AGENDA ITEM NO : 016/14 NHS Warrington Clinical Commissioning Group ANNUAL REPORT 2013/14

Transcription

1 AGENDA ITEM NO : 016/14 NHS Warrington Clinical Commissioning Group ANNUAL REPORT 2013/14 Excellence for Warrington 1

2 AGENDA ITEM NO : 016/14 FOREWORD We are very pleased to introduce the Annual Report for the year 2013/14, a year that whilst very challenging has been an exciting one, not only for Clinical Commissioning Groups, but for the NHS as a whole. When NHS Warrington Clinical Commissioning Group (the CCG) became a statutory body on 1 st April 2013, it had been through a rigorous authorisation process that assessed its fitness for purpose to carry out its duties. Since its inception, the CCG has fully embraced its statutory duties and the opportunity to make a real difference in the way that the people of Warrington access health and social care, in partnership with local partners. It has developed and strengthened its engagement processes, ensuring that our patients are at the heart of everything we do. The purpose of this annual report is to articulate to our stakeholders how the organisation has discharged its functions in the financial year 2013/14; including performance levels achieved and risks faced. Under the NHS Act 2006, the CCG is not required to prepare an annual report in its first financial year but it has been agreed that, as a learning organisation, we must reflect on this first year of operations such that we can continue to improve the quality and efficacy of the services that we commission. The annual report encapsulates a number of key statements Members Practices introduction; Strategic report; Members report; and Remuneration report. It supports the financial year-end reporting and annual accounting requirements for the whole of the NHS and will be subject to audit review. As a new statutory organisation, it is important to recognise that we could not have achieved all that we have without the loyalty and dedication of all our stakeholders and support team who work together to ensure that our local people and visitors receive the best health and care services possible, which we know as Excellence for Warrington. Once again, we would like to take this opportunity to thank everyone in our Clinical Commissioning Group and partners for their commitment and hard work. Dr Andrew Davies John Wicks Chair Interim Accountable Officer April 2014 April

3 AGENDA ITEM NO : 016/14 Contents Foreword Chair and Interim Accountable Officer Page 2 Introduction to the CCG 5-6 Member Practices introduction 7-10 Strategic Report Members Report Remuneration Report Appendix 1 Statement of Accountable Officer s Responsibility 31 Appendix 2 Annual Governance Statement Appendix 3 Declaration of interests 60 Appendix 4 Remuneration Information

4 AGENDA ITEM NO : 016/14 PUBLICATION ARRANGEMENTS The Annual Report and a full copy of the Annual Accounts will be available on the CCG website from 13 th June Paper copies and summary versions of (and alternative formats) of the Annual Report are available on request to members of the public free of charge through the Communications Department. If you would like a paper copy please contact: Paul Steele, Engagement, Experience & Communications Lead paul.steele@warringtonccg.nhs.uk Electronic copies will also available on the CCG s website: 4

5 AGENDA ITEM NO : 016/14 INTRODUCTION TO THE CCG NHS Warrington Clinical Commissioning Group (CCG) services people registered in the 26 general practices listed within the CCG area. This area is coterminous with Warrington Borough Council covering a resident population of 208,000. Our core purpose is to turn 239 million of resources into the best possible health outcomes for the people of Warrington and our vision across the whole system is to move from a reactive hospital based system of unplanned care to a preventative, anticipatory, whole person approach to care. Services will be integrated across the health and social care spectrum and redesigned with the patient and their carers at the centre, with the aim that they are easy to navigate, of higher quality and promote equity, accessibility and choice. Our aim is to enable people to be self-sufficient, providing necessary care and support to people in their own homes and communities. This vision is underpinned by our values, which are: Excellence; Valuing patients and partners; Accountability; Partnerships in everything; Honesty and integrity; Open and transparent; and Courage. Our strategic objectives are: Improve healthy life expectancy for all; Reduce inequalities; All commissioned services support delivery of the NHS Constitution for our population; Continually improve quality of commissioned services; Achieve sustained financial balance; Maintain a highly effective and motivated workforce; Ensure sound governance arrangements are in place; and Promote appropriate integration of commissioned services. In 2013/14, NHS Warrington Clinical Commissioning Group s total revenue resource limit was m. This is the amount of money the CCG had to commission services for the healthcare needs of its population. The CCG has been required to work closely with other Commissioners and Providers to fully understand the impact of the Health and Care Bill and ensure financial and service stability for the short, medium and long term planning. 5

6 AGENDA ITEM NO : 016/14 In this first year of operation, the emphasis has been on public and partner engagement, this partnership has ensured that the CCG s plans are the right ones for the people of Warrington and that the plans have been successful. It has been a year of relationship building and continued review of system performance and resilience. The CCG has concluded its first year with many great achievements against a backdrop of considerable change, risk, and challenge. As a Governing Body we have continued our development that started in February 2011 when working in shadow form under delegated arrangements from Warrington Primary Care Trust. Over the past 12 months, we have completed a number of internal reviews to ensure appropriate governance arrangements and these have been tested by our internal auditors. We have also continued our development programme for the Governing Body covering a number of important topics. Notably as a Governing Body we took part in a pilot programme organised by the NHS Leadership Academy and delivered by Deloitte looking in detail at the Governing Body effectiveness. The outcomes and learning from this has informed our development plan for the coming year. Our first year as a statutory organisation has not been without its challenges. The most noticeable as a Governing Body has been due to sickness and unforeseen circumstances that have led to interim appointments part way through the year to the key positions of Accountable Officer and Chief Finance Officer. Despite these changes in leadership we have maintained the achievement of our plans which is a testament to the strength of clinical leadership in the CCG and the resilience of our management support team. We have also taken learning from this year to implement more robust succession planning arrangements for both clinical and non-clinical members of the CCG. The enclosed report is a summation of the key issues the CCG has faced and delivered in 2013/14. In addition to closing down the financial year 2013/14, the CCG has been working with its membership and partners in developing its plans for 2014/ /19. Once finalised, these will also be published on 20 th June 2014 and available on the CCG s website or from the Communications team. 6

7 AGENDA ITEM NO : 016/14 MEMBER PRACTICES INTRODUCTION NHS Warrington CCG has a culture of strong engagement with its member practices with over 55% of individual GP s involved in working with the CCG. Dr Andrew Davies, clinical Chair of the CCG said: "It is my privilege to chair NHS Warrington CCG, working with and on behalf of a talented group of motivated people, from both clinical and non-clinical background. We are working towards Excellence for Warrington; I have seen improvements in the services available to my patients over the last twelve months. The improvements, some of which are listed below by the elected GP members who represent all of the practices in the town, are something that we should take pride in as a CCG. Through empowerment and engagement with front line clinical staff we have collectively delivered systematic changes. The most notable of which, is a 9.2% reduction in the number of people requiring unplanned admission to hospital due to illness. Health care provision is constrained by a difficult financial allocation and therefore has providers of healthcare such as the hospital, community and Primary Care GP services who are all highly efficient. The workforce in all of these sectors is stretched and will be unable to meet the needs of our town s residents without fundamentally changing the way the NHS works in Warrington. After delivering financial balance in our first year the challenge for this coming year and beyond is to continue to meet this duty but also to invest and deliver large scale change to secure sustainable health services. Our Primary Care Home model arises from the needs identified by member practices for the effectiveness and continued quality improvement of GP services. Providing a foundation for the system changes we are undertaking which will enable the local hospital to reshape its delivery of services to meet the needs of a modern NHS and a 21st century patient population. It will also reconnect practices to the communities of people and patients they serve. Sustaining the dwindling workforce in GP practices is required to be able to deliver the quality services they are capable of but are increasingly struggling to deliver. Below you will find an introduction from each of the elected members, which represents the views of their member practices. There are great things we have achieved together and also things that need to be done better. What follows in this annual report are details of the work that we have engaged in over the past year from a CCG and a member practice perspective. I would like to commend it to you and look forward to seeing you at the annual general meeting." Quote from Dr Dan Bunstone, elected Governing Body member representing the Teaching Practice Federation which comprises of Brookfield Surgery, Folly Lane Medical Centre, Lakeside Surgery, Penketh Health Centre and Stockton Health Medical Centre: 7

8 AGENDA ITEM NO : 016/14 There has been excellent engagement with member practices over the last 12 months. All of our member practices have at least 1 GP leading on a large area of work for the CCG, and all are feeling increasingly part of the process. The current projects that we have in place (Primary Care Urgent Care Unit known as PCUCU, community respiratory and Intra-venous Therapy teams and Paediatric Assessment Teams) all seem to be delivering what we had planned, and we are looking forward to involvement with the future paediatric phlebotomy service. There are increasing pressures within Primary Care to meet the increased demands of patients, the increasingly complex mix of long term conditions and also the need to manage patients early in the community after hospital discharge. With the CCG, the Federations have plans in place to better support patients in the community whilst also helping to prevent unplanned admissions, thereby utilising the scarce resources effectively and providing excellence for Warrington. The CCG strategy for the future is of providing care around each patient that is close to their home, and aims to prevent future illness The Primary Care Home (PCH). PCH was developed in close consultation with member practices to highlight the major areas of demand and need, and develop a collaborative way to address this need. The innovative aspect was involving member practices to put in bids for investment funds to support local needs. It allowed us time to think out of the box and to consider ways to improve patient care and the way it s delivered. The governing body members have been through a number of assessments to look at their effectiveness and also how they function together as a board Quote from Dr Anthony Parkins, elected Governing Body member representing the Healthy Warrington Federation which comprises of Eric Moore Partnership, Guardian Medical Centre, Helsby Street Surgery, Latchford Medical Centre, Springfields Medical Centre and Westbrook Medical Centre: Warrington CCG has set ourselves the task of achieving excellence for the people of Warrington. We have to achieve this by commissioning and monitoring the services of provider organisations, using innovation to transform the local health service, and do this within the financial constraints imposed upon us. In early 2013, practices were asked what problems they faced and what solutions there might be. Practices are under a great deal of pressure and a lot of attention is being focussed nationally on the impact of this on Accident & Emergency (A&E). The CCG has recognised the importance of diverting pressure from A&E and by adopting a Primary Care point of contact within A&E have achieved this during 2013/2014. The roll out of the Paediatric Acute Response Team throughout Warrington recently has also been designed to help take pressure off practices and reduce short stay admissions to hospital. Most recently, the concept of the Primary Care Home is being developed, which will be instrumental in providing practices with the help they need to manage many of their most vulnerable patients. There may be better means of communication between individual practices and the CCG which as a CCG we may need to work on this next year. It is very important for 8

9 AGENDA ITEM NO : 016/14 individual practices to feel involved. When the results of Primary Care Home etc. come into fruition, this should impact on practices in a positive way which will only help Quote from Dr Simon Redfearn, elected Governing Body member representing the Phoenix Federation which comprises of Birchwood Medical Centre, Fairfield Surgery, Fearnhead Cross Medical Centre, Greenbank Surgery, Holes Lane Surgery, Padgate Medical Centre: The members of the Phoenix Federation of practices are fully committed to delivering the strategic objectives of the CCG Excellence for Warrington. Several members of the Federation, including the elected representative are actively engaged in delivering these objectives. The Federation has been meeting on a monthly basis over the last 12 months to discuss both provider and commissioner issues and has been actively involved in the pilot phase of the Paediatric Acute Response Team (PART). The Federation has also been successful in developing an innovative bid looking at guided care where a trained nurse works closely with GPs and patients with complex needs to provide coordinated patient centred care. Not only has the CCG facilitated a number of service improvements including the PART team, the GP Urgent Care Centre at the local Acute Trust, the risk stratification programme and Doctor First, it has also achieved financial balance in its first year since full authorisation. The Federation welcomes the additional funding into Primary Care following the success of the bid for the Prime Ministers Challenge Fund monies. This is the first real investment into Primary Care the town has seen for a considerable time and occurs on a background of falling percentage funding going into Primary Care (8.93% total NHS funding the lowest allocation on record) despite General Practice increasing its efficiency (additional 40 million patient contacts a year compared with 2008/9) and a growing and ageing population with increasing numbers of patients with multiple complex conditions. We are looking forward to developing an integrated sustainable Primary Care model that is fit for General Practice of the future Quote from Dr Anita Malkhandi, elected Governing Body member representing the Warrington Alliance Federation which comprises of Causeway Medical Centre, Cockhedge Medical Centre, CCA Practices, Culcheth Medical Centre, Dallam Lane Medical Centre, Four Seasons Medical Centre, Park View Surgery, Stretton Medical Centre and 280 Manchester Road Medical Centre "We are heartened by the emphasis that our CCG has placed on the role of adequately resourced Primary Care and the importance of whole system transformation within our town. We can see benefits to patient care as a result of changes undertaken within the last 12 months and look forward to reforming the multidisciplinary Primary Care team with the award from the Prime Ministers Challenge fund. We are, however, concerned that patient expectation and general practice workload is not raised as a result of this resource. As a Federation of smaller practices within the Town, we have found responding to very short deadlines particularly difficult and would welcome more timely individual feedback to practices after such submissions. The practices within our Federation 9

10 AGENDA ITEM NO : 016/14 expect to continue to work closely with our CCG colleagues to enable future improvements in engagement, feedback, and development NHS Warrington CCG is committed to further development of engagement with its member practices and working with Health Economy partners to design and deliver services to meet the needs of a modern NHS and a 21st century patient population. 10

11 AGENDA ITEM NO : 016/14 STRATEGIC REPORT This strategic report forms part of the NHS Warrington CCG s Annual Report and its purpose, is to present a fair review of the clinical commissioning group s business and a description of the principal risks and uncertainties facing the organisation. NHS Warrington CCG has established a robust regime of performance monitoring and management, which includes Committees for Finance and Performance; Remuneration; Quality and Audit. There are regular Provider, NHS England and Warrington Borough Council review meetings. This combination is the assurance framework adopted by the CCG with regards to performance management. 2013/14 has been financially and operationally challenging as the period of austerity continues and the various inspection regimes continue to flag qualitative shortcomings. However, against this background, the CCG has continued to deliver on national and local targets whilst continuing to work towards long term financial stability for the Warrington health economy. The CCGs accounts which form part of this submission have been prepared in accordance with the going concern principle as part of International Financial Reporting Standards. The Governance Statement attached to this report, articulates how the CCG identifies, manages and controls risks such that business continuity is assured. The Warrington and Halton Partnership has an ambitious whole system vision to achieve Excellence for Warrington by 2015 that will have: self-sufficient communities enjoying improved health and wellbeing and better life experiences, who and when they need them have access to high quality and efficient services. In order to achieve this, we need to improve services and outcomes for patients and their carers, moving from a reactive hospital based system of unplanned care to a preventative, anticipatory, whole person approach to their management and treatment. Our vision, delivered via the large scale change programme, will enable patients, service users, carers and their families to see: a difference in service provision with holistic management of care; models of care based on service user led pathways with no organisational boundaries and systems that work; more care delivered closer to home; individuals supported to better manage their own conditions; an increased use of technology; more appropriate signposting to services, particularly in moments of crisis; increased use of education by all agencies to help people; and more use of existing support networks such as the family. To deliver this vision, a two and five year strategy has been developed with partners that will achieve transformation and performance improvement across the following programmes: 11

12 AGENDA ITEM NO : 016/14 Long Term Conditions; Urgent Care; Mental Health; End of Life; Children and Young People; and Primary Care. Business process re-engineering Supported by our member practices, we developed our QIPP programme which totalled 13m in 2013/14. Of this sum, 6.54m was delivered and the balance bridged by underspends and nonrecurrent use of reserves. We practice a business delivery process underpinned by a programme approach to drive reform. The integrated performance, incorporating the above, of the CCG as at 31 st March 2014 is as follows. CCG Finance 2013/14 Financial Performance Clinical Commissioning Groups have a statutory duty to spend within their available budget; referred to as delivering operational financial balance. As at 31st March 2014, NHS Warrington Clinical Commissioning Group achieved financial balance along with the other required financial duties and has applied its resources effectively. 12

13 AGENDA ITEM NO : 016/14 The agreed surplus level agreed with NHS Cheshire, Warrington and Wirral Area Team is 0.5m. The reported financial position at 31st March 2013 is a 0.5m surplus. Financial Targets The Clinical Commissioning Group s accounts report performance against the financial performance targets. As reported above, all financial duties have been achieved as demonstrated below: Revenue Resource Limit the CCG has a statutory duty to contain its revenue expenditure within the notified revenue resource limit of 239.2m. This was achieved with a surplus of 0.5m (which is in line with the agreed control total). Revenue Resource Limit s The CCG's performance for the year ended is as follows: 238,737 Total Net Operating Costs for the Financial Year Adjusted for prior period adjustments in respect of errors 0 Revenue Resource Limit 239,237 Under / (Over)spend Against Revenue Resource Limit (RRL) 500 Capital Resource Limit - the CCG had no capital resource allocation during 2013/14. Under/ (Over) Spend against Cash Limit - this financial target ensures that the CCG does not exceed its approved level of cash available. This target was achieved, with the CCG maximising its cash use by ending the financial year with a minimal cash balance of 47k (which was below the target set for CCG s of a 250k balance). Cash is utilised to meet invoice payments during the financial year and will not necessarily match the recorded expenditure. Under / (Over)spend against cash limit s Total Charge to Cash Limit 204,183 Cash Limit 204,230 Under / (Over)spend Against Cash Limit 47 These accounts have been prepared under a Direction as issued by the NHS Commissioning Board under the National Health Service Act 2006 (as amended). Financial Resources NHS Warrington Clinical Commissioning Group received a resource allocation of 239.2m for the 2013/14 financial year: 234.1m for programme expenditure (healthcare) and 5.1m for running cost expenditure (based on 25 per head using ONS population figures of 204,839). It should be noted that it has been confirmed during the year that this allocation is 18.9m below the target allocation for NHS Warrington CCG. 13

14 AGENDA ITEM NO : 016/14 In 2013/14 NHS Warrington Clinical Commissioning Group spent 233.7m on programme expenditure (healthcare) for Warrington residents during 2013/14 and spent 5m on running costs. This level of expenditure meant that the CCG did not achieve the initial planned surplus figure of 2.3m but did achieve the revised surplus figure of 0.5m as agreed with the NHS Cheshire, Warrington and Wirral Area Team. This movement in performance was agreed with NHS England at month 6 (September 2013) of the 2013/14 financial year. Service Element 2013/14 Resource Allocation 2013/14 Expenditure Variance 000s 000s 000s Programme - Healthcare Provision 234, , Running Costs Corporate 5,120 5, Total 239, , NHS Warrington Clinical Commissioning Group spent its resources as follows: Secondary and Community Care services 2013/14 Budget 2013/14 Outturn 2013/14 Outturn Variance 000s 000s 000s Acute services 135, , Mental Health services 25,088 25, Community services 22,527 22, Continuing Care services 12,796 13, Primary Care services (incl. Precribing) 33,915 35,029-1,114 Reablement 1, Corporate Running costs 5,120 5, Corporate Non Running costs Planned Surplus 2, ,335 Total Expenditure 2013/14 239, ,

15 AGENDA ITEM NO : 016/14 Better payment practice code NHS Warrington Clinical Commissioning Group aims to pay creditors in accordance with the confederation of British Industry s Prompt Payment Code and government accounting rules. Performance against the better payment practice code can be summarised as follows: Better Payment Practice Code Measure of compliance Non NHS Payables Number 000s Total Non NHS Trade Invoices Paid in the Year 3,359 26,231 Total Non NHS Trade Invoices Paid within Target 3,007 21,843 Percentage of Non NHS Trade Invoices Paid Within Target 89.52% 83.27% NHS Payables Total NHS Trade Invoices Paid in the Year 1, ,588 Total NHS Trade Invoices Paid within Target 1, ,856 Percentage of Non NHS Trade Invoices Paid Within Target 96.14% 98.91% The Better Payment Practice Code requires the CCG to aim to pay all valid invoices by the due date or within 30 days of receipt of a valid invoice, whichever is later. Late Payment of Commercial Debts (interest) Act 1998 There were no payments arising from claims made by businesses under this legislation (2013/14, 0), nor was any compensation paid to cover debt recovery costs (2013/14, 0). Audit Fees The Clinical Commissioning Group s appointed external auditors for the audit of the 2013/14 accounts are Grant Thornton UK LLP. Fees incurred for the audit of the 2013/14 accounts are 59,400 (excluding VAT). Internal audit services were provided by Mersey Internal Audit Agency at a cost of 58,592 (excluding VAT). Running costs As reported above the Clinical Commissioning Group operated within its 25 per head of population allocation for running costs. 15

16 AGENDA ITEM NO : 016/14 Running Cost Expenditure 2013/14 Expenditure Area 2013/14 Outturn ( 000s) 2013/14 Spend per Head % of total running costs Direct Pay Costs - CCG Employed Staff 1, % CMCSU Contract 1, % Programme Support % Estates & Facilities % GP Board Members / Clinical Leads % Service Level Agreements % Training % Local Authority Staffing - Joint Post % IM&T Director - Joint Post % Lay Members % Public Engagement % Recruitment Fees - AO % External Consultants % Other Corporate Costs % Total 5, % Exit Packages During 2013/14 there were no exit packages agreed. Performance 2013/14 NHS England monitors the CCG with respect to The NHS Outcomes Framework (by domain); the NHS Constitution Rights and NHS Warrington CCGs local priorities. To ensure that requirements are met NHS Warrington CCG has developed processes and systems to monitor and manage its providers of NHS funded healthcare services against national and local outcome indicators. NHS Warrington CCG reviews performance on a continual basis and each quarter gives assurance of this process to NHS England. For the first two quarters of 2013/14 this was through a balanced scorecard approach. For quarter three and moving forward the balanced scorecard has been renamed to reflect more appropriately its role in the process as a delivery dashboard and is refocused to become a source of intelligence which informs assurance conversations and focus across the breadth of the assurance framework. The most recent assurance report relates to quarter 3 of 2013/14 and can be seen below: 16

17 AGENDA ITEM NO : 016/14 NHS WARRINGTON CCG 2013/14 Quarter 3 CCG Assurance Report Focus Assurance Level Particular achievements noted/examples of good practice Issues identified Any issues identified requiring further action and actions agreed Are patients receiving clinically commissioned, high quality services? Are patients and the public actively engaged and involved? Are CCG plans delivering better outcomes for patients? Assured Assured Assured with Support The CCG commissioning intentions were written in conjunction with our member practices. They were then taken by our clinicians supported by our engagement team to our community to ask whether they meet the needs and standards of our patients. This was undertaken in 2014 by engagement roadshows. The CCG have developed a dedicated patient Consultation exercise for procedures experience Programme. "We re listening" is a service of low clinical priority that allows people to feedback their experiences of NHS services. The service is available through a variety of channels and the population can submit their feedback anonymously. The CCG have a system to ensure any feedback is passed to the relevant provider and acted upon accordingly with the CCG. Consultation exercise for procedures of low clinical Financial position; priority. Plan - Year to date (variance to plan as % of YTD allocation); Plan - full year (variance to plan as % of YTD allocation); Clear Identifications of risks against financial delivery and mitigations Friends and Family Test; Standard not achieved IAPT Trajectory; CCG not on trajectory The following NHS constitution Standards were narrowly missed: (Red 1) Ambulance Response - The North West Target has been narrowly missed; Same Sex Accommodation - Standard not achieved ; (HCAI) C difficile - Limit in Q3 breached and Annual limit breached. 17 Financial Position: A revised planned Surplus has been agreed with the CCG. Where possible, QIPP schemes have been accelerated. In addition, the CCG has worked with its main provider to contain the risk of overperformance towards the end of the financial year. Friends and Family Test: Contractual penalty applied in Q1, 50% of it will be returned if the position improves in Q4. The Trust has assured the CCG that the position will improve for Q4. IAPT Trajectory: Audit and data refresh shows YTD performance is in-line with the plan and on course to achieve the 13% CCG requirement by the yearend; (Red 1) Ambulance Response: The CCG is working collaboratively with other CCGs and NHS Blackpool CCG as the coordinating commissioner; Same Sex Accommodation: Formal Contract Query Notice issued and the CCG will ensure that this issue is then followed through the contractual process and applies, in conjunction, the appropriate remedial actions. (HCAI) C difficile: The Trust has already presented action plans to ensure that trajectories are not further breached. A detailed clinical discussion was held and whilst the figures are not acceptable the commissioners were assured that all steps have and remain being taken to reduce any risks.

18 AGENDA ITEM NO : 016/14 NHS WARRINGTON CCG 2013/14 Quarter 3 CCG Assurance Report continued.. Focus Assurance Level Particular achievements noted/examples of good practice Issues identified Any issues identified requiring further action and actions agreed Does the CCG have robust governance arrangements? Assured A recent internal audit report was given high assurance by Mersey Internal Audit. Are CCGs working in partnership with others? Assured Consider that this is strong, one example is Joint Appointments - at a senior level these include Assistant Director Integrated Commissioning with Warrington Borough Council and Director of Information with Warrington & Halton Hospitals NHS Foundation Trust. In addition regular board to board meetings to agree strategy with LA, Halton CCG and all providers. Working with mid Mersey CCGs and NHS E on the End to End assessment. Does the CCG have strong and robust leadership Assured The CCG has an advanced programme of organizational development. The CCG is working closely with the North West Leadership Academy to develop our approach to talent management and succession planning. The CCG are part of the Aspirant Talent Programme and have a member of staff attending the Mary Seacole Programme. Further embedding of performance management systems and enhancing the coaching culture of the CCG are planned for 14/15. 18

19 2 week cancer suspect ed t ar get is in com AGENDA ITEM NO : 016/14 The NHS Constitution gives patients specific rights, and these include: The right to begin treatment within 18 weeks of a GP referral (or within 62 days if the referral is for cancer); The right to be seen at A&E within 4 hours of arrival; In urgent cases, the right to an ambulance within 19 minutes of 999 call; Where an operation is cancelled at the last minute for non-clinical reasons, the right to an operation within 28 days of the cancellation. What we have achieved against our plans at the end of March 2014: REFERRAL TO TREATMENT - PATIENTS SEEN WITHIN THE STANDARDS Admitted Non-Admitted Incomplete Admitted Attainment by Trust All aggregate measures are being met. Ther e was 1 specialt y f ailur e f or adm it t ed adjust ed p Green 92.9% h 2.9% 98.0% h 3.0% 95.4% h 3.4% 100% 92.4% 96.2% 97.3% 88% 90% 92% 94% 96% 98% 100% WHHFT Spire Cheshire St H & K Key Issues: All aggregate measures are being met. There was 1 specialty failure for admitted adjusted pathways (T&O). 95% 90% 85% Admitted Non-Admitted Breaches Admitted Comp to Prev Month Non-Admitted Comp to Prev Month WHHFT There was 1 non-admitted specialty failure in Neurology caused by 1 patient breaching the 18 week standard. Spire Cheshire St H & K DIAGNOSTIC TESTS WAITING NO MORE THAN 6 WEEKS Actual Target 99.93% 99.86% 99% Key Issues: Provider Performance Total Activity WHHFT 0% 0 Bridgewater 0% 0 Central M'chester Previous mth 0% 0 St H & K 0% 0 Walton Centre 0% 0 South M'chester 0% 0 Salford Royal 0% 0 CANCER Per f or m ance against t his t ar get r em ains above t The vast m ajor it y of diagnost ic act ivit y f or WCCG ha Green Performance against this target remains above target in March There are pathways over 6 weeks in Gastroscopy (Central Manchester) and Peripheral Neuroathy (South Tees). The vast majority of diagnostic activity for WCCG has taken place at Warrington & Halton Hospitals NHS Foundation Trust in 2013/14. The 6 week target was consistently met with 100% performance for WCCG patients at this trust. 2 Week Waits for Suspected Cancer 62 Day Wait from GP Referral Green Actua l Previ ous mth Ta rget Actua l Previ ous mth Ta rget 97.0% 95.1% 93% 86.0% 83.3% 85% 0 Key Issues/Actions: The The 2 week cancer suspected Total Breaches per Trust (2 week waits) target is in compliance with the 20 93% target with 97% achievement There were 15 exceptions, all at WHHFT with a maximum wait of days WHHFT St H & K 19

20 The M ar ch 95% t ar get at WHHFT f or t he t im The year end t ar get of 13% of people wit h depr The im pr ovem ent seen Accor ding t o t he f inalweekly r epor t f or STROKE AND TIA Stroke patients spending 90% of their time on a stroke unit AGENDA ITEM NO : 016/14 Previous Current Month Target TIA Breaches Current Month Month 81.0% 86.4% 80% Warrington & Halton 1 TIAs seen and treated within 24 hours Current Month Previous Month Target Key Issues/Actions: 66.7% 60.0% 60% St H & K The improvement seen in performance against the Stroke & TIA targets in February 2014 has been maintained in March with performance against both targets remaining above target levels. YTD remains below target. 0 Amber A&E WAITING TIMES Patients seen within 4hr target at WHHFT Actua l YTD Ta rget 97.0% 95.63% 95% 100% 98% 96% 94% 92% 90% Amber Key Actions: The March 95% target at WHHFT for the time spent in A&E <=4 hours was met with 97% achievement. According to the final weekly report for Q4 2013/14 on UNIFY (DoH) the year target was achieved at %. Data for the 31st March appears to be included in 2014/15 reporting. Improving Access to Psychological Therapies People with depression receiving therapies Progress to target: Green Actua l Cumulative 2013/14 Ta rget % 80% 60% Key Issues: 40% The year end target of 13% of people with depression are expected to have entered treatment was met in 13/14 with 13.1% achievement. The plan for 14/15 is for 15%. 20% 0% Progress against the above indicators is presented on a monthly basis to the CCG Quality and Finance and Performance Committees, the minutes of which are received by the CCG Governing Body. Warrington CCG also has local objectives, some of which overlap with national outcomes and some of which include indicators specific to the economy. Within these, a number of indicators are used to monitor progress of the following: 20

21 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar AGENDA ITEM NO : 016/14 Elective Admissions (FFCEs) 2595 Mar Non-elective Admissions (FFCEs) Mar Activity All 1st OP Referrals Seen 4108 Mar Performance is above plan. The actual 13/14 activity has been used to inform plans for the next 5 years A&E Attendances (YTD) Annual 2013/14 Plan = 71,037 Mar Emergency Admissions for Children with Lower Respiratory Tract Infections (LRTI) Rated per 100,000 population from standardised local query. (Cumulative) Mar CSU Data Management data showing the cumulative rate per 100,000 population Outcomes Framework - Data Management Report - Cumulative rate per 100,000 population Unplanned Hospitalisation for Chronic Ambulatory Care Sensitive Conditions. Rated per 100,000 population from standardised local query. (Cumulative) Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s. Rated per 100,000 population from standardised local query. (Cumulative) Mar Mar CSU Data Management data showing the cumulative rate per 100,000 population. CSU Data Management data showing the cumulative rate per 100,000 population Emergency admissions for acute conditions that should not usually require hospital admission Rated per 100,000 population from standardised local query. (Cumulative) Mar CSU Data Management data showing the cumulative rate per 100,000 population

22 AGENDA ITEM NO : 016/14 CLINICAL COMMISSIONING GROUP QUALITY Supporting the quality agenda Quality lies at the very heart of all that NHS Warrington CCG is hoping to achieve. The Quality strategy defines three areas that the CCG believe should be core components for providers to deliver care; Patient safety; effectiveness and experience. To achieve Excellence for Warrington for the local population the CCG recognises that there needs to be investment in aligning together a work force that can set the quality agenda, monitor standards of care and ensure that when health care provision has failed to meet contracted standards providers are held to account. Improving Quality in Primary Care The CCG has established a regular Primary Care Quality monitoring system. The group includes representation from Medicines Management, Public Health, Safeguarding /children / adult as well as a newly appointed Practice Nurse who is working with the GP Primary Care Quality leads to move forward the Primary Care agenda. General Practitioners are represented as well as the commissioning lead for Primary Care. High on the current agenda is the aim to implement the introduction to all practices of the Datix reporting system which will enable practices to report when incidents have occurred which may have impacted on the patient experience or caused patient harm. Commissioning for Quality and Innovation Schemes The CCG work with providers to ensure that the Commissioning for Quality and Innovation schemes (CQUINS) are used to promote effective outcomes for patients whilst encouraging providers to deliver them in an innovative way. This year one of the schemes, which was agreed is to encourage integrated ways of working between both the acute and community provider. An emphasis to ensure that standardisation of practice and competencies around adult and children s care has also been agreed this year and an extension for a further year for the acute provider, to build on their work around the care of patients suffering from dementia. Information Technology and the social media are also high on the agenda, promoting the importance of the patients being a central part of the decision making process, how they receive their results, and how technology can reduce unnecessary out-patient appointments. This would enable patients to maximise the opportunity to improve their lifestyles rather than awaiting the results of testing. Clinical Quality Review Meetings In an effort to raise the importance of Quality for the CCG, the monthly contract review meetings have been divided into two separate sections. Part A examines the contract and how the provider is adhering to the specifications and highlighting areas where they may be having difficulties in delivering the agreed standards. Part B is devoted purely to the Quality of care being delivered. Specific areas of the providers care delivery is regularly evaluated and where these have identified problems clinicians are requested to attend the meeting and discuss and agree with the commissioners their action plans for getting the service back on track and ensuring that health care provision is of a high standard. 22

23 23 AGENDA ITEM NO : 016/14 These sessions provide a robust mechanism where commissioners and providers can work together to identify and strive to meet standards that will serve to deliver services and improve quality. Effective relationships have been established to improve health care delivery and formalise accountability. Quality Surveillance Group (QSGs) A network of Quality Surveillance Groups have been established across the country to bring together different parts of health and care economies locally and in each region of England to routinely share information and intelligence to protect the quality of care patients receive. Over the past year, Warrington CCG has played an active role with colleagues in West Cheshire, Wirral and East Cheshire to share quality issues. Warrington is represented by two Governing Body members, GP responsible for Quality, Chief Nurse and Quality lead; a representative of the local Health-watch team and also a representative from the Local Authority. The minutes from each meeting are shared with the Safeguarding staff to ensure that any issues which may have been discussed are also shared with their safeguarding colleagues from other areas. Engagement, Experience & Communications NHS Warrington CCG is committed to carrying out meaningful engagement with the population, communicating effectively as well as capturing patient experience and acting upon it. The CCG has a dedicated Engagement, Experience & Communications team responsible for delivering this across Warrington. The team consists of an Engagement, Experience & Communications Lead and two Engagement, Experience & Communications Support Officers. NHS Warrington CCG has a number of methods and tools for engaging and communicating across Warrington. The team prides itself in capturing patient experience and acting upon it. This enables further engagement and encourages participation of the local population. During 2013/14 there have been a number of public events; Patient Participation Group (PPG) network meetings; Warrington Health Forum and other events across the town to ensure the population as a whole are engaged with the NHS. The team has ensured that all voices, including the most vulnerable of the population, are heard. The Engagement, Experience & Communications Team organised an event for patients and the public to Get Engaged with local health and social care services. Over 140 people attended the day, of those 80 were members of the public or representatives of the Third Sector. The other attendees were from our statutory partners, these included Warrington and Halton Hospitals NHS Foundation Trust, Bridgewater Community Healthcare NHS Trust, 5 Borough Partnership NHS Foundation Trust, St George Healthcare Group, pharmacists, GPs, CCG Staff, Warrington Borough Council Staff, including Public Health and Outreach Team and Councillors. Feedback from the day was extremely positive. From this feedback it was agreed that the next Get Engaged event will focus on children and young people. The CCG has recently refreshed its Experience, Engagement and Communications Strategy and published the annual report for Engagement, Experience & Communications reflecting the previous 12 months and a look to the future. A detailed work plan underpins the strategy. The Engagement, Experience & Communications Lead presents papers at the Governing Body and Quality Committee on a regular basis to showcase the work undertaken. Governing Body

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25 MEMBERS REPORT AGENDA ITEM NO : 016/14 Clinical Commissioning Group & Governing Body NHS Warrington Clinical Commissioning group was formally constituted on 1st April 2013 following authorisation as a Wave 1 CCG with no conditions as part of the process led by NHS England. Warrington has formed one Clinical Commissioning Group and each GP Practice in Warrington is a member of the Clinical Commissioning Group. NHS Warrington CCG Practices Birchwood Brookfield Causeway CCA Culcheth, Chapelford & Appleton Practices Cockhedge Culcheth MC Dallam Lane Eric Moore Partnership Fairfield Fearnhead Folly Lane Four Seasons Greenbank Guardian Street Helsby Street Holes Lane Lakeside Latchford Manchester Road Parkview Padgate Penketh Springfields Stockton Heath Stretton Westbrook Further details of our GP member practices can also be found on our public facing website: Our member practices work together across the town with each being part of one of four GP Federations as shown in the diagram below. Each of the member practices within each Federation is represented on the CCG governing body by an elected GP member. All GP Federations also have an appointed GP Chair that is separate to their CCG Governing Body representative. 25

26 AGENDA ITEM NO : 016/14 Copies of the Clinical Commissioning Groups Strategic Plan & Prospectus for 2013/14 are available on the public facing website at The Governing Body are also responsible for preparing an Annual Governance Statement which sets out how the Governing Body discharged its responsibilities. This Statement is provided within Appendix 2 of this report. The Governing Body comprises: 26

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28 AGENDA ITEM NO : 016/14 REMUNERATION REPORT Terms of Reference for the Remuneration Committee The Remuneration Committee of Warrington Clinical Commissioning Group has recommended to their Governing Body the remuneration and terms of service for the Accountable Officer, Chair, Chief Finance Officer, and members of the Senior Management Team to ensure they are fairly rewarded for their individual contribution to the organisation. These recommendations are in accordance within the requirements of the nationally developed Framework for Very Senior Managers. Advice to the Governing Body on such remuneration includes all aspects of salary, provisions for other benefits including pensions and cars as well as arrangements for termination of employment and other contractual terms. Additionally, the Remuneration Committee: Make recommendations to the Governing Body on the remuneration, allowances and terms of service of other officer members to ensure they are fairly rewarded for their individual contribution to the organisation; Monitor and evaluate the performance of individual and other members of the senior management team; and Advise on, and oversee, appropriate contractual arrangements for such staff including the proper calculation and scrutiny of termination payments taking account of such national guidance as is appropriate. Composition & Membership of the Remuneration Committee The membership comprises of the two Lay Members, Gareth Hall and Nick Atkin, the Chair of the Governing Body Dr Andrew Davies, and three of the GP Governing Body Members Dr Simon Redfearn, Dr Anita Malkhandi, and Dr Dan Bunstone. The Committee is chaired by the Governing Body Lay Member, Nick Atkin. Further details relating to the attendance and frequency at meetings can be found in the Annual Governance Statement (Appendix 2) of this report. Independent Human Resources (HR) advice and guidance is provided by the Head of Human Resources through the service level agreement in place with the Cheshire & Merseyside Commissioning Support Unit and, if required, ad hoc external subject matter expert consultancy. This ad-hoc advice relates to legislative employee matters and benchmarking of NHS salaries not included in the service level agreement. The majority of the CCG support staff are on Agenda for Change (AfC) terms and conditions. For other appointments such as Accountable Officer, Chair, Chief Financial Officer, and GP Governing Body Members; remuneration is based on HAY Group guidance. For staff who are not on Agenda for Change local agreements, for example GP leads; agreement with respect to salary is based on independent HR advice as sighted above in relation to terms and conditions. The Committee s role is to oversee and agree the remuneration and Terms of Service of the Accountable Officer, the Senior Management Team of the Governing Body, together with any staff employed by the CCG whose terms of service are not covered by the national agreements. It provides advice to the Governing Body on a range of employment issues for all staff (for 28

29 29 AGENDA ITEM NO : 016/14 example pensions, car schemes and termination of employment). The committee is established in accordance with NHS Warrington CCG s Constitution, and Scheme of delegation. Remuneration of senior managers current financial year The Remuneration Committee determined the salaries of the following senior positions: Accountable Officer, Chair, GP Board Members, Lay Members, Chief Nurse and Quality Lead, and the Chief Financial Officer. The remuneration packages for these senior posts comprised base salary in the light of the requirements of the national Very Senior Managers policy and Hay Group recommendations. Senior Managers Performance Related Pay The remuneration awarded to the senior managers of NHS Warrington CCG is not subject to the achievement of defined performance conditions. Policy on Senior Manager Contracts The roles of Accountable Officer and Chief Financial Officer are permanent appointments, subject to six months formal notice period for termination of contract by either the employee or employer. The CCG reserves the right to make payment in lieu of giving notice of termination of the Employee s employment. The role of Chair is subject to election and therefore the role is contracted for a single financial year on a temporary basis. The contract will cease if the post holder fails to be elected to serve as Chair of the CCG during the re-election process. It is extremely unlikely that the post holder will be regarded as redundant, and entitled to a redundancy payment, in the event that the post holder fails to be elected to serve as Chair of the CCG, while the post of Chair remains in existence. GP Governing Body members are appointed to represent their respective Federations. The contracts are therefore temporary in nature. It is extremely unlikely that the post holder will be regarded as redundant, and entitled to a redundancy payment, in the event that the post holder fails to be elected to represent their respective Federation, while the post of GP Governing Body Member remains in existence. A Governing Body member may give not less than three months written notice of its desire to cease being a member of the CCG and the CCG will agree to this change in membership, subject to receiving prior approval of NHS England. All other posts, included as senior managers, are subject to Agenda for Change terms and conditions. Salaries and Allowances Salaries & Allowances for Senior Employees of NHS Warrington CCG from 01/04/2013 to 31/03/2014 Please refer to Appendix 4 for further detail regarding this. One Governing Body member received taxable benefits from the PCT s historic lease car scheme, which was inherited by the CCG as part of the TUPE transfer of existing terms and conditions, within their remuneration. Other Governing Body Members were not eligible to be part of this

30 scheme or to receive a taxable benefit. AGENDA ITEM NO : 016/14 Pension Benefits All employees have access to and are entitled to join the NHS Pension Scheme which provides pensions on a final salary basis. There are no CCG employees who have stakeholder pensions in place of being a member of the NHS pension scheme. Pension benefits for Senior Employees at NHS Warrington Clinical Commissioning Group 2013/14 - Please refer to Appendix 4 for further detail regarding this. 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. The banded remuneration of the highest paid member of the Governing Body, when grossed up to whole time equivalent, in Warrington CCG during the financial year was 165,000. This was 4.64 times the median remuneration of the workforce, which was 35,542. In , no employees received remuneration in excess of the highest-paid member of the Governing Body. Remuneration ranged from 15,719 to 165,000. Total remuneration includes salary, non-consolidated performance-related pay, benefits-in-kind, but not severance payments. It does not include employer pension contributions and the cash equivalent transfer value of pensions. Off Payroll Engagements Details of any off-payroll engagements as of 31 March 2014, for more than 220 per day and that last longer than 6 months are disclosed in Appendix 4. Governing Body Member Profiles Further information relating to the profiles of Governing Body members can be found within the Members report. Payments to Past Senior Managers There were no payments made in the 2013/14 financial year to individuals that were not in a senior manager role for the CGG, who had been in such a role in the prior financial year. Severance payments There were no severance payments made in the 2013/14 financial year Staff Pay Awards All staff on pay Agenda for Change bandings 1 9 received a 1% increase during 2013/14. 30

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32 APPENDIX 2 AGENDA ITEM NO : 016/14 NHS WARRINGTON CLINICAL COMMISSIONING GROUP Governance Statement for 2013/14 Introduction & Context NHS Warrington Clinical Commissioning Group was authorised from 1 April 2013 under provisions enacted in the Health & Social Care Act 2012, which amended the National Health Service Act The clinical commissioning group operated in shadow form prior to 1 April 2013, to allow for the completion of the authorisation process and the establishment of function, systems and processes prior to the clinical commission group taking on its full powers. As at 1 April 2013, the clinical commissioning group was authorised without conditions. In its first year of authorisation, NHS Warrington Clinical Commissioning Group has developed its approach to and delivery of corporate governance. This statement describes how that governance has worked in practice in terms of its Governing Body, Sub-Committees and relationship with the wider system architecture. As a member organisation that is founded on clinical leadership and system engagement, the CCG has developed its governance structure to support effective and transparent decision making that embraces genuine accountability. 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 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. To fulfil my role as Accountable Officer I have ensured that the CCG: complies with its: - duty to exercise its functions effectively, efficiently and economically; - duty to exercise its functions with a view to securing continuous improvement in the quality of services provided to individuals for, or in connection with, the prevention, diagnosis or treatment of illness; - financial obligations, including information requests; - obligations relating to accounting and auditing; 32

33 AGENDA ITEM NO : 016/14 - duty to provide information to the NHS Commissioning Board, following requests from Secretary of State; and - obligations under any other provision of the NHS Act 2006 Act specified by the Board for these purposes. performs its functions in a way which provides good value for money. Compliance with the UK Corporate Governance Code We are not required to comply with the UK Corporate Governance Code. However, we have reported on our Corporate Governance arrangements by drawing upon best practice available, including those aspects of the UK Corporate Governance Code we consider to be relevant to the CCG and best practice. The Clinical Commissioning Group Governance Framework NHS Warrington CCG has a well-developed Governance Framework with partners to support effective, safe and transparent decision making and performance management. To support the maximisation of the Warrington pound and integrated working, Warrington CCG operates within this overall structure which is highlighted below: Figure: The Architectural Framework for the Warrington & Halton Partnership The next section of this report articulates the roles and functions of the CCG s Governing Body and Committee s and also details of work carried out in 2013/14. Governing Body The National Health Service Act 2006 (as amended), at paragraph 14L (2) (b) states: 33

34 AGENDA ITEM NO : 016/14 The main function of the governing body is to ensure that the group has made appropriate arrangements for ensuring that it complies with such generally accepted principles of good governance as are relevant to it. Functions - The Governing Body has the following functions conferred on it by sections 14L(2) and (3) of the 2006 Act, inserted by section 25 the 2012 Act, together with any other functions connected with its main functions as may be specified in regulations or in this constitution. The governing body functions shall include: a) ensuring that the group has appropriate arrangements in place to exercise its functions effectively, efficiently and economically and in accordance with the groups principles of good governance (its main function); b) Determining the remuneration, fees and other allowances payable to employees or other persons providing services to the group and the allowances payable under any pension scheme it may establish under paragraph 11(4) of Schedule 1A of the 2006 Act, inserted by Schedule 2 of the 2012 Act; c) Approving any functions of the group that are specified in regulations d) Additional functions delegated by the group to the governing body in the other parts of the constitution. Composition of the Governing Body - the Governing Body shall not have less than eleven and comprise of: a) The chair b) Four representatives of member practices c) Two lay members: i) One to lead on audit, remuneration and conflict of interest matters, who has qualifications, expertise or experience such as to enable the person to express informed views about financial management and audit matters ; ii) One to lead on patient and public participation matters, who has knowledge about the area specified in the groups Constitution such as to enable the person to express informed views about the discharge of the groups functions d) One registered nurse e) One secondary care specialist doctor f) The Accountable Officer g) The Chief Finance Officer h) Local patient representative 34

35 AGENDA ITEM NO : 016/14 The Governing Body met six times during 2013/14 and attendance was as below. Due to sickness absence, there has been one interim appointment and two acting arrangements within the Body. Date of Meeting Voting Members CHAIR Dr Andrew Davies x x x x x John Wicks (in Interim CO capacity) x x x CHIEF Dr Sarah Baker x OFFICER Steve Sutcliffe (in Acting CO capacity) x x CFO Steve Sutcliffe x David Cooper (in Acting CFO capacity) x x x x Dr Anita Malkhandi x x x x FED'N Dr Dan Bunstone x x x x LEADS Dr Simon Redfearn x x x x x x Dr Anthony Parkins x x x x x DOCTOR Dr Stephen Bentley x x x x NURSE John Wharton x x x x x x LAY Gareth Hall x x x x x MEMBER Nick Atkin x x x x x PATIENT Pat Taylor x x x x x Non Voting Members Linda Bennett (non voting) x x x Simon Kenton (non voting) x x x x Committees of the Governing Body The Governing Body has appointed the following committees and sub-committees: a) Audit Committee the audit committee, which is accountable to the group s governing body, provides the governing body with an independent and objective view of the CCG s financial systems, financial information and compliance with laws, regulations and directions governing the group in so far as they relate to finance. The governing body has approved and keeps under review the terms of reference for the audit committee, which includes information on the membership of the audit committee. The Audit Committee met five times during 2013/14 with attendance was as below: 35

36 AGENDA ITEM NO : 016/14 Date of Meeting CHAIR/LAY ADVISOR Gareth Hall x x x x GP MEMBER Dr Andrew Davies x x LAY ADVISOR Nick Atkin x IN ATTENDANCE Stephen Sutcliffe (Chief Finance Officer) x x x Stephen Sutcliffe (Acting Chief Officer) David Cooper (Acting Chief Finance Officer) x x David Cooper (Head of Financial Management) x x Sarah Blackwell, MIAA x x x x x Phil Raymond, MIAA x x x x Virginia Martin, MIAA x Claire Deegan, Grant Thornton x x Judith Tench, Grant Thornton x Wendy Curram, MIAA x Robin Baker, Grant Thornton x Dr Stephen Bentley x x x x Dan Bunstone x Nick Armstrong x x x Steve Connor, MIAA x x Roger Causer, MIAA x Paul Basnett, Grant Thornton x John Wicks (Interim Chief Officer) n/a n/a n/a n/a x Rebecca Knight x Gerard Small x Dr Anita Malkhandi x b) Remuneration Committee the remuneration committee, which is accountable to the CCG s governing body makes recommendations to the governing body on determinations about the remuneration, fees and other allowances for employees and for people who provide services to the group and on determinations about allowances under any pension scheme that the group may establish as an alternative to the NHS pension scheme. The governing body has approved and keeps under review the terms of reference for the remuneration committee, which includes information on the membership of the remuneration committee. The Remuneration Committee met five times during 2013/14 and attendance was as below: Date of Meeting VOTING MEMBERS (ALL GOVERNING BODY MEMBERS) CHAIR/LAY MEMBER Nick Atkin (Chair) x x x x x LAY MEMBER Gareth Hall x x x GP BOARD MEMBERS Dr Anita Malkhandi x x Dr Simon Redfearn x x x x Dr Anthony Parkins x x x x Dr Dan Bunstone x x Dr Andrew Davies x x x CHIEF OFFICER Stephen Sutcliffe x Dr Sarah Baker x CFO David Cooper x x Stephen Sutcliffe x DOCTOR Dr Stephen Bentley x x x NURSE John Wharton x x 36

37 AGENDA ITEM NO : 016/14 c) Quality Committee the Quality Committee, which is accountable to the group s governing body, with the purpose of assuring the group on the safety of commissioned services any associated risks or areas of quality improvement. It operates to a programme of business, agreed by the governing body, which is flexible to new and emerging priorities and risks. Date of Meeting The governing body has approved and keeps under review the terms of reference for the Quality Committee, which includes information on the membership of the Quality Committee. The Quality Committee met ten times during 2013/14 and attendance was as below: Voting Members CHAIR Dr Anita Malkhandi x x x x x x x x x x John Wicks (Interim Chief Officer) x x CHIEF OFFICER Dr Sarah Baker x Stephen Sutcliffe x QUALITY LEAD John Wharton x x x x x x x x x CHIEF OPERATING OFFICER Nick Armstrong x x x x x x LAY MEMBER Nick Atkin x x x x x x CLINICAL MEMBER Dr Anthony Parkins x x x x x x x x x x Non Voting Members Stephen Sutcliffe (CFO) x CORE ADVISORY David Cooper (Acting CFO) x x x Rebecca Knight x x x x x IN ATTENDANCE Dr Dan Bunstone x x x x Gareth Hall x x x x x x Paul Steele x x x x x Dr Simon Redfearn x x x x x x x x Dr Justin McCarthy x x x x x Dr Sarah Baker x Julie Ryder x Linda Bennett x x x x x x x Dr Neil Fisher x Dr Andrew Davies x x x x x x x Dr Stephen Bentley x x x x x x x x Cheryl McKay x Simon Kenton x x x x x x d) Finance and Performance Committee the Finance and Performance Committee, which is accountable to the group s governing body, with the purpose of ensuring robust arrangements are in place to oversee the financial and performance management of services commissioned by the Group. The governing body has approved and keeps under review the terms of reference for the Finance and Performance Committee, which includes information on the membership of the Finance and Performance Committee. 37

38 AGENDA ITEM NO : 016/14 The Finance and Performance Committee met eleven times during 2013/14 and attendance was as below: Date of Meeting Voting Members CHAIR Dr Dan Bunstone x x x x x x x x x John Wicks x x x CHIEF OFFICER Dr Sarah Baker x Steve Sutcliffe x x x x x CFO Steve Sutcliffe x x x David Cooper x x x x x x x x LAY MEMBER Gareth Hall x x x x x x x x CLINICAL MEMBER/ Dr Simon Redfearn x x x x x x x x x Non Voting Members CORE ADVISORY IN ATTENDANCE David Cooper (Head of Financial Management) x x x Simon Kenton (Assistant Director of Integrated Commissioning x x x x x x Pam Broadhead (Head of Contracts) x x x x x x x x x Linda Bennett (Associate Director of Health Services Commissioning x x x x x x x Cheryl McKay x x x x x x x x x x Dr Anita Malkhandi x x x x x x x x x x Dr Anthony Parkins x x x x x x x x x x x Dr Stephen Bentley x x x x x x x x x x Nick Atkin x x x x x x Nick Armstrong x x x x x x x x x x Bryan Webb x x x x x x x x John Wharton x x x x x x x x Dr Andrew Davies x x x x x x e) Clinical Forum the Clinical Forum, which is accountable to the group s governing body, the purpose of ensuring that all commissioning undertaken by the Group is informed by multidisciplinary clinical engagement across all sectors of the health and social care community. The governing body has approved and keeps under review the terms of reference for the Clinical Forum, which includes information on the membership of the Clinical Forum. The Clinical Forum met four times during 2013/14 and attendance was as below: Date of meeting CLINICAL GOVERNING BODY MEMBERS OTHER CLINICAL REPRESENTATIVES Dr Andrew Davies x x x x Dr Simon Redfearn x x x Dr Anita Malkhandi x Dr Anthony Parkins x x Dr Pippa Brough x Dr Ipsita Chatterjee x x x x Dorothy Finnerty x x Diane Evans x Dr Rita Robertson x Mark Woodgar x x x Dr Tony Rimmer x x x Dr Nieves Mercadillo x 38

39 AGENDA ITEM NO : 016/14 As Accountable Officer, I am assured that both the Governing Body and its Sub-Committees continue to review their performance and effectiveness during 2013/14, through self-assessment and annual reports. The Clinical Commissioning Group 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. CCG Risk Management 2013/14 The CCG has a statutory and regulatory responsibility to ensure that systems of control are in place to minimise the impact of all types of risks, which could affect the proper functioning of NHS Warrington CCG. There is a systematic process for the identification of risk throughout the organisation that is documented in operational risk registers and the corporate risk register, which feeds the Assurance Framework. Risks are reported to the appropriate Committee which retain an overview of the management of that risk. This includes the control measures in place and assurance mechanisms and any actions required to further mitigate the risk. The risk assessment model is based on a grading of impact and likelihood. Risks are then scored against impact and likelihood and either managed locally or raised to the strategic corporate risk register/assurance Framework, which is reviewed and monitored by the Audit Committee and Governing Body. The Assurance Framework is maintained by the Head of Assurance & Risk. The Risk Management Policy identifies the actions to be taken depending on the risk assessment score. This is as follows: Risk score Risk level description Reporting to the Governing Body Risk review frequency Authority to manage risk High (15-25) Medium (6-12) Low (1-5) Unacceptable level of risk requiring immediate corrective action. To be monitored by the Audit Committee and Governing Body Unacceptable level of risk exposure requiring measures to be put in place and monitored by Senior Manager Acceptable level of risk subject to regular monitoring at management level Quarterly via Assurance Framework Six monthly Annually Monthly Quarterly 6 monthly As agreed by Governing Body As agreed by Senior Manager As agreed by Manager 39

40 AGENDA ITEM NO : 016/14 Assurance Framework For the period 2013/14, the CCG reviewed its strategic objectives to ensure that they were fit for purpose for the CCG. The strategic objectives which were identified and associated strategic risks are as follows: Strategic objectives A Improve healthy life expectancy for all B Reduce inequalities C All commissioned services support delivery of the NHS Constitution for our population D Continually improve quality of commissioned services E Achieve sustained financial balance F Maintain a highly effective and motivated workforce G Ensure sound governance arrangements are in place H Promote appropriate integration of commissioned services Strategic risks A1 Failure to demonstrate improvement in healthy life expectancy A2 Failure to demonstrate improvement to the whole population B1 Failure to identify appropriate segmentation for the local population B2 Failure to appropriately deliver resources that target identified need C1 Failure to understand the NHS Constitution in a local context C2 Failure to ensure commissioned services deliver the NHS Constitution C3 Failure to impact on indirectly commissioned services with regard to delivery of the NHS Constitution D1 Failure to agree a common definition of quality D2 Failure to establish effective quality monitoring D3 Failure to identify and act on early warnings of a failing by any Provider D4 Failure to performance manage to ensure continuous improvement D5 Failure to impact on quality standards applied to indirectly commissioned services E1 Failure to develop a financial strategy E2 Failure to implement the financial strategy E3 Failure to ensure sound business practices are at the heart of running the CCG F1 Failure to define the needs of the workforce F2 Failure to promote the organisational culture that meets the needs of the workforce F3 Failure to implement a system which monitors success G1 Failure to ensure that we are compliant with our statutory responsibilities G2 Failure to put in place sound governance arrangements H1 Failure to achieve integration of care pathways H2 Failure to achieve integration of commissioned services 40

41 AGENDA ITEM NO : 016/14 Internal Controls All identified risks have been assessed to ascertain the following: Risk score with existing control measures in place; Key controls in place to mitigate the risk; Assurances and evidence that the CCG is managing its risks via its controls (this includes internal and external assurance); Any gaps in control and assurances; Action plan to address any gaps; and Timescales to complete action plan. The purpose of control mechanisms are: Prevention of risk; Deterrent to risks arising; and Management of current risks. Some of the control measures put in place for the strategic objectives and associated risks are as follows: Objective Control measures A Improve healthy life expectancy Public Health engagement for all Joint Strategic Needs Assessment (JSNA) Community engagement Equality Impact Assessments Local data observatory Collaborative commissioning approaches Joint Health & Wellbeing Strategy Transformational change programmes NHS Outcomes Framework indicators B Reduce inequalities JSNA Public Health observatory data Collaborative commissioning approaches Health & Wellbeing Strategy C All commissioned services support CCG Integrated Strategic Operating Plan delivery of the NHS Constitution Contractual requirements with Providers Service specifications Sanctions relating to non-delivery Balance scorecard / Assurance Framework D Continually improve the quality of Quality strategy developed and shared commissioned services Clinical quality meetings with Providers Unannounced visits to Providers Serious Incident Policy Safeguarding Policies Quality Risk Profiles issued by the Care Quality 41

42 E Achieve sustained financial balance F Maintain a highly effective and motivated workforce G Ensure sound governance arrangements are in place H Promote appropriate integration of commissioned services Assurances AGENDA ITEM NO : 016/14 Commission Triangulation of information with local authority and other agencies Review of serious incident investigation reports Financial strategy developed and shared Programme Management Office in place Financial awareness training delivered to member practices Service Level Agreement in place with Commissioning Support Unit Governance Manual in place Team meetings Organisational Development Plan Clinical achievement awards Audit plan for internal audit Committee structures in place with terms of reference Principles of integration shared across the local health and social care economy Collaborative commissioning approaches A definition of assurance is where we gain evidence that our control measures, on which we are placing reliance, are effective. Assurance is gained from an internal or external source but the CCG strives to gain assurance from an external source as this is considered to be provide more of an independent view. Typical sources of assurance include the following: Internal audit reviews; External audit reviews; Management reviews; Reports or inspections from Regulators; Patient surveys / experience; Performance reports to Committees / Governing Body; Minutes of meetings demonstrating review and scrutiny of controls; Monitoring of Key Performance Indicators (KPIs); Staff survey results; and Planned testing of systems. Assurance is considered throughout the year to ensure that the CCG does not have any gaps. In the event that assurance is not robust, it would be highlighted by the Audit Committee to the Governing Body with a recommendation as to how to address the issue. Further developments relating to risk The CCG has recognised that further review and scrutiny of risk is required. The CCG is developing a programme whereby all senior managers who lead each strategic risk will have to attend the Audit Committee throughout the financial year to provide further detail relating to the risks in their portfolio of work. This will allow more robust scrutiny of each strategic risk by the Audit Committee 42

43 43 AGENDA ITEM NO : 016/14 which will in turn make recommendations where necessary in the event that control measures and/or assurances are not appropriate. In addition, a programme is being developed to establish and fully embed a risk culture throughout the CCG to ensure that all risk is appropriately captured and managed at every level. In relation to GP member practices, a programme is also being established which will see the rollout of an incident reporting tool to all member practices which will allow the capture of all incidents and therefore oversight of any risks which need to be added to the risk register and managed accordingly. Emergency Preparedness, Response and Resilience CCGs have been identified as being Category 2 responders under the Civil Contingencies Act This requires them to share information and co-operate with other agencies in terms of planning for emergencies. The Department of Health, however, has indicated an expectation that CCGs also undertake the duties assigned to Category 1 responder; this requires production of Emergency Plans, Business Continuity Plans, Assessment of Risk and ensuring that there are arrangements for informing and warning the public. This will allow CCGs to be part of the overall planning process within both the Local Resilience Forum and the Local Health Resilience Partnership. Under the guidance issued by NHS England, CCGs are required to have a system in place which will allow their commissioned services to contact them on a 24/7 basis. This 24/7 access will additionally allow the NHS England Area Team to make contact in emergencies, allowing CCGs to work with the Area Team in support of the wider NHS response to any incident. CCGs are required to ensure they have a Business Continuity and Incident Response Plan in place which complies with the NHS Core Standards for Emergency Preparedness, Response and Resilience (EPRR) and are also required to assure themselves that their commissioned services have plans in place to respond to and recover from emergencies. NHS Warrington CCG has a service level agreement in place with the Cheshire & Merseyside Commissioning Support Unit to support work in the area of EPRR. A programme of activity was undertaken which addressed the following areas of work: Training needs analysis of all staff operating on the on call rota; Training delivered to staff including Integrated Emergency Management and Strategic Management in a Crisis; Business Impact Analysis undertaken in all areas of work; and Business Continuity Plan (including Incident Response Plan) developed, which is compliant with ISO and NHS Core Standards. As the CCG moves into 2014/15, there is a programme established for regularly testing the plan, of which the results will be reported to the Quality Committee and Governing Body Safeguarding Children NHS Warrington Clinical Commissioning Group (CCG) is statutorily responsible for ensuring that the organisations from which they commission services provide a safe system that safeguards children

44 44 AGENDA ITEM NO : 016/14 at risk of abuse or neglect. This includes specific responsibilities for looked after children and for supporting the Child Death Overview process, to include sudden unexpected death in childhood. Local authorities have the same responsibilities in relation to the public health services that they commission. NHS Warrington CCG has a statutory duty to be member of Local Safeguarding Children Board (LSCB) and is expected to be working in partnership with local authorities to fulfil their safeguarding responsibilities. NHS Warrington CCG ensures that robust processes are in place to learn lessons from cases where children die or are seriously harmed and abuse or neglect is suspected. This will include contributing fully to Serious Case Reviews (SCRs) which are commissioned by the LSCB and also, where appropriate, conducting individual management reviews and Domestic Homicide Reviews. NHS Warrington CCG needs to assurance that the organisations from which they commission services have effective safeguarding arrangements in place. This assurance is sought through contract management and audit. NHS Warrington CCG has implemented all recommendations from The Safeguarding Vulnerable People in the Reformed NHS Accountability and Assurance Framework 2013 to demonstrate that there are appropriate systems in place for discharging their responsibilities in respect of safeguarding, including; Plans to train their staff in recognising and reporting safeguarding issues; A clear line of accountability for safeguarding, properly reflected in the CCG governance arrangements; Appropriate arrangements to co-operate with local authorities in the operation of LSCB and health and wellbeing boards; Ensuring effective arrangements for information sharing; Securing the expertise of a designated doctor and nurse for safeguarding children and for looked after children and a designated paediatrician for unexpected deaths in childhood CCG is able to demonstrate that their designated clinical experts (children ), are embedded in the clinical decision making of the organisation, with the authority to work within local health economies to influence local thinking and practice; The role of designated professionals for safeguarding children is explicitly defined in job descriptions, and sufficient time, funding, supervision and support is allowed to enable them to fulfil their child safeguarding responsibilities effectively; and Designated professionals as clinical experts and strategic leaders are a vital source of advice to the CCG, the local authority, the LSCB and the health and wellbeing board, and of advice and support for other health professionals in provider organisations. NHS Warrington CCG considers its role is more than managing contracts and employing expert practitioners. It is about working with others to ensure that critical services are in place to respond to children who are at risk or have been harmed, and it is about delivering improved outcomes and improving the life chances for the most vulnerable. Looking after personal data & 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

45 AGENDA ITEM NO : 016/14 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. As technological advances multiply, so do people s concerns about the safety of their personal data. Information Governance is addressed at the highest level within Warrington Clinical Commissioning Group. All staff are required to receive mandatory Information Governance training and during 2013/14 the Clinical Commissioning group gained Level 2 status. Privacy Impact Assessments are carried out before introducing new projects or changing a service involving person-identifiable information. We continue to develop and agree Information Sharing Protocols, working in partnership with health, social care, other statutory bodies, commercial healthcare bodies and the voluntary sector. SUMMARY OF PERSONAL DATA INCIDENTS IN 2013/14 Category Nature of Incident Total I Loss of inadequately protected electronic equipment, devices or 0 paper documents from secured NHS premises II Loss of inadequately protected electronic equipment, devices or 0 paper documents from outside secured NHS premises III Insecure disposal of inadequately protected electronic equipment, 0 devices or paper documents IV Unauthorised disclosure 0 V Other 0 There were no Information Governance related incidents reported to the Information Commissioners during 2013/14. Pension Obligations As an employer with staff entitled to membership of the NHS Pension Scheme, control measures are in place to ensure all employer obligations contained within the scheme regulations are complied with. This includes ensuring that deductions from salary, employer s contributions and payments into the scheme are in accordance with the scheme rules, and that member pension scheme records are accurately updated in accordance with the timescales detailed in the regulations. Equality, Diversity & Human Rights Obligations Control measures are in place to ensure that the clinical commissioning group complies with the required public sector equality duty set out in the Equality Act Equality & Diversity Warrington Clinical Commissioning Group approved an Equality and Diversity strategy highlighting the key mechanisms the CCG will use to promote equality and diversity across the organisation and Equality Objective plan in October 2013 in line with their specific duties and requirements under the Equality Act An Equality Delivery System Self-Assessment was completed early in 2013 and supported the development of the Objectives 45

46 AGENDA ITEM NO : 016/14 The Equality Objective plan lays out clear work streams that will support the organisation to meet and pay due regard across its key functions to meet our exacting Public Sector Equality Duty to: Eliminated discrimination Advance Equality of opportunity Foster good community relations The Equality Objectives are: Improved completion and publication of equality analysis- to ensure we consider the needs of our population Improving identification of key areas of risk related to equality agenda- Training about CCG responsibilities and risks has been delivered to Commissioners in January 2014 Embed Equality into good governance structures systems and processes- ensuring we have robust consultation and engagement with protected groups Monitoring provider equality compliance- ensuring that our providers are meeting the requirements of the Equality Act 2010 and improving their equality performance around access and outcomes. Work around this has been progresses between November 2013 and March 2014 with the key NHS providers including Bridgewater, 5 Borough partnership and Warrington and Halton Hospital Equality and Diversity policy and other relevant policies have been approved at the Cheshire and Merseyside CCG and CSU Partnership Forum in December The Clinical Commissioning Group undertook a Diversity survey in conjunction with NHS England in July The gender analysis of NHS Warrington CCG as at the 31st March 2014 is as follows: Role Female Male Total Female % Male % Governing Body Members % 90.0% Senior Management Team % 71.4% Total CCG Staff % 39.7% The CCG produced key Equality Objectives and an Equality and Diversity Strategy to progress the equality agenda. The Objectives were a specific requirement stipulated by the Equality Act 2010 and were informed through the NHS Equality Delivery Systems (EDS) Self-Assessment. The Strategy highlighted the key mechanisms needed to progress the issue forward. Progress made throughout the year against the objectives is as follows: Sustainable Development Obligations NHS Warrington CCG takes its responsibilities to the environment very seriously. It undertakes a range of measures that are mindful of the future environment and these include: 46

47 AGENDA ITEM NO : 016/14 The move to a new CCG Headquarters (Arpley House) has allowed the regular recycling of paper and plastics; The CCG promotes the use of telephone/video conferencing to reduce the carbon emissions from use of cars; The CCG encourages car sharing when attending off-site meetings; Promoting back to back black & white printing where paper copies are required (for example, Governing Body papers for members of the public); Using tablet computers for all staff, reducing the need for hard paper copies; and Storing scanned documents electronically where legally appropriate. We are developing plans to assess risks, enhance our performance and reduce our impact, including against carbon reduction and climate change adaptation objectives. This includes establishing mechanisms to embed social and environmental sustainability across policy development, business planning and in commissioning. We will ensure the clinical commissioning group complies with its obligations under the Climate Change Act 2008, including the Adaptation Reporting power, and the Public Services (Social Value) Act We are also setting out our commitments as a socially responsible employer. Risk Assessment in Relation to Governance, Risk Management & Internal Control The description of how risk has been assessed, including the clinical commissioning group s risk profile, and how it has been managed is identified in the risk section above. The key risks that have been faced by the CCG in 2013/14 have been primarily around Provider performance and the CCG s financial position including non-delivery of QIPP. The CCG has also been mindful of its first year of operation in a hugely changed commissioning landscape which has resulted in a much leaner commissioning structure which has been challenged by an amount of authorised absence within the senior team. As 2013/14 has closed and the CCG enters into the first quarter of 2014/15, the CCG has not identified any risks that are significant enough to jeopardise its licence. The CCG is confident that any such risks will be highlighted, monitored and managed through - The effectiveness of governance structures, The responsibilities of Directors and committees; Reporting lines and accountabilities between the Governing Body, its committees and subcommittees and the executive team; The submission of timely and accurate information to assess risks to compliance with the clinical commissioning group s licence; and, The degree and rigour of oversight the Governing Body has over the clinical commissioning group s performance. 47

48 Review of Economy, Efficiency & Effectiveness of the Use of Resources AGENDA ITEM NO : 016/14 With regard to economy, efficiency and effectiveness, the CCG measures this through its standard monthly reporting which is reviewed by monthly Finance and Performance Committee. Specifically, the value for money aspects of services commissioned are reviewed in an integrated performance manner taking appropriate cognisance of outcomes achieved for service users. Robust contract monitoring exists to ensure that value for money is secured and that appropriate levers can be applied to maximise this. Any investment/disinvestment decisions are subjected to business case rigour and agreement of partner agencies. The outcomes of performance review and investment/disinvestment decisions are reflected in the CCG s operational and strategic plans. Review of the Effectiveness of Governance, Risk Management & Internal Control As Accounting Officer I have responsibility for reviewing the effectiveness of the system of internal control within the clinical commissioning group. In addressing this responsibility, I ensure that the Committees of the organisation are appropriately developed, attended and are considering the key risk and control issues within the economy. In this regard, I place particular reliance on Audit and Quality Committees which devote a significant portion of their agenda to consider the adequacy of the internal control framework and management of risk. Capacity to Handle Risk The identification, monitor and management of risk is the responsibility of all CCG officers. The Chief Operating Officer leads on risk for the Governing Body and is supported by a full time Head of Assurance and Risk. The processes and controls around risk are detailed within this statement under Risk Review of Effectiveness My review of the effectiveness of the system of internal control is informed by the work of the internal auditors and the executive managers and clinical leads within the clinical commissioning group who have responsibility for the development and maintenance of the internal control framework. I have drawn on performance information available to me. My review is also informed by comments made by the external auditors in their management letter and other reports. The Assurance Framework itself provides me with evidence that the effectiveness of controls that manage risks to the clinical commissioning group achieving its principles objectives have been reviewed. 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, and internal control. The Head of Internal Audit concluded that: 48

49 1. Director of Audit s Opinion 1.1 Introduction In accordance with Public Sector Internal Audit Standards, the Director of Internal Audit (HoIA) is required to provide an annual opinion, based upon and limited to the work performed, on the overall adequacy and effectiveness of the organisation s risk management, control and governance processes (i.e. the organisation s system of internal control). This is achieved through a risk-based plan of work, agreed with management and approved by the Audit Committee, which should provide a reasonable level of assurance subject to the inherent limitations described below. The purpose of this Director of Internal Audit Opinion is to contribute to the assurances available to the Accountable Officer and the Governing Body which underpin the Governing Body s own assessment of the effectiveness of the organisation s system of internal control. This Opinion will assist the Governing Body in the completion of its Annual Governance Statement. 1.2 Opinion My overall opinion is: Significant Assurance, can be given that that there is a generally sound system of internal control designed to meet the organisation s objectives, and that controls are generally being applied consistently. However, some weaknesses in the design or inconsistent application of controls put the achievement of particular objective at risk 1.3 Basis of Forming the Opinion The basis for forming my opinion is as follows: Assurance Framework An Assurance Framework has been established which is designed and operating to meet the requirements of the Annual Governance Statement and provide reasonable assurance that there is an effective system of internal control to manage the principal risks identified by the organisation 49

50 Assurance across the organisation s critical business systems: Access to Services The review of Financial Reporting & Budgetary Control provided Significant Assurance. There are appropriate arrangements in place to manage and monitor the contract with the CSU. Transparency and Governance The year end opinion of the Assurance Framework was assessed at Level A and identified strong engagement with the Governing Body and the continous development of systems and processes. Limited assurance was assigned in relation to the risk management arrangements. The utilisation of the risk registers requires strengthening to ensure they are 'live' documents. High assurances provided in relation to the arrangements place to assure the CCG Governing Body that they are compliant with the NHS England CCG Assurance Framework assessment process. The best practice mapping exercise relating to Conflicts of Interest identified some areas to enhance the processes. Patient Participation and Customer Service The review of Patient Experience highlighted the proactive work commenced to improve patient experience and involvement. Signifcant Assurance was provided. Informed Commissioning The review of the Information Governance Toolkit provided Significant Assurance and demonstrated the CCG's commitment to information governance. Higher Standards Significant assurance has been assigned in relation to the monitoring of the Quality of Services provided. Appropriate mechanisms in place to monitor and manage the delivery of health outcomes for CCG work streams. 50

51 Contribution to Governance, Risk Management and Internal Control enhancements: Detailed insight into the overall Governance and Assurance processes gained from liaison throughout the year with the Senior Management Team. Specific audit review of CSU Contract Management and review of the audit readiness report providing third party assurances to the CCG. Review and advice on the corporate governance documentation and management of conflict of interests. Ongoing discussion with lead officers, Lay Members and the membership throughout the year. Effective utilisation of internal audit including in year communication, and changes to the audit plan in respect of a review of Corporate Governance documentation. Follow up, demonstrating significant progress against recommendations to improve systems and controls. Provision of briefings and CCG involvement through MIAA events. The Opinion does not imply that Internal Audit have reviewed all risks and assurances relating to the organisation. The opinion is substantially derived from the conduct of risk-based plans generated from a robust and organisation-led Assurance Framework. As such, it is one component that the Governing Body takes into account in making its Annual Governance Statement. Tim Crowley Director of Audit, MIAA March 2014 Appendix A provides a summary of the Audit Reviews undertaken during the year. Appendix B provides further information to consider when compiling the Annual Governance Statement (AGS). 51

52 Appendix A: Audit Review Outcomes and Delivery Performance against Plan The Internal Audit Plan has been delivered in accordance with the schedule agreed with the Audit Committee at the start of the financial year. This position has been reported within the progress reports across the financial year, with the final report concluding completion of the Internal Audit Plan. Risk Based Reviews The audit assignment element of the Opinion is limited to the scope and objective of each of the individual reviews. Detailed information on the limitations to the reviews has been provided within the individual audit reports and through the Audit Committee Progress reports throughout the year. The schedule below provides a summary of the reviews/objectives contribution to this element of the Opinion. HIGH ASSURANCE Our work found some low impact control weaknesses which, if addressed would improve overall control. However, these weaknesses do not affect key controls and are unlikely to impair the achievement of the objectives of the system. Therefore we can conclude that the key controls have been adequately designed and are operating effectively to deliver the objectives of the system, function or process NHS Assurance Framework England Objective: To assess the performance monitoring framework in place to assure the CCG Governing Body that they are compliant with the NHS England CCG Assurance Framework assessment process. 52

53 There are some weaknesses in the design and/or operation of controls which could impair the achievement of the objectives of the system, function or process. However, either their impact would be minimal or they would be unlikely to occur Financial Reporting & Budgetary Control Objective: To evaluate the adequacy of systems and processes operating within the CCG, particularly in respect of Budgetary Control & Financial Reporting. Additionally, the review focused on those controls operated by the CCG in relation to Accounts Payable and Accounts Receivable processes. Stakeholder Engagement SIGNIFICANT ASSURANCE Objective: To provide an opinion and offer the opportunity to consider how the various activities to explore and improve patient engagement and experience are currently configured and suggest potential development of further activities in this regard. IG Toolkit Objective: To provide an opinion on the adequacy of policies, systems and operational activities to complete, approve and submit the IG Toolkit scores. In addition an opinion was provided in relation to the validity of the scores based on the evidence available. Quality of Services Commissioned Objective: To undertake an assessment of the mechanisms in place at the CCG to ensure that the organisation receives assurance from their providers in relation to the quality of services commissioned. Delivery of Outcomes Objective: To provide an opinion on the mechanisms in place to monitor and manage the delivery of health outcomes for CCG work streams. CSU Contract Management Objective: To provide assurance regarding the mechanisms established to support effective contract management with the CSU. Follow Up Objective: To provide an update on the progress of implementation of Internal Audit recommendations made. 53

54 NO ASSURANCE LIMITED ASSURANCE There are weaknesses in the design and / or operation of controls which could have a significant impact on the achievement of the key system, function or process objectives but should not have a significant impact on the achievement of organisational objectives. Risk Management Arrangements Objective: To assess the adequacy of systems and processes in place to ensure that risks are identified and appropriately and accurately escalated through the CCG s risk management structures as documented within the Risk Management Policy. There are weaknesses in the design and/or operation of controls which [in aggregate] have a significant impact on the achievement of key system, function or process objectives and may put at risk the achievement of organisational objectives. No reviews were assigned no assurance 54

55 CONTRIBUTION TO CONTROL ENVIRONMENT There are weaknesses in the design and/or operation of controls which [in aggregate] have a significant impact on the achievement of key system, function or process objectives and may put at risk the achievement of organisational objectives. Assurance Framework Opinion Objective: To undertaken an interim assessment of the Assurance Framework against the key requirements set out under NHS guidelines to support its development and utilisation. Corporate Governance Manual Objective: To undertake a comparison of Corporate Governance manuals from other Clinical Commissioning Group s to assess whether all key areas are included within the manual in line with best practice and to ensure the financial limits are consistent throughout the document. Duties and Powers Review Objective: To undertake a mapping exercise, ensuring that operational and executive responsibility for key statutory duties and powers is clearly understood and that mechanisms are in place to assure the CCG Board that these are being fulfilled. HFMA Audit Committee Survey Objective: MIAA completed the CCG Audit Committee Survey on behalf of the CCG for the Healthcare Financial Management Association and communicated the results to the Audit Committee members. The aim of the survey was to establish how CCG governance is evolving - in particular how the audit committees are functioning and how CCGs are working together in matters relating to governance. Benchmarking Reports Objective: Benchmarking Reports have been issued in the following areas: o Conflicts of Interest o Committee Structure & Membership o Audit Committee Effectivenes Briefing Notes Objective: Briefing Notes have been issued on the following topics: o Medicines Management o Duty of Candour 55

56 Appendix B: Contribution to Annual Governance Statement Roles and Responsibilities The whole Governing Body is collectively accountable for maintaining a sound system of internal control and is responsible for putting in place arrangements for gaining assurance about the effectiveness of that overall system. The Annual Governance Statement is an annual statement by the Accountable Officer, on behalf of the Governing Body, providing assurance on the stewardship of the CCG, including: How the individual responsibilities of the Accountable Officer are discharged with regard to maintaining a sound system of internal control and governance that supports the achievement of policies, aims and objectives. The purpose of the system of internal control as evidenced by a description of the risk management and review processes, including the Assurance Framework process; The conduct and results of the review of the effectiveness of the system of internal control including any disclosures of significant control failures together with assurances that actions are or will be taken where appropriate to address issues arising. The organisation s Assurance Framework should bring together all of the evidence required to support the Annual Governance Statement requirements. Director of Internal Audit Opinion The purpose of the Director of Audit Opinion is to contribute to the assurances available to underpin the Governing Body s own assessment of the effectiveness of the organisation s system of internal control (see figure 1 below). This opinion will therefore assist the Accountable Officer and the Governing Body in the completion of its Annual Governance Statement 56

57 57 Figure 1 Director of Audit Opinion Contribution to AGS