RCA Meetings and liaises with GP practices where further information is required about patient care and treatment, prior to admission to St. Mary s Hospital. Recent RCAs have identified areas of good practice which CCG have fed back to the Trust Corporate Governance Team and asked they be cascaded across the Trust for shared learning. The IOWNHS Trust and CCG are also attending the Hampshire and Isle of Wight Infection Prevention and Control meeting where identified themes and learning are being shared, as well as updates on national guidance discussed. Wessex Area (Cumulative totals as at April 2017) CCG Apr 2017 YTD (2017/18) Variance to projected total. at Apr 2017 Number % CCG Population YTD Total as ratio per 100,000 population Southampton % 282, Portsmouth % 227, Isle of Wight % 143, North East Hampshire & Farnham % 226, Fareham & Gosport % 204, West Hampshire % 557, South Eastern Hampshire % 213, North Hampshire % 224, Source: Public Health England (via South Commissioning Support Unit, Performance Portal) (Population Numbers GP Registrations Data) Page 27

49 Part 2 Quality and Safeguarding Commentary continued HCAI: MRSA IWNHST and IWCCG There were no additional cases assigned to either the IWCCG or IWNHST in month. Wessex Area (Cumulative totals as at April 2017) CCG Apr 2017 YTD Total. at Apr 2017 CCG Population YTD Total as ratio per 100,000 population Portsmouth , Isle of Wight , West Hampshire , North East Hampshire & Farnham , South Eastern Hampshire , Southampton , Fareham & Gosport , North Hampshire , Cumulative numbers of cases of MRSA in 2015/16, for other CCGs listed in the above table, have been revised following completion of Post Infection Reviews Source: Public Health England (via South Commissioning Support Unit, Performance Portal) (Population Numbers GP Registrations Data) CCG assurance: A member of the CCG Quality team, who is a registered nurse and a member of the medicines optimisation team, attends all Trust post infection review meetings. The IOWNHS Trust and CCG are also attending the Hampshire and Isle of Wight Infection Prevention and Control meeting where identified themes and learning are being shared, as well as updates on national guidance discussed. Page 28

50 Part 2 Quality and Safeguarding Commentary continued Improving Access to Psychological Therapy (IAPT): Entering treatment: Performance for accessing the service, in April was reported at 18.40% reduced from the reported performance achieved in March. This fell short of the Annual target rate of 22%. NB: Since Bank Holidays and the pattern by which weekends can fall within a month, have the potential to impact on the number of clinics that can be held and thereby directly influence the performance rate achieved. The month of April included the Easter weekend, which may have influenced the rate achieved. Moving to Recovery: For those moving to recovery, a rate of 55.92% was achieved, down on the previous month s result but continuing to achieve the required target rate of 50%. Indicator Improved access to psychological services: The proportion of people that enter treatment against the level of need in the general population. Entering treatment Target 2016/17 22% Numerator: No. of people who receive psychological therapies Denominator: No. of people who have depression and/or anxiety disorders Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar ,087 1,087 1,087 1,087 1,087 1,087 1,087 1,087 1,087 1,087 1,087 1,087 Percentage 23.19% 20.43% 23.28% 18.96% 20.06% 22.27% 19.69% 21.62% 14.82% 26.77% 26.22% 26.22% Moving to Recovery CCG assurance: Whilst many indicators continue to achieve, CCG recognise is not always consistent with the quality and safety of the service. CCG is monitoring improvement work required in response to the CQC findings and attends the Quality Improvement Plan Oversight Group and Mental Health Improvement Group. Performance of all indicators is monitored via Officer Level Meetings. Page 29

51 Part Three Commissioning Page 30

52 Part 3 - Commissioning Summary 1. Commissioning Updates Mental Health Review and Reconfiguration The Isle of Wight Clinical Executive had agreed the following option to go to business case: Mental Health Enhanced Reablement / Rehabilitation Pathway A 10 bedded supported living unit (without nursing) for individuals with complex mental health, this will be coupled with recovery focussed support, this will also include enhancing the current reablement community reablement team to work 7 days. Small task and finish groups being set up to look at procurement option and care model in order to finalise business case to take forward. Dementia Pathway The trust were given extra time to work up an option of an inpatient unit (relocation of current Shackleton) within Seven acres main unit. Trust option is to be provided at next Mental Health Reconfiguration Board or sooner in order to finalise option paper to go to Clinical Executive. Community Child and Adolescent Mental Health Service (CCAMHS) The Children and Young People s Improving Access to Psychological Therapies (CYP IAPT) programme is the Child and Adolescent Mental Health Service (CAMHS) local transformation plan. The Isle of Wight NHS Trust is looking to join the London CYP IAPT collaborative who offer to provide the training. A meeting is scheduled to take place on the 13th July, Clinical Commissioning Group (CCG) and third sector AQP (Any Qualified Provider) Tier 2 counselling providers invited. The event to launch the Hampshire and Isle of Wight Frankie Workers is taking place on the 6 July 2017, Time: 10.30am pm at The Orchard, Basingstoke Voluntary Action, White Hart Lane, Basingstoke. The Frankie Workers aim to provide therapeutic counselling to prevent trauma turning into poor mental health Learning Disabilities The Peer Review Action plan has been developed and was agreed at Joint Commissioning Board 14 June2017. Learning Disability Commissioning Strategy plan to be presented to Learning Disability Partnership Group 13 July Learning Disability Section of Joint Strategic Needs Assessment is under construction, to be ready September Page 31

53 Part 3 - Commissioning Summary (continued) Urgent Care Service Urgent Care Service remains a risk for sustainable delivery. Overnight home visits will be trialled by Ambulance Community Practitioner s (CP) from July. Sub-contract with PHL Ltd. for GP call-backs have been extended. Bi-weekly meetings continue, chaired by the Chair of the CCG. The service remains on the CCG Risk Register and the Trust has also included the GP Rota and Clinical Leadership in their Risk Register. A new approach to the Clinical Lead role (separating clinical and operational lead role) is being explored, with clarity around corporate responsibility / liability to attract potential leads. Wessex Cancer Alliance The CCG is a member of the Wessex Cancer Strategic Clinical Network (WCSCN), which has established the Wessex Cancer Alliance as outlined in 96 Achieving World-Class Cancer Outcomes; A Strategy for England recommendations. As a part of this network and Alliance, the CCG has supported the development and submission of regional bids against the national Cancer Transformation Funding. In wave one, WCSCN were approved for funding for a risk stratification (also known as patient triggered follow-up) bid and also Recovery Model bid (to support survivorship of cancer). At the time of writing this update, the release of funding from the national fund had not occurred, because centrally some monies have been withheld to support delivery of the 62 day target; bids in relation to this are under development with local need most likely to focus on diagnostic capacity and development of an MDT multi-provider coordinator. Page 32

54 Part 3 - Commissioning Summary (continued) 2. Planning Update Better Care Fund 2017/19 BCF Planning guidance is expected imminently, indicative submission date of September Planning is well underway, see agenda item for further details. Page 33

55 Governing Body Finance Report Sponsor: Loretta Outhwaite, Chief Finance Officer Summary of issue: Action required/ recommendation: Principle risks: Other committees where this has been considered: Financial /resource implications: Legal implications/ impact: Public involvement /action taken: Equality and diversity impact: The Governing Body is presented with a CCG Finance Report for May to note and comment upon. To note and comment on the content of the Finance Report. The principle risk is that the CCG will not deliver its planned break-even position for 2017/18, due to the size of QIPP target savings of 12.9m. Information contained in the report has been considered at: Strategic Finance Group Internal Performance Review Meetings If break-even is not achieved for 2017/18 it will impact on the 2018/19 financial position There are no significant legal issues within the Report. Report is publicly available and provides patients and public with information on the CCG s financial position and use of resources. No impact Author of Paper: Becky Wastall, Deputy Chief Finance Officer Date of Paper: 4 July 2017 Date of Meeting: 13 July 2017 Agenda Item: 5.2 Paper number: GB17-021

56 FINANCIAL REVIEW MONTH 2 May P age

57 SUMMARY FINANCIAL REVIEW Month 2 May Income & Expenditure Position YTD Budget ( 000) YTD Actual ( 000) YTD Variance ( 000) Annual budget ( 000) Year End Variance Forecast Notified Resource limit 37,317 37, , ,271 0 Application Acute 17,639 17,866 (227) 108, ,841 0 Mental Health 3,223 3,303 (80) 19,439 19,439 0 Community 1,555 1,842 (287) 9,377 9,377 0 Better Care Fund 3,013 3,038 (26) 18,143 18,143 0 Children's ,075 2,075 0 Continuing Care 2,327 2,506 (179) 14,094 14,094 0 Primary Care 8,532 8, ,481 53,481 0 Other Programme Staff Costs/ Project Costs (116) Vanguard funding 0 21 (21) Commisioning Schemes 0 (92) Reserves ,992 2, % Risk Reserve ,037 1,037 0 Total ,730 4,730 0 Running Costs ,090 3,090 0 Total Application of funds 37,317 37,421 (104) 233, ,271 0 Surplus 0 (104) (104) The CCG s 2017/18 financial plan delivers a break-even position. This is the first year in which CCG control totals have been allocated at STP level by NHS England. The NHS England Local Area Team (Wessex) worked with the Hampshire and Isle of Wight (H&IW) STP CCGs to agree control totals within that envelope. The Isle of Wight was allocated a break-even position to achieve. In line with the 2017/18 NHS England business rules the CCG has committed only 50% ( 1.1m) of its risk reserve and maintains a 0.5% contingency, which has not been utilised in the year to date position. From 201/18 onwards NHS England business rules requiring in-year reporting, rather than cumulative reporting. This means that any prior year surpluses will not be accounted for in the following year. Instead, the CCG s financial performance will measured against allocations relating to 2017/18 only. As in prior years, CCGs will 2 P age

58 not be able to use any previous year s surplus, without explicit and exceptional permission to draw it down. The CCG has been advised that t is likely, for the foreseeable future, that it will be given permission to draw down its 1% (c2m) surplus from 2016/17. As at the end of May 2017 (Month 2), the CCG is forecasting to achieve the planned in-year break-even position. However, due to the challenging 12.9m (5.6%) savings (QIPP) target, the CCG is currently reporting un-mitigated risks to the year-end position of 2m. For the same period, the CCG s year to date position is 104k behind plan, primarily due to the current 826k under-delivery of savings (QIPP) on schemes relating to reducing demand and cost within the IOW Trust Contract. This under-spend is partially off-set by the non-recurrent benefit of accrued 2016/17 expenditure that has come in lower than estimated. A summary of the key variances to date is as follows: Savings (QIPP) schemes, in relation to Isle of Wight Trust are underachieving. The total year to date savings target is 1.6m of which 1m has been applied to the Trust contract, and therefore delivered. The remaining 0.6m relates to the part of the QIPP risk share agreement with the Trust that the CCG agreed not to apply until schemes proved delivery. GP prescribing is 323k better than plan. This is mainly due accrued 2016/17 expenditure which has come in lower than estimated. Continuing Healthcare is showing an overspend of 54k. The overspend is mainly due additional and more complex Mental Health-over 65 and End of Life packages of care. Personal Budgets are on track. However, there are a number of cases awaiting decision that may lead to cost pressures. The CCG has a number of savings (QIPP) schemes in relation to Continuing Healthcare, where processes are currently being reviewed to ensure that they offer the best value. The CCG is still negotiating fee increases, jointly with the Local Authority, with care providers and this is likely to lead to a cost pressure. CCG staffing budgets are underspent by 77k and the CCG remains within its running cost allocation. 3 P age

59 Resource Limit As at the end of May 17 (month 2), non-recurrent allocations have been received in relation to: A change in the technical rules used to identify specialised (non-ccg) commissioning activity. The new tariff system for acute activity (HRG4+). 2.7m has been received towards an estimated cost of 3.7m. This gap is a cost pressure for the CCG The CCG resource limit is set out in the table below:- 2017/18 Month Recurrent Non- Recurrent Total '000 '000 '000 Funding CCG Core Programme Allocation 207, ,027 Growth funding Running Cost Allocation 3,090 3,090 Primary Care Delegated Co-commissioning 19,258 19,258 HRG 4+ funding 2,685 2,685 Specialised funding changes Total Opening Funding (as per plan submission) 229,713 3, ,271 Total Funding 229,713 3, ,271 QIPP Position The QIPP target for 2017/18 is 12.9m (5.6%) and 5.7m (2.5%) in 2018/19, which is 2-3 times the level usually achieved by the CCG. To recognise the risk around the delivery of the savings (QIPP) schemes relating to the Trust, a risk-share was put in place to cover the 10.3m savings plan, where the CCG has applied 6m (c60%) of the savings to the Trust contract. The remaining 4.3m (c40%) of savings, will be applied once further confidence in delivery has been secured. The 2017/18 savings (QIPP) target is shown in the first table below, and the year to date position in the second table. 4 P age

60 Delivery Plan Grouper /18 QIPP TOTAL Trust Risk share (Removed from Contract up-front) CCG risk share Value CCG Budgets Other savings The year to date position is 826k behind plan. This relates to the Trust related QIPP schemes still held by the CCG as part of the risk-share agreement and underdelivery against Continuing Healthcare savings. Total Excess Bed Days Procedure of limited clinical effectiveness 1, ,267 Outpatient Reductions 1, ,340 Ambulatory / Urgent Care Urgent Care Centre Continuing Healthcare Medicines Management 1, ,589 1,589 Mental Health cost rebasing 1,393 1, ,393 Mental Health transformation Community cost rebasing 1, ,320 Community Contract - Rehab 2,283 1,000 1, ,283 Community Services Transformation Reduce Running costs Total 12,904 5,763 4,057 3,084 12,904 Delivery Plan Grouper 000 Year to date Budget Year to date Actual Year to date variance Excess Bed Days (38) Procedure of limited clinical effectiveness (53) Outpatient Reductions (112) Ambulatory / Urgent Care (54) Urgent Care Centre (50) Continuing Healthcare (100) Medicines Management Mental Health cost rebasing (58) Mental Health transformation (51) Community cost rebasing (55) Community Contract - Rehab (214) Community Services Transformation (41) Reduce Running costs Total 2,151 1,324 (826) The non-delivery of Trust related schemes relate to a number of the schemes that have not yet been implemented. This is being addressed through a partnership approach, via the Isle of Wight Local Care Board, attended by the Chief Officers and Chairs of the CCG, Council and Trust and Paul Sly, the Interim System Convener. It should be remembered that although the CCG and partners may succeed in reducing demand, there is no true saving to the Island s health and care system until the costs within the provider service are removed. This is why savings must be delivered through a health and care partnership approach. 5 P age

61 Risk and Opportunities Risks RISKS Full Risk Value m Probability of risk being realised % Potential Risk Value m Acute SLAs % 0.20 Community SLAs 0.00 Mental Health SLAs % 0.20 Continuing Care SLAs % 0.50 QIPP Under-Delivery % 3.92 Other Risks 0.00 TOTAL RISKS OPPORTUNITIES Contingency Held % 1.04 Contract Reserves 0.00 Investments Uncommitted 0.00 Further QIPP Extensions 0.00 Non-Recurrent Measures % 0.75 Delay/ Reduce Investment Plans 0.00 Other Mitigations % 1.00 TOTAL MITIGATION NET RISK / HEADROOM (3.66) (2.03) Due to the significant value of the required savings (QIPP) schemes, the CCG has estimated a forecast position of 2m of un-mitigated risks. The key risks to achieving break-even are as follows:- Non delivery of balance of QIPP savings relating to Isle of Wight Trust ( 3.7m) Continuing healthcare QIPP savings not delivered and other potential cost pressures ( 0.5m). Potential additional high cost Mental Health placements ( 0.2m) Prescribing savings not being delivered ( 0.4m). The risks are partially off-set by:- Contingency 0.5% ( 1.1m) Non-recurrent funding adjustment ( 1m) Other mitigations: ( 1m) Due to its significant savings (QIPP) target, the CCG is being given practical support towards the delivery of QIPP schemes by NHS England, the details of which are in the process of being agreed and then quickly implemented. 6 P age

62 Key Performance Indicators Balanced Scorecard - Monthly Target Mar-17 May-17 Finance Efficiency: Invoice payment: <30 days % achievement - value Finance Efficiency: Invoice payment: <30 days % achievement - volume 95% 99.99% 99.99% 95% 99.59% 99.46% Finance Efficiency: Debtors >30 <=5% 4.15% 4.03% Finance Efficiency: Creditors >30 <=5% 0.00% 0.00% All performance indicators were achieved in May % NHS invoices and 99.9% of all Non NHS were paid with payment terms. CASH As at the end of May the CCG has drawn-down 37.6m which is 17.8% of cash available for the year. There is a requirement at year-end only that the CCG holds a maximum of 1.25%. WRITE OFFS There have been no write offs or impairment s within the account period to May CAPITAL The CCG currently has no capital assets. 7 P age

63 Governing Body Annual Report and Annual Accounts Sponsor: Summary of issue: Action required/ recommendation: Principle risks: Other committees where this has been considered: Financial /resource implications: Legal implications/ impact: Public involvement /action taken: Equality and diversity impact: Author of Paper: Helen Shields, CCG Chief Officer The CCG is required to prepare and approve an Annual Report and Accounts which provides a fair and true statement of the CCG s position at the end of 2016/17. To note the Annual Report and Accounts as approved at the Governing Body part II meeting on the 25 May There is a statutory requirement to produce the Annual Report and Accounts by the national timescales. The process for the development of the annual report has been discussed at the Audit Committee. The final report and accounts have been approved at the Audit Committee. The Annual Accounts provides a summary of the financial position at the end of the year 2016/17. This has been externally audited. The requirement to produce an Annual Report and Accounts is a statutory obligation. Guidance in relation to its content is provided by NHS England and must be adhered to by the CCG. The front section of the annual report is intended to be a standalone document which is written specifically for members of the public. It is designed to provide sufficient information for a lay person to understand the operation, overarching strategic intentions and performance of the CCG in the previous financial year. The CCG intends to publish this as a separate document for use to support public engagement in the coming year. The Annual Report includes information regarding equality and diversity and the CCG s agreed equality objectives. Loretta Outhwaite, Chief Finance Officer Phil Hartwell, Head of Corporate Governance Date of Paper: May 2017 Date of Meeting: 13 July 2017 Agenda Item: 5.3 Paper number: GB17-022

64 Isle of Wight CCG Annual Report and Accounts 2016/2017

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66 Table of Contents PERFORMANCE REPORT OVERVIEW Statement from the Accountable Officer Isle of Wight NHS Clinical Commissioning Group Our Island a unique set of healthcare challenges Who we are and how we work What we do Our financial allocation Our objectives and critical success factors Key Transformation Programmes Health and Wellbeing Board Primary Care Performance Summary Performance Finance Risk management Stakeholder relationships and engagement Factors affecting future performance Finance & Performance Workforce PERFORMANCE ANALYSIS Financial Performance CCG Performance CCG Assurance Framework 2016/ NHS Constitution Targets and other Performance Metrics Quality Sustainability Report Reducing Inequality Other disclosures Going concern Accountability Report MEMBERS REPORT The Members and Membership Council The Governing Body Disclosure to Auditors Members interests Disclosure of personal data related incidents Emergency Preparedness, Resilience and Response (EPRR)... 40

67 6.7 Employee consultation Modern Slavery Act Statement of Accountable Officer Responsibility Governance Statement Introduction & Context Scope of Responsibility Governance arrangements and effectiveness The Membership Council The Governing Body The Clinical Executive The Quality and Patient Safety Committee (QPSC) The Audit Committee The Remuneration Committee Isle of Wight Primary Care Committee Compliance with the UK Corporate Governance Code Discharge of Statutory functions Risk Management arrangements and effectiveness Capacity to Handle Risk Risk Assessment Other Sources of Assurance Review of Economy, Efficiency & Effectiveness of the Use of Resources Delegation of Functions Business Critical Models Third party assurances Control Issues Counter Fraud Arrangements Head of Internal Audit Opinion Review of the Effectiveness of Governance, Risk Management & Internal Control REMUNERATION AND STAFF REPORT Remuneration report Senior Manager s Remuneration Staff report Employment Policies and Processes Social, Community and Human Rights issues... 70

68 List of Tables Table Title Page 1 Better Care Fund (BCF) Summary of budgets 16 2 Summary of budgets 25 3 Year end income and expenditure /17 QIPP Savings Programme 27 5 NHS Constitution - CCG Performance 33 6 Attendance at Membership Council 45 7 Attendance at Governing Body Meetings 47 8 Attendance at the Clinical Executive 48 9 Attendance at Quality and Patient Safety Committee Attendance at Audit Committee Attendance at Remuneration Committee Attendance at Joint Committee for Primary Care Internal audits Senior Manager Service contract details Senior manager salaries and allowances 2016/ Senior Manager Pension Benefits Pay Multiples Off-Payroll Engagements as of 31st March Assurance sought in relation to Income Tax & NI Obligations Senior Managers who are off-payroll engagements Employee benefits and staff numbers 69 List of Figures Fig Title Page 1 CCG investment in NHS services 2016/ My Life a Full Life model of care 14 3 CQC grading IW NHS Trust 19 4 Governing Body and sub-committee structure 45

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70 PERFORMANCE REPORT 1. OVERVIEW 1.1. Statement from the Accountable Officer Welcome to the Isle of Wight Clinical Commissioning Group (CCG) Annual Report and Accounts for financial year 2016/17. This report summarises the CCG financial and operational performance highlighting both the positive changes that we have made and outlining how we intend to progress the ongoing and complex problems we are facing. 2016/17 has been a very challenging year and the CCG has continued to tackle a range of performance and quality issues whilst also engaging in the most comprehensive transformational change programme experienced in the Island health system for many years. The CCG met all of its 2016/17 statutory financial duties across both programme and running costs. In order to achieve this position some difficult decisions have been made regarding the Urgent Care Service, Gluten Free Food provision and Procedures of limited Clinical Value. This will be vital to support an increasingly financially challenged position for next financial year. To achieved the required break-even position for 2017/18, the CCG will have to deliver savings of 12.9m (5.6%), which is almost four times the level of savings normally achieved by the CCG. In recognition of the CCG s significant financial risk of delivering a 5.6% savings (Quality, Innovation, Productivity and Prevention) programme in 2017/18, in the Annual Results Report, the CCG s External Auditors, Ernst and Young, has issued a qualified conclusion on reporting by exception in relation to Value for Money. There were no other qualifications given in the CCG s External Auditors 2016/17 Annual Results Report. One of the reasons for the CCG s significant savings target is that the NHS CCG Allocation Formula shows the Island as remaining 11.9% ( 22m) over its target allocation, which means the Island will receive minimal funding growth, until it reaches less than 5% distance from target, despite an increasingly elderly and dependent population and the financial challenges that are inherent in running health care services for a small island population. There have been continued performance issues with the Isle of Wight NHS Trust in 2016/17. Despite having a system resilience plan in place the Island health system remained under significant pressure. Improvement Plans failed to deliver the anticipated recovery in performance. Targets around Emergency and Urgent Care were missed this year including A&E 4 hour waits, the hospital reported 68 trolley waits over 12 hours, the Ambulance Service missed its response time targets and the hospital was at a high level of alert during autumn and early winter. Treatment waiting times also missed national targets, however the waiting list at the Trust has been reducing and cancer waiting times have improved. 8

71 The Care Quality Commission (CQC) has carried out several inspections of Isle of Wight Service providers over the last year. The Isle of Wight NHS Trust inspection took place November and CQC issued the Trust with a section 31 notice to urgently impose conditions on the Trust s registration in relation to mental health services. Further inspections of mental health services have been carried out. The full report was published 12 April 2017 where the Trust was rated as inadequate and CQC recommended the Trust be placed into special measures. In relation to the CQC s inspection of other Island healthcare providers, in March 2017 Earl Mountbatten Hospice was rated as Outstanding by CQC. During the year CQC inspected 12 of the 16 GP Practices and they were all rated as Good, the remaining 4 Practices were inspected last year and were also rated as Good. The CCG has completed its first year since receiving delegated Primary Care Commissioning from NHS England. The Isle of Wight Primary Care Committee chaired by the CCG s Independent Lay Member has overseen the delegation of primary care to the CCG. The CCG has engaged with the local community and GP Practices on a new primary care strategy and the final version will be published in June Health and care organisations across Hampshire and the Isle of Wight have been working together, as a Sustainability and Transformation Partnership, to agree how best to respond to the many opportunities and challenges facing the local health and care system around the need to empower people to stay well and to provide safe, high quality, consistent and affordable health and care to everyone. This has led to the production of the Hampshire and Isle of Wight Sustainability and Transformation (STP) plan. The My Life a Full Life programme is the mechanism that will locally deliver the STP and is a vital part of the longer term sustainability for Island health and care services working across not only statutory partners but also with local GPs and the voluntary and independent sectors. As part of the My Life a Full Life programme, an acute service re-design is underway and once the recommendations have been identified a public consultation will be carried out. It will consider how services should be delivered and whether there are more effective or efficient ways of achieving high quality sustainable services for patients. There is also a mental health service reconfiguration taking place and in phase one it will focus on dementia care, crisis care and recovery. There are unprecendented challenges ahead, however the transformation programme will enable the Health and Care system, together with wider partners, to determine the future of health and care services for Island residents. Helen Shields 25 May

72 2. Isle of Wight NHS Clinical Commissioning Group The Isle of Wight NHS Clinical Commissioning Group (CCG) was formed on the 1st April 2013 following the changes that took place in the NHS as a result of the Health & Social Care Act One of the key changes involved putting clinicians in charge of commissioning the healthcare services their local community needs for both Island residents and visitors. We work in partnership with colleagues from GP Practices, hospital and community services, social care, independent and the voluntary sectors to maintain and make real improvements to the health and wellbeing of every person on the Isle of Wight. This collaborative approach is key to addressing the unprecedented challenges we are facing as the demand for health services increases. By integrating services so they are more efficient, we will be able to deliver better value for local residents and ensure the sustainability of services Our Island a unique set of healthcare challenges The Isle of Wight is a wonderful place to live and work, but it also has distinct challenges for commissioning healthcare services. The Island has significant needs with nearly a quarter of its population aged 65 and over. As this number increases and residents live longer, more people will be living with longterm conditions (LTC). Currently it is estimated 45,000 (one in three) people locally have one or more LTC such as coronary heart disease, stroke and diabetes. There is also an increasing prevalence of dementia on the Island which will affect 21% of those aged over 65 by With around 16,000 people on the Island suffering common mental health problems there is a need to address the emotional wellbeing of residents. There is signficant economic disparity between areas on the Island which gives rise to corresponding inequalities in health and life expectancies. Commissioning services to meet these challenges places increasing demands on local services, whilst at the same time there is a requirement to improve quality and make efficiency savings to ensure services are sustainable in the long term Who we are and how we work In 2016/17 the CCG was made up of 16 GP practices supported by a team of commissioning staff. It is responsible for commissioning that is the planning, purchasing and monitoring - healthcare services for the Isle of Wight. At the centre of the CCG are four key bodies which are described in detail later in this report. The Membership Council, on which every Island GP practice has a nominated Practice 10

73 Representative and collectively holds to account and sets the strategic direction for the Governing Body; The Governing Body is responsible for overseeing the CCG s commissioning responsibilities and ensuring the group uses its resources effectively to provide quality services which meet the needs of Island residents; The Clinical Executive manages the day-to-day operations of the organisation, and is accountable to the Governing Body; Isle of Wight Primary Care Committee functions as a corporate decision-making body for the management of the delegated Primary Care functions and the exercise of the delegated powers. To ensure clinical input in every level of CCG work, the Island GP practices are clustered into three Locality Groups, each with a population of 30-50,000; North & East, West & Central and South Wight. These groups look at the health needs of their local communities and practices work collaboratively to improve primary care services. For more information about the various bodies and committees visit our website: we are What we do We commission services from NHS and independent and voluntary sector providers both on and off the Island. Our vision is to commission high quality, sustainable and integrated services. Together with our partners, we are developing person-centred, coordinated health and social care on the Isle of Wight. We work to maintain and improve the quality of services, to keep patients safe and ensure services can be delivered when and where people need them. We are integrating services to make efficient use of the resources that we have in order to meet the healthcare challenges we face as a community both now and in the future. With the Isle of Wight NHS Trust and Isle of Wight Council, and our partners in the voluntary and independent sectors we aim to put in place the support, information and advice needed to help people improve the way they look after their own health so they can lead longer, healthier and more independent lives. Our Constitution, Commissioning plans and other publications can be found on our website: Our financial allocation In 2016/17 the CCG received 239m for both healthcare programme and running costs, which included 2.8m (1.4%) of growth funding and 4.9m of non-recurrent national funding for My Life a Full Life, the Island s New Care Model (Vanguard) programme. In addition, for the first time the CCG s allocation included 19m for Primary Care Services, which the CCG 11

74 took delegated responsibility for from 2016/17. Within its allocation, the CCG is given an annual limit for running costs. For 2016/17 this was 3.1m ( per head of the Island s population) and c1.3% of the CCG s total allocation. The running cost allocation has reduced by c15% since the CCG was set up in To provide an overview of how the CCG uses its allocation, Figure 1 below shows its expenditure across the different types of healthcare services for 2016/17. Further details can be found in section 4.3. The CCG s two highest areas of spend were: Acute Services (hospital based physical health services) and Primary Care Services (GP practices and their prescribing of drugs). The Better Care Fund is a pool of community and mental health services which are managed by the CCG and Council s Joint Commissioning Board see section for further information. Running Costs 1% Other 3% Primary Care 23% Acute 45% Continuing Care 6% Better Care Fund 8% Community 6% Mental Health 8% Figure 1: CCG % spend in 2016/17 One of the CCG s biggest financial challenges is that its current funding allocation is 11.9% ( 22m) above the target set by the NHS CCG Allocation Formula. For 2016/17 onwards, this means that the CCG has been given a minimal level of growth funding in order to, over time, address this distance from target. The consequence of this is the requirement for the CCG to deliver a higher % of savings each year, as the small amount of growth funding received does not cover the impact of inflation and increased healthcare need Our objectives and critical success factors 12

75 The CCG Governing Body set four objectives for the organisation in 2016/17, which are detailed in the Governing Body Assurance Framework: To support system transformation and sustainability; To meet the finance, quality, commissioning and performance targets within the operating plan; To implement and deliver delegated commissioning of primary care; To evolve the culture and governance within the CCG to deliver transformation. Against each of the four objectives a number of critical success factors were set. An assessment of whether the organisation has met the critical success factors can be found in the performance analysis section of this report Key Transformation Programmes My Life a Full Life The CCG together with local health and social care partners has been developing a new care model aimed at improving health, wellbeing and care of our Island population, improving care and quality outcomes, delivering appropriate care at home and in the community and making health and wellbeing clinically and financially sustainable. This is known as the My Life a Full Life programme. Care on the Island has historically been heavily reliant on statutory services, which has limited the range of care available to Island residents, and based on forecast demand is no longer clinically or financially sustainable. Our new care model will mean that people will have much greater support from their community, family and friends, as it: Builds on assets and mobilises social capital to help reshape care delivery to meet peoples changing needs; Integrates services to improve quality and increase system efficiencies using technology; Is based in the community or at home; Is a significant shift to prevention and early intervention, self-help and care, with the aim of reducing health inequalities and the health and wellbeing gap; Reduces reliance on statutory services. Progress towards implementation of the My Life a Full Life Model of Care has continued through 2016/17 with national Vanguard (New Care Models) funding of 4.74m received to drive forward the Island-Wide Transformation Programme. 13

76 Figure 2: My Life a Full life model of care Progress includes: Establishing and embedding Care Navigators and Local Area Coordinators across the Island; Delivering End of Life training across partner organisations; Implementing a number of Primary Care projects to explore new ways of working across general practice; Progressing the the Whole Integrated Service Redesign (WISR) Programme implementation of best practice working eg implementing Ambulatory Care an Acute Service Redesign Programme; Implementing Integrated Locality Services to improve joint working across Health and Care Services; Supporting development of the GP Federation (all Island practices); Developing Island wide Local Estates Strategy; Engaging with Town and Parish Councils to support local joint working; Implementing case management of highest risk patients in practices using the Risk Stratification Tool Hampshire & Isle of Wight Sustainability & Transformation Plans Over the past eight months, health and care organisations across Hampshire and the Isle of Wight have been working together, as a Sustainability and Transformation Partnership to 14

77 agree how best to meet the many opportunities and challenges facing the local health and care system around the need to empower people to stay well and to provide safe, high quality, consistent and affordable health and care to everyone. The central role of the Sustainability and Transformation Plans (STP) has been to support the local place based plans such as My life a Full Life to achieve the changes that local people and local clinicians have told us they want. The plan does not replace or slow down local transformation programmes. Instead, the Hampshire and Isle of Wight health and care organisations, have come together to do the things that can be best achieved by working in partnership. While people in Hampshire and the Isle of Wight are generally living longer, many are also living with multiple long-term physical and mental health conditions. Too many people stay in hospital longer than they need to because of difficulties in getting the necessary support outside. There are increasing shortages in the number of doctors, nurses and other health workers needed, which the organisations are working in partnership to address. Providing the highest quality acute care for southern Hampshire and the Isle of Wight University Hospital Southampton NHS Foundation Trust, Portsmouth Hospitals NHS Trust, the Isle of Wight NHS Trust and Lymington Hospital are working together to deliver the highest quality safe and sustainable hospital services to people living in southern Hampshire and the Isle of Wight, with a particular focus on making sure that Isle of Wight residents have safe and sustainable healthcare services. Improving mental health services The four NHS trusts that provide mental health services in Hampshire and the Isle of Wight (Southern Health Foundation NHS Trust, Solent NHS Trust, Sussex Partnership Foundation NHS Trust and Isle of Wight NHS Trust) have formed an alliance with the health care planners, local authorities, third sector organisations and people who use services to improve the quality, capacity and access to mental health services in the area. This will mean that patients will have access to the same high quality care, wherever they live in the area, as close to home as possible and will be supported to live independently Better Care Fund The Better Care Fund (BCF) is a single pooled budget for local health and care services which has been created as a national requirement to drive greater integration of services, in relation to both commissioning and provision (delivery), to enable the NHS and local government to work more closely together around people and placing their well-being as the focus of health and care services. The BCF is an enabler for the My Life A Full Life Programme. As the fund and the relationship between the partners develops over time, there will be a focus on introducing new ways of working which will drive efficiency gains across the whole health and social care system. For 2016/17 the value of the budget was 31m, the break-down of which is shown in the 15

78 table below. It is important to note that the BCF is not new or additional money, but is a pooling of existing money to be used to support an integrated approach to health and social care support. Whilst the CCG and Isle of Wight Council were not able to reach agreement to sign a Section 75 agreement to formally pool the funds for 2016/17, BCF budgets were aligned. An independent Better Care Advisor has been working with the CCG and Council to develop the pooled fund for , and the CCG and Council has appointed a joint post to lead integrated commissioning. CCG Contribution Council Contribution Total MENTAL HEALTH SERVICES 1, ,668 LEARNING DISABILITY SERVICES 1,442 2,430 3,872 REHABILITATION & REABLEMENT 7,307 3,785 11,092 LOCALITY / COMMUNITY MODEL 7,658 2,782 10,440 CARERS SERVICES CARE ACT PREVENTION PROTECTION OF ADULT SOCIAL CARE ,711 TOTAL 20,142 11,189 31,332 Table 1: Better Care Fund Schemes 2016/17 The CCG and Council Joint Commissioning Board (JCB) oversees the BCF, including the financial, performance and risk aspects. The JCB reports and is accountable to the Health and Wellbeing Board. 2.7 Health and Wellbeing Board The Isle of Wight Health and Wellbeing Board (HWB) brings together key partners with a common vision, working to promote health and wellbeing, build resilient communities and reduce inequalities to improve the quality of life on the Isle of Wight. The health and wellbeing strategy sets out key local themes: Health inequalities are reducing so the gap in health life expectancy between the more wealthy and less well-off becomes smaller; 16

79 People feel supported to achieve their potential to live a full life regardless of age, disability or disease; Health and wellbeing are improving; Neighbourhoods are inclusive places where people are able to contribute to ensure they are healthy, safe, resilient and sustainable. The CCG Chair and Chief Officer are members of the Health and Wellbeing Board and in the last year the following items have been presented to the Board: Sustainability and Transformation plan; Primary Care Strategy; My Life a Full Life reports; Better Care Fund reports; Minutes of the Joint Commissioning Board; Updates on the Care Quality Commission Inspection. 2.8 Primary Care During 2016/17, the CCG developed a new strategy to support the development and transformation of primary medical care aligned to the wider My Life a Full Life programme, as part of the assumption of wider delegated powers for primary medical care. This will be implemented alongside the GP 5 Year Forward View over the next three to five years. Key aspects of this strategy include improving access to Primary Care, investing in and developing the workforce and implementing digital solutions alongside develoopment of locality working and Primary Care at scale. The CCG has continued to support workforce development in Primary Care, investing in 2016/17 over 300k in support of the development of new clinical staffing in primary care including the development of a new class of clinical pharmacists, a programme of work with Southampton University to develop Advanced Nurse Practitioners and a project to support the development of Musculoskeletal practitioners through the My Life a Full Life programme. 17

80 3 Performance Summary 3.1 Performance The CCG monitors a series of NHS Constitutional Targets that are set nationally. These primarily cover waiting periods for treatments and response times for emergency services. Performance across the system has been disappointing this year due to capacity pressures throughout the health and care system. Progress with major service change has started, however although small changes have been delivered, which improve care for patients, this has yet to deliver the fundamental system transformation required. A detailed analysis of the CCG s performance can be found in the Performance analysis section. A summary of performance against the key targets is shown below: Patients to start treatment within a maximum of 18 weeks from referral Achieved: 87.29% Target: 92% The Hospital was unable to ring fence beds for planned treatments due to problems with patient flow through the hospital and out into the community. The Trust has also had issues with recruiting senior staff for a number of specialisms impacting on the Trusts ability to meet demand. Patient choice has been promoted with the use of mainland providers as alternative sites for treatment. In comparison this was achieved rate was below a national average of 90%. Plans are in place to recover the target by March Patients admitted, transferred or discharged within 4 hours of arrival at A&E Achieved: 85.74% Target: 95% A&E services have continued to be affected by the problems of patient flow through the local hospital, combined with staffing issues and the complex conditions of patients presenting at A&E. A review was undertaken in February 17 from which an Action Plan to develop improvements are being planned. Revised trajectories were submitted in March 2017 modelled to achieving the national standard of 95% by March The national average was 89.99% in 2016/17. Max 62 day wait from urgent GP referral to first definitive treatment for cancer Achieved: 81.71% Target: 85% 3 of the 9 cancer targets consistently met the National target in 2016/17 with an overall achievement of 7 targets met at year end. The CCG continually monitors the reasons that patients did not receive treatment within 62 days. This is often as a result of complex treatment requirements, or capacity issues experienced at mainland hospitals or the result of patient choice, particularly at the earlier 2 Week referral point. Ambulance response Times (Category A, Red 1 within 8 minutes) Achieved: 63.16% Target:75% There are number of targets for ambulance. The service failed to meet the target for the 18

81 3.2 Quality most urgent calls due to capacity issues and consequential delays in handing patients over to the Emergency Department. Actions aim to improve patient flow and reduce handover delays at the Trust with the intention being to aid improvement to the response times achieved. Diagnostics, People should wait less than 6 weeks for tests Achieved: 99.48% Target: 99% Performance for diagnostic tests has been good for a number of years and the CCG has met its target again this year. The CCG continues to improve and strengthen assurance arrangements in respect of quality and safety of the services it commissions. The CCG sets quality metrics for all contractors through its contractual arrangements, collects intelligence on quality, safety and patient experience which is then used to inform its work programme. Details of the quality agenda can be found in the Performance Analysis section of this report. During 2016/17, our approach to improving quality across the healthcare system included: the alignment of quality strategic objectives through collaborative working with providers, partners and stakeholders; looking to transfer care from hospital to community settings closer to home, whilst maintaining sustainable hospital services for care that cannot be delivered elsewhere; and robust contract management arrangements. Care Quality Commission Inspection of Isle of Wight NHS Trust The Isle of Wight NHS Trust inspection took place November and Care Quality Commission issued the Trust with a section 31 notice to urgently impose conditions on the Trust s registration in relation to mental health services. Further inspections of mental health services was carried out. The full report was published 12 April 2017 where the Trust was rated as inadequate and CQC recommended the Trust be placed into special measures. Overall rating for the Trust Inadequate F i g u r e Are services at this trust effective? Inadequate Are services at this trust caring? Good Are services at this trust responsive? Inadequate Are services at this trust well-led? Inadequate Individual Services Mental Health Service Inadequate 3 Ambulance Service Inadequate Community Services Requires improvement Acute Services Requires improvement 19

82 Figure 3 IW NHS Trust CQC inspection grades NHS Improvement have appointed an Improvement Director to support the Trust. The Trust is required to produce an Improvement Plan by the end of May, which the CCG, NHS Improvement and NHS England will then monitor. The CCG has reflected on the Isle of Wight NHS Trust CQC report and will be strenghtening the quality monitoring of the Trust inlcuding more visits to the services provided by the Trust. In relation to the CQC s inspection of other Island healthcare providers, in March 2017 Earl Mountbatten Hospice was rated as Outstanding by CQC. During the year CQC inspected 12 of the 16 GP Practices and they were all rated as Good, the remaining 4 Practices were inspected last year and were also rated as Good. 3.3 Finance The CCG s financial plan and budget for 2016/17 was developed in line with the CCG s Strategy and Operational Plan and were approved by the Governing Body. As demonstrated in Note 23 of the annual accounts, for the reporting period, the CCG met all of its financial duties. At the start of 2016/17, under NHS England s new CCG Assurance Annual Assessment, the Isle of Wight CCG was rated as Requires Improvement. This is for a number of reasons, including that the financial plan was unable to deliver the nationally required 1% surplus (c 2m) and, in order to meet its planned break-even position, the CCG had to draw down its prior year surplus of 4.5m. As set out in the 2016/17 NHS Planning Guidance, CCGs were required to hold a 1% 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 provided 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 Isle of Wight CCG has released its 1% reserve to the bottom line, resulting in an additional surplus for the year of 2.3m. This additional surplus will be carried forward for drawdown in future years. To achieve its financial position, the CCG delivered a Quality, Innovation, Productivity and Prevention (QIPP) savings programme of 6.5m (2.7%). Further details are in Section 5.1. Although the CCG achieved a break-even position for 2016/17, the CCG has an underlying deficit of 2.9m to be addressed in 2017/18. In recognition of the CCG s underlying financial deficit and the significant financial risk of delivering a 5.6% savings (QIPP) programme in 2017/18 as detailed in section 4.2, in the Annual Results Reports, the CCG s External Auditors, Ernst and Young, has issued a Qualified 20

83 conclusion on reporting by exception in relation to Value for Money. Further detail is in section 4.2. There were no other qualifications given in the CCG s External Auditors 2016/17 Annual Results Report. 3.3 Risk management The principle risks faced by the CCG are captured in the Governing Body Assurance Framework, which are linked to the strategic objectives of the CCG. At the end of this reporting period, the Governing Body had identified the following key risks: Workforce pressures Risks relate to the capacity and capability of the CCG s main service provider, the Isle of Wight NHS Trust to undertake quality improvements due to large numbers of vacancies and difficulties in recruitment. Funding Risks relating to the CCG s 11.9% ( 22m) distance from the NHS CCG Allocation Target, leading to reduced/no growth funding and higher savings targets. Performance Failure to meet key targets Accident & Emergency 4 hours, Ambulance and Referral to Treatment. Transformation Risks associated with STP and the engagement of all partners, the overall ambition may not meet the challenges of the system, delivery of the Acute Services redesign. 3.4 Stakeholder relationships and engagement Relationships with local stakeholders have been maintained with close working on the My Life a Full Life programme. The CCG works closely with HealthWatch, and they provide a representative on the Quality and Patient Safety Committee as well as the Joint Committee for Primary Care. The Governing Body meetings continue to be held in different locations across the Island seeking to engage with as many people as possible and raising the profile of the CCG and its role locally. Although the numbers of the public who attend these meetings are low, those that do report that they find the meetings welcoming and easy to access. During 2016/17, the Isle of Wight (IW) Clinical Commissioning Group (CCG) has undertaken several public engagement activities on a variety of healthcare topics with the aim of redesigning services which are sustainable within the challenging healthcare budget. A variety of methods have been used based on input from a multitude of stakeholders in the statutory and voluntary sectors to gain valuable feedback from the public. Online and paper surveys were conducted and face to face meetings including public forums in District Parishes, public meetings and presenting during formal, regularly held meetings with health professionals and the public. Topics have included : Gluten-free foods on prescription getting people s views on stopping the provision of 21

84 gluten free foods on the NHS for people with coeliac disease (Wight Bread Service); NHS Wheelchair Service provision gathering people s views on prioritising wheelchairs for those who need them full-time; NHS Rehabilitation service redesign to consider moving the rehabilitation beds from the hospital into the community; Primary Care Strategy development of a strategy for the delivery of primary care services in the community; Emergency Care Service, Walk-in Service Access - people s views were sought on the impact of not having an Urgent Care Service during the day time (8:30 am to 18:30 pm) when GP surgeries are open. The CCG took part in the CCG 360 stakeholder survey and the results have shown a marked deterioration in 2016/17. While the CCG was seen as the system leader and stakeholders felt they knew CCG plans and were happy to raise concerns with the organisation, the stakeholder feedback also identified a fall in overall level of engagement, a deterioration in the position with respect to reduced level of confidence in the CCG s ability to deliver changes and it being unable to influence plans. The CCG with its Membership is developing plans to address issues raised. 22

85 4 Factors affecting future performance 4.1 Finance & Performance For 2017/18 the CCG has received an allocation of 233m. As explained in Section 2.4. Under NHS England s CCG funding formula, the CCG s core services allocation for 2017/18 is 11.9% ( 22m) above target, which means that until the % falls to below 5%, the CCG will receive minimum growth funding each year. For 2017/18 the CCG has therefore only received growth funding of 0.3m (0.2%). The CCG is actively working with the NHS England national allocations team to understand and address the causes of the Island s significant distance from target allocation. Although the CCG will start 2017/18 with a brought forward surplus of 2.3m, NHS England has advised that this surplus will not be available in the near future for the CCG to drawdown. The CCG s two year financial plan delivers a break-even position for 2017/18 and a 1m surplus (0.5%) for 2018/19. This is the first year in which CCG control totals have been allocated at Sustainability and Transformation Partnership (STP) level by NHS England. The NHS England Local Area Team (Wessex) has worked with the Hampshire and Isle of Wight (H&IW) STP CCGs to agree control totals within that envelope. STPs have been required to submit local financial plans showing how the organisations within their system will achieve financial balance within the available resources. The CCG s control totals for both 2017/18 and 2018/19 meet the STP control total requirements. In order to deliver the financial plan, the Quality, Innovation, Productivity and Prevention (QIPP) savings target for 2017/18 is 12.9m (5.6%). This is almost four times the level of savings historically delivered by the CCG. To recognise the risk around the delivery of the QIPP schemes relating to the Isle of Wight NHS Trust, a risk-share has been agreed for schemes to the value of 10.3m, with the CCG initially applying 6m (c60%) of the savings to the contract. The remaining 4.3m (c40%) of savings will be applied to the Trust s contract once further confidence in delivery has been secured. As stated in section 3, in recognition of the CCG s significant financial risk of delivering a 5.6% savings (QIPP) programme in 2017/18, in the Annual Results Report, the CCG s External Auditors, Ernst and Young, has issued a Qualified conclusion on reporting by exception in relation to Value for Money, as follows. The CCG reported a surplus of 2.3m in its financial statements for the year ending 31 March 2017, but with an underlying decifit of 2.9m. Achieving this outturn surplus relied on the return of a 4.5m prior year surplus; this non-recurrent funding will not be available in the future. The CCG has not yet succeeded in addressing the underlying deficit in its budget through putting appropriate arrangements in place to fully achieve its 12.9m recurrent QIPP target for 2017/18. 23

86 This issue is evidence of weakness in proper arrangements for planning finance effectively to support the sustainable delivery of strategic priorities and maintain statutory functions. For the CCG to achieve a financially sustainable position will require transformational change across both health and social care. As in both 2015/16 and 2016/17, for 2017/18 the Island s New Care Model (Vanguard) programme, My Life a Full Life, will receive national, nonrecurrent funding to support this transformation. The indicative value of this investment is 3.3m. Under the new national Sustainability and Transformation Partnership (STP) arrangements, the Isle of Wight is a Local Delivery System (LDS) within the Hampshire and Isle of Wight STP. The CCG, Isle of Wight NHS Trust and Isle of Wight Council are the members of the LDS. A Single Change Plan is being developed, which reflects each organisation s strategic objectives and incorporates both My Life a Full Life and the recommendations from the Trust s recent Care Quality Commission (CQC) inspection report, to deliver the service improvements and transformations required for high quality, sustainable health and social care services. In addition to meeting the national strategic (Five Year Forward View), financial and constitutional requirements, the CCG s 2017/18 Financial Plan supports delivery of the Isle of Wight LDS Single Change Plan. Any cost pressures/overspending areas for 2016/17 have been taken into account in the financial planning for 2017/18. The CCG s over-arching investment strategy has been and will continue to be, to move investment away from the acute/hospital setting, into community and primary care services. This is in line with the Island s My Life a Full Life, Health, Care and Wellbeing Strategy of reducing/avoiding hospital admissions through enhanced support in community and primary care settings and bringing health and care closer to home. To illustrate how the CCG s spending plans support its strategic objectives table 2 below provides an overview of the 2017/18 budgets. 24

87 2017/18 Summary of budgets Budget '000 Allocation 233,278 Spend Acute 109,087 Mental Health 18,957 Community 9,195 Better Care Fund 19,099 Children's 2,177 Continuing Care 14,704 Primary Care 52,851 Other Programme Staff Costs/ Project Costs 810 Contingency 1,167 Vanguard (non-recurring allocation) 1% Risk Reserve 2,266 Total 4,243 Running Costs 2,965 Total Application of funds 233,278 Surplus 0 Table 2: Summary of budgets 4.2 Workforce The Island has an ongoing challenge with the recruitment and retention of sufficient qualified staff to meet the needs of the local population. This is particularly acute in nursing across all sectors and in relation to General Practice where a number of practices are carrying multiple GP vacancies. While workforce redesign can mitigate the impact of this workforce shortage to some extent, it remains a risk for the NHS and affects the way in which the CCG can commission services. 25

88 5 PERFORMANCE ANALYSIS 5.1 Financial Performance Table 3: Year end (Month 12) March 2017 Income and Expenditure Position A summary of the key variances to the 2016/17 financial plan is as follows:- Mainland contract expenditure was 0.8m higher than plan due to both elective (planned) and non-elective (emergency) activity; The Continuing Healthcare (CHC) budget overspent by 1.9m mainly due to an increase in the number and complexity of continuing healthcare patients and an increase in 1:1 care within the nursing homes. CHC is an area of focus within the CCG s 2017/18 Quality, Innovation, Productivity and Prevention (QIPP) programme, to ensure that value for money is being achieved; Prescribing budgets under-achieved the savings target by 0.8m, due to capacity issues caused by vacancies within the Medicines Management Team, which are now recruited to; 26

89 Isle of Wight NHS Trust contract was 2.1m lower than plan due to elective (planned) activity being significantly below contracted levels; reimbursement of payment for community and mental health services due to a reduction in actual cost; Delegated Primary Care underspent by 0.4m due to lower premises, locum and Primary Medical Services (PMS) contract costs. To meet the planned break-even position, the CCG planned to achieve a c 6m (2.5%) Quality, Innovation, Productivity and Prevention (QIPP) savings programme. During 2016/17 the CCG had support from a Turnaround Director, which resulted in an increased target of 7.1m. The actual savings delivered for 2016/17 was 6.5m (2.7%). A summary of the schemes delivered is provided below. Delivery Plan Grouper Planned QIPP 000 Actual QIPP 000 Variance 000 Procedure of limited clinical effectiveness (207) Urgent Care Centre Continuing Healthcare (33) Medicines Management 1,673 1,157 (516) review of thresholds Turn-around Investment review Mental Health Staff vacancies Community Health Services vacancies Other (18) Investment review 1,643 1, Reduce Running costs Total 7,147 6,538 (609) Table 4: Summary of 2016/17 QIPP savings schemes year-end position In relation to cash, at the year end, the CCG had a ledger balance of 123k and physical cash balance of 127k. In accordance with NHS England cash management policy CCG s were allowed to retain up to 1.25% of their March cash drawdown, which equated to 213k for the Isle of Wight CCG. The CCG did not have any capital allocation or expenditure. 27

90 5.2 CCG Performance As part of the Governing Body Assurance Framework (GBAF), the Governing Body set critical success factors against which the organisation monitors its progress. The following table offers Governing Body s assessment of progress against these factors: Objective 1: To support system transformation and sustainability Critical Success Factor To complete the My Life full Life work programme for 2016/17 Achieved The vanguard funding has been released and the CCG has received 16/17 funding. The project management office is now integrated with the IW NHS Trust and three project managers have been recruited. New governance arrangements will mainstream the MLFL programme. To complete the agreed Whole Integrated Systems Review (WISR) programme and meet agreed timescales To integrate the commissioning function with the local authority in accordance with the agreed plan Not achieved Partially achieved The WISR business case was developed and submitted as part of the NHS England stage 1 assurance process. Further work was required on the models of care and a revised business case is being produced which will not be complete until summer 2017 following further work on acute services redesign. The joint post of assistant director of integrated commissioning has been appointed. A new Director of Social Services has been appointed by the Local Authority but with recent changes to the leadership of the IW Council this critical success factor will not be fully achieved this year but will be achieved in 17/18. Clear priorities across the system need to be agreed. To agree the Sustainability Transformation Plan (STP) across Wessex including: a) the local estates strategy and b) the Digital Road Map Partially achieved The Sustainability Transformation Plan (STP) across Wessex has been agreed by most organisations with the exception of the IW Council. The Plan has been approved by Governing Body and the local estates strategy and digital road map are in place. To deliver the case for an "Island Premium" Partially achieved The cost based review programme at the IW NHS Trust was suspended during the year but it is now being implemented as part of the turnaround process. This will provide the evidence for the case for an Island premium. The CCG has reviewed the national allocation formula and identified a number of areas where the Island seems to be disadvantaged. The Chief Finance Officer met with the national allocations team and agreed that the CCG will work with the National Team in advance of the national CCG allocations formula being refreshed. 28

91 Objective 2: To meet the finance, quality, commissioning and performance targets within the operating plan Critical Success Factor To meet the "must do" performance trajectories including developing an action plan to improve services for people with learning disability To achieve finance balance in 2016/17 meeting statutory responsibilities including delivery of QIPP targets To develop a robust financial plan for 17/18 To develop a plan to improve quality and safeguarding in commissioned services To achieve the quality indicators in the contracting schedules throughout the year To deliver the agreed system resilience plan Not achieved Achieved Partially achieved Not achieved N/A Partially achieved The key performance targets and trajectories have not been achieved in year. A task and finish group will be looking at Delayed Transfers of Care (DTOC), market positon and incentives to increase capacity. A turnaround programme has been established overseen by a new Turnaround Board. The QIPP programme was reviewed and strengthened during the year to focus on the key schemes for delivery. The IW NHS Trust has underperformed against the contract this year which has offset in-year cost pressures such as continuing health care and will enable the CCG to achieve its planned breakeven year end position. The level of QIPP savings required to achieve financial balance in 17/18 is 3-4 times the usual savings level achieved. Approximately 4m (33%) of savings plans are medium to high risk as they rely on system transformation. Mitigating actions are being put in place. There is a capacity and capability issue within the IOW NHS Trust to deliver and sustain quality improvements in commissioned services. The CQC inspection in November identified a series of quality issues including issuing a section 31 enforcement notice for mental health services. This was followed up by a further inspection in January. The formal CQC report was published 12 April The Governing Body agreed to combine this with the critical success factor (above) at the September meeting The system resilience plan was agreed and delivery of the plan has been a challenge due in part to workforce capacity. A revised A&E recovery plan was agreed in October and much of the plan has been delivered but this has failed to deliver any material improvements in performance. There has been considerable pressure over the winter period with several black alerts and a number of 12 hour breaches. 29

92 Objective 3: To implement and deliver delegated commissioning of primary care Critical Success Factor To publish a strategy for primary care Achieved The Primary Care Strategy has been published and approved by Governing Body and Primary Care Committee. To manage the budget in year and achieve finance balance within the delegated budget Achieved The processes supporting the delegated budget are in place and there has been review of standing orders and Standing Financial Instructions to incorporate the delegation. The delegated budget is projected to be in surplus at year end. Financial reporting is in place and being reviewed to provide more comprehensive information. To agree a quality framework for primary care To agree a performance dashboard and report Not achieved Partially achieved Quality is a standing item on the Primary Care Committee and Primary Care Operational Group (PCOG) agenda and a quality dashboard has been agreed however the framework requires a significant level of data collection and this has not been agreed with the GP Practices. While Primary Care Operational Group has agreed a performance dashboard there is an issue with the capacity to maintain the dashboard and work is ongoing with GP Practices to provide the necessary data. Objective 4: To evolve the culture and governance within the CCG to deliver transformation Critical Success Factor To embed the My Life a Full Life behavioural framework within the CCG by the end of the financial year Not achieved The CCG Constitution has been amended and approved by NHS England. A system HR lead was appointed to oversee the change programme. However a decision was made not to change the behaviours enshrined in the CCG constitution at this point because the new framework is focused on provider issues rather than Commissioning ones. To create and deliver an organisational development (OD) plan building on the CCG OD Strategy and including system leadership development Not achieved A system HR lead has been appointed to oversee the change programme and MLFL is leading the project however less progress has been made this year than anticipated. 30

93 To develop an outcome framework to support new contract, payment and pricing models To complete a review of the structure and governance of the CCG Not achieved Partially achieved There is a lack of capability and capacity within the CCG to develop robust outcome based commissioning framework during the year and develop new payment and pricing mechanisms. The HIOW STP has established a Commissioning Board and this Board will be developing a framework to support the new contract models. The Membership has been included in the discussions about governance of the CCG including how to improve communication and strengthen the locality meetings. There is a MLFL Board in place and the HIOW STP has established a Commissioning Board to improve the governance arrangements. Regular reports are submitted to Clinical Executive and Governing Body. It is anticipated that further changes to the structure and governance of the CCG will be needed in the future. Implement the stakeholder strategy Partially achieved There is a WISR stakeholder strategy in place and public engagement has taken place around individual service changes and the primary care strategy. There is a review of service provision currently being undertaken to create additional capacity to improve the process, however the strategy still requires a substantial refresh in order to embed learning and processes within the organisation. 5.3 CCG Assurance Framework 2016/17 A new CCG Assurance framework was introduced for 2016/17 which focusses around 4 key facets of our functions which are better health, better care, sustainability and leadership. There are 42 indicators, 17 of which are linked to the 6 clinical priorities of Mental Health, Dementia, Learning Disability, Cancer, Diabetes and Maternity. The indicators and ratings are updated at various stages of the year but final ratings for 2016/17 will not be published until around June At the time of publishing the annual report, ratings concerning up to Qtr2 was available. Key areas of note include: Leadership Probity and Corporate Governance and Staff Engagement indicators are positive. Effective working relationships across the system need to be improved. Sustainability In year financial performance and establishment of key enabling transformation plans such as the Digital Roadmaps met expectations. However current digital interactions between primary care and secondary care are behind expectations. 31

94 Clinical Priorities Dementia - Rated as Top Performing The indicators relate to diagnosis targets. Diabetes - Rated as Needs Improvement The indicator for treatment targets was good but poor in education. The education service has now been introduced. Learning Disability - Rated as Needs Improvement The CCG benchmark above average in numbers of inpatients registered. Cancer - Rated as Needs Improvement Indicators for early diagnosis are good but treatment within 62 days missed national targets. Mental Health - Rated as Performing Well Based on IAPT Recovery and Early Intervention in psychosis. Maternity - Needs Improvement Similar to most CCGS on 3 indicators but poor in respect of the number of mothers smoking whilst pregnant. The full and latest indicator ratings can be found on the MY NHS Website. 5.4 NHS Constitution Targets and other Performance Metrics During 2016/17 performance against constitutional targets was compromised predominantly by capacity pressures and patient flow issues throughout the health and care system. The CCG met 8 of the 15 national NHS Constitution Key Standards. Key problem areas were the 18 week referral to treatment (RTT) target, A&E 4 hour waits and Ambulance response times. Robust monitoring and detailed reporting applies to all constitutional targets and in 2016/17 a Systems Resilience Group was established with agreed trajectories intended to lead to a recovery of National targets across a range of key indicators including A&E 4 hour waits and RTT 18 week targets. The group was a collaborative process between key representatives from the CCG and Isle of Wight NHS Trust with regular reporting of performance and discussion around actions to gain improvement. During 2016/17 the IOW NHS Trust has failed to deliver its contracted activity levels for planned elective treatments both for inpatients and day cases. This was predominantly due to the inability to ring fence beds for planned treatments because of problems with patient flow through the hospital and out into the community. This has had consequences for the 18 week RTT constitutional target. 32

95 NB: All rates are as at the end of March 2017 and exhibit the YTD position up to and including February Table 5: NHS Constitution achievement 2016/17 The CCG has actively promoted increased activity at mainland trusts and the independent sector to help alleviate the pressures on the IOW waiting list. Outsourcing from the existing IOW NHS Trust waiting list has had limited success however, by actively promoting choice through targeted media campaigns to the public and primary care, there has been an increasing number of direct referrals to local mainland independent sector providers by island GP s. In addition action plans were developed to support patient flow and non-elective impact on waiting lists, together with improved booking efficiencies and theatre utilisation. Accordingly there has been a drop in the number of new referrals to the IOW NHS Trust. The CCG has determined the activity and trend information available to understand the activity demand levels at the IOW NHS Trust and mainland providers for 2016/17. Throughout the next year we will continue to actively promote patient choice and demand plans have been developed with all our major providers to ensure sufficient activity levels are commissioned, including ongoing commissioning of mainland independent sector capacity. 33

96 Performance against the A&E target remained disappointing for 2016/17. A review by the Emergency Care Intensive Support Team (ECIST) in February 2017 reported significant flow issues through the system as the main cause, as demand for non-elective admissions has been contained by schemes that have been put in place. The Trust has been working closely with the Trust Development Agency (TDA) as well as ECIST to develop an action plan from recommendations that followed a series of improvement meetings and assessments. The Trust and the System Resilience Group will continue to work to improve Urgent and Emergency care services including in both Medical Assessment Unit and Emergency Department along with progressing the development of the local Ambulatory Care model. The CCG has reported twelve breaches of mixed sex accommodation during the year, all of which occurred at the Isle of Wight NHS Trust in the latter half of the year and there were no reported instances where individuals had their operations cancelled twice. There have also been 68 individuals who waited on trolleys in A&E for more than 12 hours and 12 patients waiting more than 52 weeks for an operation or procedure both measured against a target of zero. Performance against Cancer 62 day waits improved but Ambulance targets remained inconsistent during 2016/17. Trajectories for 2017/18 reflect a step change of improvement aimed at recovering and sustaining performance at the constitutional standards. These trajectories are supported by agreed action plans and capacity plans. 5.5 Quality The Isle of Wight CCG developed a Quality Strategy during 2016/17 setting out how it intends to promote year-on-year improvement in patient safety, quality and patient experience. The CCG continues to strive to deliver real improvements in the quality of care as well as improving physical and emotional health and wellbeing of patients within our local communities and across the Island. To achieve this the CCG have set out a comprehensive range of goals to promote a wide reaching quality and patient safety culture focused on reducing avoidable harm, improving care and embedding essential learning to support quality and safety improvements as well as the overall patient experience of care. This process establishes baselines and targets for quality, safety and patient experience improvements across commissioned providers. In 2016/17 the CCG expanded the work of the quality team to promote quality within primary care and care homes. A multi-agency Infection Prevention and Control Group was established to address hospital and community acquired infections. The CCG will continue our focus on gaining assurance that our providers have robustly embedded local and national learning to reduce the risks of future harm, including any action points and learning arising from CQC inspections of providers. 34

97 5.5.1 Complaints/Concerns During 2016/17 the CCG received 14 formal complaints managed in line with the NHS complaints procedure. Of the 14, four were in relation to continuing healthcare decisions. There were 43 concerns received during the same period by the organisation. The main areas were primary care, waits for appointments and concerns related to provider services at the Isle of Wight NHS Trust Safeguarding The CCG continues to face significant challenges within the Safeguarding arena, however it has made some clear improvements in 2016/17, supporting providers in their capacity and capability to safeguard individuals effectively. These improvements have included: The CCG Designated Nurse for Safeguarding Adults and Children, now also incorporates the role of Designated Nurse for Looked After Children (LAC); The CCG Designated Nurse has reviewed the system for the undertaking of annual Review Health Assessments (RHAs) in LAC. As a result the Public Health Nursing Team, specifically School Nurses, have agreed to implement a new model, whereby they undertake RHAs in 5-11 year old children. This new model will enable the School Nurses to be more involved with this vulnerable cohort of children and will enable the NHS Trust LAC Nurse to increase capacity to support children and young people aged who are transitioning into adolescence, adulthood and care leaver status; The CCG Named GP for Safeguarding and the CCG Designated Nurse have embarked upon an improvement and support programme for safeguarding practice across Primary Care, including the delivery of targeted/bespoke training, the development of safeguarding resources on the CCG Extranet, the undertaking of face to face safeguarding case reviews to examine lessons to be learned, as well as established plans for dedicated training/supervision for GP Leads for Safeguarding; The CCG has secured 75% grant funding to support the appointment of a Safeguarding Nurse for Primary Care, for one year through the Burdett Nursing Trust. The CCG commissioned training sessions focusing on the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). This training was targeted at hospital-based doctors and GPs and was delivered by an expert legal firm Medicines Optimisation Prescribing is the most common intervention in the NHS. The Medicines Optimisation Team has been working to ensure that medicines within the CCG are prescribed safely, effectively and provide value for money. There is a small team of pharmacists, nurses and technicians who work closely with GPs to review patient s medication and support prescribers and patients to manage medicines. It may involve stopping some medicines and starting others. This is important in order to ensure people get the best health outcomes from the drugs and 35

98 preparations that are prescribed. The CCG ensures that they meet the statutory responsibility for making medicines with a positive National Institute for Health and Care Excellence technical appraisal (NICE TA) available to services that the CCG commissions within 90 days of publishing. GPs have been using a prescribing tool to assist them in ensuring they prescribe the best and most cost-effective treatments for patients on the island. All practices are involved in this initiative which is led by an expert group of GPs, nurses and pharmacists known as the Primary Care Prescribing Committee. GP Practices and the medicines team have been focussing on safer use of antibiotics, the aim being to reduce variation in prescribing on the island. Peer review and benchmarking has been used to drive further improvements and start to reduce variation. The Isle of Wight CCG has a significant number of people in care homes; work is ongoing with care home staff to review their overall management of medicines Performance and Prescribing Primary care prescribing was 783k over the planned budget, but overall inflation against this budget remained below the England rate. 5.6 Sustainability Report Background The CCG is committed to purchasing health care in a way that supports the UK sustainable development agenda and contributes to environmental improvements, regeneration and reducing health inequalities Policy and governance As part of its Sustainability Policy the CCG is committed to the concept of holistic commissioning, which actively takes into account the determinants of health that affect individuals, groups and the wider population of the Isle of Wight. The CCG works to a strategy and framework to ensure that our commissioning processes such as service design, tendering and contracting takes account of environmental sustainability and social value of services at the same time as improving quality Sustainable Development Management Plan In line with the SDU requirements, the CCG has a Sustainable Development Management Plan (SDMP) and strategy to progress the sustainability agenda. This plan was created jointly with the Isle of Wight NHS Trust. In the last year we have continued to promote the principles of sustainable development throughout the organisation especially through the My Life a Full Life Programme. This programme helps people to manage their own health and wellbeing whilst improving the 36

99 quality of care and support that services provide. The CCG is housed in an energy efficient building with energy and water efficient technologies and has a bike pool for staff travelling short distances. The CCG has an effective recycling scheme whereby under desk bins have been removed and replaced with shared waste stations. As a result 50% recycling rates for premises were achieved. Systems are in place to recycle batteries and toners and cartridges, electronic and electrical waste. 5.7 Reducing Inequality The CCG has published its equality objectives, reports on these annually and sets new objectives at least every four years. The targets are: Objective one seeks to embed the principle of equality into day to day business of the CCG. The CCG ensures a narrative on reducing inequality is provided to the Governing Body and each of its subcommittees on every paper and decision; and has implemented mandatory Equality and Diversity training for all staff. Objective two seeks to improve physical health checks amongst those with serious mental illness. This continues to be an area of work and is being implemented across mental health services through contractual mechanisms and is part of the quality improvement programme in primary care. Objective three is about helping people to help themselves by taking control of their health and setting their own goals and ambitions. This work stream is monitored against the protected characteristics to understand what areas the CCG should particularly target in rolling out projects such as care planning and access to medical records. The Equality Act (2010) requires public organisations to eliminate unlawful discrimination, advance equality of opportunity and foster good relations between people who may or may not share a protected characteristic. To achieve this we are required to analyse the effect of any policy, strategy, business case, and project or service change. The CCG has developed a template to support staff to consider equality impact and to identify where analysis is required. We encourage the use of equality analysis at an early stage and again towards the end of a project so that any evidence gaps can be considered as part of the stakeholder engagement element of the project. The results of this analysis are reported to those committees where decisions are made to ensure that a fully rounded decision can be arrived at. 5.8 Other disclosures Systems and processes Continued improvement to systems and processes is achieved through an active internal 37

100 audit programme. As discussed later in this report, the CCG has received a draft opinion of reasonable assurance from the auditors. The CCG has a strong focus on the management of corporate risk and performance with reporting at all key governing body sub-committees and at the Governing Body itself. Clear lines of accountability are established across the organisation feeding into these committees. 5.9 Going concern NHS Isle of Wight CCG Governing Body is required to assess and satisfy itself that it is appropriate to prepare the financial statements on a going concern basis for at least 12 months from the date of the accounts. To carry out the task the Governing Body has over the year considered factors that individually or collectively, might cast doubt on the going concern assumption. These issues are concerned with financial risk, operating losses (historical and current), nonachievement of savings plans or other financial targets, cash flow problems, loss of staff or management without replacement, serious non-compliance with regulatory or statutory requirements. Within the CCG s External Auditors Annual Results Report, Ernst and Young has confirmed that no conditions or events were identified, either individually or in aggregate that indicated there could be doubt about NHS Isle of Wight CCG s ability to continue as a going concern for the 12 months from the date of our report (May 2017). The Governing Body is able to confirm there are no material uncertainties that may cast significant doubt about the Group s ability to continue as a going concern for at least 12 months beyond the date of the 2016/17 statement of accounts. We certify that the CCG has complied with the statutory duties laid down in the NHS Act 2006 (as amended). The accounts were prepared under Direction: NHSCB under NHS Act Signed, Helen Shields Accountable Officer 25 May

101 Accountability Report 6 MEMBERS REPORT This report has been produced by the Governing Body on behalf of the CCG. (See Governance statement for diagram of relationship of committees). 6.1 The Members and Membership Council NHS Isle of Wight Clinical Commissioning Group is made up of 16 GP practices grouped to form the three Island Localities listed below: West and Central North and East South Wight The Dower House Carisbrooke Medical Centre Medina Healthcare Brookside Health Centre Cowes Medical Centre Tower House Surgery Esplanade Surgery East Cowes Surgery St. Helen's Medical Centre Argyll House Shanklin Medical Centre Sandown Health Centre Ventnor Medical Centre Beech Grove, Brading Grove House South Wight Medical Each practice is represented at the CCG Membership Council, which acts as the electoral college for the CCG to elect member clinicians onto the Clinical Executive. It also approves the process for recruiting and removing non-elected members from the Governing Body and agrees the CCG s overarching vision, values and overall strategic direction. 6.2 The Governing Body The Governing Body is responsible for overseeing key relationships concerning the CCG s statutory functions. In 2016/17, the Governing Body comprised Dr John Rivers (chairman), Helen Shields (Chief Officer and Accountable Officer), Dr Joanna Hesse (Clinical Executive GP), David Newton (Lay member Patient Public Involvement), Loretta Outhwaite (Chief Finance Officer), Martyn Davies (Deputy Chair/Lay Member Governance), Laurence Taylor (Lay Member Chair of Primary Care Committee), Dr Ian Reckless (Secondary Care Doctor), Lindsay Voss (Governing Body Nurse) and Loretta Kinsella (Director of Quality and Clinical Services) The Governing Body has delegated responsibility to the following five Committees according to the scheme of delegation in the CCG constitution. These are: The Audit Committee, provide the Governing Body with an independent and objective view of Governance and financial systems, financial information and compliance with laws, regulations and directions; 39

102 The Remuneration Committee, makes recommendations to the Governing Body on the remuneration, fees and other allowances for employees and for people who provide services to the CCG; The Quality and Patient Safety Committee, ensures that all decisions are safe and effective and that they improve the quality of care experienced by patients; The Clinical Executive, is responsible for the monthly operational oversight of the CCG, developing and recommending strategy, undertaking the majority of the commissioning function and ensuring that clinical decision making remains central to its work; The Isle of Wight Primary Care Committee, takes delegated responsibility for primary care commissioning from NHS England and for decisions relating to the overall strategy, management of budgets and operational oversight of the management of primary care The Membership of these committees together with their attendance at meetings can be found in the Governance Report at section Disclosure to Auditors Each of the Group s Governing Body members confirms: that so far as the member is aware, that there is no relevant audit information of which the CCG s external auditor is unaware; and that the member has taken all the steps they ought to have taken as a member in order to make themselves self-aware of any relevant audit information and to establish that the CCG s auditor is aware of that information. 6.4 Members interests The CCG maintains a register of members interests which can be viewed on the CCG website: Disclosure of personal data related incidents During 2016/17 there was one Information Governance serious incident requiring investigation (SIRI) reported to the Information Commissioners Office (ICO), however no further action was taken by the ICO and the incident has now been closed with the relevant actions implemented. No cyber security incidents were reported in 2016/ Emergency Preparedness, Resilience and Response (EPRR) The CCG needs to be able to plan for, and respond to, a wide range of incidents that could impact on health or patient care. These could be anything from prolonged period of severe pressure on services, extreme weather conditions, an outbreak of an infectious disease, a major transport accident or industrial action. 40

103 The CCG is a category 2 responder as defined by the Civil Contingencies Act The key responsibilities are: Member of the Hampshire & Isle of Wight Local Health Resilience Partnership; Participating in training and testing exercises which are used to test response plans; Assisting with the local co-ordination of emergencies in partnership with the NHS England (Wessex); Ensuring a 24 hour a day, seven day a week on-call system; Ensuring compliance with the national core standards for EPRR for both CCG and NHS funded healthcare providers. The CCG and Isle of Wight NHS Trust completed a self-assessment of their compliance with the NHS EPRR core standards. The Isle of Wight CCG was rated by NHS England (Wessex) as substantially compliant with the core standards and the Isle of Wight NHS Trust as partially compliant. The CCG worked with the Trust and the NHS England (Wessex) as part of this assurance process. NHS England (Wessex) represents the NHS at the Hampshire and Isle of Wight Local Resilience Forum (LRF) meetings. 6.7 Employee consultation The CCG is committed to the involvement of all of its key stakeholders in the process of creating and delivering its strategic aims including its employees. A process for formal consultation with employees takes place through the Wessex staff partnership forum which includes staff representatives, CCG managers and Human Resource managers from the CCG s HR provider. There is also an informal CCG Staff Forum which ensures staff from areas and levels of the organisation are able to bring issues to the CCG management. A staff survey has been carried out. 6.8 Modern Slavery Act The Isle of Wight CCG fully supports the Governments objectives to eradicate modern slavery and human trafficking. Our Slavery and Human Trafficking Statement for the financial year ending 31 March 2017 will be published on our web site at by 30 September

104 7 Statement of Accountable Officer Responsibility 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 Helen Shields to be the Accountable Officer of NHS Isle of Wight CCG. The responsibilities of an Accountable Officer are set out under the National Health Service Act 2006 (as amended), Managing Public Money and in the Clinical Commissioning Group Accountable Officer Appointment Letter. They include responsibilities for: The propriety and regularity of the public finances for which the Accountable Officer is answerable, For keeping proper accounting records (which disclose with reasonable accuracy at any time the financial position of the Clinical Commissioning Group and enable them to ensure that the accounts comply with the requirements of the Accounts Direction), For safeguarding the Clinical Commissioning Group s assets (and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities). The relevant responsibilities of accounting officers under Managing Public Money, Ensuring the CCG exercises its functions effectively, efficiently and economically (in accordance with Section 14Q of the National Health Service Act 2006 (as amended)) and with a view to securing continuous improvement in the quality of services (in accordance with Section14R of the National Health Service Act 2006 (as amended)), Ensuring that the CCG complies with its financial duties under Sections 223H to 223J of the National Health Service Act 2006 (as amended). 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; 42

105 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; and, Prepare the financial statements on a going concern basis. To the best of my knowledge and belief, I have properly discharged the responsibilities set out under the National Health Service Act 2006 (as amended), Managing Public Money and in my Clinical Commissioning Group Accountable Officer Appointment Letter. I also confirm that: as far as I am aware, there is no relevant audit information of which the CCG s auditors are unaware, and that as Accountable Officer, I have taken all the steps that I ought to have taken to make myself aware of any relevant audit information and to establish that the CCG s auditors are aware of that information. that the annual report and accounts as a whole is fair, balanced and understandable and that I take personal responsibility for the annual report and accounts and the judgments required for determining that it is fair, balanced and understandable. Helen Shields Accountable Officer; 25 May

106 8 Governance Statement 8.1 Introduction & Context NHS Isle of Wight Clinical Commissioning Group is a body corporate established by NHS England on 1 April 2013 under the National Health Service Act 2006 as amended. The clinical commissioning group s statutory functions are set out under the National Health Service Act 2006 (as amended). The CCG s general function is arranging the provision of services for persons for the purposes of the health service in England. The CCG is, in particular, required to arrange for the provision of certain health services to such extent as it considers necessary to meet the reasonable requirements of its local population. As at 1 April 2016, the clinical commissioning group is not subject to any directions from NHS England issued under Section 14Z21 of the National Health Service Act Scope of Responsibility As Accountable Officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of the clinical commissioning group s policies, aims and objectives, whilst safeguarding the public funds and assets for which I am personally responsible, in accordance with the responsibilities assigned to me in Managing Public Money. I also acknowledge my responsibilities as set out under the National Health Service Act 2006 (as amended) and in my Clinical Commissioning Group Accountable Officer Appointment Letter. I am responsible for ensuring that the clinical commissioning group is administered prudently and economically and that resources are applied efficiently and effectively, safeguarding financial propriety and regularity. I also have responsibility for reviewing the effectiveness of the system of internal control within the Clinical Commissioning Group as set out in this governance statement. 8.3 Governance arrangements and effectiveness The main function of the Governing Body is to ensure that the group has made appropriate arrangements for ensuring that it exercises its functions effectively, efficiently and economically and complies with such generally accepted principles of good governance as are relevant to it. NHS Isle of Wight CCG has a Membership Council, Governing Body, Primary Care Committee (for delegated functions) and a series of Governing Body subcommittees. Statutory responsibilities have been delegated as set out in the Strategic Scheme of Delegation within the Group s Constitution. This provides for the majority of decisions to be made by the Clinical Executive a clinically-driven subcommittee of the Governing Body. 44

107 Governing Body Isle of Wight Primary Care Committee Audit Committee Remuneration Committee Quality & Patient Safety Committee Clinical Executive Figure 4 - Governing Body and Sub-Committee Structure The Membership Council The Membership Council has specific responsibilities to ensure that the Governing Body retains the confidence of the membership and to participate in the development of the overarching clinical strategy of the CCG. It also acts as the Electoral College to the Clinical Executive on the expiry of clinical executive terms. The Membership Council has met once during the year in September to agree changes to the constitution and the process for the Clinical Executive elections. It was also given an update on the financial position of the CCG. Table 6 below indicates the members of the Membership Council and their attendance/involvement during the reporting period: Name Practice Dr Adam Poole GP Argyll House, Ryde X Dr Andreas Lehmann GP Medina Healthcare X Dr Peter Hill GP South Wight Medical Centre / Dr Cabrini Salter GP Shanklin Medical Centre / Dr Jenny Want GP East Cowes Medical Centre / Dr David Isaac GP Carisbrooke Health Centre X Dr George Thomson GP Brookside Health Centre, Freshwater / Dr Himanka Rana GP Tower House Surgery, Ryde / Dr Jagannadha Boorle GP Cowes Medical Centre X Dr David Stephenson GP Ventnor Medical Centre / Dr Mira Hueppe GP St Helens Medical Centre / Dr Hugh Trowell GP Sandown Health Centre (chair) / Dr Spencer Fox GP Esplanade Surgery, Ryde / Dr Stephen Doggett GP Grove House, Ventnor / Dr Richard Loach GP Beech Lodge, Brading / Dr Stephen Selby GP Dower House / Table 6: Attendance at Membership Council 45

108 An election for new Clinical Executive members to start in April 2017 was undertaken by the Membership Council in October with four nominations made. A vote was held after which Dr David Anderson and Dr Cabrini Salter were mandated onto the Clinical Executive. 8.4 The Governing Body The Governing Body is concerned with ongoing assurance within the CCG as described within the CCG s Constitution. It makes decisions on specific issues, largely concerned with the strategy of the CCG, as set out in the Strategic Scheme of Delegation and in the event that the Clinical Executive is unable to act due to conflicts of interest. During the reporting period, the Governing Body: approved the budget and operational plan for the CCG approved new objectives for the organisation aligned to the operational plan received regular updates on the major risks being run by the CCG received regular updates on progress against NHS Constitution targets and other performance and quality measures agreed the Hampshire & Isle of Wight System Transformation Plan (STP) approved the system resilience plan approved Quality, Innovation, Productivity and Prevention (QIPP) Plan approved the Local Estates Strategy & Digital Road Map approved Procedures of Limited Clinical Value (PLCV)/Threshold Procedures and Conditions implementation of New Rehabilitation Service proposed Changes to Wheelchair Provision reports were received on Ambulance, Mental Health and GP Out of Hours services reports on CQC inspection at IW NHS Trust approved the removal of Gluten Free Prescribing The Governing Body remains concerned at the CCG's inability to meet key NHS constitution targets, particularly the 18 week referral to treatment time target and the A&E 4 hour wait as well as ambulance targets despite detailed action plans being in place. Table 7 indicates the members of the Governing Body during this reporting period (2016/17) and their attendance at meetings held in public: 46

109 Name Title Apr May July Sept Oct Nov Dec Feb Mar RIVERS, John CCG Chair x x DAVIES, Martyn Lay Member for Governance (Deputy Chair) HESSE, Jo Clinical Executive Member and GP x x NEWTON, David Lay Member for Patient and Public Involvement KINSELLA. Loretta Director of Quality and Clinical Services x OUTHWAITE, Loretta Chief Finance Officer RECKLESS Ian Secondary Care Doctor x x SHIELDS, Helen Chief Officer TAYLOR, Laurence Lay Member independent x x VOSS, Lindsay Governing Body Nurse x Table 7: Attendance at Governing Body Meetings During the financial year, the Governing Body met in seminar form to review the financial positon and received reports from the Turnaround Director as well as reviewing their own performance and the overarching governance of the CCG The Clinical Executive The Clinical Executive is responsible for monthly operational oversight of the CCG and the commissioning function and ensuring that clinical decision making remains central to its work. From 1 April 2016, Dr Timothy Whelan and Dr Sarah Westmore joined the Clinical Executive. During the last year the Clinical Executive: agreed the Urgent and Emergency Care Strategy; reviewed the GP Out of Hours Provision; agreed the Operational Plan 2016/17; received Urology Review; approved System Resilience Action plan to achieve NHS Constitution targets; receieved Gluten Free Prescribing; agreed Estates and Technology Transformation Programme (ETTP); revised Isle of Wight Adult Physical Rehabilitation Service; reviewed the Urgent Care Service; agreed the Turnaround Plan; recommended the Governing Body agreed Sustainability Transformation Plan (STP); 47

110 were updated on the CQC inspection with the Isle of Wight NHS Trust. The issues regarding both the quality and financial sustainability of the Isle of Wight NHS Trust have continued to feature at the Clinical Executive, where updates have been received from the Trust on Ambulance, Mental Health and GP Out of Hours services and reports following the CQC Inspection in November. The Clinical Executive remains concerned with slow progress in taking forward the cost base analysis at the Isle of Wight Trust. In terms of the operation of the committee itself, the Clinical Executive reviewed its terms of reference in year. The members of the Clinical Executive and their attendance during the reporting period were: Name Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar BAKER, Gillian x BROWNE, Ben x ELKHEIR, Rida x x x x x HESSE, Joanna P* KINSELLA, Loretta P x LEGG, Michele x x OUTHWAITE, Loretta x x RIVERS, John x x x SHIELDS, Helen (Chair) x WESTMORE, Sarah x x x x x WHELAN, Tim x x x *attended part of the meeting Table 8: Attendance at the Clinical Executive The Quality and Patient Safety Committee (QPSC) The Quality and Patient Safety Committee is a non-statutory committee established by the Governing Body responsible for ensuring that the CCG acts with a view to securing continuous quality improvement in commissioned services; oversees safeguarding and ensures that systematic assurance on the quality of services commissioned by the CCG is provided to the Governing Body. The committee reviewed its terms of reference. The key achievements of the Quality and Patient Safety Committee in 2016/17 are: reviewed Quality Dashboard receieved Safeguarding Adults and Children s Reports 48

111 received NHS 111 Patient Survey; received Healthwatch Annual Report and various subject reports; reviewed Clinical Governance Report; reviewed Risks relating to quality; reviewed Serious Incident Requiring Investigation (SIRI) Reports; received Continuing Healthcare Quality Annual Report. During the year the committee has pursued a number of areas of concern with providers including the high numbers of pressure ulcers being experienced by patients on the island, Ambulance Service and Mental Health Services. Attendance at the Quality and Patient Safety Committee is as follows for the reporting period: Name May Aug Sept Nov Jan Mar NEWTON, David Lay Member for Patient and Public x Involvement RECKLESS, Ian (Chair) Secondary Care Doctor BROWNE, Ben GP x x KINSELLA, Loretta Director of Quality and Clinical Services SMITH, Joanna Healthwatch x VOSS, Lindsay Governing Body Nurse The Audit Committee Table 9: Attendance at QPSC The Audit Committee is a statutory committee responsible for providing the Group with an independent and objective review of its financial systems, compliance with laws, guidance and regulations and overseeing the Group s risk management and governance processes. The Audit Committee has reviewed and approved: Annual Report and Accounts ; the financial plan, budgets and associated risks; the risk management process, the risk register and governing body assurance framework; the external audit reports; 49

112 the delivery of the Internal audit plan; Internal audit reports: risk management, information governance, conflicts of interest, Continuing Health care, payroll compliance, Financial Accounting and Non-Pay expenditure and income systems; Counter Fraud Annual Report; External Audit Procurement; Financial Scheme of Delegation; Information governance reports; Conflicts of Interest compliance and the register of interest. The Committee also reviews the work, function and terms of reference of other committees within the CCG whose work can provide relevant assurance to the Audit Committee s own scope of work. In addition the Audit Committee carried out a self-assessment of committee effectiveness. Due to the financial challenges experienced during the year a Turnaround Board was established which reported to the Audit Committee. The membership of the Audit Committee and their attendance at meetings during this reporting period were: Name May Sept Nov Jan Mar DAVIES Martyn (Chair) Lay Member for Governance COLEMAN, Peter GP x GRIST, David Independent Lay Advisor RECKLESS, Ian Secondary Care Doctor x x x The Remuneration Committee Table 10: Attendance at Audit Committee The Remuneration Committee is a statutory committee required to make recommendations to the Governing Body regarding the remuneration and fees for Clinical Commissioning Group senior employees, and for others providing services to the group and allowances under pension schemes other than the NHS pension scheme. The members of the remuneration committee during the reporting period and their attendance are indicated below. 50

113 Name May Nov Mar DAVIES, (Chair) Martyn Lay Member for Governance HESSE, Joanne GP x x NEWTON, David Lay Member for Patient and Public Involvement x VOSS, Lindsay Governing Body Nurse RECKLESS, Ian Secondary Care Doctor TAYLOR, Laurence Lay Member independent Isle of Wight Primary Care Committee Table 11: Attendance at Remuneration Committee On 1 April 2016 NHS England delegated the exercise of certain specified primary care commissioning functions to the Isle of Wight CCG. These functions are: to plan, including needs assessment, primary medical care services; to undertake reviews of primary medical care services; to co-ordinate a common approach to the commissioning of primary care services generally; to manage the budget for commissioning of primary medical care services; to exercise these functions, the CCG established the Primary Care Commissioning Committee. The committee functions as a corporate decision-making body for the management of the delegated functions and the exercise of the delegated powers for Isle of Wight CCG. The Isle of Wight Primary Care Committee has approved: new terms of reference to reflect delegation; Primary Care Financial plan for 2016/17; Primary Care strategy development and consultation; a new Attention Deficit Hyperactivity Disorder (ADHD) for Adults ; a Prescribing Quality and Patient Safety Scheme; Primary Care corporate risks and Board Assurance Framework; GP Practice operational management decisions; 51

114 GP out of hour s service; Performance report; Safeguarding report. The members of the committee and their attendance record are as follows: Name May July Nov Mar TAYLOR, Laurence (Chair) x SHIELDS, Helen KINSELLA, Loretta x OUTHWAITE, Loretta x x ELKHIR, Rida x x x MORRIS, Caroline VOSS, Lindsay Table 12: Attendance at Isle of Wight Primary Care Committee The work of the committee this year focused initially on overseeing the transfer of delegated functions from NHS England. The committee has considered and approved the locally commissioned services and local incentive schemes for Isle of Wight GP practices, made decisions on estate issues and reviewed Primary Medical Service contracts. In addition it has had oversight of quality issues within GP Practices. The Primary Care Operational Group has been established. This group meets monthly and escalates work to the Primary Care Commissioning Committee when required. 8.5 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 with the principles it contains is considered to be good practice. For the financial year ended 31 March 2017, and up to the date of signing this statement, the CCG has not sought to comply with the provisions set out in the code, but has applied the principles of the Code. 8.6 Discharge of Statutory functions In light of recommendations of the 1983 Harris Review, the clinical commissioning group has reviewed all of the statutory duties and powers conferred on it by the National Health Service Act 2006 (as amended) and other associated legislative and regulations. As a result, I can confirm that the clinical commissioning group is clear about the legislative requirements associated with each of the statutory functions for which it is responsible, including any restrictions on delegation of those functions. Responsibility for each duty and power has been clearly allocated to a lead Director. Directorates have confirmed that their structures provide the necessary capability and 52

115 capacity to undertake all of the clinical commissioning group s statutory duties. 8.7 Risk Management arrangements and effectiveness The CCG s approach to risk management is described in the integrated risk management policy which is available on the CCG web site: It outlines how the Group takes decisions about the future in an uncertain world and how it assesses the risks associated with those decisions. Risk is an inevitable part of managing healthcare and living with, and understanding risk is an everyday part of our making commissioning decisions. The responsibilities of the Governing Body and its committees and sub-committees are clearly defined. The roles of key personnel are also clearly described including the role of the CCG s Risk Management Lead. Risks are identified through two key mechanisms: The Governing Body Assurance Framework (GBAF) which assesses and manages strategic risks; The Corporate Risk Register which captures and assesses all corporate risks. Governing Body is responsible for setting the strategic objectives for the organisation and reviewing the risks that might prevent their delivery. As part of the risk management process Governing Body agrees the risk appetite for the organisation and sets the parameters for managing risk. All papers presented to the the Governing Body or its subcommittees for decision are required to articulate the key risks associated with the matter in question and the impact on issues such as inequality and patient engagement. These papers are available to the public for wider scrutiny Capacity to Handle Risk The Clinical Commissioning Group gives leads the risk mangement process in the following ways: Ensuring that effective governance structures are in place through the CCG Consitution, supporting policies and proceedures, standing orders and Standing financial instructions; Ensuring that all directors and committees are clear in their remit and terms of reference including limits on their personal authority; Having clear lines of reporting between the Governing Body, the Primary Care Committee and the sub committee structure, reviewed through the internal audit process; Using a clear performance monitoring approach consisting of a triumverate of the corporate risk register, Governing Body Assurance Framework and monthly 53

116 performance reports to ensure that risks are being identified and mitigated through the organisation; Staff are trained and updated to ensure that they are aware of their responsiblities and authority, including providing regular update training sessions across a number of different areas of risk management including corporate risk, fraud and Information Governance Risk Assessment The principle risks faced by the CCG are captured in the Governing Body Assurance Framework, linked to the strategic objectives of the CCG. At the end of this reporting period, the Governing Body had identified the following key risks: Workforce pressures Risks relate to the capacity and capability of the CCG s main service provider, the Isle of Wight NHS Trust to undertake quality improvements due to large numbers of vacancies and difficulties in recruitment. This is being handled through an Acute Services Review which will make recommendations for the future of services aligned to the STP ambitions and will report in the Autumn of Funding Risks relating to the CCG s 11.9% ( 22m) distance from the NHS CCG Allocation Target, leading to reduced/no growth funding and higher savings targets. The CCG has put in place an ambitious savings programme and is also seeking to raise awareness at national level of the impact of the changes to the allocation targets. Performance Failure to meet key targets Accident & Emergency 4 hours, Ambulance and Referral to Treatment. Recovery trajectories together with detailed work plans aimed at resolving the failure have been put in place and are being monitored closely by the Governing Body. Transformation Risks associated with STP and agreement by all parties, the overall ambition may not meet the challenges of the system, delivery of the Acute Services redesign. The Local Delivery System Board which has been set up under the STP will support the Island organisations to work together more effectively to achieve transfomation Other Sources of Assurance NHS Isle of Wight CCG Internal Control Framework A system of internal control is the set of processes and procedures in place in the clinical commissioning group to ensure it delivers its policies, aims and objectives. It is designed to identify and prioritise the risks, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically. The system of internal control allows risk to be managed to a reasonable level rather than eliminating all risk; it can therefore only provide reasonable and not absolute assurance of effectiveness. 54

117 The CCG s key control mechanisms are as follows: Policies, procedures and guidelines The CCG has put in place a range of policies and procedures to support the proper identification and mitigation of risk, making it clear that risk is inherent in all activity and the CCG is not risk averse but risk aware. These policies and procedures are kept under review. The Standard of Business Conduct Policy was updated in line with the new conflict of interest guidance issued to CCGs. Governing Body Assurance Framework The Governing Body Assurance Framework, developed from the approved organisational aims and objectives, identifies key critical success factors for the organisation and the risks associated with achievement of those success factors. This document identifies risks before they arise and seeks to mitigate the likelihood of their occurrence. This document is updated for each Governing Body and reviewed at Quality and Patient Safety Committee and Isle of Wight Primary Care Committee. Corporate Risk Register The CCG s Corporate Risk Register captures existing risks and risk owners undertake regular reviews of their risks. It is reviewed monthly at the Clinical Executive and a summary of high risks are provided to each Governing Body meeting and at a variety of internal meetings to ensure that risk has been appropriately identified and is well managed and mitigated. An Internal Audit Review of risk management indicated reasonable assurance in-year. Incident reporting culture The CCG has developed an incident reporting culture amongst both staff and member practices. It supports staff and members to embed improvements to processes and to pick up issues at an early stage and seek resolution. External Support The CCG uses the expertise of internal auditors to undertake assessment of agreed areas of management responsibility to ensure that processes have been properly developed and are being followed. The programme of internal audit is agreed by the audit committee for the year and reports are received and actions reviewed by the committee. The CCG uses a Counter Fraud Specialist who attends audit committee and regular newsletters regarding fraud are circulated to all staff Annual Audit of Conflicts of Interests Management The revised statutory guidance on managing conflicts of interest for CCGs (published June 2016) requires CCGs to undertake an annual internal audit of conflicts of interest management. To support CCGs to undertake this task, NHS England has published a template audit framework. 55

118 The Isle of Wight CCG has undertaken the annual audit of conflicts of interests and has been deemed compliant by the auditors as follows: with reasonable assurance Based on the review, the CCG's arrangements for handling conflicts are assessed as being: Partially compliant regarding overall governance; Fully compliant in respect of processes for declaring interests and gifts and hospitality; Partially compliant relating to registers of interests, gifts and hospitality and procurement decisions; Fully compliant regarding decision making processes and contract monitoring; and Fully compliant in respect of reporting concerns and identifying and managing breaches/ non-compliance Data Quality The quality of data presented to our Membership Council and Governing Body is considered accurate and trusted. The data used in the formal reports is extracted from validated information submitted nationally by the Trusts. The format of the reports is regularly reviewed to ensure it captures the desired level of information. The business information team analyse data to identify trends that can be explored to improve planning Information Governance The NHS Information Governance Framework sets the processes and procedures by which the NHS handles information about patients and employees, in particular personal identifiable information. The NHS Information Governance Framework is supported by an information governance toolkit and the annual submission process provides assurances to the clinical commissioning group, other organisations and to individuals that personal information is dealt with legally, securely, efficiently and effectively. The CCG published its Information Governance toolkit assessment on the 29th March 2017 with a score of 88% which was an improvement from the previous year s submission of 86%. We place high importance on ensuring there are robust information governance systems and processes in place to help protect patient and corporate information. We have established an information governance management framework and have developed information governance processes and procedures in line with the information governance toolkit. We have ensured all staff undertake annual information governance training and have implemented a staff information governance handbook to ensure staff are aware of their information governance roles and responsibilities. There are processes in place for incident reporting and investigation of serious incidents as described in the risk management control mechanisms above. 56

119 8.8 Review of Economy, Efficiency & Effectiveness of the Use of Resources The CCG aims to maximise the impact of each pound spent supporting the health and wellbeing of those for whom we are responsible. The decision to invest in, disinvest in or redesign a commissioned service requires a judgement of whether the expected health benefits will justify the costs. The diversity in the Group s portfolio makes it difficult to produce comparable measures of what constitutes good value for money for many services. As the CCG is relatively small and geographically isolated, we have a strong focus on ensuring the sustainability of the services we commission. This means we do not necessarily seek the cheapest or easiest solution, but we seek to understand what is driving our and our providers costs and make sure that we are getting the desired quality at the lowest reasonable price. I am assured that the CCG plans, implements and measures the outcomes of the services it commissions according to a commissioning cycle which informs the steps taken in order to justify investment or disinvestment. It pays particular attention to the evidence base in developing business cases for change. Through Quality Innovation Productivity and Prevention (QIPP) plans, it seeks to predict the improvement expected and where possible measures that objectively. This process is overseen by the Clinical Executive. The CCG is required to manage its business within a maximum administration budget. I am assured that in all our work, we seek to achieve our objectives with the minimum of bureaucracy consistent with good governance. The Governing Body is supported in its review of the extent to which the CCG is achieving its ambition through the Integrated Performance Report and the Governing Body Assurance Framework. These look both at the measures we have agreed and those expected of us and the organisation s ability to manage and mitigate any risks to us achieving our objectives. The Audit Committee, through the internal audit programme, reviews the systems and processes employed by the Group ensuring that there are no serious threats to the achievement of its aims. Finally, NHS England undertakes its own assurance processes through quarterly reviews of CCG results against key metrics based on a number of domains. 8.9 Delegation of Functions The CCG did not delegate any of its functions during 2016/ Business Critical Models In line with best practice recommendations of the 2013 MacPherson review into the quality assurance of analytical models, confirm that an appropriate framework and environment is in 57

120 place to provide quality assurance of business critical models Third party assurances The CCG has arrangements in place with South Central Commissioning Support Unit to provide business intelligence, HR and GP IT functions on behalf of the CCG. During the year it has reviewed the sepcifications for those services and undertaken regular performance management processes Control Issues The CCG has implemented governance, risk management and internal control processes and subjected these to both internal scrutiny through the various committees of the Governing Body as well as a comprehensive internal audit programme. No material gaps have been identified in relation to governance and risk management and an internal audit of governance processes has offered reasonable assurance to the CCG Counter Fraud Arrangements The Counter Fraud Service is provided by the Hampshire and Isle of Wight Fraud and Security Management Service. The budget is agreed at the start of the financial year and the appropriate level of resource is always made available to meet the fluctuating demands of the service. The CCG has an accredited, nominated Local Counter Fraud Specialist who reports directly to the Chief Finance Officer who is responsible for tackling fraud, bribery and corruption; and provides a risk assessed plan of work which is agreed and reviewed throughout the year by Audit Committee. There is a programme of fraud awareness work including an Anti Fraud, Bribery and Corruption Policy, leaflets posters, newsletter and face to face fraud training and drop in sessions. The CCG receive all local and national fraud alerts and prevention notices and have been risk assessed in key areas including procurement and invoicing. All investigation work is conducted in accordance with relevant legislation. The annual Self Review Tool was rated as green in all four generic areas Head of Internal Audit Opinion Following completion of the planned audit work for the financial year for the clinical commissioning group, the Head of Internal Audit issued an independent and objective opinion on the adequacy and effectiveness of the clinical commissioning group s system of risk management, governance and internal control. The Head of Internal Audit concluded that: 58

121 SUMMARY HEAD OF INTERNAL AUDIT S ANNUAL OPINION I am satisfied that sufficient internal audit work has been undertaken to allow me to draw a reasonable conclusion as to the adequacy and effectiveness of NHS Isle of Wight Clinical Commissioning Group's risk management, control and governance processes. In my opinion, NHS Isle of Wight Clinical Commissioning Group has adequate and effective management, control and governance processes to manage the achievement of its objectives. System Performance Management Quality Conflicts of Interest Progress Update Payroll Compliance Review of the CHC Broadcare System Financial Accounting and Non-Pay Expenditure and Income systems Assurance Framework and Risk Management Conflicts of Interest Information Governance Toolkit Assurance Assessment Limited Not Applicable Substantial Limited Substantial Reasonable Reasonable Substantial Table 13: Internal audit assessments For each audit a work programme with a clear managerial lead has been put in place with timed actions to be taken to remedy the agreed weakeness in the control system. The Audit Committee has oversight of the progress against the action plan and reviews progress at each meeting Review of the Effectiveness of Governance, Risk Management & Internal Control My review of the effectiveness of the system of internal control is informed by the work of the internal auditors, executive managers and clinical leads within the clinical commissioning group who have responsibility for the development and maintenance of the internal control framework. I have drawn on performance information available to me. My review is also informed by comments made by the external auditors in their annual audit letter and other reports. 59

122 Our assurance framework provides me with evidence that the effectiveness of controls that manage risks to the clinical commissioning group achieving its principles objectives have been reviewed. I have been advised on the implications of the result of this review by the audit committee and Internal audit that have concluded that the internal control system is working effectively and both identifying and mitigating risks appropriately Conclusion I confirm that no significant internal control issues have been identified. Helen Shields Accountable Officer 25 May

123 9 REMUNERATION AND STAFF REPORT 9.1 Remuneration report The Group s Remuneration Report has been prepared in line with the 2016/17 Reporting Guidance. All CCG senior managers who hold or have held office during the reporting year are included in the report. Senior managers are defined as being: those persons in senior positions, having authority or responsibility for directing or controlling the major activities of the clinical commissioning group. This means those who influence the decisions of the clinical commissioning group as a whole rather than the decisions of individual directorates or departments. Such persons include advisory and lay members. Taking the above definition into account, the Accountable Officer, has confirmed the following people to be Senior Managers: Members of the Governing Body Members of the Clinical Executive CCG Senior Management Team, who are members of the CCG Officers Group CCG Associate Lay Member: Finance 9.2 Senior Manager s Remuneration Policy on Senior Managers Contracts Duration of contracts and notice periods The duration of contract and notice period for senior managers is dependent on their terms and conditions. The Chief Officer, Chief Finance Officer, Deputy Chief Officer, Director of Quality and Clinical Services and Assistant Director of Primary Care and Corporate Business are appointed on a permanent basis. The Chief Officer s notice period is six months in line with Very Senior Manager (VSM) terms and conditions. The Chief Finance Officer s notice period was agreed by the remuneration committee and is also set at six months. For the other senior officer posts, the notice period is three months. Termination payments In the event of a decision by the CCG to terminate the employment of any member of staff, reckonable service will be used and will be calculated on the basis of the service up to the date of the termination of the contract, based on the current Agenda for Change rules. 61

124 Policy on remuneration of senior managers including performance related pay In setting the pay for the CCG s Accountable Officer (AO), the committee agreed to use the VSM contract terms and conditions. The terms and conditions for the Chief Finance Officer, Deputy Chief Officer, Director of Quality and Clinical Services and Assistant Director of Primary Care and Corporate Business remain on Agenda for Change. For the GP appointments, including the Chair, pay and conditions remain in line with NHS Agenda for Change policy. Lay Members continue to be paid at a rate equivalent to the non- executive directors for the Isle of Wight NHS Trust and the equivalent terms and conditions apply. The Associate Lay Member for Finance only attends Audit Committee meetings and is therefore paid on the basis of 300 per meeting attended, which includes any preparation time. The Secondary Care Doctor is paid at a rate equivalent to his substantive position and compensated for any expenses in relation to his travel and attendance at CCG meetings. The post-holder opted for his substantive organisation to recharge for their time and expenses. The Governing Body Nurse has been paid the standard CCG Lay Member rate. The Chief Finance Officer, Deputy Chief Officer, Director of Quality and Clinical Services and Assistant Director of Primary Care and Corporate Business and all GP appointments received an annual uplift agreed by the NHS for staff under Agenda for Change. Changes in salary for the Chief Officer and Lay Members are agreed by the Remuneration Committee. There are no plans to change the CCG s remuneration policy within the next financial year. The table below provides a summary in relation to each Senior Manager s service contract. Senior managers service contract details Name Title Contracted Hours Date of Unexpired contract term (end date) Notice period Provision for termination Helen Shields Chief Officer Full time 01/04/13 No end date 6 months No Loretta Outhwaite Gillian Baker Chief Finance Officer Deputy Chief Officer Full time 01/04/13 No end date 6 months No Full time 01/04/13 No end date 3 months In line with A4C Caroline Morris Loretta Kinsella Assistant Director of Primary Care & Corporate Business Director of Quality and Clinical Services Dr John Rivers GP Chair 4.5 sessions per week Full time 01/04/13 No end date 3 months In line with A4C Full Time 01/01/14 No end date 3 months In line with A4C 01/04/13 31/03/17 3 months In line with A4C 62

125 Dr Joanna Hesse GP Executive 2 sessions per week 01/04/13 31/03/17 None, as fixed term In line with A4C Martyn Davies Lay Member: Governance 4 sessions per month 01/12/15 30/11/18 None, as fixed term None, as fixed term Laurence Taylor Lay Member 4 sessions per month 01/12/15 30/11/18 None, as fixed term None, as fixed term David Newton Lay Member: Public & Patient Involvement 4 sessions per month 01/04/13 31/03/19 None, as fixed term None, as fixed term Dr Ian Reckless Secondary Care Doctor 4 sessions per month 04/09/13 04/09/17 None, as fixed term None, as fixed term Lindsay Voss Governing Body Nurse 4 sessions per month 28/05/15 27/05/18 None, as fixed term None, as fixed term Dr Michele Legg GP Executive 5 sessions per week 01/04/15 31/03/18 None, as fixed term None, as fixed term Dr Browne Benjamin GP Executive 2 session s per week 01/04/15 31/03/18 None, as fixed term None, as fixed term Dr Timothy Whelan GP Executive 1 session per week 1/04/16 31/03/19 None, as fixed term None, as fixed term Dr Westmore Sarah GP Executive 1 session per week 1/04/16 31/03/19 None, as fixed term None, as fixed term David Grist Associate Lay Member: Finance 8 sessions per annum 01/05/15 30/04/17 None, as fixed term None, as fixed term Table 14: Senior Manager Service contract details 63

126 Salaries and allowances Table 15 below provides the details in relation to senior manager s salaries and allowances paid during 2016/1. This table is subject to audit. Name and title Salaries and fees Bands of 5,000 Expense payments (taxable) Bands of 5,000 Perf pay & bonuses Bands of 5, C17 Long-term per pay and bonuses Bands of 5,000 All pension related benefits Bands of 2,500 Total Bands of 5,000 Salaries and fees Bands of 5,000 Expense payments (taxable) Bands of 5,000 Perf pay & bonuses Bands of 5,000 Long-term All pension per pay and related benefits bonuses Bands of Bands of 2,500 5,000 Helen Shields Chief Officer Loretta Outhwaite Chief Finance Officer Gillian Baker Deputy Chief Officer Caroline Morris Assistant Director, Corporate Business and Primay Care Loretta Kinsella Director of Quality and Clinical Services Dr John Rivers Note Note GP Chair Dr Joanna Hesse GP Executive Martyn Davies 5-10 Note Note Lay Member: Governance Laurence Taylor 5-10 Note Note Lay Member David Newton 5-10 Note Note Lay Member: Public & Patient Involvement Dr Ian Reckless Note Note Secondary Care Doctor Lindsay Voss 5-10 Note Note Governing Body Nurse Dr Michele Legg GP Dr Benjamin Browne Note 5 Note GP David Grist 0-5 Note Note Associate LayMember: Finance Dr Timothy Whelan Note 5 Note 5 Note 4 Note 4 Note 4 GP Dr Sarah Westmore Note 4 Note 4 Note 4 GP 201DC16 Total Bands of 5,000 Notes Note 1: Employee is no longer contributing to the NHS Pension Scheme. Note 2: These are non-executive director posts and therefore do not receive pensionable remuneration. Table 15: Senior Manager senior manager s salaries and allowances Note 3: Employed by Milton Keynes NHS Trust & recharged for salary plus employer s on- costs & expenses related to CCG attendance (4 sessions per month). Note 4: Dr T Whelan and Dr S Westmore were not in post in 2015/16. Note 5: The CCG has been unable to get appropriate figures from NHS Pensions in relation to Dr T Whelan and Dr B Browne. Other notes: There was a correction to Dr M Legg s pay, relating to the prior year, which resulted in a negative adjustment to pension. In addition to working as a CCG Clinical Executive, Dr B Browne supports public health. All pension related benefits is calculated on the basis of how much an employee would receive over a 20 year period of retirement. So, for example, if an employee s pension benefits have increased by 2,000 in the year and their lump sum receivable on retirement has gone up by 5,000 in the year, the increase shown would be 2,000 x 20 years , so 45,000 During the reporting period, the NHS Isle of Wight CCG has not made any payments to past senior managers. During the reporting period, NHS Isle of Wight CCG has not made any payments made for loss of office. 64

127 Benefits Table 16 below provides a summary of the Senior Manager s pension benefits for 2016/17. This table is subject to audit. Name and title Real Real Total Lump Cash Cash Real Employer's increase increase in accrued sum at equivalent equivalent increase contribution in pension at pension age pension lump sum at pension age pension at pension age at 31st March'17 pension age related to accrued pension at 31st March'17 Bands Bands of Bands of Bands of 2,500 of 2,500 5,000 5,000 transfer value (CETV) at 31st March'16 transfer value (CETV) at 31st March'17 in cash equivalent transfer value to stakeholder pension SHIELDS, H n/a Chief Officer OUTHWAITE, L n/a Chief Finance Officer BAKER, G n/a Deputy Chief Officer MORRIS, C n/a Assistant Director, Primary Care & Corporate Business KINSELLA, L n/a Director of Quality & Clinical Services LEGG, M n/a GP BROWNE, B Note 1 Note 1 Note 1 Note 1 Note 1 Note 1 Note 1 n/a GP HESSE, J n/a GP WHELAN, T Note 1 Note 1 Note 1 Note 1 Note 1 Note 1 Note 1 n/a GP WESTMORE, S n/a GP Notes Table 16: Senior Manager Pension Benefits Note 1: The CCG has been unable to get appropriate figures from NHS Pensions in relation to Dr T Whelan and Dr B Browne. Note 2: Dr S Westmore was not in post in 2015/16 so there is no CETV value for that year. Other notes: There was a correction to Dr M Legg s pay, relating to the prior year, which resulted in a lower pension figure for 2016/17. There is no disclosure for the Lay Members, as they do not quality for the NHS Pension Scheme or for any employee/gp who is no longer in the pension scheme. The Secondary Care Doctor is employed by another body and his CCG related working time recharged. His pension information is not available to the CCG and has therefore not been disclosed. 65

128 Cash equivalent transfer values A cash equivalent transfer value (CETV) is the actuarially assessed capital value of the pension scheme benefits accrued by a member at a particular point in time. The benefits valued are the member s accrued benefits and any contingent spouse s (or other allowable beneficiary s) pension payable from the scheme. A CETV is a payment made by a pension scheme or arrangement to secure pension benefits in another pension scheme or arrangement when the member leaves a scheme and chooses to transfer the benefits accrued in their former scheme. The pension figures shown relate to the benefits that the individual has accrued as a consequence of their total membership of the pension scheme, not just their service in a senior capacity to which disclosure applies. The CETV figures and the other pension details include the value of any pension benefits in another scheme or arrangement which the individual has transferred to the NHS pension scheme. They also include any additional pension benefit accrued to the member as a result of their purchasing additional years of pension service in the scheme at their own cost. CETVs are calculated within the guidelines and framework prescribed by the Institute and Faculty of Actuaries. Real increase in CETV This reflects the increase in CETV effectively funded by the employer. It takes account of the increase in accrued pension due to inflation, contributions paid by the employee (including the value of any benefits transferred from another scheme or arrangement) and uses common market valuation factors for the start and end of the period. Pay multiples Reporting bodies are required to disclose the relationship between the remuneration of the highest-paid director in their organisation and the median remuneration of the organisation s workforce. It should be noted that the calculations below are based on the salary people would earn if they were working full time. Within the CCG, 31% of staff work on a part-time basis. Table 17 below is subject to audit. 2016/17 Lead executive total earnings 149,394 Median total earnings 38,043 Ratio 3.93 Table 17: Pay Multiples The banded remuneration of the highest paid member of the Membership Body/Governing Body in the Clinical Commissioning Group in the financial year 2016/17 was 149,394. In 2015/16 this was 150,878. It is a requirement to explain in the annual report the steps taken to establish that a salary, in excess of 142,500 pro-rata (the Prime Minister s salary), is reasonable. The salary is for the 66

129 CCG s GP Chair, who works 4.5 sessions (actual salary is therefore 67,227). The CCG Remuneration Committee has set the salary for the CCG Chair, at a rate which is consistent with that of other CCG GP Chairs across the region. The remuneration of the highest paid member of staff was 3.93 times the median remuneration of the workforce, which was 38,043. In 2015/16 the figures were 4.33 times and 34,876. In 2016/17 no employees received remuneration in excess of the highest paid member of the Membership Body/Governing Body. Excluding the highest paid director, remuneration ranged from 16,800 to 117,160. In 2015/16 the figures were 15,100 to 130,130. The majority of CCG members of staff are subject to Agenda for Change terms and conditions. For 2016/17 all staff on Agenda for Change received a 1% consolidated pay increase. Total remuneration includes salary and on-call payments. There were no bonuses or benefitsin-kind paid to staff during the year. It does not include severance payments, employer pension contributions and the cash equivalent transfer value of pensions. Off-payroll engagements As part of this annual report, CCGs must publish information on their highly paid and/or senior off-payroll engagements. Off-payroll engagements as of 31 March 2017, for more than 220 per day and that last longer than six months are shown in Table 18 below: No. Number that have existed: 3 For less than one year at the time of reporting 1 For between one and two years at the time of reporting 0 For between two and three years at the time of reporting 1 Total number of existing engagements as of 31 March Table 18: Off-Payroll Engagements as of 31st March 2017 One of the off-payroll engagements relates to the Secondary Care Doctor who is employed by an NHS Trust and costs recharged to the CCG. One of the off-payroll engagements relates to an Interim Associate Director of Commissioning who supported the CCG between April to December. The CCG paid an agency via invoice. The final off-payroll engagement is for the independent chair of the Continuing Healthcare Panel, who invoices the CCG for the limited number of hours they work. All existing off-payroll engagements, outlined above, have at some point been subject to a risk based assessment as to whether assurance is required that the individual is paying the right amount of tax. Table 19 below shows that the CCG has not sought formal assurance for any offpayroll engagements, in relation to Income Tax and National Insurance obligations. This is for the following reasons: 67

130 Number of new engagements, or those that reached six months in duration, between 1 April 2016 and 31 March 2017 Number of the above which include contractual clauses giving the CCG the right to request assurance in relation to Income Tax & National Insurance obligations Number for whom assurance has been requested 0 Of which, the number: For whom assurance has been received For whom assurance has not been received Τhat have been terminated as a result of assurance not being received Table 19: Assurance sought in relation to Income Tax & NI Obligations For those engagements relating to the Secondary Care Doctor and interim Associate Director of Commissioning the substantive employer and the agency would have ensured that the correct tax had been paid. From 2016/17 the CCG s policies only allowed for off-payroll engagements in the following circumstances: For Secondary Care Doctor, Governing Body: where the post-holder opts for their substantive employer to be reimbursed for their CCG time and expenses. All Clinical Lead appointments have been paid through payroll. As explained above and as Table 20 below demonstrates, one employee who meets the definition of Senior Manager is an off-payroll engagement. 0 0 Number of off-payroll engagements of Membership Body &/or Governing Body members, &/or, senior officials with significant financial responsibility, during the financial year Number of individuals that have been deemed Membership Body 9 and/or Governing Body members, and/or, senior officials with significant financial responsibility, during the financial year (this figure includes both off-payroll and on-payroll engagements) 1 33 Table 20: Senior Managers who are off-payroll engagements 9.3 Staff report The CCG has 96 members of staff of which 76 are female and 20 are male. A number of our staff work part time so this is equivalent to whole time staff. This equates to an average of 79.9 WTE staff throughout the year. The staff gender breakdown is as follows: At the end of 2016/17, the Governing Body comprised 5 males and 5 females. Within the CCG senior leadership team there are two further senior managers who are female. There are 6 GPs acting in leadership positions comprising 3 male and 3 female. 68

131 Of the remaining staff on agenda for change, 66 are female and 12 male and broken down into staff bands Bands 1-7: there are 46 females and 5 males Bands 8a 9: there are 20 females and 7 males The CCG sickness rate is at 4.42% which is an increase to last year due to some long term sickness. There were no negotiated exit packages during this or the previous financial year. NHS Isle of Wight CCG - Annual Accounts Employee benefits and staff numbers Employee benefits Total Employee Benefits Total Permanent Employees Other '000 '000 '000 Salaries and wages 2,758 2,758 0 Social security costs Employer Contributions to NHS Pension scheme Gross employee benefits expenditure 3,420 3,420 0 Less recoveries in respect of employee benefits (note 4.1.2) ,420 3,420 0 Less: Employee costs capitalised Net employee benefits excluding capitalised costs 3,420 3, Employee benefits Total Total Permanent Employees Other '000 '000 '000 Employee Benefits Salaries and wages 2,692 2,692 0 Social security costs Employer Contributions to NHS Pension scheme Gross employee benefits expenditure 3,246 3,246 0 Less recoveries in respect of employee benefits Total - Net admin employee benefits including capitalised costs 3,246 3,246 0 Less: Employee costs capitalised Net employee benefits excluding capitalised costs 3,246 3,246 0 Table 21: Employee benefits and staff numbers 69

132 9.4 Employment Policies and Processes The CCG reviews and updates its employment policies and processes on a cycle in conjunction with our HR provider. The CCG equality policy offers equal opportunities to all staff and job applicants recognising that it has a legal and moral responsibility to ensure that neither it nor its employees discriminate directly or indirectly. All policies used within the CCG apply equally to both disabled and non-disabled staff with the understanding that it must have due regard and need to take steps to enable an individual with a disability to access certain types of career development or training. Our policy applies to all staff, contractors who are on site, students and volunteers. 9.5 Social, Community and Human Rights issues The Human Rights Act (HRA) 1998 sets out a range of rights that have implications for the way the CCG buys services and manages its workforce. The CCG has ensured that our service specifications meet the requirements of the Act. The CCG maintains a whistleblowing policy to facilitate this process. As part of our Equality analysis, issues relating to the HRA are taken into account. 70

133 Final page Left Blank 71

134 Data entered below will be used throughout the workbook: Entity name: NHS Isle of Wight CCG This year Last year This year ended 31-March-2017 Last year ended 31-March-2016 This year commencing: 01-April-2016 Last year commencing: 01-April-2015 These account templates are a proforma for a set of NHS England Group Entity Accounts, this is not a mandatory layout for local accounts. The CCG does not have any other financial commitments at the end of the financial period Please review and adjust to local reporting requirements

135 NHS Isle of Wight CCG - Annual Accounts CONTENTS Page Number The Primary Statements: Statement of Comprehensive Net Expenditure for the year ended 31st March Statement of Financial Position as at 31st March Statement of Changes in Taxpayers' Equity for the year ended 31st March Statement of Cash Flows for the year ended 31st March Notes to the Accounts Accounting policies 5 Other operating revenue 9 Employee benefits and staff numbers 10 Operating expenses 13 Better payment practice code 14 Income generation activities 14 Net gain/(loss) on transfer by absorption 15 Operating leases 15 Trade and other receivables 16 Cash and cash equivalents 17 Trade and other payables 18 Provisions 19 Contingencies 20 Commitments 20 Financial instruments 20 Operating segments 22 Pooled budgets 22 Related party transactions 23 Events after the end of the reporting period 24 Third party assets 24 Financial performance targets 24

136 NHS Isle of Wight CCG - Annual Accounts Statement of Comprehensive Net Expenditure for the year ended 31 March Note '000 '000 Income from sale of goods and services 2 (128) (137) Other operating income 2 (5) (5) Total operating income (133) (142) Staff costs 4 3,420 3,246 Purchase of goods and services 5 232, ,933 Depreciation and impairment charges Provision expense (55) Other Operating Expenditure Total operating expenditure 236, ,259 Net Operating Expenditure 236, ,117 Net Gain/(Loss) on Transfer by Absorption Total Net Expenditure for the year 236, ,117 Comprehensive Expenditure for the year ended 31 March , ,117 3

137 NHS Isle of Wight CCG - Annual Accounts Statement of Financial Position as at 31 March Note '000 '000 Current assets: Trade and other receivables 10 3,875 2,003 Cash and cash equivalents Total current assets 3,999 2,081 Total assets 3,999 2,081 Current liabilities Trade and other payables 13 (13,294) (12,580) Provisions 14 (539) (50) Total current liabilities (13,833) (12,630) Net Current Assets/Liabilities (9,834) (10,549) Assets less Liabilities (9,834) (10,549) Financed by Taxpayers Equity General fund (9,834) (10,549) Revaluation reserve 0 0 Other reserves 0 0 Charitable Reserves 0 0 Total taxpayers' equity: (9,834) (10,549) The notes on pages 16 to 19 form part of this statement The financial statements on pages 1 to 24 were approved by the Governing Body on 25th May 2017 and signed on its behalf by Chief Finance Officer 25th May

138 NHS Isle of Wight CCG - Annual Accounts Statement of Changes In Taxpayers Equity for the year ended 31 March 2017 Changes in taxpayers equity for Revaluation Other Total General fund reserve reserves reserves '000 '000 '000 '000 Balance at 01 April 2016 (10,549) 0 0 (10,549) Transfer between reserves in respect of assets transferred from closed NHS bodies Adjusted NHS Clinical Commissioning Group balance at 31 March 2017 (10,549) 0 0 (10,549) Changes in NHS Clinical Commissioning Group taxpayers equity for Net operating expenditure for the financial year (236,773) 0 0 (236,773) Net Recognised NHS Clinical Commissioning Group Expenditure for the Financial Year (236,773) 0 0 (236,773) Net funding 237, ,487 Balance at 31 March 2017 (9,835) 0 0 (9,835) Changes in taxpayers equity for Revaluation Other Total General fund reserve reserves reserves '000 '000 '000 '000 Balance at 01 April 2015 (10,160) 0 0 (10,160) Transfer of assets and liabilities from closed NHS bodies as a result of the 1 April 2013 transition Adjusted NHS Clinical Commissioning Group balance at 31 March 2016 (10,160) 0 0 (10,160) Changes in NHS Clinical Commissioning Group taxpayers equity for Net operating costs for the financial year (210,117) 0 0 (210,117) Net Recognised NHS Clinical Commissioning Group Expenditure for the Financial Year (210,117) 0 0 (210,117) Net funding 209, ,728 Balance at 31 March 2016 (10,549) 0 0 (10,549) The notes on pages 5 to 24 form part of this statement 5

139 NHS Isle of Wight CCG - Annual Accounts Statement of Cash Flows for the year ended 31 March Note '000 '000 Cash Flows from Operating Activities Net operating expenditure for the financial year (236,773) (210,117) Depreciation and amortisation Impairments and reversals Unwinding of Discounts 0 0 (Increase)/decrease in trade & other receivables 10 (1,872) (302) (Increase)/decrease in other current assets 0 0 Increase/(decrease) in trade & other payables Increase/(decrease) in other current liabilities 0 0 Provisions utilised 14 0 (3) Increase/(decrease) in provisions (55) Net Cash Inflow (Outflow) from Operating Activities (237,441) (209,706) Cash Flows from Investing Activities Interest received 0 0 Rental revenue 0 0 Net Cash Inflow (Outflow) from Investing Activities 0 0 Net Cash Inflow (Outflow) before Financing (237,441) (209,706) Cash Flows from Financing Activities Grant in Aid Funding Received 237, ,728 Capital grants and other capital receipts 0 0 Net Cash Inflow (Outflow) from Financing Activities 237, ,728 Net Increase (Decrease) in Cash & Cash Equivalents Cash & Cash Equivalents at the Beginning of the Financial Year Effect of exchange rate changes on the balance of cash and cash equivalents held in foreign currencies 0 0 Cash & Cash Equivalents (including bank overdrafts) at the End of the Financial Year The notes on pages 5 to 24 form part of this statement 6

140 NHS Isle of Wight CCG - Annual Accounts Notes to the financial statements 1 Accounting Policies NHS England has directed that the financial statements of clinical commissioning groups shall meet the accounting requirements of the Group Accounting Manual issued by the Department of Health. Consequently, the following financial statements have been prepared in accordance with the Group Accounting Manual issued by the Department of Health. The accounting policies contained in the Group Accounting Manual follow International Financial Reporting Standards to the extent that they are meaningful and appropriate to clinical commissioning groups, as determined by HM Treasury, which is advised by the Financial Reporting Advisory Board. Where the Group Accounting Manual permits a choice of accounting policy, the accounting policy which is judged to be most appropriate to the particular circumstances of the clinical commissioning group for the purpose of giving a true and fair view has been selected. The particular policies adopted by the clinical commissioning group are described below. They have been applied consistently in dealing with items considered material in relation to the accounts. 1.1 Going Concern These accounts have been prepared on the going concern basis. Public sector bodies are assumed to be going concerns where the continuation of the provision of a service in the future is anticipated, as evidenced by inclusion of financial provision for that service in published documents. Where a clinical commissioning group ceases to exist, it considers whether or not its services will continue to be provided (using the same assets, by another public sector entity) in determining whether to use the concept of going concern for the final set of Financial Statements. If services will continue to be provided the financial statements are prepared on the going concern basis. 1.2 Accounting Convention These accounts have been prepared under the historical cost convention modified to account for the revaluation of property, plant and equipment, intangible assets, inventories and certain financial assets and financial liabilities. 1.3 Acquisitions & Discontinued Operations Activities are considered to be acquired only if they are taken on from outside the public sector. Activities are considered to be discontinued only if they cease entirely. They are not considered to be discontinued if they transfer from one public sector body to another. 1.4 Movement of Assets within the Department of Health Group Transfers as part of reorganisation fall to be accounted for by use of absorption accounting in line with the Government Financial Reporting Manual, issued by HM Treasury. The Government Financial Reporting Manual does not require retrospective adoption, so prior year transactions (which have been accounted for under merger accounting) have not been restated. Absorption accounting requires that entities account for their transactions in the period in which they took place, with no restatement of performance required when functions transfer within the public sector. Where assets and liabilities transfer, the gain or loss resulting is recognised in the Statement of Comprehensive Net Expenditure, and is disclosed separately from operating costs. Other transfers of assets and liabilities within the Department of Health Group are accounted for in line with IAS 20 and similarly give rise to income and expenditure entries. 1.5 Charitable Funds From , the divergence from the Government Financial Reporting Manual that NHS Charitable Funds are not consolidated with bodies own returns is removed. Under the provisions of IAS 27: Consolidated & Separate Financial Statements, those Charitable Funds that fall under common control with NHS bodies are consolidated within the entities accounts. 1.6 Pooled Budgets Where the clinical commissioning group has entered into a pooled budget arrangement under Section 75 of the National Health Service Act 2006 the clinical commissioning group accounts for its share of the assets, liabilities, income and expenditure arising from the activities of the pooled budget, identified in accordance with the pooled budget agreement. If the clinical commissioning group is in a jointly controlled operation, the clinical commissioning group recognises: The assets the clinical commissioning group controls; The liabilities the clinical commissioning group incurs; The expenses the clinical commissioning group incurs; and, The clinical commissioning group s share of the income from the pooled budget activities. If the clinical commissioning group is involved in a jointly controlled assets arrangement, in addition to the above, the clinical commissioning group recognises: The clinical commissioning group s share of the jointly controlled assets (classified according to the nature of the assets); The clinical commissioning group s share of any liabilities incurred jointly; and, The clinical commissioning group s share of the expenses jointly incurred. 1.7 Critical Accounting Judgements & Key Sources of Estimation Uncertainty In the application of the clinical commissioning group s accounting policies, management is required to make judgements, estimates and assumptions about the carrying amounts of assets and liabilities that are not readily apparent from other sources. The estimates and associated assumptions are based on historical experience and other factors that are considered to be relevant. Actual results may differ from those estimates and the estimates and underlying assumptions are continually reviewed. Revisions to accounting estimates are recognised in the period in which the estimate is revised if the revision affects only that period or in the period of the revision and future periods if the revision affects both current and future periods Critical Judgements in Applying Accounting Policies There have been no material critical judgements, that management has made in the process of applying the clinical commissiong group's accounting policies Key Sources of Estimation Uncertainty There are no key sources of estimation uncertainty 1.8 Revenue Revenue in respect of services provided is recognised when, and to the extent that, performance occurs, and is measured at the fair value of the consideration receivable. Where income is received for a specific activity that is to be delivered in the following year, that income is deferred. 1.9 Employee Benefits Short-term Employee Benefits Salaries, wages and employment-related payments are recognised in the period in which the service is received from employees, including bonuses earned but not yet taken. The cost of leave earned but not taken by employees at the end of the period is recognised in the financial statements to the extent that employees are permitted to carry forward leave into the following period Retirement Benefit Costs Past and present employees are covered by the provisions of the NHS Pensions Scheme. The scheme is an unfunded, defined benefit scheme that covers NHS employers, General Practices and other bodies, allowed under the direction of the Secretary of State, in England and Wales. The scheme is not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities. Therefore, the scheme is accounted for as if it were a defined contribution scheme: the cost to the clinical commissioning group of participating in the scheme is taken as equal to the contributions payable to the scheme for the accounting period. For early retirements other than those due to ill health the additional pension liabilities are not funded by the scheme. The full amount of the liability for the additional costs is charged to expenditure at the time the clinical commissioning group commits itself to the retirement, regardless of the method of payment. Some employees are members of the Local Government Superannuation Scheme, which is a defined benefit pension scheme. The scheme assets and liabilities attributable to those employees can be identified and are recognised in the clinical commissioning group s accounts. The assets are measured at fair value and the liabilities at the present value of the future obligations. The increase in the liability arising from pensionable service earned during the year is recognised within operating expenses. The expected gain during the year from scheme assets is recognised within finance income. The interest cost during the year arising from the unwinding of the discount on the scheme liabilities is recognised within finance costs. Actuarial gains and losses during the year are recognised in the General Reserve and reported as an item of other comprehensive net expenditure. 7

141 NHS Isle of Wight CCG - Annual Accounts Notes to the financial statements 1.10 Other Expenses Other operating expenses are recognised when, and to the extent that, the goods or services have been received. They are measured at the fair value of the consideration payable. Expenses and liabilities in respect of grants are recognised when the clinical commissioning group has a present legal or constructive obligation, which occurs when all of the conditions attached to the payment have been met Property, Plant & Equipment Recognition Property, plant and equipment is capitalised if: It is held for use in delivering services or for administrative purposes; It is probable that future economic benefits will flow to, or service potential will be supplied to the clinical commissioning group; It is expected to be used for more than one financial year; The cost of the item can be measured reliably; and, The item has a cost of at least 5,000; or, Collectively, a number of items have a cost of at least 5,000 and individually have a cost of more than 250, where the assets are functionally interdependent, they had broadly simultaneous purchase dates, are anticipated to have simultaneous disposal dates and are under single managerial control; or, Items form part of the initial equipping and setting-up cost of a new building, ward or unit, irrespective of their individual or collective cost. Where a large asset, for example a building, includes a number of components with significantly different asset lives, the components are treated as separate assets and depreciated over their own useful economic lives Valuation All property, plant and equipment are measured initially at cost, representing the cost directly attributable to acquiring or constructing the asset and bringing it to the location and condition necessary for it to be capable of operating in the manner intended by management. All assets are measured subsequently at valuation. Land and buildings used for the clinical commissioning group s services or for administrative purposes are stated in the statement of financial position at their re-valued amounts, being the fair value at the date of revaluation less any impairment. Revaluations are performed with sufficient regularity to ensure that carrying amounts are not materially different from those that would be determined at the end of the reporting period. Fair values are determined as follows: Land and non-specialised buildings market value for existing use; and, Specialised buildings depreciated replacement cost. HM Treasury has adopted a standard approach to depreciated replacement cost valuations based on modern equivalent assets and, where it would meet the location requirements of the service being provided, an alternative site can be valued. Properties in the course of construction for service or administration purposes are carried at cost, less any impairment loss. Cost includes professional fees but not borrowing costs, which are recognised as expenses immediately, as allowed by IAS 23 for assets held at fair value. Assets are re-valued and depreciation commences when they are brought into use. Fixtures and equipment are carried at depreciated historic cost as this is not considered to be materially different from current value in existing use. An increase arising on revaluation is taken to the revaluation reserve except when it reverses an impairment for the same asset previously recognised in expenditure, in which case it is credited to expenditure to the extent of the decrease previously charged there. A revaluation decrease that does not result from a loss of economic value or service potential is recognised as an impairment charged to the revaluation reserve to the extent that there is a balance on the reserve for the asset and, thereafter, to expenditure. Impairment losses that arise from a clear consumption of economic benefit are taken to expenditure. Gains and losses recognised in the revaluation reserve are reported as other comprehensive income in the Statement of Comprehensive Net Expenditure Subsequent Expenditure Where subsequent expenditure enhances an asset beyond its original specification, the directly attributable cost is capitalised. Where subsequent expenditure restores the asset to its original specification, the expenditure is capitalised and any existing carrying value of the item replaced is written-out and charged to operating expenses Donated Assets Donated non-current assets are capitalised at their fair value on receipt, with a matching credit to Income. They are valued, depreciated and impaired as described above for purchased assets. Gains and losses on revaluations, impairments and sales are as described above for purchased assets. Deferred income is recognised only where conditions attached to the donation preclude immediate recognition of the gain Government Grants The value of assets received by means of a government grant are credited directly to income. Deferred income is recognised only where conditions attached to the grant preclude immediate recognition of the gain Non-current Assets Held For Sale Non-current assets are classified as held for sale if their carrying amount will be recovered principally through a sale transaction rather than through continuing use. This condition is regarded as met when: The sale is highly probable; The asset is available for immediate sale in its present condition; and, Management is committed to the sale, which is expected to qualify for recognition as a completed sale within one year from the date of classification. Non-current assets held for sale are measured at the lower of their previous carrying amount and fair value less costs to sell. Fair value is open market value including alternative uses. The profit or loss arising on disposal of an asset is the difference between the sale proceeds and the carrying amount and is recognised in the Statement of Comprehensive Net Expenditure. On disposal, the balance for the asset on the revaluation reserve is transferred to the general reserve. Property, plant and equipment that is to be scrapped or demolished does not qualify for recognition as held for sale. Instead, it is retained as an operational asset and its economic life is adjusted. The asset is de-recognised when it is scrapped or demolished Leases Leases are classified as finance leases when substantially all the risks and rewards of ownership are transferred to the lessee. All other leases are classified as operating leases The Clinical Commissioning Group as Lessee Property, plant and equipment held under finance leases are initially recognised, at the inception of the lease, at fair value or, if lower, at the present value of the minimum lease payments, with a matching liability for the lease obligation to the lessor. Lease payments are apportioned between finance charges and reduction of the lease obligation so as to achieve a constant rate on interest on the remaining balance of the liability. Finance charges are recognised in calculating the clinical commissioning group s surplus/deficit. Operating lease payments are recognised as an expense on a straight-line basis over the lease term. Lease incentives are recognised initially as a liability and subsequently as a reduction of rentals on a straight-line basis over the lease term. Contingent rentals are recognised as an expense in the period in which they are incurred. Where a lease is for land and buildings, the land and building components are separated and individually assessed as to whether they are operating or finance leases Services Received The fair value of services received in the year is recorded under the relevant expenditure headings within operating expenses Inventories Inventories are valued at the lower of cost and net realisable value using the first-in first-out cost formula. This is considered to be a reasonable approximation to fair value due to the high turnover of stocks Cash & Cash Equivalents Cash is cash in hand and deposits with any financial institution repayable without penalty on notice of not more than 24 hours. Cash equivalents are investments that mature in 3 months or less from the date of acquisition and that are readily convertible to known amounts of cash with insignificant risk of change in value. 8

142 NHS Isle of Wight CCG - Annual Accounts Notes to the financial statements In the Statement of Cash Flows, cash and cash equivalents are shown net of bank overdrafts that are repayable on demand and that form an integral part of the clinical commissioning group s cash management Provisions Provisions are recognised when the clinical commissioning group has a present legal or constructive obligation as a result of a past event, it is probable that the clinical commissioning group will be required to settle the obligation, and a reliable estimate can be made of the amount of the obligation. The amount recognised as a provision is the best estimate of the expenditure required to settle the obligation at the end of the reporting period, taking into account the risks and uncertainties. Where a provision is measured using the cash flows estimated to settle the obligation, its carrying amount is the present value of those cash flows using HM Treasury s discount rate as follows: Timing of cash flows (0 to 5 years inclusive): Minus 2.70% (previously: minus 1.55%) Timing of cash flows (6 to 10 years inclusive): Minus 1.95% (previously: minus 1.%) Timing of cash flows (over 10 years): Minus 0.80% (previously: minus 0.80%) When some or all of the economic benefits required to settle a provision are expected to be recovered from a third party, the receivable is recognised as an asset if it is virtually certain that reimbursements will be received and the amount of the receivable can be measured reliably. A restructuring provision is recognised when the clinical commissioning group has developed a detailed formal plan for the restructuring and has raised a valid expectation in those affected that it will carry out the restructuring by starting to implement the plan or announcing its main features to those affected by it. The measurement of a restructuring provision includes only the direct expenditures arising from the restructuring, which are those amounts that are both necessarily entailed by the restructuring and not associated with on-going activities of the entity Clinical Negligence Costs The NHS Litigation Authority operates a risk pooling scheme under which the clinical commissioning group pays an annual contribution to the NHS Litigation Authority which in return settles all clinical negligence claims. The contribution is charged to expenditure. Although the NHS Litigation Authority is administratively responsible for all clinical negligence cases the legal liability remains with the clinical commissioning group Non-clinical Risk Pooling The clinical commissioning group participates in the Property Expenses Scheme and the Liabilities to Third Parties Scheme. Both are risk pooling schemes under which the clinical commissioning group pays an annual contribution to the NHS Litigation Authority and, in return, receives assistance with the costs of claims arising. The annual membership contributions, and any excesses payable in respect of particular claims are charged to operating expenses as and when they become due Continuing healthcare risk pooling In a risk pool scheme was been introduced by NHS England for continuing healthcare claims, for claim periods prior to 31 March Under the scheme clinical commissioning group contribute annually to a pooled fund, which is used to settle the claims Contingencies A contingent liability is a possible obligation that arises from past events and whose existence will be confirmed only by the occurrence or nonoccurrence of one or more uncertain future events not wholly within the control of the clinical commissioning group, or a present obligation that is not recognised because it is not probable that a payment will be required to settle the obligation or the amount of the obligation cannot be measured sufficiently reliably. A contingent liability is disclosed unless the possibility of a payment is remote. A contingent asset is a possible asset that arises from past events and whose existence will be confirmed by the occurrence or non-occurrence of one or more uncertain future events not wholly within the control of the clinical commissioning group. A contingent asset is disclosed where an inflow of economic benefits is probable. Where the time value of money is material, contingencies are disclosed at their present value Financial Assets Financial assets are recognised when the clinical commissioning group becomes party to the financial instrument contract or, in the case of trade receivables, when the goods or services have been delivered. Financial assets are derecognised when the contractual rights have expired or the asset has been transferred. Financial assets are classified into the following categories: Financial assets at fair value through profit and loss; Held to maturity investments; Available for sale financial assets; and, Loans and receivables. The classification depends on the nature and purpose of the financial assets and is determined at the time of initial recognition Financial Assets at Fair Value Through Profit and Loss Embedded derivatives that have different risks and characteristics to their host contracts, and contracts with embedded derivatives whose separate value cannot be ascertained, are treated as financial assets at fair value through profit and loss. They are held at fair value, with any resultant gain or loss recognised in calculating the clinical commissioning group s surplus or deficit for the year. The net gain or loss incorporates any interest earned on the financial asset Held to Maturity Assets Held to maturity investments are non-derivative financial assets with fixed or determinable payments and fixed maturity, and there is a positive intention and ability to hold to maturity. After initial recognition, they are held at amortised cost using the effective interest method, less any impairment. Interest is recognised using the effective interest method Available For Sale Financial Assets Available for sale financial assets are non-derivative financial assets that are designated as available for sale or that do not fall within any of the other three financial asset classifications. They are measured at fair value with changes in value taken to the revaluation reserve, with the exception of impairment losses. Accumulated gains or losses are recycled to surplus/deficit on de-recognition Loans & Receivables Loans and receivables are non-derivative financial assets with fixed or determinable payments which are not quoted in an active market. After initial recognition, they are measured at amortised cost using the effective interest method, less any impairment. Interest is recognised using the effective interest method. Fair value is determined by reference to quoted market prices where possible, otherwise by valuation techniques. The effective interest rate is the rate that exactly discounts estimated future cash receipts through the expected life of the financial asset, to the initial fair value of the financial asset. At the end of the reporting period, the clinical commissioning group assesses whether any financial assets, other than those held at fair value through profit and loss are impaired. Financial assets are impaired and impairment losses recognised if there is objective evidence of impairment as a result of one or more events which occurred after the initial recognition of the asset and which has an impact on the estimated future cash flows of the asset. For financial assets carried at amortised cost, the amount of the impairment loss is measured as the difference between the asset s carrying amount and the present value of the revised future cash flows discounted at the asset s original effective interest rate. The loss is recognised in expenditure and the carrying amount of the asset is reduced through a provision for impairment of receivables. If, in a subsequent period, the amount of the impairment loss decreases and the decrease can be related objectively to an event occurring after the impairment was recognised, the previously recognised impairment loss is reversed through expenditure to the extent that the carrying amount of the receivable at the date of the impairment is reversed does not exceed what the amortised cost would have been had the impairment not been recognised Financial Liabilities 9

143 NHS Isle of Wight CCG - Annual Accounts Notes to the financial statements Financial liabilities are recognised on the statement of financial position when the clinical commissioning group becomes party to the contractual provisions of the financial instrument or, in the case of trade payables, when the goods or services have been received. Financial liabilities are derecognised when the liability has been discharged, that is, the liability has been paid or has expired. Loans from the Department of Health are recognised at historical cost. Otherwise, financial liabilities are initially recognised at fair value Financial Guarantee Contract Liabilities Financial guarantee contract liabilities are subsequently measured at the higher of: The premium received (or imputed) for entering into the guarantee less cumulative amortisation; and, The amount of the obligation under the contract, as determined in accordance with IAS 37: Provisions, Contingent Liabilities and Contingent Assets Financial Liabilities at Fair Value Through Profit and Loss Embedded derivatives that have different risks and characteristics to their host contracts, and contracts with embedded derivatives whose separate value cannot be ascertained, are treated as financial liabilities at fair value through profit and loss. They are held at fair value, with any resultant gain or loss recognised in the clinical commissioning group s surplus/deficit. The net gain or loss incorporates any interest payable on the financial liability Other Financial Liabilities After initial recognition, all other financial liabilities are measured at amortised cost using the effective interest method, except for loans from Department of Health, which are carried at historic cost. The effective interest rate is the rate that exactly discounts estimated future cash payments through the life of the asset, to the net carrying amount of the financial liability. Interest is recognised using the effective interest method Value Added Tax Most of the activities of the clinical commissioning group are outside the scope of VAT and, in general, output tax does not apply and input tax on purchases is not recoverable. Irrecoverable VAT is charged to the relevant expenditure category or included in the capitalised purchase cost of fixed assets. Where output tax is charged or input VAT is recoverable, the amounts are stated net of VAT. 1.3 Foreign Currencies The clinical commissioning group s functional currency and presentational currency is sterling. Transactions denominated in a foreign currency are translated into sterling at the exchange rate ruling on the dates of the transactions. At the end of the reporting period, monetary items denominated in foreign currencies are retranslated at the spot exchange rate on 31 March. Resulting exchange gains and losses for either of these are recognised in the clinical commissioning group s surplus/deficit in the period in which they arise Third Party Assets Assets belonging to third parties (such as money held on behalf of patients) are not recognised in the accounts since the clinical commissioning group has no beneficial interest in them Losses & Special Payments Losses and special payments are items that Parliament would not have contemplated when it agreed funds for the health service or passed legislation. By their nature they are items that ideally should not arise. They are therefore subject to special control procedures compared with the generality of payments. They are divided into different categories, which govern the way that individual cases are handled. Losses and special payments are charged to the relevant functional headings in expenditure on an accruals basis, including losses which would have been made good through insurance cover had the clinical commissioning group not been bearing its own risks (with insurance premiums then being included as normal revenue expenditure) Subsidiaries Material entities over which the clinical commissioning group has the power to exercise control so as to obtain economic or other benefits are classified as subsidiaries and are consolidated. Their income and expenses; gains and losses; assets, liabilities and reserves; and cash flows are consolidated in full into the appropriate financial statement lines. Appropriate adjustments are made on consolidation where the subsidiary s accounting policies are not aligned with the clinical commissioning group or where the subsidiary s accounting date is not co-terminus. Subsidiaries that are classified as held for sale are measured at the lower of their carrying amount or fair value less costs to sell Associates Material entities over which the clinical commissioning group has the power to exercise significant influence so as to obtain economic or other benefits are classified as associates and are recognised in the clinical commissioning group s accounts using the equity method. The investment is recognised initially at cost and is adjusted subsequently to reflect the clinical commissioning group s share of the entity s profit/loss and other gains/losses. It is also reduced when any distribution is received by the clinical commissioning group from the entity. Joint ventures that are classified as held for sale are measured at the lower of their carrying amount or fair value less costs to sell Joint Ventures Material entities over which the clinical commissioning group has joint control with one or more other parties so as to obtain economic or other benefits are classified as joint ventures. Joint ventures are accounted for using the equity method. Joint ventures that are classified as held for sale are measured at the lower of their carrying amount or fair value less costs to sell Joint Operations Joint operations are activities undertaken by the clinical commissioning group in conjunction with one or more other parties but which are not performed through a separate entity. The clinical commissioning group records its share of the income and expenditure; gains and losses; assets and liabilities; and cash flows Research & Development Research and development expenditure is charged in the year in which it is incurred, except insofar as development expenditure relates to a clearly defined project and the benefits of it can reasonably be regarded as assured. Expenditure so deferred is limited to the value of future benefits expected and is amortised through the Statement of Comprehensive Net Expenditure on a systematic basis over the period expected to benefit from the project. It should be re-valued on the basis of current cost. The amortisation is calculated on the same basis as depreciation Accounting Standards That Have Been Issued But Have Not Yet Been Adopted The Government Financial Reporting Manual does not require the following Standards and Interpretations to be applied in , all of which are subject to consultation: IFRS 9: Financial Instruments ( application from 1 January 2018) IFRS 14: Regulatory Deferral Accounts ( not applicable to DH groups bodies) IFRS 15: Revenue for Contract with Customers (application from 1 January 2018) IFRS 16: Leases (application from 1 January 2019) The application of the Standards as revised would not have a material impact on the accounts for , were they applied in that year. 10

144 NHS Isle of Wight CCG - Annual Accounts Other Operating Revenue Total Total '000 '000 Education, training and research 13 8 Non-patient care services to other bodies Other revenue 5 5 Total other operating revenue Revenue in this note does not include cash received from NHS England, which is drawn down directly in to the bank account of the CCG and credited to the General Fund. 3 Revenue Total Total '000 '000 From rendering of services From sale of goods 0 0 Total

145 NHS Isle of Wight CCG - Annual Accounts Employee benefits and staff numbers Employee benefits Total Total Permanent Employees Other '000 '000 '000 Employee Benefits Salaries and wages 2,758 2,758 0 Social security costs Employer Contributions to NHS Pension scheme Gross employee benefits expenditure 3,420 3,420 0 Less recoveries in respect of employee benefits (note 4.1.2) ,420 3,420 0 Less: Employee costs capitalised Net employee benefits excluding capitalised costs 3,420 3, Employee benefits Total Total Permanent Employees Other '000 '000 '000 Employee Benefits Salaries and wages 2,692 2,692 0 Social security costs Employer Contributions to NHS Pension scheme Gross employee benefits expenditure 3,246 3,246 0 Less recoveries in respect of employee benefits Total - Net admin employee benefits including capitalised costs 3,246 3,246 0 Less: Employee costs capitalised Net employee benefits excluding capitalised costs 3,246 3,

146 NHS Isle of Wight CCG - Annual Accounts Average number of people employed Total Permanently employed Other Total Number Number Number Number Total Of the above: Number of whole time equivalent people engaged on capital projects Staff sickness absence and ill health retirements Number Number Total Days Lost Total Staff Years Average working Days Lost Number Number Number of persons retired early on ill health grounds 0 0 '000 '000 Total additional Pensions liabilities accrued in the year Exit Packages agreed in the financial year There were no negotiated exit packages during this or the previous financial year. 13

147 NHS Isle of Wight CCG - Annual Accounts Pension costs Past and present employees are covered by the provisions of the NHS Pension Scheme. Details of the benefits payable under these provisions can be found on the NHS Pensions website at The Scheme is an unfunded, defined benefit scheme that covers NHS employers, GP practices and other bodies, allowed under the direction of the Secretary of State, in England and Wales. The Scheme is not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities. Therefore, the Scheme is accounted for as if it were a defined contribution scheme: the cost to the clinical commissioning group of participating in the Scheme is taken as equal to the contributions payable to the Scheme for the accounting period. The Scheme is subject to a full actuarial valuation every four years (until 2004, every five years) and an accounting valuation every year. An outline of these follows: Full actuarial (funding) valuation The purpose of this valuation is to assess the level of liability in respect of the benefits due under the Scheme (taking into account its recent demographic experience), and to recommend the contribution rates to be paid by employers and scheme members. The last such valuation, which determined current contribution rates was undertaken as at 31 March 2012 and covered the period from 1 April 2008 to that date. Details can be found on the pension scheme website at For , employers contributions of 413,596 were payable to the NHS Pensions Scheme ( : 361,094) were payable at the rate of 14.3% of pensionable pay. The scheme s actuary reviews employer contributions, usually every four years and now based on HMT Valuation Directions, following a full scheme valuation. The latest review used data from 31 March 2012 and was published on the Government website on 9 June These costs are included in the NHS pension line of note 4.1 with the exception of the Chair and Non-Executive's contributions which are held with non-pay as per NHS Guidance. 14

148 NHS Isle of Wight CCG - Annual Accounts Operating expenses Total Admin Programme Total '000 '000 '000 '000 Gross employee benefits Employee benefits excluding governing body members 3,041 1,735 1,306 2,990 Executive governing body members Total gross employee benefits 3,420 2,113 1,306 3,246 Other costs Services from other CCGs and NHS England 1, ,243 Services from foundation trusts 7, ,515 7,248 Services from other NHS trusts 140, , ,127 Services from other WGA bodies Purchase of healthcare from non-nhs bodies 30, ,241 29,686 Chair and Non Executive Members Supplies and services clinical Supplies and services general 5, , Consultancy services Establishment Transport Premises Impairments and reversals of receivables Depreciation Amortisation Audit fees Other non statutory audit expenditure Internal audit services Other services General dental services and personal dental services Prescribing costs 25, ,415 24,850 Pharmaceutical services General ophthalmic services GPMS/APMS and PCTMS 20, ,037 1,835 Other professional fees excl. audit Grants to Other bodies Clinical negligence Research and development (excluding staff costs) Education and training Change in discount rate Provisions (55) CHC Risk Pool contributions Other expenditure Total other costs 233, , ,013 Total operating expenses 236,906 3, , ,260 Please note that the above schedule contains rounding differences of 1k In 2016/17 The CCG took on the responsibility for Delegated Primary Care which is reflected above in GPMS/APMS and PCTMS 15

149 NHS Isle of Wight CCG - Annual Accounts Better Payment Practice Code Measure of compliance Number '000 Number '000 Non-NHS Payables Total Non-NHS Trade invoices paid in the Year 6,728 76,799 6,017 45,378 Total Non-NHS Trade Invoices paid within target 6,645 74,631 5,909 44,828 Percentage of Non-NHS Trade invoices paid within target 98.77% 97.18% 98.21% 98.79% NHS Payables Total NHS Trade Invoices Paid in the Year 1, ,964 1, ,875 Total NHS Trade Invoices Paid within target 1, ,964 1, ,791 Percentage of CCG NHS trade invoices paid within target 99.61% % 98.79% 99.94% 6.2 The Late Payment of Commercial Debts (Interest) Act '000 '000 Amounts included in finance costs from claims made under this legislation 0 0 Compensation paid to cover debt recovery costs under this legislation 0 0 Total Income Generation Activities The CCG does not undertake any income generation activities 16

150 NHS Isle of Wight CCG - Annual Accounts Net gain/(loss) on transfer by absorption The CCG had no transfers during this financial period 9. Operating Leases 9.1 As lessee The CCG has a lease with NHS Property Services for its headquarters building (Building A, The Apex, St Cross Business Park, Newport). The lease commenced in September 2013, for a 10 year period, with a break clause at Year Payments recognised as an Expense Land Buildings Other Total Land Buildings Other Total '000 '000 '000 '000 '000 '000 '000 '000 Payments recognised as an expense Minimum lease payments Contingent rents Sub-lease payments Total Future minimum lease payments Land Buildings Other Total Land Buildings Other Total '000 '000 '000 '000 '000 '000 '000 '000 Payable: No later than one year Between one and five years After five years Total

151 NHS Isle of Wight CCG - Annual Accounts Trade and other receivables Current Non-current Current Non-current '000 '000 '000 '000 NHS receivables: Revenue NHS receivables: Capital NHS prepayments NHS accrued income 1, Non-NHS and Other WGA receivables: Revenue Non-NHS and Other WGA prepayments Non-NHS and Other WGA accrued income Provision for the impairment of receivables VAT Other receivables and accruals Total Trade & other receivables 3, ,003 0 Total current and non current 3,875 2,003 Included above: Prepaid pensions contributions 0 0 Please note that the above schedules contain rounding differences of 1k The majority of trade receivables is with other NHS organisations Receivables past their due date but not impaired '000 '000 By up to three months By three to six months 0 0 By more than six months 8 8 Total k of the amount above has subsequently been recovered as at 30 April No amounts were written off during the year. The clinical commissioning group did not hold any collatoral against receivables outstanding at 31st March Provision for impairment of receivables '000 '000 Balance at 01 April Amounts written off during the year 0 0 Amounts recovered during the year 0 0 (Increase) decrease in receivables impaired 0 0 Transfer (to) from other public sector body 0 0 Balance at 31 March The CCG does not consider any receivables should be impaired during this financial period 18

152 NHS Isle of Wight CCG - Annual Accounts Cash and cash equivalents '000 '000 Balance at 01 April Net change in year Balance at 31 March Made up of: Cash with the Government Banking Service Cash with Commercial banks 0 0 Cash in hand 0 0 Current investments 0 0 Cash and cash equivalents as in statement of financial position Bank overdraft: Government Banking Service 0 0 Bank overdraft: Commercial banks 0 0 Total bank overdrafts 0 0 Balance at 31 March The CCG does not hold any patients money. 19

153 NHS Isle of Wight CCG - Annual Accounts Trade and other payables Current Non-current Current Non-current '000 '000 '000 '000 Interest payable NHS payables: revenue NHS payables: capital NHS accruals 3, ,639 0 NHS deferred income Non-NHS and Other WGA payables: Revenue ,146 0 Non-NHS and Other WGA payables: Capital Non-NHS and Other WGA accruals 6, ,760 0 Non-NHS and Other WGA deferred income Social security costs VAT Tax Payments received on account Other payables and accruals 2, ,944 0 Total Trade & Other Payables 13, ,580 0 Total current and non-current 13,294 12,580 Other payables include 212k outstanding pension contributions at 31st March ( 56k - 31st March 2016) Please note that the above schedule contains rounding differences of 1k 20

154 NHS Isle of Wight CCG - Annual Accounts Provisions Current Non-current Current Non-current '000 '000 '000 '000 Pensions relating to former directors Pensions relating to other staff Restructuring Redundancy Agenda for change Equal pay Legal claims 0 (0) 0 0 Continuing care Other Total 539 (0) 50 0 Total current and non-current Pensions Relating to Former Directors Pensions Relating to Other Staff Restructuring Redundancy Agenda for Continuing Change Equal Pay Legal Claims Care Other Total '000 '000 '000 '000 '000 '000 '000 '000 '000 '000 Balance at 01 April (0) Arising during the year Utilised during the year Reversed unused (50) 0 (50) Unwinding of discount Change in discount rate Transfer (to) from other public sector body Transfer (to) from other public sector body under absorption Balance at 31 March (0) Expected timing of cash flows: Within one year Between one and five years (0) 0 0 (0) After five years Balance at 31 March (0) Continuing Care provision relates to the potential CCG liability on Continuing Care restitution cases 21

155 NHS Isle of Wight CCG - Annual Accounts Contingencies The CCG had no contingencies at the end of the financial period 16 Commitments 16.1 Capital commitments The CCG does not have any capital commitments at the end of the financial period 16.2 Other financial commitments The CCG does not have any other financial commitments at the end of the financial period 17 Financial instruments 17.1 Financial risk management Financial reporting standard IFRS 7 requires disclosure of the role that financial instruments have had during the period in creating or changing the risks a body faces in undertaking its activities. Because NHS Clinical Commissioning Group is financed through parliamentary funding, it is not exposed to the degree of financial risk faced by business entities. Also, financial instruments play a much more limited role in creating or changing risk than would be typical of listed companies, to which the financial reporting standards mainly apply. The clinical commissioning group has limited powers to borrow or invest surplus funds and financial assets and liabilities are generated by day-to-day operational activities rather than being held to change the risks facing the clinical commissioning group in undertaking its activities. Treasury management operations are carried out by the finance department, within parameters defined formally within the NHS Clinical Commissioning Group standing financial instructions and policies agreed by the Governing Body. Treasury activity is subject to review by the NHS Clinical Commissioning Group and internal auditors Currency risk The NHS Clinical Commissioning Group is principally a domestic organisation with the great majority of transactions, assets and liabilities being in the UK and sterling based. The NHS Clinical Commissioning Group has no overseas operations. The NHS Clinical Commissioning Group and therefore has low exposure to currency rate fluctuations Interest rate risk The Clinical Commissioning Group borrows from government for capital expenditure, subject to affordability as confirmed by NHS England. The borrowings are for 1 to 25 years, in line with the life of the associated assets, and interest is charged at the National Loans Fund rate, fixed for the life of the loan. The clinical commissioning group therefore has low exposure to interest rate fluctuations Credit risk Because the majority of the NHS Clinical Commissioning Group and revenue comes parliamentary funding, NHS Clinical Commissioning Group has low exposure to credit risk. The maximum exposures as at the end of the financial year are in receivables from customers, as disclosed in the trade and other receivables note Liquidity risk NHS Clinical Commissioning Group is required to operate within revenue and capital resource limits, which are financed from resources voted annually by Parliament. The NHS Clinical Commissioning Group draws down cash to cover expenditure, as the need arises. The NHS Clinical Commissioning Group is not, therefore, exposed to significant liquidity risks. 22

156 NHS Isle of Wight CCG - Annual Accounts Financial instruments cont'd 17.2 Financial assets At fair value through profit and loss Loans and Receivables Available for Sale Total '000 '000 '000 '000 Embedded derivatives Receivables: NHS 0 1, ,881 Non-NHS Cash at bank and in hand Other financial assets Total at 31 March , ,560 At fair value through profit and loss Loans and Receivables Available for Sale Total '000 '000 '000 '000 Embedded derivatives Receivables: NHS Non-NHS Cash at bank and in hand Other financial assets Total at 31 March , , Financial liabilities At fair value through profit and loss Other Total '000 '000 '000 Embedded derivatives Payables: NHS 0 3,144 3,144 Non-NHS 0 10,058 10,058 Private finance initiative, LIFT and finance lease obligations Other borrowings Other financial liabilities Total at 31 March ,202 13,202 At fair value through profit and loss Other Total '000 '000 '000 Embedded derivatives Payables: NHS 0 2,656 2,656 Non-NHS 0 9,849 9,849 Private finance initiative, LIFT and finance lease obligations Other borrowings Other financial liabilities Total at 31 March ,505 12,505 23

157 NHS Isle of Wight CCG - Annual Accounts Operating segments The CCG only has one operating segment, which is the commissioning of healthcare services. 19 Pooled budgets The CCG has entered into pooled budget arrangements with the Isle of Wight Council. Under the arrangements funds are pooled under Section 75 of the NHS Act 2006 for NHS Funded nursing Care. The Better Care Fund was a Section 75 in 2015/16 however the CCG and Isle of Wight Council did not sign a Section 75 agreement but signed a Section 256 agreement which means the Better Care Fund was not a pooled budget in 2016/17. The pooled budgets are hosted as follows:- NHS funded nursing care Host Isle of Wight Council The Clinical Commissioning Group's share of the pooled budgets income and expenditure where: Income Expenditure Income Expenditure NHS Funded Nursing Care 2,471 2,469 1,913 1,826 Better Care Fund ,614 14,229 Total 2,471 2,469 16,527 16,055 24

158 NHS Isle of Wight CCG - Annual Accounts Related party transactions The CCG's related parties are GP practices that have one or more Governing Body/Clinical Executive members and could be seen as having significant influence. The payments made to practices relate to Locally Enhanced Services, Delegated Primary Care and GP prescribing incentive scheme. Details of related party transactions with individuals are as follows: Payments to Related Party Receipts from Related Party Amounts owed to Related Party Amounts due from Related Party '000 '000 '000 '000 Esplanade Surgery J. Hesse 1, Shanklin medical Centre J. Rivers 1, Tower House Surgery M. Legg 1, East Cowes Medical Centre B. Browne 1, The Dower House Surgery T. Whelan 1, Cowes Medical Centre S. Westmore 1, The Department of Health is regarded as a related party. During the year the CCG has had a significant number of material transactions with entities for which the Department is regarded as the parent Department. For example: NHS England; NHS Foundation Trusts; NHS Trusts; NHS Litigation Authority NHS Business Services Authority. NHS Commissioning Support Units In addition the CCG has had a number of material transactions with other government departments and other central and local government bodies. Most of these transactions have been with the Isle of Wight Council. 25

159 NHS Isle of Wight CCG - Annual Accounts Events after the end of the reporting period There are no post balance sheet events which will have a material effect on the financial statements of the CCG 22 Third party assets The CCG does not hold any cash or cash equivalents on behalf of third parties The CCG does not have any other financial commitments at the end of the financial period 23 Financial performance targets NHS Clinical Commissioning Group have a number of financial duties under the NHS Act 2006 (as amended). NHS Clinical Commissioning Group performance against those duties was as follows: Target Performance Target Performance Expenditure not to exceed income 239, , , ,260 Capital resource use does not exceed the amount specified in Directions Revenue resource use does not exceed the amount specified in Directions 239, , , ,117 Capital resource use on specified matter(s) does not exceed the amount specified in Directions Revenue resource use on specified matter(s) does not exceed the amount specified in Directions Revenue administration resource use does not exceed the amount specified in Directions 3,100 2,999 3,490 3, Purchase of Healthcare Non-NHS Purchase of Non NHS Healthcare Independent/ Local Devolved 2015/16 Voluntary Total Private Authorities Administrations Total '000 '000 '000 '000 '000 '000 Total Primary Healthcare Purchased Purchase of Secondary Healthcare Social Care 114 3,604 3,718 3,592 Mental Health 2, ,454 3,505 Maternity 0 General and Acute 2,104 2,104 2,128 Accident and Emergency 0 Community Health Services 5, ,720 7,240 8,692 Continuing Care incl different types of NHS funded care provided on 11,302 3,136 14,438 11,769 continuous basis Total Secondary Healthcare Purchased 20, , ,954 29,686 TOTAL 21, , ,248 29,686 26

160 Governing Body Governing Body Assurance Framework Sponsor: Helen Shields, CCG Chief Officer The Governing Body Assurance Framework has been updated using the strategic objectives and critical success factors agreed at the last Governing Body meeting. In line with recommendations made by the Internal auditors and with the agreement of the CCG Officers Group the risks are now aligned with the high risks from the corporate risk register. Those risks that could have an impact on the delivery of CCG s strategic objectives and the corresponding critical success factors. There is also an additional column in the GBAF that links each risk to the strategic objectives that it might impact on and other identifies other risks that are linked to it. The following high risks have been identified: Objective 1: To co-produce with the IW NHS Trust & IW Council System Transformation and Sustainability Y5/5 Partner Resilience - 20 Y5/21 Acute Service Re-design 16 Y5/3 Mental Health Reconfiguration 20 Y5/9 GP 7 Day working 20 Summary of issue: Objective 2: To meet the finance and performance targets set within the operating plan working with the national allocations team in relation to the funding formula. Y5/13 NHS Constitution targets 16 Y5/1 System resilience 20 Y5/11 Finance and QIPP - 16 Objective 3: To demonstrate measurable improvements in the quality and safety of our commissioned services Y5/2 Ambulance Service 20 Y5/6 CQC Inspection - 20 Y5/7 GP Out of hours 20 Y5/10 Children in Care - 20 Objective 4: To develop the culture and governance within the CCG to deliver transformation No risks score above 15 Action required/ recommendation: The Governing Body is asked to review the GBAF and determine whether it is assured that the CCG is capturing and managing the strategic risks appropriately.

161 Principle risks: Other committees where this has been considered: Financial /resource implications: Legal implications/ impact: Public involvement /action taken: Equality and diversity impact: The Governing Body is a presented with a summary of the key corporate risks faced by the organisation. The underlying risks associated with this document are discussed at Primary Care Committee, Quality Patient Safety Committee and CCG Officers Group. There remain risks associated with the delivery of the financial plan and QIPP programme and the reduction of the underlying deficit. There are legal implications relating to the CQC Inspection for the IW NHS Trust and for the CCG the duty to deliver financial balance. The CCG has a statutory duty to ensure that adequate public engagement takes place as part of service re-design. There are currently no equality or diversity issues identified. Author of Paper: Phil Hartwell, Head of Corporate Governance Date of Paper: 30 June 2017 Date of Meeting: 13 July 2017 Agenda Item: 5.4 Paper number: GB17-023

162 IW CCG Governing Body July 2017 GOVERNING BODY ASSURANCE FRAMEWORK 2017/18 (What could prevent this objective being achieved?) Key Controls Sources of Assurance Gaps in control/assurance (What controls do we have in place to assist in securing the delivery of this objective?) (Where can the Governing Body gain evidence that our controls/systems on which we place reliance are effective?) May Assurance level Jul Assurance level Sept Assurance Level Nov Assurance level severity x likelihood Feb Assurance level (Where we are failing to put controls/systems in place) Action plan to address gaps Owner Review/ Completion date Link to strategic objectives Links to other risks Reporting Committee Objective 1: To co-produce with the IW NHS Trust & IW Council System Transformation and Sustainability Critical Success Factor 1: To co-produce System Transformation and participate effectively in the local delivery system planning process ensuring delivery of all plans the CCG has agreed to lead in. Y5/5 Partner Resilience Clinical Executive Contract Meeting Local Care Board AD Integrated Commissioning commences end of June 17 New Local Care Board has been set up and will set priorities and monitor delivery of key system plans. Notes of Local Care Board Plans not yet developed Controls and assurance not yet in place Ensuring appropriate capacity to deliver within task and finish groups Local Care plan to be developed Setting system priorities by LCB Establish task & finish groups and monitoring systems through LCB Ensure appropriate leadership capacity to deliver key projects GB 1 CE 5*4 5*4 Y5/6 Critical Success Factor 2: To complete the Acute Services Redesign project according to the agreed project plan and ensure that the CCG has undertaken all the actions within its power. Y5/21 Acute Service Re-design - Poor modelling of options and lack of ambition Monthly ASR steering group Clinical Executive oversight Local Care Board Notes of ASR steering group Clinical Executive minutes LCB minutes Preferred model to be agreed by IW system Modelling of preferred option Clinical Senate workshop to offer challenge to developing schemes Key priorities for LCB who will ensure robust monitoring of project plan GB 1 & 3 CE (LCB) 4*4 Critical Success Factor 3: To lead the Mental Health reconfiguration programme and the Mental Health five year forward programme Y5/3 Mental Health Services - capacity to deliver the required number of changes SMT review with Trust Mental Health Improvement Group Quality Surveillance summits Clinical Quality review meetings MH Reconfiguration board Local Care Board Close monitoring of improvement plans. Attendance at risk and quality surveillance summits and Clinical Quality Review Meetings notes of LCB and MH Reconfiguration Board 5*4 5*4 Clear project plans for re-configuration to be still to be finalised Lack of understanding of baseline cost of services Project teams not fully in place Intensive Quality Assurance visits begun Quality Improvement plan Project chaters to be developed cost based review to be finalised and agreed Bid for additional vanguard funds to enable additional project support MR/GB 1&3 Y5/6 Y5/14 QPSC (LCB) Page 1 of 6

163 IW CCG Governing Body July 2017 (What could prevent this objective being achieved?) Key Controls Sources of Assurance Gaps in control/assurance (What controls do we have in place to assist in securing the delivery of this objective?) (Where can the Governing Body gain evidence that our controls/systems on which we place reliance are effective?) May Assurance level Jul Assurance level Sept Assurance Level Nov Assurance level severity x likelihood Feb Assurance level (Where we are failing to put controls/systems in place) Action plan to address gaps Owner Review/ Completion date Link to strategic objectives Links to other risks Reporting Committee Critical Success Factor 4: To implement the project plans within the GP 5 Year forward view and the local primary care strategy. Y5/9 GP 7 Day Access Project plan and project lead in place Legal Advice received Procurement Advice Received Single Tender Waiver agreed Project plan and project lead - Letter of agreement for delivery of service from One Wight Health in partnership with Lighthouse - Procurement advice received and single tender waiver agreed - legal advice received and contract in development 4x5 4x5 Operational model needs to be developed primary care buy-in to service model needs to be delivered CCG and Federation working closely to codesign operational model Federation holding a planning workshop for primary care Primary Care Clinical Lead visiting all localities to explain what the service will look like CM 1 Y5/18 PC Y5/18 GP workforce Performance report, PCOG monitoring, MLAFL reporting, Primary Care strategy Primary Care strategy supports the provision of bursaries for GPs Pilot project to develop Physician's Assistants underway Exploring opportunities in the national international recruitment programme for GPs 4x3 4x3 The workforce plans have not yet been produced. Details regarding the international recruitment programme have yet to be finalised - PC team to finalise international recruitment requirement for Island - bursary scheme to be developed - review of existing workforce enhanced service to be undertaken CM 1&3 Y5/9 PC Page 2 of 6

164 IW CCG Governing Body July 2017 (What could prevent this objective being achieved?) Key Controls Sources of Assurance Gaps in control/assurance (What controls do we have in place to assist in securing the delivery of this objective?) (Where can the Governing Body gain evidence that our controls/systems on which we place reliance are effective?) May Assurance level Jul Assurance level Sept Assurance Level Nov Assurance level severity x likelihood Feb Assurance level (Where we are failing to put controls/systems in place) Action plan to address gaps Owner Review/ Completion date Link to strategic objectives Links to other risks Reporting Committee Objective 2: To meet the finance and performance targets set within the operating plan working with the national allocations team in relation to the funding formula. Critical Success Factor 1: To meet the NHS Constitution targets set for the CCG Integrated Improvement plans The CCG, NHSE and NHSI have Contract management process approved IWNHS Trust improvement plans and trajectories are in place approved by the CCG, NHSE and NHSI. Y5/13 NHS Constitution Targets Delivery will be overseen via the Trust's Integrated Improvement Plan and assurance provided to the CCG. Formal monitoring of performance is carried out through the monthly contract management process. 4*4 4*4 Trajectories are in place approved by the CCG, NHSE and NHSI. Trust Integrated Improvement plan LO 2&3 Y5/1 CE Y5/1 System Resilience Local Care Board System Resilience Delivery Group Whole System Escalation Plan System Resilience Funding allocations Development of live System performance/escalation tool Key performance Recovery Trajectories Integrated Improvement Programme/Framework 4x5 4x4 4x5 4x4 Lack of Agreed priorities System wide workshop 14 Jun to review the 7 pillars in the plan: 111 calls, on line, Ambulance, GP, Urgent Treatment Centre, Hospital, home from Hospital Critical Success Factor 2: To achieve financial balance and deliver the QIPP programme The CCG has established a formal NHS England has recently assessed Strengthen local delivery arrangements to At present the CCG has 4.3m of schemes QIPP Programme led by the Chief the QIPP programme and their team include additional support. which are subject to the ability to 'stretch' 1,2&3 Finance Officer, with system wide has recommended that support be scheme delivery. This is considered high risk. It provided to the CCG to enable is anticipated that c 2m of other schemes schemes delivered through LDS delivery. could be delivered to support this leaving arrangements. Delivery of CCG financial plan and The QIPP schemes which rely on 2.3m without any current mitigation. Y5/11 LO CE QIPP target A QIPP oversight group has been established, and COG is reviewing weekly. Monthly executive performance review meetings with CCG delivery teams. Revised performance trajectories submitted to NHS E & I which outline when key indicators will to be achieved: ED - Mar 18, RTT - Sept 17 The National Urgent and Emergency Care Delivery Plan published in April 2017 forms a strategic blue print in managing urgent care demand at alternative locations delivered by a wider mix of skilled staff. partnership delivery between the Trust as part of the Local Delivery System (LDS) governance arrangements HS 2&3 Y5/13 Y5/5 CE Page 3 of 6

165 IW CCG Governing Body July 2017 (What could prevent this objective being achieved?) Y5/14 Cost Based Review Key Controls Sources of Assurance Gaps in control/assurance (What controls do we have in place to assist in securing the delivery of this objective?) Agreed methodology and process to review. The cost based review will be part of the new LDS governance arrangements. (Where can the Governing Body gain evidence that our controls/systems on which we place reliance are effective?) Received outputs of recent CBR which CCG will review by end of June CBR information will be needed for the Trust's independent financial review/financial recovery plan required by NHSI. May Assurance level 4x3 Jul Assurance level Sept Assurance Level Nov Assurance level severity x likelihood 4x3 Feb Assurance level (Where we are failing to put controls/systems in place) Action plan to address gaps Owner Review/ Completion date Link to strategic objectives Links to other risks Received outputs of recent CBR which CCG will review by end of May 17 CBR information will be needed for the Trust's 1,2&3 independent financial review/financial recovery plan required by NHSI. LO CE Y5/5 Y5/11 Y5/3 Reporting Committee Page 4 of 6

166 IW CCG Governing Body July 2017 (What could prevent this objective being achieved?) Key Controls Sources of Assurance Gaps in control/assurance (What controls do we have in place to assist in securing the delivery of this objective?) (Where can the Governing Body gain evidence that our controls/systems on which we place reliance are effective?) May Assurance level Jul Assurance level Sept Assurance Level Nov Assurance level severity x likelihood Feb Assurance level (Where we are failing to put controls/systems in place) Action plan to address gaps Owner Review/ Completion date Link to strategic objectives Links to other risks Reporting Committee Objective 3: To demonstrate measurable improvements in the quality and safety of our commissioned services Critical Success Factor 1: To take all actions available to the CCG to ensure provider compliance with the health and Social Care Act 2008 Regulations and fundamental standards. Ambulance Recovery Action plan, Reports to QPSC May 17 - Performance review still being Monitoring via SRG and contract, Weekly performance reporting reviewed by Trust internally. Amb quality reports to CQRM, Findings at high level discussed with EPRR Core standards Director of Quality Apr 17 - Cultural review recommendations being implemented by the Trust 1&3 Y5/2 Ambulance Service MR QPSC 4x5 4x5 Y5/6 Y5/6 IoW NHS Trust CQC inspection, S31 enforcement notice Continue monitoring service quality through monthly CQRM, Officer Level Meetings Contract Monitoring Service Review Meetings Monitoring service quality through monthly CQRM, Officer Level Meetings and Contract Monitoring and Service Review Meetings Several QA visit and reports including recommendations undertaken by CCG. Attendance at Quality summit, and regular attendance at each Quality Improvement Plan Oversight Group and Mental Health Improvement Group. 5x4 5x4 A single item QSG was held on 30/1/17 with regulators, Trust and CCG, concerns were raised regarding Trust capacity, capability and pace. CCG to provide a resource 1 day a week to support CQC monitoring & audit Trust Quality Improvement plan MR 1&3 Y5/2 Y5/3 Y5/7 QPSC Y5/7 GP Out of hours Service Contract review meeting. Urgent Care SRG Programme Board will review progress monthly GP Callback Service has been subcontracted by IW NHST Conitngency plans in place using Ambulance Service and Emergency Dept 5x4 5x4 Evaluation of pilot scheme Longer term solutions for delivery of the OOHs service is being reviewed, including working the GP Federation to support the service. Further Demand planning is taking place to provide accurate information to ensure an alternative delivery model/service can best manage the requirements. Ongoing discussions with the Federation including a collaboration meeting which will include GP OOH as well as Primary care extended access. HS 1&3 Y5/18 CE - Safeguarding framework in place Designated Doctor for Safeguarding on CCG agreed to commission local named GP to - LAC Nurse attendance at Governing sick leave travel to London to complete IHAs 3 Y5/10 Body Seminar to brief group Urgent review of LAC service required by Children in Care ensuring the - LAC Nurse attending Safeguarding IWNHST CCG is meeting statutory Operational Board (SOG) Caseload for nurse currently exceeds the responsibilities. national average of 105 MR QPSC 4x4 4x4 Page 5 of 6

167 IW CCG Governing Body July 2017 (What could prevent this objective being achieved?) Key Controls Sources of Assurance Gaps in control/assurance (What controls do we have in place to assist in securing the delivery of this objective?) (Where can the Governing Body gain evidence that our controls/systems on which we place reliance are effective?) May Assurance level Jul Assurance level Sept Assurance Level Nov Assurance level severity x likelihood Feb Assurance level (Where we are failing to put controls/systems in place) Action plan to address gaps Owner Review/ Completion date Link to strategic objectives Links to other risks Reporting Committee Objective 4: To develop the culture and governance within the CCG to deliver transformation Critical Success Factor 1: To develop and improve the Governance framework within the CCG to take account of the Local Delivery System and STP Local Delivery Service plan Single plan System Transformation team is producing a resource plan which the CCG is adding to. 1&4 Y5/15 Capacity and Capability to deliver Change 4x3 4x3 LO Y5/5 Y5/20 Y5/3 CE Critical Success Factor 2: To improve stakeholder and staff engagement in support of the organisation s objectives and key work programmes Existing Service Level Agreement Networks in place My Life communication strategy May - Meetings with new Provider Agreement with new service provider Finalisation of new contract due June 17 1&4 Y5/16 Communication and Engagement CM CE 4x3 4x3 Y5/15 Page 6 of 6

168 Governing Body Risk Register Summary Report Sponsor: Helen Shields, CCG Chief Officer In line with previous years the CCG reviewed the corporate risk register in April and new risk references were assigned to the existing risks and several new risks were added. Summary of issue: The following risks were added to the corporate risk register: Y5/4 Community Mental Health Services Y5/12 Wheelchair Services Y5/13 - NHS Constitution Y5/14 Cost Based review Y5/15 - Capacity to drive change Y5/19 - Specialised commissioning Y5/20 CSU financial Services Y5/16 Communication and Engagement Service Y5/17 Human Resource Service Transfer Y5/9 - GP 7 Day Service The following risks were removed from the corporate risk register: Y4/4 - Quality Premium Y4/25 - Enteral Feeds Y4/14 Spinal MPTT Y4/9 Prescribing QIPP Y4/11 - Haematology The Clinical Executive reviewed the Corporate Risk Register at their May and June meetings and agreed the following changes to the risks: Y5/12 Wheelchair Services score increased to 20 Y5/3 and Y5/4 - Mental Health In Patient and Community Services. Risks should be amalgamated to cover all Mental Health Services with bullet points to identify the key risk areas. Action required/ recommendation: Principle risks: Other committees where this has been considered: The Governing Body is asked to review the summary report and determine whether it is assured that the CCG is capturing and managing corporate risks appropriately. Achievement of financial and savings targets alongside concerns about the clinical sustainability of certain services remain the highest risks and are subject to detailed and ongoing work to mitigate the impact and likelihood of the risks materialising. All changes to risk are discussed at the Commissioning Officer s Group as they arise. In addition, the risk register is reviewed in detail monthly at the Clinical Executive and the outcomes of that review are detailed within the Clinical Executive minutes. Individual risks are discussed with teams during performance review meetings. Primary Care committee and Quality & Patient Safety committee review the risks which are appropriate to them.

169 Financial /resource implications: Legal implications/ impact: Public involvement /action taken: Equality and diversity impact: Author of Paper: The CCG has a significant financial risk including the achievement of the required QIPP savings. There are no material legal implications within the risk register at this point in the year. The risks associated with the finances and the future design of services for the Island are included as part of the public engagement exercise. The risks associated with the delivery of services on the island could impact adversely on a number of protected groups. Any changes to services will need to be accompanied by an equality assessment to ensure that all groups are able to access services appropriately. Phil Hartwell, Head of Corporate Governance Date of Paper: 30 June 2017 Date of Meeting: 13 July 2017 Agenda Item: 5.4 Paper number: GB17-024

170 Governing Body August 2016 Summary Risk Register Total 19 Time on Register Months >12 >6 >3 New Risks Risk Distribution Comm Fin Qual Corp High Medium Low Risk Activity Risks added to register 1 Ref Score Title 1 Y5/16 12 Communications & Engagement Y5/17 12 Human Resource Service Transfer Y5/9 20 GP 7 Day Working Risks removed from the register Y5/3 20 Community Mental Health Services Risks with Increased Score 1 Increased Scores Reduced Scores 0 Ref Score Y5/12 20 Risks with Reduced Score Ref Score Wheelchair Services Title Title High Risks Commissioning System Resilience 20 Ambulance 20 Partners Resilience 20 Wheelchair 20 GP OOH Service 20 GP 7 Day Working 20 Finance Financial plan 16 NHS Constitution 16 Corporate IWNHST Emergency Planning 20 Quality Mental Health Services 20 Ambulance Service 20 CQC Inspection 20 GB Risk Register Summary Jul 17

171 Governing Body Better Care Fund and Plan Sponsor: Gillian Baker The Better Care Fund (BCF) is a single pooled budget for health and social care services which has been created nationally to drive integrated health and adult social care services through greater integrated commissioning and provision. Summary of issue: Action required/ recommendation: Principle risks: Other committees where this has been considered: Financial /resource implications: The CCG and Local Authority are required to have a BCF Plan covering and a Section 75 which pools the funds between the two organisations. The BCF Plan and the Section 75 are in the final stages of development; technical guidance was issued on 4 July 2017, with a submission deadline of 11 September That the Governing Body approve in principle the draft proposals to pool funds between the IOW CCG and the IOW Council, under the Better Care Fund (BCF) and Improved Better Care Fund (ibcf). Workforce capacity constraints limit service transformation. Targets as set out as part of the national conditions are not achieved due to demand on services. IOW Council Cabinet, June 2017 IOW Health and Wellbeing Board, June 2017 The document sets out provisional financial implications of the Better Care Fund. The CCG is supporting Adult Social Care by contributing the mandated 3.637m in On top of this it is giving an additional 1m as nonrecurrent support. This is a reduction on previous years, but will enable continuation of existing services while transformation of services through the BCF and ibcf plans takes place. The total anticipated CCG Contribution to the pooled fund for is m within a total fund of m. This is subject to finalisation of the schemes and is net of anticipated CCG savings programmes as part of QIPP. Legal implications/ impact: The Section 75 pooled fund agreement for the Better Care Fund is being developed between the IOW CCG and IOW Council and is a legal document.

172 Public involvement /action taken: Equality and diversity impact: Author of Paper: None directly for this document, although extensive consultation has taken place under the My Life A Full Life programme and a provider workshop has been held to inform providers of health and social care of the proposals and to enable them to contribute their views. The CCG as a public body must meet its statutory obligations under the Equality Act 2010 and have due regard to eliminate unlawful discrimination, provide equal opportunities between people from different groups and to foster good relations between people who share a protected characteristic and people who do not share it. There are no negative equality and diversity impacts associated with this document, and it will positively support older and more vulnerable people. Catherine Budden, Projects and Planning Manager, CCG Date of Paper: 4 th July 2017 Date of Meeting: 13 July 2017 Agenda Item: 5.6 Paper number: GB17-025

173 Committee ISLE OF WIGHT CCG GOVERNING BODY Date 4 July 2016 Title BETTER CARE FUND 2017/19 PLANS AND SECTION 75 RECOMMENDATION 1. That the Governing Body approve in principle the draft proposals to pool funds between the IOW CCG and the IOW Council, under the Better Care Fund (BCF) and Improved Better Care Fund (ibcf). 2. That the Chair of the IOW CCG and the Chief Officer can approve the BCF plan on behalf of the Governing Body before the submission date. 3. That the final BCF Section 75 agreement is signed by the Chief Officer of the CCG. EXECUTIVE SUMMARY 4. This paper sets out an overview of the approach and requirements for developing the BCF and ibcf for 2017/ The report requires agreement in principle to the way in which the BCF and ibcf are being developed. 6. There is a requirement for the CCG and the Local Authority to have a pooled fund to support integrated commissioning and provision. The minimum requirement for is 9.7m, and for is 10.8m subject to release of technical guidance. 7. The pooled fund is to include the ibcf, which is new funding to support transformation. For the Isle of Wight this funding totals 6.5m, which tapers off over the next 3 years. 8. The CCG and the LA are proposing a total fund of m for and m for subject to finalisation upon receipt of the national technical guidance. The value was m in 2016/ There is a requirement to submit a high level BCF plan for 2017/19, the first draft of which is to be submitted within six weeks of the issue of the BCF Technical Guidance. Assurance and review of submitted plans is then undertaken, and local systems are able to redraft plans in advance of final submission. 10. The Health and Wellbeing Board is required to sign off the BCF Plans in advance of submission. 11. The Section 75 agreement the pooled fund for 2017/19 is in development and must be in place by the final submission date, however we hope to reach agreement before this date.

174 BACKGROUND 12. The Better Care Fund (BCF) is a single pooled budget for local health and social care services which has been created as a national requirement to drive greater integration of commissioning and provision. After producing detailed proposals, the Island was fully assured on its BCF Plan by NHS England for 2016/ In March, the government confirmed additional funding for social care to be paid directly to local authorities as part of an expanded Improved Better Care Fund grant (ibcf). The grant has three purposes: Meeting adult social care needs. Reducing pressures on the NHS, including supporting people to be discharged from hospital when they are ready. Ensuring the local social care market is supported. 14. The ibcf Allocation for the Isle of Wight is as follows: 2017/ m 2018/ m 2019/ m 15. The purposes of the money are set out in the grant determination issued by the Government and apply to both the original allocation (announced in the Spending Review in autumn 2016) and the new allocation. 16. There is a condition in the grant to require that the money is pooled into the local BCF. Following the announcement of the additional money it was agreed to include a new National Condition in the Better Care Fund. This condition requires all areas to implement the High Impact Change Model for Managing Transfers of Care to support system-wide improvements in transfers of care. There is a complementary grant condition on the ibcf requiring that it be used to implement the High Impact Change Model. 17. Key changes to the policy framework since include: A requirement for plans to be developed for the two-year period , rather than a single year. The number of national conditions which local areas will need to meet through the planning process in order to access the funding has been reduced from eight to four. 18. The BCF Technical Guidance was issued on the 4 July 2017, with a submission deadline of 11 September 2017; a draft of the guidance was released by the Local Government Association in April The guidance identifies four national conditions that we are required to meet: That a BCF Plan, including a minimum of the pooled fund specified in the Spending Review, should be signed off by the HWB and by the constituent LAs and CCGs. A demonstration of how the area will maintain in real terms the level of spending on social care services from the CCG minimum contribution to the fund in line with inflation. That a specific proportion of the area s allocation is invested in NHS commissioned out-of-hospital services, or retained pending release as part of a local risk sharing agreement. All areas to implement the High Impact Change Model for Managing Transfers of Care to support system-wide improvements in transfers of care. 20. The reduction in national conditions is intended to focus the conditionality of the BCF, but does not diminish the importance of the issues that were previously subject to conditions. These remain key enablers of integration. Narrative plans should describe how partners will continue to build on improvements locally against these formal conditions to: Develop delivery of seven day services across health and social care. Improve data sharing between health and social care. Ensure a joint approach to assessments and care planning. 21. The Island has been making progress on the national conditions as reported in the quarterly report Q4 for 2016/17.

175 22. We can confirm that we are spending on NHS commissioned out of hospital care and that an action plan for delayed transfers of care is in development. The CCG is contributing 3.637m in as NHS support for Social Care, as nationally mandated, and an additional 1m as non-recurrent support, as a contribution to maintaining the provision of Social Care services and including the Care Act. 23. The Section 75 will commit the CCG and the LA to commissioning the services in an integrated way. 24. There is a formal assurance process which the CCG and LA have to go through to have the BCF plans agreed. 25. The BCF plan and pooled budget should be seen as an enabler to the My Life a Full Life Programme (MLAFL) rather than a separate planning process. However the National requirements for the BCF do have to be met. THE PROPOSAL FOR INTEGRATED FUNDS 26. The officers within the CCG and the LA have reviewed the existing schemes within the pooled fund and have adopted a more focussed approach for 2017/19, identifying targeted BCF schemes with key deliverables in year, and developing new ibcf Schemes to deliver the purposes of the ibcf grant in meeting adult social care needs generally, reducing pressures on the NHS (including DTOC) and stabilising the care provider market. 27. There are now ten schemes. Existing pooled fund schemes and their budgets have been reorganised, with some services no longer included in the BCF; new ibcf schemes have been developed, some of which have been incorporated within existing BCF Schemes (see Appendix A). Work is ongoing in finalising the funding. 28. The BCF does not include the MLAFL Vanguard funds which also support integration. It is based on existing LA and CCG commissioned / provided services, and new services funded through the ibcf. 29. The IOW Local Care Board and Operational Delivery Group will oversee the BCF, finance, performance and risk. Work within the BCF must continue to be reported to the Health and Wellbeing Board. BCF Quarterly Reports are to be submitted, signed off by HWB, to NHS England, while ibcf Quarterly Reports are to be submitted to the Department for Communities and Local Government. NATIONAL METRICS 30. The BCF Policy Framework establishes that the national metrics for measuring progress of integration through the BCF will continue as they were set out for , with only minor amendments to reflect changes to the definition of individual metrics. In summary these are: Non-elective admissions (General and Acute); Admissions to residential and care homes; Effectiveness of reablement; Delayed transfers of care. 31. Trajectories for these Metrics are in development and will be within the final plan. CONCLUSION 32. Due to the lateness of the guidance and the timing of the Governing Body and HWB meetings it is not possible to submit a final plan for approval before the national deadlines. It is hoped the direction of travel is supported and that the chairs of the HWB and Governing Body can agree the plan on behalf of the HWB and Governing Body as long as it is in line with proposals outlined in this paper. 33. The final plan will be presented to the next Governing Body meeting following submission.

176 BCF SCHEME DESCRIPTIONS BCF SCHEME DESCRIPTION Locality Community Model The Locality / community model scheme will provide a phased and structured approach for reviewing, aligning and integrating community services for the population of the Isle of Wight. The benefits of this change will increase the level of innovation and deliver truly integrated teams which are based upon skills needed as opposed to services currently delivered. It will also deliver system wide efficiencies and better outcomes for people. This scheme is being undertaken by the My Life a Full Life programme, Transforming Community Services (TCS). There are already three integrated locality teams which are providing the foundation to delivering co-ordinated care and early intervention and prevention. New roles have been developed and piloted including care navigators and Locality area co-ordinators. The next phase is for services and staff to be aligned with locality and a new operating model put in place to support full integration. The key outputs for the TCS workstream include, but are not limited to: Implementation of locality governance and organisational structures including focus on safeguarding and the vulnerable. Implementation of integrated locality services Implementation of case management of those at risk Review of existing co-ordination provision in each locality Development of community resilience and community assets in each locality Development whole system business model and new way of contracting for community services e.g. Alliance contracting. Development and implementation of MH Crisis Café s in each locality Hospital to Home By improving discharge planning and patient flow, and by investing in capacity to care for patients in more appropriate and cost effective settings we will ensure that no patients stays longer in acute, community or mental health bed based care, than their clinical condition and care programme demands. The scheme will ensure that every patient has an integrated Discharge Plan, informed by their presenting condition and known social circumstances where complex needs are identified early in their journey and appropriate support models are in place to prevent readmission, reduce length of acute spells and minimises patient decompensation. The scheme will be achieved by using the 8 High Impact Change self-assessment tool to determine system baseline and will agree a time bound trajectory to move those areas forward. The scheme is further supported by ibcf additional funding of a for change/project management lead who will drive, implement and monitor the improvement plan. EXPECTED OUTCOMEs Appendix A Improved Quality and satisfaction of care for people, through clear service navigation and easy access to integrated coordinated services closer to home. Improved case management which prevents and, where possible, avoids deterioration and crisis leading to nonelective admission to hospital, or admission to residential care. Commissioned services will be sustainable, provide value-for-money and meet the needs of the Isle of Wight population. Multidisciplinary teams supporting people with complex needs, including community health and social care, mental health and voluntary services. Reduced complexity of services. Services that offer an alternative to hospital stay. Services wrapped around primary care and the individual. Power of the wider community is harnessed. People will remain in hospital no longer than their clinical condition requires People their families and carers will remain at the centre of care planning during their hospital journey Home first will be the default position, delivering care closer and in peoples homes and communities and encouraging independence. People will experience a safe discharge coordinated discharge

177 BCF SCHEME DESCRIPTIONS Living Well (VCS) The Living Well project has 4 elements for maximum impact supporting: Older people People living with learning disability People living with mental health conditions Carers Element 1: Creation of a VCS Living Well team working across the hospital, and embedded into ILS. Within hospital complementing the Improving Transfers of Care project, realignment of existing VCS staff (Support to Home from Hospital staff) to work within the Living Well model and improve links with ILS. Within community embedding VCS into ILS and extending capacity through recruitment of Living Well Support workers and a mental health support worker. Element 2: Recruitment of a Learning Disability Worker, working with Social Care to alleviate pressure on ASC, reduce use of residential care and where relevant support improved transfers of care between hospital and home. Element 3: Creation of a hospital based carers support service, and GP champion role, to complement community based services. Element 4: Creation of a VCS Brokerage Scheme, helping people live well independently. Collectively, the Living Well Project will reduce pressure on ASC and support the high impact change model to better manage transfers of care between hospital and home; specifically early discharge planning, joint assessment as part of an MDT, supporting Home first/discharge to assess, trusted assessment and enable choice as well as reduce/delay the need for residential care. ASC CARE CLOSE TO HOME It is recognised that that the current model of delivery for ASC is neither efficient nor cost effective: it does not lend itself to delivering person centred care and is resulting in a significant over reliance on residential and nursing care. To address this, a new strategy for Adult Social Care entitled Care Close to Home. This is predicated on 7 pillars: three core delivery pillars; and four enabling pillars. The four enabling pillars comprise the focus of the scheme and comprise: Competent, confident critical thinking staff Commissioning for value and impact Person centred professional practice and care Partnerships and integration Underpinning each of these four pillars are key work streams whose full implementation will secure more effective use of resources, a remodelling of practice, culture and systems and delivery of the community services element of My Life a Full Life Appendix A Outcomes A Living Well project within the VCS that will: Support a reduction in delayed transfers of care through contribution to the high impact change model Create community capacity to divert demand for Adult Social Care, particularly those ineligible for statutory funding (42% of enquiries) Support people to increase their ability to self-care, live well and retain their independence Help to reduce/delay the need for emergency admissions and a move to residential care Create a robust and sustainable ASC system Maximise best use of resources Reduce costs where possible ensuring value for money Create a diverse and robust market place Underpin the Care Closer to Home Strategy Reduce DTOC s by creating a sustainable diverse marketplace, facilitating effective and swift discharges Reduce the use of residential and nursing home provision Create a viable Personal Assistant (PA) marketplace to support direct payment recipients Implement a system that supports self-funders to become empowered consumers using adam Life (Life co.)

178 BCF SCHEME DESCRIPTIONS SUPPORT FOR PROVIDERS The purpose of this bid is to provide support to all market sectors. This scheme includes the following areas: Commercial provider secondment opportunity VCS secondment opportunity Sector led Safeguarding training Sector led specialist dementia training Provision of an Independent Chair (and administrative/co-ordinator support) for the local associations Health and Social Care Market Day Independent training needs analysis of CQC report and findings across all market sectors Grant funding to nominated provider to lead on programme of improvement across all market sectors Positive behaviour support training Aim: 1. Improving quality across all market sectors 2. Increasing the learning and development offer available to providers 3. Increasing commissioning capacity and capability 4. Improving provider engagement 5. Building strong and sustainable relationships between commissioners and providers Promoting Independence (Equipment) The Promoting Independence Scheme will comprise of a number of different services all aimed at supporting people to remain independent for longer by providing a structured and integrated community service for the people of the Isle of Wight. The Scheme will comprise of the following services: Community Equipment Service Wheelchairs Service Independent Living Centre and User Led Organisation Assistive Technology Disabled Facility The assistive technology elements of this scheme are supported by the ibcf and this will enable wider implementation of technology enabled Appendix A Outcomes This scheme will build Individual & Community resilience, develop, regain and sustain independence and help those we serve to live as independently as possible. This scheme will have a positive impact on the way in which services are delivered Empower the provider to look at the services they deliver more innovatively and this in turn will lead to improvement in the quality of service for individuals and support the building of both personal and community resilience The provision of higher quality care and support will enable people who need service to have greater control. Improving quality across all market sectors Increasing the learning and development offer available to providers Increasing commissioning capacity and capability Improving provider engagement Building strong and sustainable relationships between commissioners and providers Outcomes Prevention of unnecessary care placements Supporting people to live independently for longer. Increase in proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement / rehabilitation services. Enhanced domiciliary care services with ability to undertake reablement Aims The aim of this service is to help those we serve live as independently as possible, for as long as possible, in their own home or a community of their choosing.

179 BCF SCHEME DESCRIPTIONS Rehabilitation, Reablement & Recovery All the services included within this Better Care Fund Scheme aim to ensure that people can achieve maximum independence with their activities of daily living with the aim of remaining in their homes as long as possible, thus decreasing the need for long term care. Synergies in provision may enable these services to work more closely together, driving efficiencies in the system through integrating and simplifying pathways. The ibcf Reablement Scheme will develop an enhanced domiciliary care Reablement Service to ensure that people with complex reablement needs can receive a service which is currently not available. The Team will include Occupational Therapists, Physiotherapists and support workers who will focus on the needs of people who need double-handed carer support and also those who are in Reablement beds in the Adelaide and Gouldings Specific Actions 2017/19: Procure new Community Rehabilitation beds Mobilise new Rehabilitation Service Enable implementation of ibcf Reablement Scheme Integrate Rehabilitation Service with Reablement Service Integrated Mental Health Provision An integrated primary, secondary health, social care and third sector mental health system built around need of individuals with agreed outcomes based on shadowing payments by cluster The priority is to improve people s mental health and wellbeing by supporting the shift in services from hospital to community and ensuring the delivery of a more integrated model of support that recognises wider social networks and the importance of physical wellbeing, resilience and recovery. Deliverables Established mental health reconfiguration programme board to undertake a comprehensive and fundamental redesign of mental health, social care and third sector care pathways that delivers: o Review and reconfiguration of mental health reablement / rehabilitation pathway (Woodlands). o Review of Mental Health Day Service Provision. Service specifications with recovery based outcomes developed through co-creation (health, social care and third sector) Appendix A Outcomes Prevention of unnecessary care placements Supporting people to live independently for longer. Increase in proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement / rehabilitation services. Enhanced domiciliary care services with ability to undertake reablement Outcomes People in emotional distress or in mental health crisis will be able to access support 24/7 People with a mental health problem will receive personalised care that is focused on recovery including employment and housing support. People with mental health problems will be able to easily find information, advice and guidance; this will ensure that they feel supported to manage their own condition. People with mental health problems will be supported to maintain independence for as long as possible

180 BCF SCHEME DESCRIPTIONS Learning Disability Transforming Care Programme In November 2015 NHS England published Building the right support, a radical plan to develop more community services for people with a learning disability and/or autism who display behaviour that challenges support provision. Locally we will: Co-create with people with a learning disability, their family, carers and other stakeholders, a joint commissioning plan which locally defines and implements new models of care to enhance quality of life for all people with a learning disability living on the Island and those placed out of area. Ensure co-creation and implementation of the Peer Review action plan Refine the process to prevent unnecessary admission to specialist by supporting those in crisis via the Care Treatment Review process. Review /gap analysis of current Isle of Wight respite provision Invest in workforce to develop competent, confident, critical thinking staff Review and develop current local accommodation and support provision to ensure it meets the current and projected future needs of the Island population and reduces reliance on residential care provision. Undertake review of all highly specialist placements to ensure they meet the needs of the individual and deliver value for money Appendix A Outcomes Personalisation - To promote and develop self-directed strengths based support and approaches to personalisation that reflect the individual s preferences and aspirations, balancing this with the need to ensure resources are used cost effectively. Building individual and family resilience, reducing the need for formal support. Choice and Control To increase the choice and quality in the local market for health and social care services to ensure people with a learning disability across the island have access to a diverse range of high quality options to choose from, that are local to where they live, enhance quality of life and represent good value for money. Quality - Improved quality of support provided for people with a learning disability and their families, in particular ensuring that services are continually improving on person centred planning, approaches to communication and are developed with the full involvement of the people being supported. Information - Improve information and advice available to people with a learning disability in order to empower them to make more informed choices about the options available to them. To improve the information available with regard to population and needs to ensure intelligent commissioning strategically co-created with people with a learning disability.

181 BCF SCHEME DESCRIPTIONS Employment Support In February 2016 NHS England Published the Five Year Forward View for Mental Health. Integral to this strategy is the need for alignment of an Employment Support offering across the health and care system for: People with mental health problems People with a learning disability People with physical disability People with a combination of the above. Nationally and locally, the employment rate for adults with mental health problems remains unacceptably low: 43 per cent of all people with mental health problems are in employment, compared to 74 per cent of the general population Deliverables for the BCF 17 /19 scheme through alignment of existing provision: We will ensure access to psychological therapies for people: living with common mental health problems, in order to support them to find or stay in work. We will increase access to individual placement and support programmes for people: living with severe mental illness, living with a learning disability, living with physical disability in order to support them to find and or maintain employment. Appendix A Outcomes People with learning disability will receive timely access to individual placement and support programmes in order to facilitate them to maintain or find employment through IPS mode People with physical disability will see an improvement in their quality of life through increased opportunities of access and or maintaining employment through IPS model People with common mental health problems and or severe will receive timely access to psychological therapies to support them to find and or maintain employment People with common and severe mental health problems will see an improvement in their quality of life through increased opportunities of access and or maintaining employment through IPS model, including living as independently as possible

182 Governing Body IFR Highlight Report Sponsor: Helen Shields, Chief Officer Summary of issue: Action required/ recommendation: The Individual Funding Request Annual Report sets out the level of requests made in 2016/17. To note the report. Principle risks: Other committees where this has been considered: Financial /resource implications: Legal implications/ impact: Public involvement /action taken: Equality and diversity impact: None Individual Funding Request Panel. Clinical Executive 18 May 2017 No financial implications. No legal implications from the report. No public involvement in the report. N/A Author of Paper: Tracy Savage, Assistant Director, Medicines Optimisation Date of Paper: May 2017 Date of Meeting: 13 July 2017 Agenda Item: 5.7 Paper number: GB17-026

183 INDIVIDUAL FUNDING REQUESTS ANNUAL REPORT 2016/17 Introduction The Isle of Wight Clinical Commissioning Group have an Individual Funding Request (IFR) policy which sets out those procedures/drugs which are not normally funded, except in certain circumstances or where the patient demonstrates exceptional circumstances. This report sets out the position in 2016/17 and the outcome of the referrals. Panel Membership The IFR Panel membership comprised Helen Shields (Chair), Professor. Rida Elkheir (Director of Public Health, IW Council), Dr Andreas Lehmann (GP), Dr Sunitha Jinka (GP & NICE Clinical Lead), Loretta Kinsella (Director of Quality & Clinical Services) and Gillian Baker (Deputy Chief Officer) who is Chair in Helen Shields absence. Dr Lehman has been on sick leave. Dr Ben Browne, Clinical Executive member, has been the GP member on the panel. Additionally Dr Jinka resigned part way through 16/17 and a new Assistant Director, Medicines Management, Tracy Savage, joined the CCG in November Tracy Savage has since joined the panel. Review of IFR Process During 2016, the IFR policy was incorporated into the Clinical Funding Authorisation Policy which was updated in October The Clinical Funding Authorisation Policy was developed in order to support the launch of the Procedures of Low Clinical Value Policy (PLCV). With the recruitment of a new Assistant Director, Medicines Optimisation (ADMO) the members of the panel needed to be updated. Therefore a review of the policy was undertaken by the Chief Officer and ADMO. Changes made to the policy were undertaken to enable timely decision making, especially the appeal process. At the same time other amendments have been made in light of national and local guidance. Summary of Individual Funding Requests received 2016/17 A breakdown of the referrers and outcomes, and procedures and outcomes is shown in Appendix A. In 2016/17 the Isle of Wight CCG received 92 requests for Individual Funding. Sixty-nine of those applications were submitted to the IFR panel for their consideration. Please see figure 1. Fourteen requests were returned for additional information but these were not resubmitted by the referrer. Nine applications were considered not suitable for the IFR Panel. Figure 2 shows the reasons why. Going forward the CCG (Medicines Optimisation Team) will be providing education/communications to aid GP s with the IFR pathway/process, via their Newsletter and s. Table 1 shows the number and types of procedures that were approved by the IFR panel (20 approved) and table 2 those not approved (28). As outlined above, 2016 the Procedures of Limited Clinical Value Policy (PLCV) was launched. This policy details clear clinical criteria for a number of procedures that historically may have been sent to the IFR Panel. These requests are dealt with by a dedicated Prior Authorisation Team. It is possible that this is reflected in the reduction in requests received by the IFR team in 2016/17.

184 Appendix A Figure 1: Shows the IFR applications received during 2016/17 IFR Applications Received 2016/ Requests went to IFR Panel Figure 2: Demonstrates the applications that were not suitable for panel and reasons why Not Suitable for Panel Figure 3: IFR panel outcomes Prior Authorisation Pathway in Place IFR Criteria not Met IFR Panel Outcomes Withdrawn Approved Outstanding Not Approved Table 1 shows the number and types of procedures that were approved in 2016/17 Procedures Approved /17 Number Acupuncture 5 Medication/Drug 4 ASD/ADHD Assessment 3 Children's Brain Injury Referral 1 Counselling 1 FES (Functional Electrical Stimulation) 1 Hernia Repair 1 IVF 1 MRI 1 Sebaceous Cyst 1 Varicose Vein 1 Total 20

185 Table 2 demonstrates the number and types of procedures that were not approved during 2016/17 Procedures Not Approved /17 Number Breast Surgery 11 Abdominoplasty 2 IVF 2 Assessment 1 Chest Implant 2 Cosmetic Surgery 1 Counselling 1 Laser Treatment 2 Joint Flexion Device 1 Varicose Veins 2 Physiotherapy 1 Specialist Clothing 1 Vasectomy Reversal 1 Total 28

186 Governing Body Local Care System Sponsor: Helen Shields Summary of issue: To provide an update on the development of the Local Care System. Action required/ recommendation: Principle risks: Other committees where this has been considered: Financial /resource implications: Legal implications/ impact: Public involvement /action taken: Equality and diversity impact: To note progress The key risk is the system capacity to implement the changes at the scale and pace required. Local Care Board Health and Wellbeing Board The plan requires all organisations to achieve financial balance in the medium term. To be considered as the priority schemes are identified. There has been significant stakeholder and public engagement in the development of the My Life care model. To be considered as the priority schemes are identified. Author of Paper: Paul Sly Date of Paper: 3 July 2017 Date of Meeting: 13 July 2017 Agenda Item: 5.8 Paper number: GB17-027

187 1. Local Care System 1.1. The paper provides a brief update on the development of the Isle of Wight Local Care System 2. Summary 2.1 The Local Care System is the mechanism by which the Isle of Wight will bring together the Council, Clinical Commissioning Group and the NHS Trust along with wider partners and stakeholders to continue to deliver the Local Care System Vision outlined below. 2.2 The Local Care System has agreed to streamline, speed up and prioritise the way we work and what we do - with a focus on the few things that will make the biggest difference to the population we serve. 2.3 A Local Care Board has been established to unite efforts to improve the overall quality of health and social care on the Isle of Wight, and put patients, communities and taxpayers interests above those of our individual organisations. 2.4 A Local Care plan is being developed and will be agreed by Local Care Board, and brought to the Governing Body for approval. This plan will identify and prioritise the changes required to improve care across the island. 2.5 Paul Sly is supporting the Local Care System in the post of System Convenor for a time limited period. The key deliverables of this post include: - To identify and prioritise the changes required to improve care across the island, in line with the Island s vision.

188 To support the development of a credible strategic plan for the Isle of Wight Local Care System. To streamline the existing governance arrangements and further develop a joint programme office to drive system wide quality improvements and financial efficiencies. To act as the Executive interface between the Hampshire and IOW STP and the IOW Local Care System. To support the Local Care System discussions with NHS England and NHS Improvement. Paul is working with the System wide Transformation team on the above. 2.6 A review of the Local Care System governance and accountability has been carried out and a streamlined approach agreed by the Local Care Board. This new approach will remove duplication, ensure clear accountability and responsibility, and monitor delivery of the Local Care Plan. 3. Decisions, recommendations and any options 3.1 The Governing Body is asked to note the report and update provided Paul Sly (System Convenor) 3 July 2017

189 Governing Body Seven Day Primary Care Services Update Sponsor: Helen Shields, Chief Officer The CCG is required to commission 7 day primary care services from September This service must meet a number of criteria as set out in the 2017/18 Operational Planning Guidance. Summary of issue: For the Island it means commissioning 78 hours of primary care to be delivered between 6.30pm and 8pm Monday to Friday and according to local demand at weekends and bank holidays and at other times. The CCG has been working with One Wight Health, the GP Federation to develop the service specification to a point where the initial service plan can now be shared. Action required/ recommendation: The Governing Body is asked to note the update. There are a number of risks associated with this project, the primary ones being: Principle risks: Achieving a safe service, operational by September This is being mitigated through shared project planning and a collaborative approach to delivery One Wight Health capacity to deliver project management and operational management. This has been mitigated by buying in project management support. Willingness of the local primary care community to provide additional hours on top of their existing commitments to primary care. This is being mitigated through careful joint working with the primary care community to develop a service which they feel is valuable and useful. This subject is being overseen by the Primary Care Committee which has already received an update at the meeting in June. However at the time of the meeting the initial service plan was not available. Other committees where this has been considered: Progress is being reviewed monthly at the Primary Care Operational Group. In addition, NHSE Wessex is reviewing progress with the CCG on a weekly basis.

190 Financial /resource implications: Legal implications/ impact: The CCG is due to receive an allocation of 948k recurrently to fund the new service. This is likely to be received in July. In the first year, this will cover all set up costs as well as delivery. For future years, the allocation will need to cover all costs of delivering and managing the service. The CCG has taken both legal advice and procurement advice to determine the way in which the service should be procured. As the service is a pilot, the CCG has published a Prior Information Notice which sets out the intention to award the contract to One Wight Health without competition. An APMS contract rather than a standard NHS Contract will be used as this fits better to the primary care nature of the services to be provided. Public involvement /action taken: The CCG consulted widely with patients and primary care in the development of the primary care strategy which discussed this issue. This consultation has helped us to understand some of the key issues patients face in relation to access and have been addressed in developing the service plan. In addition, the CCG has commissioned Healthwatch to undertake a piece of work to understand the demand for 7 day services to help shape both the times that the service and the nature of services over the life of the pilot. One of the key requirements of implementing this policy initiative is to demonstrate how the service seeks to tackle health inequality. This paper shows how the new service will address in particular issues with access to primary care: Equality and diversity impact: by using non face-to-face methods of consultation reducing the need for travel by providing a number of specific bookable clinics outside working hours by providing early morning appointments for commuters Author of Paper: Caroline Morris, AD Primary Care and Corporate Business Date of Paper: 4 July 2017 Date of Meeting: 13 July 2017 Agenda Item: 5.9 Paper number: GB17-028

191 Commissioning 7 Day Primary Care Services Briefing for Governing Body and Progress Report

192 The Policy Context The CCG Primary Care Strategy approved in May 2017 sets out our approach to commissioning seven day primary care services. This is a requirement of the GP Five Year Forward View

193 Seven core requirements of service 1. Timing of services commission weekday provision of access to pre-bookable and same day appointments to general practice services in evenings (after 6:30pm) to provide an additional 1.5 hours a day; commission weekend provision of access to pre-bookable and same day appointments on both Saturdays and Sundays to meet local population needs; provide robust evidence, based on utilisation rates, for the proposed disposition of services throughout the week; 2. Capacity commission a minimum additional 30 minutes consultation capacity per 1000 population, rising to 45 minutes per 1000 population 3. Measurement ensure usage of a nationally commissioned new tool to be introduced during 2017/18 to automatically measure appointment activity by all participating practices, both in-hours and in extended hours. This will enable improvements in matching capacity to times of high demand 4. Advertising and ease of access ensure services are advertised to patients, including notification on practice websites, notices in local urgent care services and publicity into the community, so that it is clear to patients how they can access these appointments and associated service 5. Digital use of digital approaches to support new models of care in general practice. 6. Inequalities issues of inequalities in patients experience of accessing general practice identified by local evidence and actions to resolve in place. 7. Effective access to wider systems Effective connection to other system services enabling patients to receive the right care from the right professional, including access from and to other primary care and general practice services such as urgent care services.

194 Governance of the Project The Primary Care Committee and the Primary Care Operational Group are overseeing the delivery of the programme. Updates are being requested biweekly to NHS England on an individual basis with further biweekly conference call across Wessex.

195 Project Management A comprehensive project plan is in place which shows how the CCG will deliver 7 day services by September including Gantt charts, a risk assessment and quality impact assessment. As at June 2017, there are no delays in the project plan