GOVERNING BODY. Purpose of the report: To ensure the Governing Body has knowledge of and approve the annual report ahead of submission to NHS England.

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1 Enclosure: L Agenda item: 15 GOVERNING BODY Title of paper: NHS Greenwich CCG Annual Report 2015/16 Date of meeting: 25 May 2016 Presented by: Diane Jones Prepared by: Diane Jones Title: Director of Integrated Governance & contact: diane.jones11@nhs.net Title: As above & contact: As above 1. To commission high quality, cost effective services to meet the needs of local people which improve health outcomes and reduce inequalities. 2. To ensure that the patients and the public s voice is heard so that we improve the quality of the services that we commission for the diverse needs of our population. 3. To develop Greenwich CCG as a clinically driven organisation with effective member engagement, that can attract and retain excellent staff, deliver effective governance and its full statutory and financial duties. 4. To create and optimise a data and intelligence rich environment to inform commissioning decisions at CCG, Transformation Steering Group, Syndicate and practice level. 5. To develop a long term approach to improving healthcare and delivering more integrated services for the population of Greenwich delivered by sustainable providers through partnership working with RBG, local providers, the community and voluntary sector. Please provide a summary of the paper being presented x x x x x Purpose of the report: To ensure the Governing Body has knowledge of and approve the annual report ahead of submission to NHS England. Issues Arising: None Summary of Actions, if any, following this meeting: Annual Report to be shared with the staff and public. Annual report to be presented at the Annual General Meeting (AGM) September 2016 Previous committee involvement: Audit committee 25 May 2016

2 Recommendations to the Governing Body: The GB is asked to approve the annual report (Please provide details below where Yes is indicated below) Impact on Governing Body Assurance Framework (x) Yes X No N/A Impact on Environment (x) Yes X No N/A Legal Implications (x) Yes X No N/A Resource and or financial implications (x) Yes X No N/A Equality impact assessment (x) Yes X No N/A Privacy impact assessment (x) Yes X No N/A Impact on current NHS Outcomes Framework areas (x) Yes X No N/A Patient and Public Involvement (x) Yes X No N/A Communications and Engagement (x) Yes X No N/A Impact on CCG Constitution (x) Yes x No N/A Attachments: (i) Annual Report 2016/17 2

3 NHS GREENWICH CCG ANNUAL REPORT AND ANNUAL ACCOUNTS

4 Contents SECTION 1: PERFORMANCE REPORT... 4 Welcome... 5 Services in Greenwich... 6 Our objectives... 6 Greenwich Health and Wellbeing Board... 7 Joint Health and Wellbeing Strategy... 7 Joint Strategic Needs Assessment... 8 Our population... 9 The challenges in Greenwich...10 Main areas of poor health...10 Managing risk...12 How we spend your money...13 Our achievements in 2015/ Medicines management...15 Primary Care...15 Eltham Community Hospital...16 Continuing healthcare...16 Our Healthier South East London...16 Connect Care...16 Office move...17 NHS Health Help Now...17 Urgent Care Centre...17 Improved standards...17 Performance Analysis: improving quality and performance...18 Challenges addressed:...19 Integrated working and Better Care Fund (BCF)...22 Quality, Improvement, Productivity and Prevention (QIPP)...23 Financial overview...25 Sustainable Development...27 Quality and safety...29 Friends and Family Test...30 Patient Safety...30 Quality Issues...31 Safeguarding adults and children

5 Medicine s security...32 Medicines Management...33 Patient engagement...33 Clinical Effectiveness...33 Patient and public involvement...35 Clinical Engagement...36 Working together: Our Healthier South East London...38 Equality and diversity...41 Our Communities...41 Meeting the Public Sector Equality Duties (PSED) in 2015/ Public Sector Equality Duties (PSED)...42 Equality Objectives 2012/ Emergency preparedness and resilience (EPRR)...45 SECTION 2: ACCOUNTABILITY REPORT...47 Member s report...48 Our members...48 Executive Committee...49 Governing Body...50 Statement on disclosure to auditors...53 Our audit committee...53 Statement of Accountable Officer s Responsibilities...54 Annual Governance Statement...56 Governance Framework...56 Finance Recovery Board (FRB)...60 Risk Management Framework...61 Internal Control Framework...65 Information Governance...66 Head of Internal Audit Opinion...70 Remuneration and staff report...76 Remuneration Committee...76 Remuneration Policy...77 Our staff...82 SECTION 3: STATEMENT OF FINANCIAL POSITION

6 SECTION 1: PERFORMANCE REPORT 4

7 Welcome As we reach the end of our third year as a CCG, I am pleased to say that that we are making really good progress in many of our priority areas. Improving healthcare for Greenwich residents is the main role of the CCG and as the population of the borough grows and changes, the opportunities and challenges for improving health and healthcare change too. We have seen some real successes throughout the year and you will find more detail within the report of the areas highlighted here. Working with our GP members, we have developed our four geographically-based GP provider networks to enable patients to access more primary care services and in a way that means we can commission these services at scale. For the first time, we were able to meet the two week wait for cancer and 62 week wait for cancer by the end of the year. This is a huge achievement and one that will make a big difference to the health and lives of people living in Greenwich. Several services have won national recognition; the Medicines Management Team won an award at the Journal of Wound Care Awards for their work to develop an electronic wound care template, and NHS England has also approved the video that we made to help people understand continuing healthcare, which has been shared widely at a local and national level. As an organisation we have also seen some changes during the year. We moved offices to re-locate with the Royal Borough of Greenwich, which has enabled us to build much better relationships with our council colleagues and work collaboratively in key areas. For example, we successfully rolled out Connect Care to our GP practices to provide them, and other health and social care providers, with immediate access to up-to-date patient information. Nevertheless 2015/16 has not been without its challenges. The most significant for us locally has been recognising that we were facing real financial difficulties halfway through the year. In response, we took decisive action to make sure that we addressed these issues quickly and efficiently. As a CCG we placed ourselves in Turnaround to make sure that we could focus on our finances and bring the CCG back to a sustainable financial position. This has proved challenging but we are in a much better position now and expect to be back on a stable footing by 2018/19. I would like to thank all of our local partners in health and social care who have worked with us during the year and to all our dedicated staff; we would not have achieved so much without your commitment and support. Dr Ellen Wright Clinical Chair, NHS Greenwich CCG 5

8 Services in Greenwich Most NHS care is now provided in community settings and work will continue to increase this still further. Local people should only have to go into hospital when they are acutely unwell and should be able to have the majority of their health needs met closer to home. Lewisham & Greenwich Healthcare NHS Trust (LGT) is the main provider of hospital services to Greenwich residents, and also to the residents of Lewisham and Bexley. The main local hospital is the Queen Elizabeth in Woolwich, which is one of two hospitals run by the Trust. It has an Accident & Emergency (A&E) department that operates 24 hours a day. There is also an Urgent Care Centre (UCC) based there, which was initially open from 8am to 11pm, seven days a week, that moved to 24 hours a day, seven days a week since September It also provides a wide range of outpatient services, diagnostics and in-patient beds. Greenwich residents are also served by other acute trusts across south east London. Guy s and St. Thomas NHS Foundation Trust (GST) serves the whole of south east London and it provides specialist services for patients from much further afield. King s College Hospital NHS Foundation Trust (KCH) provides a full range of general hospital services for over 700,000 people in the boroughs of Lambeth, Bromley and Southwark and specialised services that are available to patients across a wider area. Oxleas NHS Foundation Trust provides a wide range of health and social care services and specialises in caring for people with mental health needs and learning disabilities. It is the main provider of mental health and adult learning disabilities services for Greenwich as well as forensic mental health services. It is also the provider of community health services for Greenwich patients. Additionally, Greenwich residents are served by South London and Maudsley NHS Foundation Trust (SLaM) which provides the most extensive portfolio of specialist mental health and substance misuse services in the UK. In south east London there is one of only five Academic Health Sciences Centres (AHSC) in England. King s Health Partners (KHP) is a partnership between King s College London, Guys and St. Thomas NHS Foundation Trust, King s College Hospital NHS Foundation Trust and South London and Maudsley NHS Foundation Trust. Our objectives NHS Greenwich Clinical Commissioning Group was established on 1 April 2013 as a result of the Health and Social Care Act It is a membership organisation made up of the 41 GP practices across the borough. It is responsible for commissioning hospital, community and mental health services for the local population of Greenwich. Our mission is to secure the best possible health and care service for the population that we serve, specifically in primary care settings and in hospitals as necessary. In doing this, 6

9 we work with patients, and the wider public, to develop the services that we offer, reduce health inequalities and improve health outcomes. Other health services such as pharmacies, opticians, dentists and some specialist health services are commissioned by NHS England. We have five objectives that guide the work of the CCG. They are: 1. to commission high quality, cost effective services to meet the needs of local people, which improve health outcomes and reduce inequalities. 2. to ensure that the patients and the public s voice is heard so that we improve the quality of the services that we commission for the diverse needs of our population. 3. to develop Greenwich CCG as a clinically driven organisation with effective member engagement, that can attract and retain excellent staff, deliver effective governance and its full statutory and financial duties. 4. to create and optimise a data and intelligence rich environment to inform commissioning decisions at CCG, Transformation Steering Group, Syndicate and practice level. 5. to develop a long term approach to improving healthcare and delivering more integrated services for the population of Greenwich delivered by sustainable providers through partnership working with RBG, local providers, the community and voluntary sector. Greenwich Health and Wellbeing Board The Health and Wellbeing Board (HWB) considers matters relating to the provision of public health services and the commissioning of adult social services and children's services across health and social care and the impact of these on the health and wellbeing of the local population. Greenwich has a Health and Wellbeing Board, which provides a sense of place, bringing together the key NHS and Local Authority leaders for children, adults and public health services with local Healthwatch, GAVS and our local providers LGT and Oxleas. The Health and Wellbeing Board plays a key role in driving the Greenwich Health and Wellbeing strategy, which sets out high-level objectives and commitments for the Royal Borough of Greenwich and NHS commissioners to improve health and wellbeing in the borough. Joint Health and Wellbeing Strategy The Greenwich Health and Wellbeing strategy - Healthy Greenwich, Healthy People - involves the development of a healthier population in Greenwich with a focus on reducing avoidable healthcare conditions such as heart and respiratory disease, diabetes, stroke and common mental illness. It aims to do this by: Reducing levels of obesity. 7

10 Prioritising the development of mental health services alongside services for physical illness. Building a healthy workforce. We are working jointly with the Royal Borough of Greenwich to modernise and systematise our approach, and building on our recent success in reducing smoking prevalence, to help people stay healthy by preventing ill health and helping them to live independently for as long as possible. We will do this by putting prevention at the heart of all we do and adopting a Make Every Opportunity Count approach through the actions of our staff and the decisions we make, such as commissioning and policy decisions. The focus in the coming years will be on improving population health through a focus on improving both physical and mental health. The CCG will support the implementation of these programmes to encourage healthier lifestyles and improve morbidity outcomes over the next four to five years. Joint Strategic Needs Assessment The Joint Strategic Needs Assessment (JSNA) analysed the health needs of our local population. We use the JSNA to inform and guide our planning and funding of health and wellbeing services in the borough. The JSNA is available on the Royal Borough of Greenwich website. Building on the Joint Health and Wellbeing Strategy (JHWS), Greenwich CCG and The Royal Borough of Greenwich aim to develop and commission person-centred and coordinated care. We will achieve this by using our experience of enabling people to stay healthy using a range of initiatives such as self-directed support, personal budgets and developing integrated services. 8

11 Our population Greenwich is a diverse inner London Borough with areas of affluence and deprivation. With the rapid increase in new housing, the borough has seen its population increase rapidly and this rise is predicted to continue. The demography of the population has also changed, with approximately half of the borough s population now of black and minority ethnic background. There has been significant migration into the borough, most notably from Nigeria and other West African countries, Nepal and a number of Eastern European countries such as Poland and Lithuania. Life expectancy in Greenwich remains shorter than the national average at birth and at age 65, and for both males and females. On average, healthy life expectancy is shorter in Greenwich than it is in England for both males and females; improvements in life expectancy have been made and inequalities in life expectancy have reduced, although the picture remains mixed. The table below summarises the demographic and related health needs: Demographics % of population aged 0-16 remains stable in the next decade Ageing population expected to increase over the coming years. Social and Ethnic profile Significantly more deprived than the national average. Areas of greater deprivation are located mainly in the north and east of the Royal Borough but there are areas of higher deprivation across the whole of Greenwich. Diverse ethnic profile with 37.5% of population being BME populations. Life expectancy and Mortality and other Public Health Outcomes Life expectancy for males (78.7) and females (82.8) is increasing at a faster rate than England average but there remains considerable variation between the least and most deprived areas. 9

12 The challenges in Greenwich Main areas of poor health In Greenwich we have a growing and ageing population, making ever increasing demands, with ever growing expectations on health care services. According to the Joint Strategic Needs Assessment for Greenwich, the major causes of death in Greenwich are cancer and coronary heart disease (CHD), although death rates from both are improving. For respiratory diseases, including COPD, rates are falling faster than London. The JSNA priorities include six major conditions, six risk factors and seven underlying determinants of health as below: With our partners, we have identified the key underlying determinants of health that impact on the health of people in Greenwich. These are shown in the green boxes in the diagram above. There is ample evidence that social and environmental factors, including employment, income level and the suitability of housing have a marked influence on health. 10

13 The amber boxes then show the major risk factors for the major conditions listed in the boxes in red. We describe these conditions as the avoidable burden of ill health, as with the right help and support, for example, to give up smoking or to get people back into employment, the development of some of the diseases may be prevented. Main diseases, their causes and underlying Determinants of Health The diagram above shows improvements/declines in key Public Health Outcome indicators and their associated burden. Improvements have been made in a range of indicators, including some areas of preventable mortality (CVD, COPD), smoking prevalence and uptake in childhood immunisations. However, as can be seen in the top right hand red box, there is still much work to do, in particular to tackle inequality, preventable mortality from cancer and liver disease, death related to serious mental health issues and winter and obesity in both children and adults. 11

14 Too many people in the borough die early from deaths that could have been prevented by leading healthier lifestyles; therefore it is vital that we increase activity to promote healthier lifestyles for all. We also have a challenged provider landscape; both our hospital and community providers are grappling with delivering the NHS Constitutional Standards, specifically for Cancer and A&E. We also need to make sure that we are able to deliver community-based care that is patient-centred and improves the patient experience and outcomes across Greenwich. The Local Care Networks (LCN) will provide local services mapped across four areas (see page 15 for more information). This will enable the shift from care in hospitals to more appropriate community and primary settings, which in turn will help to address the financial gap. Managing risk The CCG has assessed its key risks and uncertainties throughout the year using the Governing Body Assurance Framework. The Assurance Framework sets out the principal risks to delivering our strategic objectives and how these risks are managed. There is an established method to identify, monitor, control and mitigate risks throughout the organisation as part of and within the CCGs Risk Management Strategy and Assurance Framework. The Assurance Framework is presented to the Governing Body at every meeting, so members can review the risks and mitigations and receive assurances that the risks are being managed. The top three risks for Greenwich CCG identified in 2015/16 are: 1. Risk of the CCG failing to fulfil its statutory duties in relation to the financial position 2015/ Risk of the CCG failing to work within budgetary framework. 3. Risk of over-performance in hospital contracts impacting on the CCG S financial position. As the CCG was unable to meets its full statutory financial duties, in February 2016 the CCG informed NHS England that it would move into Turnaround. This involved appointing an interim Turnaround Director to drive and lead a financial recovery programme. The CCG continues to meet with NHS England to provide assurance on the financial recovery plan and get back to a balanced position by 2016/17. Further details on risk are included in the governance statement on page

15 How we spend your money The CCG commissions and provides healthcare services to meet the needs and improve the health of the population of the London Borough of Greenwich. The main NHS providers are Lewisham and Greenwich Healthcare NHS Trust, Guy s and St Thomas NHS Foundation Trust and Oxleas NHS Foundation Trust. The CCG co-commissions (with NHS England) a number of other services, such as primary care (GPs), from a range of providers and also meets the prescribing costs of its GP Practice population. An analysis of the CCG s proportional spend in 2015/16 is shown in the following pie-chart : Acute Services 54% 11% 4% 13% Primary Care Services Continuing Care Services Mental Health Services 1% 1% 4% 2% 10% Community Services Other Programme Services Other Corporate Costs Reserves and Contingency Running Costs The table below illustrates the allocation of CCG budget together with expenditure against each category for 2015/16: Net Operating Expenditure for the year to 31 March 2016 Annual Budget '000 Outturn '000 Variance '000 Acute 192, ,071 (3,557) Non-Acute 110, ,776 (5,883) CCG responsible Primary Care 40,184 39, Corporate Costs 4,325 4, Running Costs 5,883 5,

16 Reserves 7,538-7,538 Surplus 4,174 3,250 (924) Resource 365, ,511-14

17 Our achievements in 2015/16 Medicines management NHS Greenwich CCG's Medicines Management team won the "Cost-effective Wound Management" award at the JWC awards in March 2016, hosted by the Journal of Wound Care (JWC). Working with commercial partners Blue Bay Medical Systems, the team won the award for their work in developing and introducing an electronic wound care template for clinicians to operate in conjunction with clinical software systems used in GP practice. This interoperability of systems to improve care is, to date, the only one of its kind in the UK and has resulted in huge cost savings and better patient care. Primary Care During the year all of the Practices in Greenwich came together to provide four geographically-based GP provider networks to enable them to provide increased Primary Care services to patients at scale. The Networks worked with INPS Vision and Bluebay Medical to pioneer the development of software that would collect and collate data at each practice to facilitate consistent recording of patient data. The GP provider networks also invested in clinical software that would allow them to provide services, within the contract, to each other s patients to facilitate improved care and quality. The CCG subsequently agreed a Long Term Conditions (LTC) contract with the four GP provider networks, that incorporated the Year of Care initiative. The contract focused on heart failure, Chronic Obstructive Pulmonary Disease, hypertension and diabetes. As part of the requirements of the contract, GPs and Nurses attended various training to up-skill them in providing Year of Care planning and support for eligible patients. They also attended various diagnostic and extended skills training to support them in identifying patients, who might have a diagnosis in one of these areas. This has enabled them to confirm the diagnosis and improve treatment and support for these patients and those already diagnosed. Initial results show a marked improvement in the diagnosis of patients in these four areas and as a result an improvement in the prevalence recording in Greenwich. We also became a Level 2 co-commissioner with NHS England. Level 2 is where the CCG (or CCGs) participate in decision-making with NHS England in a Joint Committee. Co-commissioning for primary care refers to the increased role of CCGs in the commissioning, procurement, management and monitoring of primary medical services contracts, alongside a continued role for NHS England. In 2015/16, the scope for primary care was only general practice services. 15

18 Eltham Community Hospital In 2015 the phased opening of the new Eltham Community Hospital took place. The first patients were welcomed to the two intermediate care wards, marking the arrival of the first of a number of primary and community care services that will be provided from this new facility. Continuing healthcare Our continuing healthcare video was produced in 2015, and is helping adults aged 18 or over with complicated, intense or unpredictable healthcare needs an excellent resource for our population and in fact for all of England, which has been approved by NHS England. For more information about continuing health care in Greenwich and to watch the video please go the NHS Greenwich CCG website. Our Healthier South East London Our Healthier South East London (OHSEL) is a five year commissioning strategy that aims to improve health, reduce health inequalities and ensure all health services in south east London meet safety and quality standards consistently and are sustainable in the longer term. The way health services are delivered needs to change in order to meet the emerging needs of an ageing population in which many more people live with long term conditions. This means that more resources must be directed towards services based in the community, keeping people out of hospital unless they really need to be there. The six local authorities across south east London have formed a Joint health Overview and Scrutiny Committee (JHOSC) to scrutinise our proposals and decision-making processes. If any of our ideas lead to a significant service change being required then a formal public consultation would be carried out. We expect to know if this is necessary later in Further information on the strategy, including a plain English summary, the Case for Change, You Said We Did documents and updates are available at Connect Care In mid-october 2015 we started to roll out Connect Care to GP practices across Lewisham and Greenwich. Connect Care provides health and social care providers with immediate access to up-to-date patient information Connect Care enables important patient information to be shared securely so that it can be viewed quickly and safely by staff directly involved in the care of a patient, such as GPs, hospital staff, district nurses, occupational therapists and social workers. It enables them 16

19 to make more informed decisions about care and treatment. Patients are able to opt-out of the system. More information is available on the NHS Greenwich CCG website. Office move We relocated from Greenwich to the Woolwich Centre in November 2015 and are now colocated with the Royal Borough of Greenwich. This has improved our working environment and is deepening and improving relationships with council colleagues. NHS Health Help Now We launched a new mobile and online service in December Developed by the South East Commissioning Support Unit, it helps people in Greenwich to understand where they should go for treatment, especially when they need health care in a hurry or late at night or at the weekend. The Health Help Now app can be downloaded free of charge to web or smart phone. It helps people check their symptoms and find the best place for treatment showing which nearby services are open. Importantly, it will help people to know when to go to A&E, and when not to. In the first five months since launch, there have been 9,565 unique users who used the mobile website 11,206 times in south east London, with each user staying on the site for approximately a minute or just over a minute. 61% of the visitors were female with the highest age group. Over the same period, the App has had 3,941 visits by 1,449 unique visitors. 59% were female, with 35/44 the highest age group. Urgent Care Centre Urgent Care Pathway improvements with an integrated GP Out of Hours and UCC services going live in September 2015, all day, every day, are now seeing on average 40% of people who attend The Queen Elizabeth Hospital A&E department. This is a significant increase from when it was only open part time. Improved standards Greenwich CCG continued to focus on improving performance across all NHS Constitution standards. While significant pressures remain for the first time the 2 week wait for cancer and 62 week wait for cancer were met by the end of the year (see page 21 for more information). The diagnosis rate for dementia was maintained at 67% for most of the year and the standards for improving access to psychological therapies improved for both waiting times and outcomes. Ongoing work is required to secure these standards in 2016/17. 17

20 Performance Analysis: improving quality and performance As part of the NHS we are measured against a range of targets that reflect what is important to patients. Whether it is waiting times in our A&E or recommending us to others in the Friends and Family test, all of these things help to reassure our patients that we are working hard to deliver the best possible care, in a timely and caring way. Our performance is measured by a set of local and national performance measures relating to patient safety, patient experience and the quality of our services. These standards help us to monitor how well we are performing and allow us to improve the care we provide to our patients. Greenwich CCG has three major reports relating to providing patients and interested parties with information all of which are reported to our Governing Body and are available on our website to the public: 1. The Quality report focuses on patient experience and outcomes 2. The Performance Report focuses on constitutional standards and the targets that interest the government as demonstrating service delivery and improvement 3. Our Finance report covers the activity and care we buy from our providers and also gives information on how we have managed our resources for local people. This information is also monitored by the NHS England (NHSE) assurance framework where the CCG is held to account by NHSE. During 2015/6 the CCG has been working to develop a new integrated performance report and dashboard which will cover all the three type of performance reports into one CCG improvement and performance framework. This should be ready to share with the public after June 2016 and draws into one summary report the NHS Constitution and other core performance and finance indicators, outcome goals, and transformational challenges. The table on page 19 shows NHS Greenwich s CCG performance against the national performance measures included in the operating framework for the NHS in England 2014/15 and 2015/16. The performance reflects the CCG s position against the indicators. 18

21 CCG Performance on measured standards 2014/15 and 2015/6 NHS Constitutional Measures Target/ Threshold 2014/15 FYE 2015/16 Month 12 NHS RAG rating (Red) NHS RAG rating (Amber) NHS RAG rating (Green) RTT Incompletes 92% 93.8% 90.6% Below 87% 87% to 92% 92% and above RTT 52+ week waiters More than 10 1 to 10 0 Diagnostics 6 weeks+ 99% 1.0% 1.1% Above 6% 1% to 6% 1% and below A&E total time 4 hour wait (LGT) 95% 87.8% 82.4% Below 90% 90% to 95% 95% and above A&E 12 hour trolley wait (LGT) (YTD) More than 0 n/a 0 Cancer 2 week wait 93% 89.1% 89.0% Below 88% 88% to 93% 93% and above Cancer Breast symptom 2 week wait 93% 89.4% 87.6% Below 88% 88% to 93% 93% and above Cancer 31 day first definitive treatment 96% 97.0% 98.7% Below 91% 91% to 96% 96% and above Cancer 31 day sub treatment surgery 94% 96.5% 100.0% Below 89% 89% to 94% 94% and above Cancer 31 day sub treatment drug 98% 99.4% 100.0% Below 93% 93% to 98% 98% and above Cancer 31 day sub treatment radiotherapy 94% 99.4% 100.0% Below 89% 89% to 94% 94% and above Cancer 62 day standard 85% 70.4% 86.1% Below 80% 80% to 85% 85% and above Cancer 62 day screening 90% 90.7% 100.0% Below 85% 85% to 90% 90% and above Ambulance Red 1 (8 mins) 75% 72.5% 59.5% Below 70% 70% to 75% 75% and above Ambulance Red 2 (8 mins) 75% 64.3% 58.0% Below 70% 70% to 75% 75% and above Ambulance Cat A (19 mins) 95% 95.5% 92.2% Below 90% 90% to 95% 95% and above Mixed sex accommodation (LGT) More than 10 1 to 10 0 Cancelled Ops for non-clinical reasons rebooked >28 days (LGT) (FYE) More than 10 1 to 10 0 CPA follow up within 7 days 95% 97.0% 100.0% Below 90% 90% to 95% 95% and above Dementia diagnosis rate 67% 69.3% 67.0% Below 67% n/a 67% and above IAPT 6 weeks first treatment 75% 97.0% 97.0% Below 75% n/a 75% and above IAPT 18 weeks first treatment 95% 100.0% 100.0% Below 95% n/a 95% and above Early Intervention in Psychosis 50% 100.0% 100.0% In development In development In development F&F Inpatient % who recommend (LGT) n/a 92.0% 96.0% n/a n/a n/a F&F A&E % who recommend n/a 93.0% 92.0% n/a n/a n/a F&F Maternity Antenatal % who recommend n/a 96.0% 95.0% n/a n/a n/a F&F Maternity Postnatal (W) % who recommend n/a 90.0% 91.0% n/a n/a n/a F&F Maternity Birth % who recommend n/a 89.0% 86.0% n/a n/a n/a F&F Maternity Postnatal (C) % who recommend n/a 98.0% 97.0% n/a n/a n/a MRSA (0 FYE) (1 FYE) More than 0 n/a 0 C. Difficile Ceiling of 52 (15/16) 62 (14/15) (51 FYE) Above YTD ceiling n/a At below YTD ceiling Venous Thromboembolism (VTE) Risk Assessment 95% 95.22% 81.2% (Q3) 0% 0% to 95% 95% and above Challenges addressed: A&E 4 hour wait standard The target is for 95 percent of patients to be seen, treated and then admitted or discharged within four hours from arriving in an A&E department. Meeting this requirement has been a challenge both nationally and in Greenwich. Lewisham and Greenwich 19

22 Hospital s Emergency Department at Denmark Hill did not meet the A&E four hour standards in any quarter of the last year. Despite this, the CCG successfully commissioned a new urgent care centre and pathway, has used the funding from the Better Care Fund to help manage the increasing demand for services by managing people out of hospital, such as the opening of the Eltham Community Hospital and has worked with the local authority and Lewisham CCG, who are the lead commissioner for Lewisham and Greenwich NHS Trust, to address the needs of patients requiring the urgent and emergency care pathway. Throughout 2015/16 the CCG worked closely with local A&E departments to improve performance including looking at how long term and complex conditions can be better managed within out of hospital services. Ambulance response times Targets for ambulance response times (see table on page 19four) were not achieved in 2015/16. The London Ambulance Service has undertaken a series of actions to address performance to ensure that targets are achieved and has had additional investment last year to improve services. The CCG will be working with Southwark CCG, the lead commissioner, to improve local response times. Locally there have been challenges associated with handovers at Lewisham Greenwich Trust (LGT) that are being addressed through the System Resilience Group (SRG) and LGT Contract Management Board (CMB). Referral to treatment times The CCG maintained a strong performance on non-admitted and incomplete referral-totreatment (RTT) performance, consistently achieving these performance targets in 2015/16. The CCG has worked with local hospitals to reduce the number of long waiting patients, with only two 52-week waits in March The CCG is working with partners to ensure that admitted RTT performance improves in 2016/17 and as part of negotiation of a new contract with Lewisham and Greenwich NHS Trust is undertaking detailed capacity planning with the provider to ensure any potential backlog cases are met within the target. Healthcare acquired infections Incidence of C difficile was lower this year than last year and was within the target for 2015/6, with 40 cases compared to 62 cases in 2014/5. Post infection reviews are also now completed whenever an MRSA case is reported to ensure learning is embedded and the overall incidence remains minimal. Mental Health The CCG continues to meet its targets for IAPTs, Community Psychiatric Assessment (CPA) and although there was a slight dip in February, has met the 67% minimum diagnosis target for dementia throughout 2015/6. Mental Health is also one of the CCG s Health and Well-Being priorities and we are working with NHS England to undertake regular stocktake meetings where performance is reviewed; the CCG demonstrated compliance with parity of esteem investment targets for local services. 20

23 In preparation for the new Early Intervention Psychosis (EIP) waiting time standard, the CCG worked in partnership with Oxleas to ensure the service is fully prepared to meet the new target from April Oxleas are updating reporting systems to ensure compliance against the EIP waiting time standard. The first December submission reported Greenwich (58%) exceeding the 50% target. In September 2015 the Oxleas service redesign programme saw the successful launch of Primary Care Plus across Greenwich. The service is set up to provide a specialist mental health liaison to primary care with the core aims of; 1) Assessment and referral management 2) Relapse prevention and shared care 3) Health promotion 4) Education, training and consultation. Cancer Waits One of the biggest challenges this year has been to address cancer waits. During 2015/6 we have worked with Lewisham CCG, NHS England specialist commissioning and local providers to develop a cancer recovery plan that will improve access to care and streamline the pathway, which was agreed with NHS England. This has resulted in substantial improvement in the 62-day wait pathway at the end of this year and we will continue to work with our partner CCGs and LGT to improve and streamline cancer services. In 2015/16 we have: 1. Completed the groundwork to set up a new LGT two week wait office, which went live on 4 April This new office provides a central response to all referrals and will have an electronic referrals system to replace the fax system and a support line for clinicians and patients. Communications and training regarding the new referrals system is being disseminated to Greenwich GP practices via the primary care engagement team. 2. Continued to work with LGT to improve performance against the backlog recovery trajectory to bring the 62 day pathway performance back on track by the end of March Set up and run the first Greenwich, Bexley and Lewisham CCG clinical forum that focused on lung cancer. Actions being taken forward include raising awareness in primary care to reduce inappropriate two week wait referrals. 4. Greenwich Clinical Quality Review Group (CQRG) continues to work with partner CCGs and LGT to conduct root cause analyses of two week wait patients identified by LGT as being managed outside formal LGT tracking systems. 5. The 2016/17 Greenwich primary care improvement plan going forward aims to focus more on educating GPs to identify cancer earlier and improving the on-going management of diagnosed patients. 21

24 Integrated working and Better Care Fund (BCF) We invested over 18m in 2015/6 to work with the council to ensure a strong focus on health and social care joint commissioning in order to develop admission avoidance and care closer to home for local patients. This Better Care Fund is currently being revised and developed for 2016/17. We focused our metrics for the 2015/16 BCF programme on the overall reduction of nonelective admissions, and from this planned a reduction of 834 non-elective admissions against our planned forecast trajectory. The capture of potentially avoidable admissions was based on improvements of care provided through training within care homes, and successfully piloting a primary care contract for our Long Term Conditions scheme to focus GPs on improving outcomes; this also relates to Delayed Transfers of Care. The chart below shows the total number of non-elective admissions that we planned to reduce on a quarterly basis, compared to the actual activity reported for each quarter. Quarter 1 was the only quarter reported where we were above planned activity. Overall, when comparing the cumulative planned trajectory, we were successful in being below this, and started to reduce more admissions by the time we had reached Quarter 3 for 2015/16. 22

25 The BCF is also targeting delayed transfer of care (DToC), which is a measure that focuses on patients receiving care at the right time and place. Whilst the London position deteriorated between December 2015 and February 2016, improvements were observed in Greenwich with 243 DToCs in February, down from 327 in January. We continue to manage DTOC rates below the London average and in England. Recent LGT emergency pathway work has been focusing on reducing levels of DTOC and streamlining discharge pathways for patients transitioning into nursing and social care facilities. Quality, Improvement, Productivity and Prevention (QIPP) QIPP is a national, regional and local level programme designed to support clinical teams and NHS organisations to improve the quality of care they deliver while making efficiency savings that can be reinvested in the NHS. For 2015/16, the CCG had original planned efficiencies of 7.3m against which savings of 5.0m were validated. Schemes take different forms but all relate to securing better value for money, for example; Frail Elderly Care, Long Term Conditions (Chronic Obstructive Pulmonary Disorder) and BCF schemes were all designed to enable vulnerable adults to be supported in their own homes and to reduce the number of unplanned admissions to acute hospital. Schemes supporting Muscular Skeletal Medicine and the use of Eltham Community Hospital Beds were designed to provide improved pathways of planned care using lower cost settings. The prescribing scheme was a continuation of best practice approaches to primary care prescribing to secure improved value for money 23

26 Trust productivity release secondary care costs by managing patients in a more effective way including reduced follow up outpatient appointments Mental Health and community schemes involve contractual arrangements for better value for money Not all of the schemes fully delivered, leaving a shortfall of 2.3m. The table below summarises the success of each scheme; QIPP Performance 2015/16 Plan Actual Deficit QIPP Current Position Acute: Frailty- Age over 80s 1,000 (1,000) COPD MSK etc. 500 (500) Trust Productivity 1, (321) Eltham (500) BCF 2,300 2, Acute Total 5,500 3,200 (2,300) MH Community Prescribing 1,000 1,000 0 Total 7,300 5,000 (2,300) 24

27 Financial overview The key financial related objectives set out in the CCG financial plan for 2015/16 are set out in the following table: Objective Criteria Target ( 000) Actual ( 000) Achieved Deliver statutory financial duties 1% Surplus 4,174 3,250 X Operate under Revenue Resource Limit 365, ,261 Not to exceed Running Cost 5,883 5,872 Operate under Capital Resource Limit Deliver the CCG s 95% of creditor payments within 30 days. administrative duty NHS Payables 95% 98.56% regarding better Non NHS Payables 95% 91.23% X payments practice Looking forward, the allocations for the next three years for the CCG are illustrated in the table below. 2016/ / /19 Total Revenue 368, , ,923 Acute 206, , ,533 Mental Health 50,859 50,199 51,514 Community 36,862 37,735 38,660 Continuing Care 18,921 19,835 20,794 Primary Care 37,050 37,310 39,082 Other Programme 12,271 7,908 4,475 BCF Total Programme Costs 362, , ,058 Running Costs 5,895 6,013 6,118 Contingency 1,848 1,870 1,915 Total Expenditure Plan 369, , ,091 Surplus/(Deficit) Cumulative (1,295) - 3,832 Net QIPP 15,540 10,450 9,081 The CCG is planning a breakeven position for the financial year 2017/18 rather than the normal CCG business rule of 1%. However the CCG is planning to return to business rules from 2018/19. The Governing Body intends to continue to put NHS Greenwich CCG 25

28 on a firm financial footing so that it is able to commission the best available services on a sustainable basis within the resources available. CCG Running Costs The CCG s running cost allocation in 2014/15 was 6,016k, which included a separate allocation of 132k for Quality Premium payments. Quality Premium payments made by the CCG are programme (health related) in nature and the associated expenditure is recorded under the CCG s programme costs. If this is excluded actual running costs were 12k underspent. Other matters Remuneration paid to the external auditors in relation to audit work was 71,550 (including non-recoverable VAT). Remuneration for non-audit work was nil. The CCG has complied with HM Treasury s guidance on setting charges for information. Annual Accounts The full annual accounts together with the Statement of Accountable Officer s Responsibilities and Independent Auditors Report are included in section 3. Signed on behalf of the Board Annabel Burn Accountable Officer 23 May 2016 Ian Fisher Chief Finance Officer 26

29 Sustainable Development During 2015/16 we took considerable steps to improve our environmental footprint. We moved out of premises that had the lowest possible environmental rating to be co-located with the Royal Borough of Greenwich in The Woolwich Centre. The Woolwich Centre is a new building with a high C carbon rating, and currently we are working with the Royal Borough to improve its environmental footprint further during 2016/17. The NHS Carbon Reduction Strategy for England provides a framework which addresses sustainability both in how we operate as an organisation in our own right, and in terms of how we contract for services from providers of healthcare. The plan aims to: 1. Drive down direct C0 2 emissions and energy usage whilst also reducing revenue expenditure 2. Influence commissioned services to reduce their carbon footprint in support of the 10% target reduction 3. Ensure that all new buildings and other initiatives are developed with reference to the plan. In line with the NHS Carbon Reduction Plan the local plans focus on the same areas. A summary of some of the key actions within the Carbon Reduction Plan are detailed below: Energy and carbon management: we have reduced our own energy and carbon footprint by moving into The Woolwich Centre, a modern building with many sustainable features (e.g. rainwater used in the toilets, automatic lighting that switches off when noone is present, etc.). In June 2015 Eltham Community Hospital, a LIFT building housing many health facilities, was opened. The CCG ensured that this development was designed with as small an environmental footprint as possible. Procurement and food: our main strategy is to influence the carbon footprint of NHS services through the use of our procurement framework, which addresses environmental issues. All contracts for healthcare services include clauses requiring providers to demonstrate their measured progress on climate change adaptation, mitigation and sustainable development, and include performance against carbon reduction management plans. Low carbon travel, transport and access: we have implemented a range of new services, and developed existing services, to bring them closer to the home. In terms of staff and visitor travel, a flat rate is operated for business mileage and also accounts for different modes of transport such as cycling. Cycling has been promoted actively for employees now we have moved to The Woolwich Centre with excellent cycle storage and related facilities. Water: Efficient use of water is embedded in new capital projects. For example, Eltham Community Hospital and The Woolwich Centre harvest rainwater for use in the building. The Woolwich Centre also has integral filtered watered in all of its kitchens for drinking. 27

30 Waste: Recyclable waste is appropriately disposed of and we are part of the Royal Borough s active strategies to reduce waste and promote recycling. During 2015/16 we also implemented a new IT solution enabling staff to conduct most meetings in a paperless manner and ensuring that printing is kept to a minimum. Designing the built environment: All new buildings are to be designed to withstand climate change and be low carbon. This was reflected in our Eltham Community Hospital development, which included a green wall and soft landscaping. Providers are also taking forward plans to reduce the carbon impact of existing estate, with a detailed programme of works being implemented by Oxleas NHS Foundation Trust in respect of the community services estate. Organisational and workforce development: Staff are given opportunities to use low carbon travel options, with walking and cycling encouraged and aligned business mileage processes. Audio, video and web conferencing technology and remote working capability are in place. Role of partnerships and networks: The Greenwich Core Strategy commits us to working in partnership with stakeholders under Local Strategic Partnerships, in particular the Royal Borough of Greenwich. Finance: As part of the exercise to calculate the carbon footprint, carbon reduction targets will be set to achieve the NHS target and take advantage of schemes which support investment in energy efficiency initiatives. 28

31 Quality and safety The focus of the NHS Greenwich CCG Quality Strategy and annual work plan is local quality challenges. We provide a quarterly Quality Report to the Governing Body and Quality Committee. The report provides an overview of Quality for the CCG and its main service providers, and highlights any good practice that has been identified and ensures that there is a focus on the key quality issues. The report provides assurance to the Governing Body that the CCG is aware of quality issues and that appropriate action is being taken to understand the situation and improve quality. We hold all of our providers to account through the work of the Quality Committee and the Clinical Quality Review Groups (CQRGs). They have been focusing on patient safety, clinical effectiveness and ensuring a good patient experience of services. From Feb 2016, as lead commissioner, we led the management of the Oxleas NHS FT Clinical Quality Review Group (CQRG) on behalf of Bexley, Bromley and Greenwich CCGs. During 2015/16, some of our Quality highlights include: The opening of the new Greenwich Birth Centre for low risk births at Queen Elizabeth Hospital in April Primary Care Plus was launched by Oxleas NHS FT on 28 September 2015, providing a specialist mental health liaison service to primary care. Safe staffing levels have been maintained; safer staffing levels and workforce (use of agency; locums; staff sickness and turnover) are monitored through CQRGs. There have been no breaches of mixed sex accommodation. We have not breached the 2015/16 NHSE trajectory (62 cases) set for C.Difficile infection. We have a Health Protection Manager who ensures that the learning from all cases is shared and has effectively managed post infection reviews (PIRs) in the community with local general practices. We are participating in the Sign Up to Safety national initiative that pledges the organisation s commitment to strengthening patient safety and supporting our key providers in their delivery of their Safety Improvement Plans. Both Oxleas FT and LGT are part of the Sign Up To Safety campaign. The focus at Oxleas is to reduce avoidable harm by half and is synonymous with the Oxleas Nursing Strategy to Drive improvements in safety and quality of care. LGT s focus is to reduce poor neonatal outcomes detailed in the Fetal Wellbeing Project. Introduction of Provider Assurance Monitoring System (PAMs): we have been working to develop a web-based quality assurance tool to be used to monitor quality within small providers. Providers started using this tool on 1 May 2016 and it is also being piloted across six early adopter nursing homes. We have established a Quality Alert Management System between local general practices and providers. The statutory Duty of Candour on healthcare providers is a direct response to the recommendation (181) of the Francis Inquiry. It is now a criminal offence to fail to provide notification of a notifiable safety incident and any conviction is liable to a 29

32 fine. Duty of Candour is monitored through the CQRGs. There have been no breaches declared of Duty of Candour. We established an NHS Greenwich CCG Serious Incident Review Panel in December A Quality Summit was held with LGT and NHS Bexley, Greenwich and Lewisham CCGs in December 2015 to review the process of Discharge Summaries. This has led to a small working group consisting of the GP Clinical Lead for Quality, the Quality and Governance Leads, and the Medical Director at LGT. An audit was undertaken by the GP Clinical Project Leads (CPL) for Quality in two large Greenwich practices to make sure that there is GP input and influence on the future design of the discharge summary template on the icare system (both sites) and in the training for Junior Doctors at LGT. Friends and Family Test At Queen Elizabeth Hospital the response rate for the Friends and Family Test (FFT) has improved throughout the year in most areas. However, there remains a poor response rate in maternity (specifically ante-natal) and the Emergency Department (ED). The FFT is monitored via the CQRGs for maternity and the ED Quality Scorecards. Generally, the response to the FFT at Oxleas has been successful. Oxleas ranks fourth out of ten in London for mental health providers and second out of fifteen for community services providers. NHS England made FFT a requirement in GP contracts from 1 December Greenwich CCG supported practices by purchasing an electronic solution to gain patient feedback. The utilisation of FFT in Greenwich is high, and we will be able to bench mark results during the next financial year. Patient Safety We have been working to continually improve Pressure Ulcer Management through Pressure Ulcer Working Groups with both Oxleas NHS FT and LGT. There has been one Never Event reported in the last year at LGT (QEH). This was a misplaced naso-gastric tube. High level categories from serious incidents include: o maternity services (unexpected admission to NICU and unplanned admission to ITU); o pressure ulcers: Grade 3 and 4. We have seen an improvement in reporting and are able to ensure that learning takes place, which has reduce reoccurrence. o Apparent, actual or suspected self-inflicted harm e.g. attempted suicide. 30

33 Quality Issues Complaint response rates have been an issue on both hospital sites at LGT during 2015/16. Through rigorous work by the Complaints Teams, this has been improved and LGT have put in place an enhanced management action plan. The action plan focuses on improving systems and processes, team skills and training, team design and structure, skills and training for investigators, data systems, and writing skills of the Divisional officers who are responsible for providing responses. The A&E four hour target presents a continued challenge at Queen Elizabeth Hospital. This has been kept under scrutiny at LGT CQRG via an ED dashboard. Performance on the two week wait and 62 day standard has been a quality issue during 2015/16. This is primarily a performance issue but failure to meet targets puts patient outcomes and experience at risk. We monitor this through the CQRG and we have also established a Cancer Pathway Clinical Review Group. The quality of Serious Incident reports from our providers has been under continual scrutiny and assurances provided in respect to training of staff in Root Cause Analysis (RCA) investigations. In February 2015, BMI Blackheath was inspected by the Care Quality Commission (CQC) and the action plan and aspirations for continuous improvement were presented to the our Quality Committee in July BMI Blackheath has been implementing the action plan and a further site visit took place in January 2016 to ensure the action plan had been implemented and improvement sustained. Safeguarding adults and children We have responsibility for ensuring that the organisations that we commission from provide safe systems for safeguarding children and adults at risk of abuse or neglect. Safeguarding is embedded within the Integrated Governance Directorate along with the quality and patient safety leads for the organisation. A range of Committees, Groups and Sub-Groups are well established within the CCG to support the delivery of the safeguarding objectives and work plans and to facilitate a coordinated approach to safeguarding across the NHS system. The NHS England Accountability and Assurance framework (2015), Working Together to Safeguard Children (2015) and the Care and Support Statutory Guidance (2015) outline the child and adult safeguarding requirements for the CCG and its commissioned services. For adult safeguarding, the start of 2015/16 saw the introduction of the Care Act (2014), which for the first time placed adult safeguarding on a statutory footing. Safeguarding assurance is sought from main providers through a combination of safeguarding indicators collected through dashboards, quality and contract monitoring and relationships with provider safeguarding leads. We are committed to working in close partnership with other agencies both through our statutory roles on the Greenwich Safeguarding Children Board and Greenwich 31

34 Safeguarding Adult Board. As well as through close working with agencies on serious case reviews, safeguarding adult reviews, safeguarding alerts and subsequent case conferences and action plans. Greenwich Safeguarding Children Board published two serious case reviews in 2015/16 and the CCG monitored the health action plans and ensured learning was disseminated across all provider services. In late 2015, the CCG participated in a deep dive review of adult and child safeguarding undertaken by NHS England (London). Overall the CCG received good assurance across most areas, with some areas for development which have been built into respective adult and child safeguarding work plans. Similarly a separate KPMG audit of adult safeguarding within the CCG resulted in an overall rating of significant assurance with minor improvement opportunities. Both reviews highlighted safeguarding assurance from smaller providers and training oversight as areas for further improvement. Medicine s security The core function of the CCG is to ensure there is safe and effective use of medicines for the benefit of patients treated within the CCG. Our Medicines Policy is an overarching corporate policy that facilitates us to establish the principles for medicines security and provides assurance to the organisation by assisting the users to implement the statutory requirements and guidance issued by various official bodies including Department of Health, NICE and professional bodies. Patients and clinicians such as GPs, non-medical prescribers and other providers are also supported in addition to the Medicines Policy with other policies, pathways and protocols published by the CCG. These include: Controlled Drugs Policy: assurance is provided by regular monitoring of controlled drug prescribing, support in incident reviews and policy implementation. It therefore provides affirmation of adherence to Misuse of Drugs Act 1971, Schedule 1 to 5. Repeat Prescribing Policy: assurance is provided by offering training to clinical and non-clinical staff to prevent errors, minimise wastage, improve access to medicines and work within the sphere of medico-legal implications of prescribing medicines. Prescribing Policy for People Intending to Travel Abroad and Private Patients: assurance is provided to ensure NHS resources are adequately utilised and patient care and clinician s role is not compromised Interface Prescribing Policy : assurance is provided by ensuring providers adhere to the guidance contained within the following circulars and supporting documents: o EL(91)127 Responsibility for prescribing between hospitals and GPs o EL(94)72 Purchasing and Prescribing o EL(95)5 Purchasing high-tech health care for patients at home o Development of the RED list (hospital only medicine list for South East London CCGs) o Development of transfer of care and shared care documents 32

35 Excessive and inappropriate prescribing Policy: assurance is provided by ensuring prescribers are following the professional guidance on standards of practice as stipulated in the General Medical Council, Good Medical Practice (2013) We also endeavour to uphold medicines security by regular communication via: o Prescribing Newsletters o Quarterly prescribing reports o Reports on unlicensed medicines o CCG Medicines Management website page Medicines Management We encourage and support clinicians to only prescribe drugs in line with the Human Medicines Regulations 2012 (SI 2012/1916), which came into force on 14 August The regulations are the result of the MHRA s consolidation and review of UK medicines legislation. The Medicines Policy is also updated to reflect changes to NHS organisational structures in England, as a result of the Health and Social Care Act We aspire to reduce clinical variability and improve equitable access by adopting the South East London Treatment Access Policy including the Individual Funding Requests by: o transparency in approvals for treatments and procedures for which restricted access criteria have been agreed o individual funding requests are assessed and approved with the clearly defined and co-ordinated approach to ensure that the resources are used in an equitable and effective way and that clear, consistent and fair procedures are in place. These are based on the principles of cost effectiveness as stipulated in the IFR policy Patient engagement We aim to engage a wide range of patient forums to seek patient views in order to develop and co-ordinate medicines strategies that reflect local priorities. Clinical Effectiveness We have been working hard during 2015/16 to utilise soft intelligence, encourage a culture of openness and transparency, and ensure shared learning across organisations. We have successfully established a quality alert system; we are developing this further with neighbouring CCGs into a web-based Quality Alert Management System (QAMs). Quality alerts are part of an Early Warning System which triggers a focus on key themes that arise. We have also developed a Provider Assurance Management System (PAMs). We have piloted this with some of our local care homes but it also has the potential to be 33

36 extended further to be used with any small provider. Both systems have been fully established during 2015/16. Members of our team continue to attend site visits as appropriate to get a first-hand view of the quality of care and gain additional assurance of patient safety. We monitor the quality of care at our local A&E and this is systematically reported through an ED dashboard at the Clinical Quality Review Groups (CQRGs). Our providers develop clinical effectiveness through: Aligning to the three quality domain areas of patient experience, patient safety and clinical effectiveness to the Quality Account priorities, and linked to the National Outcomes Framework five domains. Linking quality plans and strategies to national and local priorities. quality improvement and innovation goals being agreed with commissioners in line with contracts Setting out nursing strategies of both trusts to improve clinical effectiveness and outcomes. Opportunities for staff to engage in sharing best practice and contribute to further development in models of care. Opportunities for staff to participate in research and clinical audit. The CQRGs receive regular reports for clinical audit and assurance of compliance with NICE Guidance. These provide assurance to commissioners of the safety and clinical effectiveness of services. Integrated Governance Scorecards have been developed that include clinical effectiveness and key performance indicators linked to this. 34

37 Patient and public involvement As a CCG we recognise the importance of shaping and designing local services with the active involvement of local people and patients. We know that excellent engagement will help us to better understand our communities and how we can best develop and support resilience and respond to needs. We hold Governing Body meetings in public and before each of these we have a public forum where we extend an open invitation to local people to start a discussion with us on any matter. All Governing Body agendas and papers are published on the CCG website. Our strategic partners, Healthwatch Greenwich, are co-opted members and we have an engagement champion and a lay member on the Governing Body with responsibilities for patient and public involvement. Our Patient Participation Group (PRG) is a dedicated committee to oversee delivery of our engagement strategy. We also use existing networks, channels and groups as forums for discussion and to advise us on our plans. We have strong links with Healthwatch Greenwich and with a number of patient groups. In the last year we were concerned that Patient Participation Groups (PPG) in Greenwich are not all working as effectively as they could. As PPGs are a mandatory element of the GP contract, Greenwich CCG commissioned Picker Institute to carry out a research to identify ways in which practices and groups could be supported to both meet the contractual requirements and to work effectively to make improvements to patients experiences of their GP surgery. We have agreed an action plan to develop the PPGs into effective groups. The Patient Reference Group (PRG) is planning a summit in June 2016 to develop strategies on how to support and guide the PPGs and ensure that they are genuinely effective, offering real benefit to practices. We produce regular briefings for MPs and councillors and reports to the local authority Scrutiny Committee. The Greenwich Scrutiny Committee examines the planning and delivery of health and social care services and reviews matters relating to the health and wellbeing of local people. The remit covers both NHS and council services including provision at local hospitals and in the community, mental health services, social care and public health issues. We gather information on patient satisfaction from a wide range of sources including national and local survey programmes as well as through our quality and complaints monitoring systems. Quality and contract meetings with our providers provide opportunities to discuss issues in detail, identifying trends and assuring ourselves that the experience of our patients is being used to drive quality improvements. One example of how we have worked with the public is that we commissioned a series of engagement events with Citizen UK and Greenwich Action for Voluntary Service (GAVS). The rich information gathered through these events has informed the CCG s consideration of its commissioning intentions. 35

38 Clinical Engagement As a membership organisation, it is important that we get views from our GP members on commissioning decisions and proposals. The CCG carried out regular surveys during on a number of issues. In August 2015 we carried out Our Healthier South East London (OHSEL) Survey. 38 out of 41 practices responded, giving a response rate of 93% and providing 2,940 responses to be analysed. From the responses we identified key themes and responses, which were grouped into: what is working well that we could build on what is not working so well what changes can we make. The analysis from these responses were shared with key commissioners and Chairs of our commissioning groups to help inform service re-design as well as our GP Commissioning Project Leads (CPLs) CPLs are appointed by interview to support a number of service areas by providing clinical expertise to commissioning staff. This is achieved by working closely with the commissioning team when re-designing services and attending service meetings. CPLs also provide a forum to advise the GP Executive on decisions required within our Operating Plan. A number of CPLs were heavily engaged in the service specification for Long Term Conditions and the alliance work which took place with Lewisham and Greenwich NHS Trust and Oxleas NHS Foundation Trust. Service Areas covered by Clinical Project Leads Planned Care Urgent Care Cancer & End of Life Co-ordinated Care Children & Mental Health Medicine Management Primary Care Maternity Health and Wellbeing Independent Funding Requests Education/Learning Alliance Long Term Conditions Quality IT & Business Intelligence Examples of Patient and Public Engagement (PPE) work We have been supporting the coordination of the Makesafe Campaign, which was launched in April This national initiative is a result of the Rotherham Enquiry. Locally it is being led by the Metropolitan Police through the Greenwich Safeguarding Children s Board and aims to raise awareness locally about the risks of child sexual exploitation. We have also been supporting Mosaic, the Metropolitan Police Service led community engagement forum. The forum provides a series of events that reach out to the public through faith leaders. This has provided health with the opportunity to raise awareness 36

39 on a variety of safeguarding subjects, including female genital mutilation, neglect, local gang activity We also expect our providers to engage with their patients to improve and develop services. Oxleas NHS FT generally receive a good level of response to their various patient experience methodologies. Response rates on the Oxleas 6 must ask questions are increasing; the six questions focus on information about care and treatment, involvement in decisions about care and treatment, being treated with dignity and respect, family and carer support, and the Quality of Life improvement as a result of care. 37

40 Working together: Our Healthier South East London Our Healthier South East London (OHSEL) is a five year commissioning strategy that aims to improve health, reduce health inequalities and ensure all health services in south east London meet safety and quality standards consistently and are sustainable in the longer term. The strategy aligns to the recommendations in the Five Year Forward View, a document published by NHS England in June The way health services are delivered needs to change in order to meet the emerging needs of an ageing population in which many more people live with long term conditions. This means that more resources must be directed towards services based in the community, keeping people out of hospital unless they really need to be there. All six CCGs in south east London (Bexley, Bromley, Greenwich, Lambeth, Lewisham and Southwark) are involved in the programme alongside NHS England. Commissioners are working in partnership with local councils, hospitals, community services, mental health services, patients, carers and local people. The strategy is commissioner-led and clinically-driven. All six CCGs have already made progress on improving care outside hospital in their boroughs, and the strategy aims to build on that by focusing on collective action where there is added value from working together. In Greenwich, our 4 GP Syndicates became 4 Limited Liability Partnerships which follows the GP network (federation) model (see map below), as advocated in the OHSEL strategy. The Strategy has a key focus on scaling up primary care and getting GP practices to work together to deliver more care outside of hospital. We also continued to build on our work as a Pioneer Site for Integrated Care following a full and detailed evaluation report in May 2015 on the Greenwich Co-ordinated Care Test and Learn pilot. The pilot focused on setting up care navigation and holistic multidisciplinary care planning for complex adult patients registered with GPs in two of our syndicates. The evaluation identified very high levels of patient satisfaction and the break down of barriers between health, social care, voluntary and other public sector services. During 2015/16 the focus changed to using this care planning approach for patients who are frequent attenders at A&E. There has been good progress on the strategy during 2015/16. We published an Issues Paper to outline the challenges facing health and social care services in south east London, and our ideas for addressing them in our Emerging models and further thinking paper. 38

41 Map of GP Practices showing GP networks An early phase of early engagement has been carried out on our ideas for improving health and care services involving over 3,000 people, with direct feedback from more than 1,700. Members of the public and Healthwatch have been supported to be equals in the design of new models of care alongside clinicians, care professionals and commissioners. Equalities analyses have been informing the development of these models and our engagement approach is being externally assured by independent consultation and public engagement experts The Consultation Institute. In June 2015, events were held in all six boroughs with over 440 randomly selected members of the public. Feedback from these events was extremely valuable and uncovered a range of themes on how people want healthcare services to work for them, which we have used to refine our strategy. We continue to place patients at the heart of our plans and held the first meeting of our Planned Care Reference Group in January This group of voluntary and community sector representatives and patient voices was specifically formed to increase the involvement of people that could be most impacted by any potential changes to elective orthopaedic services through our strategy, as we are considering consolidating planned inpatient orthopaedic services to improve quality and access. In December 2015, NHS planning guidance was published which set out the requirement for the local NHS to produce a place-based whole system plan, known as a Sustainability and Transformation Plan (STP). It has been agreed south east London will produce a single STP plan, which OHSEL will feed in to. The six local authorities have formed a Joint health Overview and Scrutiny Committee (JHOSC) to scrutinise our proposals and decision-making processes. If any of our ideas 39

42 lead to a significant service change being required then a formal public consultation would be carried out. We expect to know if this is necessary later in Further information on the strategy, including a plain English summary, the Case for Change, You Said We Did documents and updates are available at 40

43 Equality and diversity NHS Greenwich Clinical Commissioning Group (CCG) has a number of equality, human rights and health inequalities duties to comply with. This report sets out our progress to assure ourselves that we are not only compliant with these duties, but also our commitment to an inclusive NHS for all people in Greenwich. We are committed to an inclusive NHS that provides quality and compassionate care for all Greenwich people. Our commissioning intentions are based on the human rights principles of Fairness, Respect, Equality, Dignity and Autonomy (the FREDA Principles). In this respect, protecting and enhancing human rights, promoting equality and diversity are integral to the CCG s core business and reflected throughout everything that we do. We are required to comply with the following duties in relation to commissioning intentions, strategies, service redesign, decommissioning, policy and procedures: 1. The Equality Act 2010 (the nine protected characteristics) 2. The Public Sector Equality Duty (PSED) 3. The Human Rights Act The Health and Social Care Act 2012 (duty on health inequalities) 5. The NHS Constitution (rights and pledges) 6. Equality Delivery System (EDS2) 7. Workforce Race Equality Standard (WRES) Our constitution stipulates that the organisation will work towards meeting the public sector equality duties and reducing health inequalities. The Governing Body members are responsible for ensuring compliance with the Public Sector Equality Duty (PSED), to enable our delivery of equality outcomes as a commissioner and an employer. It provides strategic leadership to the equality and diversity agenda, which is in part achieved by establishing and embedding the Equality and Diversity Strategy, and agreeing the organisation s objectives for improving its equality performance. We lead by example: we actively champion the equality and diversity agenda, we attend staff forums and meetings of patient and community groups, and we make sure that equality is a core consideration in our Governing Body discussions and decisions We have a Lay Member who has been appointed to lead on patient and public engagement and this Lay Member has oversight responsibility for ensuring that the voice of the local population is heard in all aspects of the CCG s business, and that equal opportunities are created and protected for patient and public engagement. Our Communities It is essential that we know our local population in Greenwich; they are a major source of evidence for decision-making and ensure that equality and diversity intelligence inform our decisions. The overarching operational plan has been derived from key strategies. These include a joint health and wellbeing strategy, which identifies three key imperatives: a focus on prevention as the most cost effective approach to health and wellbeing the need for new approaches to tackling health inequalities 41

44 greater integration in the commissioning and delivery of local services. Additionally the Borough s joint strategic needs assessment (JSNA), which together forms our integrated plan that sets out our priorities and associated commissioning intentions. These documents have therefore been used as a major source of data when setting and aligning our equality objectives. Meeting the Public Sector Equality Duties (PSED) in 2015/16 The challenges to make NHS services inclusive and fit for purpose for Greenwich s diverse population cannot be underestimated, particularly under the present financial constraints on health and social care expenditure. In this respect, the our focus for 2015/16 was to consolidate on our equality, human rights and health inequalities work. Protecting human rights and promoting inclusion are integral to our core business and reflected throughout everything that we do. The Equality Act 2010 provides a legal framework to strengthen and advance equality and human rights. The Act consists of general and specific duties. The general duty requires public bodies to show due regard to: Eliminate unlawful discrimination Advance equality of opportunity Foster good relations. We must comply with this general duty when exercising a function, when formulating policy and to any decisions made in applying policy in individual cases. Compliance with the duty should result in: 1. Better-informed decision-making and policy development 2. A clearer understanding of the needs of service users, resulting in better quality services which meet varied needs 3. More effective targeting of policy, resources and the use of regulatory powers 4. Better results and greater confidence in, and satisfaction with, public services 5. A more effective use of talent in the workforce 6. A reduction in instances of discrimination. Public Sector Equality Duties (PSED) The PSED consists of both general and specific duties. The broad aim of the general equality duty is to integrate consideration of the advancement of equality into the day-today business of all bodies subject to the duty. The general equality duty is intended to accelerate progress towards equality for all, by placing a responsibility on bodies subject to the duty to consider how they can work to tackle systemic discrimination and disadvantage affecting people with particular protected characteristics. The first aim of the general equality duty is to have due regard to the need to eliminate discrimination, harassment, victimisation and any other conduct prohibited by the Act because of any of these protected characteristics. Race Disability Sex (male/female) 42

45 Age Religion or belief Sexual orientation Gender reassignment Marriage and civil partnership Pregnancy and maternity As part of the Public Sector Equality Duty (PSED) of the Equality Act 2010, we have developed equality objectives for 2012/2016. The purpose of setting objectives is to strengthen our performance against this general equality duty. The development of the equality objectives has been aligned to the business of the organisation and aligned with the Equality Delivery System goals and outcomes. To meet our specific duties, we are required to publish relevant, proportionate information showing how we meet the PSED by 31 January each year, and set specific measurable equality objectives by 6 April every four years. The purpose of setting objectives is to strengthen our performance of the general equality duty. The second aim of the duty requires the CCG to have due regard to the need to minimise or remove disadvantages, to take steps to meet the different needs of people with different protected characteristics, and to encourage participation in activities by those whose participation is disproportionately low. We have used the PSED as part of the process of decision-making in the following areas: Service delivery - evidence of any equality impact analysis undertaken Information - details of information taken into account when assessing impact Consultation - details of engagement activity that has taken place. Equality Objectives 2012/16 The challenges to make NHS services inclusive and fit for purpose for Greenwich s diverse population cannot be underestimated, particularly under the present financial constraints on health and social care expenditure. The equality objectives, therefore, are locally not nationally driven, to reflect local equality priorities for the community. Our four year equality objectives were chosen as part of the authorisation process in They reflect the key equality priorities pertinent at that time. Under the Public Sector Equality Duty (PSED) of the Equality Act 2010, we have developed Equality Objectives for 2012/2016. The purpose of setting objectives is to strengthen our performance against the general equality duty. The development of the equality objectives has been aligned to the business of the organisation and aligned with the Equality Delivery System goals and outcomes. Our most recent equality objectives report can be found on our website. The Equality Delivery System (EDS2) We have also implemented the Equality Delivery System (EDS2), which is the NHS equalities reporting framework. EDS2 will help us to identify what we are doing well, what we need to improve on, and the equality gaps/risks that we need close or mitigate. It is a comprehensive analysis focusing on four goals (better health outcomes, improved patient 43

46 access and experience, a representative and supported workforce, and inclusive leadership) measured against eighteen equality and health inequalities outcomes. Like most other CCG s, we have taken a two-stage approach to implement EDS2. During Stage One, we have self-assessed our RAG rating on the progress made against EDS2 s four Goals and 18 Outcomes. A draft of our stage one self-assessment report, includes what evidence exists to support the RAG rating, equality gaps and actions that may need to be taken to ensure that we are heading in the right direction. Stage two involves working with local organisations, including Healthwatch, to develop a methodology e.g. focus groups and engagement events, to take critical feedback on our self-assessed RAG rating with the aim of publishing an agreed EDS2 RAG rating later in the year. Our work on stage two is on-going, and an updated progress report will be brought to the quality and safety steering group later in Introducing the EDS2 to our key stakeholders means that we will have in place a partnership approach that will enable a monitoring and evaluating process for our staff and key stakeholder user groups. The EDS2 Scores are based on parameters such as the level of engagement being undertaken across different protected groups, whether the issue has been mainstreamed and whether progress plans are in place. The relevant EDS2 outcomes have been aligned to the CCG s relevant equality objectives. Full details of these can be found at Us/Documents/Equality%20Objectives.pdf along with our Equality Objectives Action Plan, EDS2 Self-Assessment and detailed evidence of how NHS Greenwich CCG are meeting it Public Sector Equality Duty (PSED). The NHS Greenwich CCG full Equality Report can be found on the CCG website. 44

47 Emergency preparedness and resilience (EPRR) Along with other CCGs, we were required to submit our EPRR Assurance to NHS England in September Once reviewed, feedback was given to all of the CCGs in south east London that: Significant progress has been made over the past twelve months in many organisations There is an obvious and significant commitment by the South CCG s to EPRR. Following this review, we were rated as having Full Compliance, which provides assurance that the plans and work programme in place appropriately address all of the core standards for EPRR that we are expected to achieve. The CCG action plan submitted has three outstanding actions for areas rated Amber: Core standard Outstanding Action to Timeframe for Lead 1. Organisations have undertaken a pandemic influenza exercise or have one planned in the next six months: 2. Arrangements include an ongoing exercising programme that includes and exercising needs analysis and inform future work. 3. Organisations have an annual work programme to mitigate against identified risks and incorporate the lessons identified relating to EPRR (including details of training and exercises and past incidents) and improve response. be taken NHS Greenwich has participated in a SEL CCG Pandemic Flu Exercise (12 th Oct 2015) hosted by NHSE. NHS Greenwich CCG will be undertaking a local exercise with partners by end March The CCG has arrangements in place detailed in the BC Plan for training and exercising the plan. An annual table top exercise will be conducted in line with ISO22301 requirements. There will be a 6 monthly call cascade communications test. Review EPRR plan to include scoring/priorities as suggested. completion End March 2016 End March monthly call cascade End March 2016 End Sept 2016 Diane Jones Diane Jones 29 February 2016 EPLO Diane Jones 45

48 Exercises and training Our staff undertook a range of training and exercise initiatives to support EPPR during Autumn Date Exercise Attended by: 12 October 2015 Exercise Corvus Pandemic Flu Exercise Diane Jones Maggie Aiken (NHSE led) Autumn 2015 DOC training and Simon Hall Diane Jones Sam Jones Autumn 2015 Loggist Training Carol Berry 12 November 2015 Marauding Terrorist Attack Maggie Aiken (RBG led ) 18 November 2015 Strategic Leadership In A Crisis (NHSE led) Diane Jones Maggie Aiken Signed on behalf of the Board Annabel Burn Accountable Officer 23 May

49 SECTION 2: ACCOUNTABILITY REPORT 47

50 Member s report Our members These are the member practices which form the membership body of the CCG: Abbeywood Surgery Alderwood Surgery All Saints Medical Centre Bannockburn Surgery Basildon Road Surgery Blackheath Standard Surgery Briset Corner Surgery Burney Street Practice Clover Health Centre Conway PMS Dr Guram Dr M Baksh The Coldharbour Surgery Dr Mostafa PMS Dr S Ratneswaren Coldharbour Surgery Eltham Medical Practice Eltham Palace Surgery Eltham Park Surgery Ferryview Health Centre Gallions Reach Health Centre Glyndon Medical Centre Greenwich Peninsula Practice Henley Cross Medical Practice Manor Brook Medical Centre New Eltham Medical Practice Plumbridge Medical Centre Plumstead Health Centre Royal Arsenal PMS Sherard Road Medical Centre South St Medical Centre St Marks Medical Centre Tewson Road PMS Thamesmead NHS Health Centre The Fairfield Centre The Mound Medical Centre The Slade Surgery The Trinity Medical Centre The Waverley Practice Triveni PMS Vanbrugh Group Practice Westmount Surgery Woodland Surgery Practices are formed in four syndicates: Blackheath and Charlton, Eltham, Excel and Network. Each syndicate covers a geographical area and practices within the syndicate are encouraged to work together through peer review and regular meetings The table below demonstrates the growth in GP list sizes. This growth is expected to increase as the local re-generation programme that is in place across the Royal Borough of Greenwich progresses. New housing and businesses are being created and this will put an additional strain on primary care services. The Our Healthier South East London strategy is looking to be the solution for managing this growth through up-scaling primary care services by putting more investment into general practice. Each practice is signed up to the CCG s constitution. The Constitution states how member practices should be engaged through regular meetings with the GP Executive (Greenwich-wide forum meetings that take place quarterly) and the appointment of four GP Syndicate Leads who are voted in by the members of their syndicate. Syndicate 48

51 Leads are the conduit between the CCG and its membership body to deliver messages and get feedback. Syndicate meetings are held bi-monthly in line with the constitution and Syndicate Leads meet monthly with the GP Executive. An example of member engagement was the decision by the membership not to take on full delegated responsibility for co-commissioning during 2015/16 but to wait until the final deadline of April 2017 Co-commissioning is where the CCG takes back the responsibility from NHS England for managing GP contracts. Executive Committee The Executive Committee consists of the GP executive (elected Governing Body members) and the CCG senior management team and is made up of the following staff: Name Eugenia Lee (until 1 August 2015) Sylvia Nyame (From 1 August 2015) Nayan Patel Ranil Perera Rebecca Rosen (until 1 August 2015) Sabah Salman (from 1 August 2015) Krishna Subbarayan Hany Wahba Ellen Wright Annabel Burn Role GP elected member GP elected member GP elected member GP elected member GP elected member GP elected member GP elected member GP elected member GP elected member (Chair) Chief Officer 49

52 Name Role Chris Costa (until 30 November 2015) Chief Finance Officer Ian Fisher (Interim) from 1 December 2015 Chief Finance Officer Simon Hall Deputy Chief Officer / Director of Strategy & Performance Samantha Jones (until 31 March 2016) Director of Delivery & Gina Shakespeare (Interim) from 3 February 2016 Nicola Moore (until 29 May 2015) Diane Jones from 24 August 2015 Service Transformation Turnaround Director and interim Director of Delivery & Service Transformation Director of Integrated Governance Director of Integrated Governance Governing Body The Governing Body oversees the delivery of the CCG s commissioning plan, sets and leads the strategy for the CCG, and is accountable for the delivery of Greenwich CCG s functions as a statutory body. It monitors performance against objectives, provides effective financial stewardship and makes sure that high standards of corporate governance are achieved. Having GPs and other clinical members of the Governing Body ensures that the patient is at the forefront of all decision-making. The Governing Body meets on alternate months in public; the papers and the minutes of the meetings are published on our website. All meetings have declarations of interests as an agenda item and these are recorded. All members are required to record annually any interests relevant to their role on the Governing Body. The register of interests is a public document which is open to public scrutiny and published on our website. The composition of the Governing Body (including advisory and non-exec members) is as follows: NAME Maggie Buckell Annabel Burn Chris Costa (until ) Ian Fisher (from ) Councillor Position Registered Nurse on the NHS Greenwich CCG Governing Body Chief Officer, NHS Greenwich Clinical Commissioning Group Chief Financial Officer, NHS Greenwich Clinical Commissioning Group Interim Chief Financial Officer, NHS Greenwich Clinical Commissioning Group Local Authority Member on the NHS Greenwich CCG Governing 50

53 NAME David Gardner Simon Hall Diane Jones (from ) Samantha Jones (until ) Position Body Deputy Chief Officer and Director of Strategy and Performance, NHS Greenwich Clinical Commissioning Group Director of Integrated Governance, NHS Greenwich Clinical Commissioning Group Director of Delivery and Service Transformation, NHS Greenwich Clinical Commissioning Group Dr Eugenia Lee GP Member of the NHS Greenwich CCG Governing Body (until ) Nicola Moore Director of Integrated Governance, (until ) NHS Greenwich Clinical Commissioning Group Dr Sylvia Nyame GP Member of the NHS Greenwich CCG Governing Body (from ) Dr Nayan Patel GP Member of the NHS Greenwich CCG Governing Body Dr Ranil Perera GP Member of the NHS Greenwich CCG Governing Body Dr Rebecca GP Member of the NHS Greenwich CCG Governing Body Rosen (until ) Dr Sabah Salman GP Member on the NHS Greenwich CCG Governing Body (from ) Regina Interim Turnaround Director and Acting Director of Shakespeare Commissioning, NHS Greenwich CCG (from ) Dr Krishna GP Member on the NHS Greenwich CCG Governing Body Subbarayan Dr Greg Ussher Lay Member on the NHS Greenwich CCG Governing Body Dr Iyngaran Secondary Care doctor on the NHS Greenwich CCG Governing Vanniasegarum Body Dr Hany Wahba GP Member of the NHS Greenwich CCG Governing Body Steve Whiteman Director of Public Health, Royal Borough of Greenwich Public Health & Wellbeing and Member of the NHS Greenwich CCG Governing Body. Jim Wintour Dr Ellen Wright Lay Member on the NHS Greenwich CCG Governing Body Chair and GP member of the NHS Greenwich CCG Governing Body 51

54 Governing Body members attendance at Governing Body meetings 2015/ E 27.5 P P 23.9 P 30.9 AGM P P % Attendance Maggie Buckell Y Y N Y N Y Y 5/7 71% Annabel Burn Y Y Y Y Y Y Y 7/7 100% Ian Fisher (from ) Y 1/1 100% Councillor David Gardner N Y Y Y Y Y Y 6/7 86% Simon Hall Y Y Y Y Y Y Y 7/7 100% Diane Jones (from Y Y Y Y 4/4 100% ) Samantha Jones Y Y Y Y N Y Y 6/7 85% Dr Sylvia Nyame (from Y Y Y Y 4/4 100% ) Dr Nayan Patel N N Y Y Y N 3/6 50% Dr Ranil Perera Y N N Y N Y N 3/7 42% Dr Sabah Salman (from Y Y Y Y 4/4 100% ) Dr Krishna Subbarayan Y Y Y Y Y Y N 6/7 85% Dr Greg Ussher N Y Y N Y Y Y 5/7 72% Dr Iyngaran Y Y Y Y Y Y Y 7/7 100% Vanniasegarum Dr Hany Wahba Y Y N Y Y Y 5/6 83% Steve Whiteman Y Y Y Y Y Y Y 7/7 100% Jim Wintour N Y Y Y Y Y Y 6/7 85% Dr Ellen Wright Y Y Y Y N Y Y 6/7 85% Syndicate leads Dr Georgina Deighton Y 1/1 100% Dr Sajiv Gupta - Dr Jaisun N 0/1 0% Vivakanandaraja De Esme Peters - Standing Order states that Members must attend at least 75% of meetings of the Governing Body. Key: E = Extraordinary Meeting P = Public Meeting, attend the meeting. = Not required to 52

55 Statement on disclosure to auditors The Governing Body is not aware of any relevant audit information that has been withheld from the clinical commissioning group s external auditors, and members of the Governing Body have taken all necessary steps to make themselves aware of relevant information and to ensure that this is passed to the external auditors where appropriate Our audit committee The Audit Committee is established in accordance with our constitution. The terms of reference set out the membership, remit, responsibilities and reporting arrangements of the Committee. Members of the Committee are appointed by the Board. The Committee comprises four members of the Governing Body, with four Governing Body members in attendance as shown below; Name Jim Wintour Maggie Buckell Dr Iyngaran Vanniasegarum Dr Greg Ussher Annabel Burn Ian Fisher Diane Jones Dr Ellen Wright Role Lay Member (Chair), Member Registered Nurse, Member Secondary Care doctor, Member Lay Member on the NHS Greenwich CCG Governing Body Chief Officer, In attendance Chief Finance Officer, In attendance Director of Integrated Governance GP member and chair, In attendance 53

56 Statement of Accountable Officer s Responsibilities The National Health Service Act 2006 (as amended) states that each Clinical Commissioning Group shall have an Accountable Officer and that Officer shall be appointed by the NHS Commissioning Board (NHS England). NHS England has appointed the Chief Officer to be the Accountable Officer of Greenwich Clinical Commissioning Group. The responsibilities of an Accountable Officer, including responsibilities for the propriety and regularity of the public finances for which the Accountable Officer is answerable, for keeping proper accounting records (which disclose with reasonable accuracy at any time the financial position of the Clinical Commissioning Group and enable them to ensure that the accounts comply with the requirements of the Accounts Direction) and for safeguarding the Clinical Commissioning Group s assets (and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities), are set out in the Clinical Commissioning Group Accountable Officer Appointment Letter. Under the National Health Service Act 2006 (as amended), NHS England has directed each Clinical Commissioning Group to prepare for each financial year financial statements in the form and on the basis set out in the Accounts Direction. The financial statements are prepared on an accruals basis and must give a true and fair view of the state of affairs of the Clinical Commissioning Group and of its net expenditure, changes in taxpayers equity and cash flows for the financial year. In preparing the financial statements, the Accountable Officer is required to comply with the requirements of the Manual for Accounts issued by the Department of Health and in particular to: Observe the Accounts Direction issued by NHS England, including the relevant accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis; Make judgements and estimates on a reasonable basis; State whether applicable accounting standards as set out in the Manual for Accounts issued by the Department of Health have been followed, and disclose and explain any material departures in the financial statements; and, Prepare the financial statements on a going concern basis. To the best of my knowledge and belief, I have properly discharged the responsibilities set out in my Clinical Commissioning Group Accountable Officer Appointment Letter. I also confirm that: as far as I am aware, there is no relevant audit information of which the entity s auditors are unaware, and that as Accountable Officer, I have taken all the steps that I ought to have taken to make himself or herself aware of any relevant audit information and to establish that the entity s auditors are aware of that information. 54

57 that the annual report and accounts as a whole is fair, balanced and understandable and that I take personal responsibility for the annual report and accounts and the judgments required for determining that it is fair, balanced and understandable Annabel Burn Chief Officer, NHS Greenwich CCG 23 May

58 Annual Governance Statement Introduction & Context The clinical commissioning group was licenced from 1 April 2013 under provisions enacted in the Health & Social Care Act 2012, which amended the National Health Service Act As at 1 April 2014, the clinical commissioning group was licensed without conditions. 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. 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. Governance Framework The National Health Service Act 2006 (as amended), at paragraph 14L(2)(b) states: The main function of the governing body is to ensure that the group has made appropriate arrangements for ensuring that it complies with such generally accepted principles of good governance as are relevant to it. Greenwich CCG is responsible for the procurement of services on behalf of the residents of Greenwich. We are responsible for creating suitable arrangements with providers of services that are in the best interests of the service users, and also represent value for money. Considering the complexity and range of services offered it is vital that we have a governance structure with sufficient delegation to ensure that decisions can be made but also sufficient oversight to prevent any deviation from the statutes of the constitution. Greenwich CCG is accountable for exercising its statutory functions. It may delegate authority to act on its behalf to: 56

59 any of its members; the Governing Body; employees; any committees or sub-committees established by Greenwich CCG for the purpose of exercising its statutory functions. The extent of the authority of the respective bodies and individuals depends on the powers delegated to them by Greenwich CCG as expressed through: 1. its Scheme of Reservation and Delegation ; and 2. for committees, their terms of reference. The Scheme of Reservation and Delegation sets out: 1. those decisions that are reserved for the membership as a whole; 2. those decisions that are the responsibilities of the Governing Body (and its committees), and sub-committees, individual members and employees. However, Greenwich CCG remains accountable for all of its functions, including those that it has delegated. Greenwich CCG has a robust corporate governance structure with the roles and responsibilities of the members of the Governing Body and supporting committees clearly set out. Greenwich CCG uses a number of committees to provide challenge and assurance over specific areas, for example QIPP delivery through the Finance, Performance and QIPP Committee. All committees have been formed with a membership that provides a sufficient range of skills, including clinical expertise and lay membership, to provide effective management and oversight. The Committees are referenced within the NHS Greenwich CCG Constitution, including new joint arrangements that have been approved by the Governing Body such as the SEL Committee in Common and the Primary Care Joint Commissioning Committee as illustrated below in Table 1. 57

60 Greenwich CCG Governance Framework The performance of the Governing Body includes development workshops held throughout the year with external facilitation. All GP Governing Body members and the Chief Officer have a review halfway through the year, and an appraisal at the end of the year with the Chair of the CCG. Governing Body officers i.e. the Chief Finance Officer, and all Directors have an appraisal with the Chief Officer. GP Syndicate leads and Clinical Project Leads (CPLs) meet with their GP executive through a formal clinically-led meeting to review performance as well as for support and guidance outside of the meeting, e.g. to develop and lead on QIPP programmes. The CCG 360 stakeholder survey was undertaken in February Audit committee highlights During 2015/16 the Audit Committee has: Approved the annual internal audit plan with KPMG to assure the Audit Committee and Governing Body that Greenwich CCG is operating effectively and productively and to monitor any actions arising from the audits Monitored and reviewed financial and other risks and associated controls, corporate governance and financial assurance. Approved the Greenwich Charitable Funds Annual Report. 58

61 Ratified a new policy on Data Protection to be used as the first point of reference for staff. Started the review of the CCG s financial control as requested by the Chief Financial Officer at NHS England using the self-assessment template and taking account of Audit, FPQ, Internal Audit and External Audit. Quality Committee highlights During 2015/16 the Quality Committee has: Refreshed the design of The Quality Report to the Governing Body. Implemented QAMs (Quality Alert Management System) and PAMs (Provider Assurance Monitoring System) assurance systems. Maintained good oversight of provider quality, including Small Providers, OOH and UCC. Introduced a programme of site visits by the Quality Team through an agreed protocol for Quality Monitoring Visits. Monitored HCAIs and undertaken active work with local practices to ensure effective management of C.Difficile. Led the management of the Oxleas NHS FT CQRG and developed an annual work programme for the CQRG across Bexley, Bromley & Greenwich CCGs. Co-ordinated the CCG participating in the Sign Up to Safety national initiative which pledges the organisations commitment to strengthen patient safety and support our key providers in their delivery of their Safety Improvement Plans. Oxleas NHS FT and NHS Lewisham and Greenwich Trust are part of this initiative. NHS England conducted a deep dive review of safeguarding in October 2015 in order to obtain full and thorough view of Children s and Adult s safeguarding as part of CCG assurance. The deep dive considered the well led component of assurance as well as the performance component, utilising the Safeguarding Accountability and Assurance Framework. Finance, Performance and QIPP (FPQ) Committee During 2015/16 the Finance, Performance and QIPP committee has: Provided assurance to the Governing Body that affordable and appropriately prioritised budgets were set. Effectively monitored the Finance and QIPP performance throughout 2015/16 and advised on corrective actions where appropriate. Established the QIPP Planning Delivery and Monitoring Group reporting to the Financial Recovery Board for QIPP business plans. Oversaw the procurement of the Out Of Hours service/urgent Care Centre, as well as making decisions concerning procurements, including musculoskeletal (MSK) and children s services. 59

62 Finance Recovery Board (FRB) In order to drive the CCG s financial recovery, we set up a senior board in February 2016 with direct reporting to the Governing Body, as shown in the diagram below. The Finance Recovery Board continues to meet to ensure the QIPP programmes are delivering as well as to implement the financial recovery plan. The financial recovery plan has 4 work streams, which are jointly led by an executive clinical lead and senior manager. They are: a. QIPP delivery b. Organisational capability and capacity c. Operational planning for 2016/17 d. 2016/17 contract resolution within affordable envelopes This Board has a different function to the Finance, Performance and QIPP (FPQ) committee, which seeks assurance and holds the organisation to account. The members of the Governing Body and supporting committees are clearly set out. Our review of committee minutes confirmed that they were operating in accordance with their terms of reference (ToR), with effective review and scrutiny of committee papers and reports. All committees have been formed with a membership that provides a sufficient range of skills, including clinical expertise and lay membership, to provide effective management. The CCG clearly demonstrates its commitment to good governance by including Nolan s Seven Principles of Public Life within the majority of its committee terms of reference. Highlighting areas of good practice The committee structure and individual terms of reference are in line with NHS England guidance. 60

63 The Nolan principles are embedded within the CCGs governance arrangements. The risk register is maintained to a good standard giving adequate details on risks, controls and action plans in place. The Governing Body Assurance Framework (GBAF) comprehensively addresses strategic risks to the organisation. Risk Management Framework The Risk Management Framework sets out the overarching approach to the management of risk in the organisation. The Governing Body is aware of all significant risks and has sufficient information to enable it to make decisions on the implementation of appropriate controls and the allocation of appropriate resources. The Risk Management Framework lays out the definitions, accountabilities and responsibilities of all staff, the risk management process and its governance, including managing risk across organisational boundaries and training. The CCG adopted the Risk Management Framework in July 2013 and it was updated in 2015 to reflect risk management changes in the CCG under the new CCG structure. All directors and managers are required to identify risks specific to their own activities and circumstances. Risks may be identified from a number of sources, both internal and external. No valid risk will be excluded from the register due to its identification source. All staff are encouraged to be risk aware. The Director of Integrated Governance maintains a strategic overview of risk. Zero tolerance risks are clearly identified on the Clinical Commissioning Group s Risk Register and in all reporting. The Governing Board Assurance Framework (GBAF) provides the Governing Body with a clear understanding of the principal risks that may affect the achievement of performance objectives for the financial year and therefore informs the Annual Statement of Internal Control declaration. The GBAF is formally reviewed at every meeting of the Governing Body and Greenwich Executive Group (every month). Control measures are in place to ensure that all of the organisation's obligations under equality, diversity and human rights legislation are complied with. Greenwich CCG has embedded Equality Impact Assessments ( EIA ) within its core business. The QIPP planning, delivery and monitoring group utilises a QIA/EIA assessment tool for business cases. The Risk Strategy outlines the CCG s approach to risk and the manner in which the CCG seeks to prevent, eliminate and control risks and the successful management of the risks that impact most upon the CCG s objectives. We have embedded risk management within all activities of the CCG and we are able to ensure accountability of risk at all levels of the organisation. The purpose of the risk framework is to define and document the CCG s approach to risk and risk management and to: 61

64 Enable the Governing Body to have an overview of the risks it faces, taking into account all aspects of its business Provide assurance to the Governing Body that action is being taken to mitigate risk to acceptable levels Assure the public, patients, practices, partner organisations and staff that the CCG is managing its risks effectively Enable the strategic deployment of resources to meet risk, beyond allocations made if necessary, including financial funding, human resources, capacity and knowledge Enable constant and consistent improvement of healthcare provision and patient experience. Below is the Risk Appetite Statement which was agreed by the Governing Body and is included in the CCG s Risk Management Framework: NHS Greenwich CCG is working toward a mature risk appetite. NHS Greenwich CCG has no appetite for fraud/financial risk and zero tolerance for regulatory breaches. NHS Greenwich CCG has Zero Tolerance for Safeguarding; Workforce; Reputational risk; Information Governance (Data Protection). NHS Greenwich CCG may take considered risks, where the long term benefits outweigh any short-term losses. NHS Greenwich CCG supports well managed risk taking and will ensure that the skills, ability and knowledge are there to support innovation and maximise opportunities to further improve services. The Governing Body commits to review its risk appetite statement on an annual basis Zero tolerance risks are clearly identified on the Clinical Commissioning Group s Risk Register and in all reporting. All Risks are recorded on the Risk Register and clearly identify the responsible director and clinical lead with the levels of risk including any actions that should be taken to mitigate the risks. These are reviewed monthly and discussed at appropriate committees. We also identify and manage risks via internal and external methods such as complaints, claims, serious incidents, audits, patient satisfaction surveys, risk assessments, staff surveys, whistle blowing, new legislation, and reviews from partnership working. By ensuring that all staff are aware of their responsibilities in regard to both governance and health and safety, a substantial amount of progress has been made towards ensuring the ownership of risk by staff and the wider membership of each of the sub committees The CCG is responsible for overseeing the commissioning of healthcare and other services from a wide variety of providers. One of the key purposes of the CCG s risk management process is to ensure that services are commissioned from providers who themselves operate high standards of risk management processes. We place high importance on ensuring there are robust information governance systems and processes in place to help protect patient and corporate information. 62

65 We have established an information governance management framework and have developed information governance processes and procedures in line with the information governance toolkit. We have ensured all staff undertake annual information governance training and have implemented a staff information governance handbook to ensure staff are aware of their information governance roles and responsibilities. There are processes in place for incident reporting and investigation of serious incidents. We have information risk assessments and management procedures and a programme has been established to fully embed an information risk culture throughout the organisation. Public involvement in managing risk We use a variety of patient experience data to understand how different services are performing. Whilst these are individually addressed, we run a quarterly thematic analysis, the results of which are presented to the Greenwich Executive Group and the Quality Committee and are used to inform our commissioning intentions. There are a number of methods used to ensure our public stakeholders are involved in managing any risks that impact on them: Quality Alerts can be raised by GPs and other healthcare professionals on behalf of their patients. Alongside our Quality Alert system, there are many other routes through which the public can make us aware of any concerns. They can raise issues through their GP practice s Patient Participation Group (PPG). All practices have an established patient participation group - PPG. Lay members sit on the Governing Body and a number of committees - through their attendance they are involved in the review of the Risk Register and input into the way in which the organisation mitigates those risks. The Risk Register that details all identified risks and plans for how they will be addressed is published on our public website. Prior to Governing Body meetings held in public, there is a question and answer session where any issues can be raised. All questions are answered at the time, where possible, and then taken away to be answered more fully, if necessary. The feedback is then published on our public website and fed back in person at the next Governing Board meeting. A Patient Reference Group (PRG), that includes representation from Healthwatch, Greenwich Action for Voluntary Service (GAVS), and Citizen UK, has been established to seek assurance and monitor engagement, and to develop, implement and review progress on our patient and public engagement strategy. This group also provides guidance to our commissioners to ensure involvement is embedded into every stage of the commissioning cycle, including identifying risks and their mitigation. 63

66 Public stakeholders inform and service redesign and the issues and concerns they raise are picked up during this process. We have built relationships with our local MPs who are able to raise their constituents issues with us and we have a system in place to respond appropriately. Deterrents to risk arising: Counter Fraud During 2015/16 we commissioned a Counter Fraud Service - the Local Counter Fraud Specialist (LCFS) TIAA. The Local Counter Fraud Specialist (LCFS) TIAA regularly met with the Chief Finance Officer to review the Counter Fraud Plan and discuss cases. The LCFS also presented regular reports to the CCG Audit Committee and also undertook Counter Fraud training to all CCG Staff. Counter fraud policies and services are provided by Internal Audit. Regular updates and alerts are communicated to all staff. We have had a counter fraud programme in place throughout the year. The counter fraud lead meets with the Chief Finance Officer on a regular basis as well as counter fraud being a permanent agenda item at the Audit Committee. The following arrangements are in place: Proactive and reactive measures are taken by the Counter Fraud services to deter and identify fraud as well as to encourage staff to report fraud. The CCG s Standing Orders, Standing Financial Instructions and the Scheme of Reservation and Delegation. Conflicts of Interests (CoI) are declared at all Governing Body and Committee meetings and sub committee meetings. The CCG is compliant with current CoI guidance and the Governing Body and Senior Management Team participate in development sessions on CoI. Management notify the Local Counter Fraud Service (LCFS) and/or Chief Finance Officer of any concerns of fraud. At the conclusion of an investigation, the LCFS forwards recommendations to the Chief Finance Officer, which are also reported to the Audit Committee. Internal Audit and the LCFS hold liaison meetings during the year in order to discuss high risk areas. Where management identify any risk of fraud they are able to introduce appropriate controls to counter the risk. Risks relating to fraud and bribery have been added to the Risk Register which are reviewed by the Governing Body. Risk Assessment Risk management is embedded within all activities of the CCG. Through its main subcommittees (Audit Committee, Finance QIPP and Performance Committee and Quality Committee) and other committee structures, the CCG is able to ensure accountability of risk at all levels of the organisation. 64

67 The Governing Body is aware of all significant risks and has sufficient information to enable it to make decisions on the implementation of appropriate controls and the allocation of appropriate resources. The Integrated Risk Management Framework details definitions, accountabilities and responsibilities of all staff, the risk management process and its governance, including managing risk across organisational boundaries and training. All risks are recorded on the organisation s risk register and clearly identify the responsible director and clinical lead with the levels of risk including actions which should be taken to mitigate the risks. These are reviewed monthly by the Patient Safety Manager with all responsible Associate Directors, with oversight by the Director of Integrated Governance. Risks from the risk register are reviewed and monitored at appropriate sub-committees and is a standing agenda item. The CCG also identifies and manages risks via internal and external methods such as complaints, claims, serious incidents, audits, patient satisfaction surveys, risk assessments, staff surveys, whistle blowing, new legislation, and review from partnership working. The organisation s risk register, inclusive of all RAG rated and scored risks, is the main process through which the Greenwich Executive Group (GEG) receives assurance on the management of all corporate risks. The detailed review and scrutiny of the risk register ensures that appropriate controls and assurances are in place to manage the mitigations of these risks. Analysis identifies any risks that are scored as extreme and high and provides opportunities for remedial action which increases the level of assurance. The risk register is presented by the Director of Integrated Governance at each GEG meeting. The Governing Board Assurance Framework (GBAF) provides the Governing Body with a clear understanding of the principal risks which may affect the achievement of performance objectives for the financial year. Risks recorded on the GBAF are RAG rated and scored with a risk rating of 12 and above, which is the top level of the organisation s risk register. The GBAF is presented for formal review on a monthly basis at each Governing Body meeting by the Director of Integrated Governance. Internal Control Framework A system of internal control is the set of processes and procedures in place in the CCG to ensure it delivers its policies, aims and objectives. It is designed to identify and prioritise the risks, evaluate the likelihood of those risks being realised and the impact should they be realised, and manage them efficiently, effectively and economically. The system of internal control allows risk to be managed to a reasonable level rather than eliminating all risk; it can therefore only provide reasonable and not absolute assurance of effectiveness. NHS Greenwich CCG s system of Internal Control is intended to manage risks and not to eliminate risks. To this effect, we have different committees who are responsible for overseeing the process of risk management within the CCG. Overall responsibility for Risk Management rests with the Governing Body. 65

68 Our system of internal control has been maintained through the monitoring and delivery of its Governing Board Assurance Framework (GBAF) by the Governing Body. Led by the Director of Integrated Governance, the GBAF provides a structure and process that enables the CCG to focus on those risks that might compromise achieving its most important (principal) annual objectives. It maps out both the key controls that should be in place to manage those objectives and confirms that the Governing Body has gained sufficient assurance about the effectiveness of those controls. The effectiveness of the system of internal control is informed by the work of Internal Auditors, External Auditors, Governing Body, Committees, Directors and Clinical Leads within the CCG who have responsibility for the development and maintenance of the internal control framework. The Governing Body Assurance Framework provides the evidence that the effectiveness of controls that manage the risks of the CCG achieving its strategic corporate objectives have been reviewed. The framework has been actively managed and reviewed regularly by the Executive Team, Governing Body and Audit Committee. The Risk Management Framework sets out the overarching approach to the management of risk in the organisation. The Governing Body is aware of all significant risks and has sufficient information to enable it to make decisions on the implementation of appropriate controls and the allocation of appropriate resources. The CCG s aims and objectives are aligned to the Governing Body Assurance Framework, which is presented at each meeting of the Governing Body in Public. The CCG s objectives are embedded in the annual objectives of all CCG staff at all levels within the organisation and success in the achievement of these are measured through the staff appraisal process. All CCG policies follow a standard operating procedure and adhere to the CCG s Policy on Policies. The Policy on Policies outlines the appropriate governance route for approval of policy documents. Information Governance The NHS Information Governance Framework sets the processes and procedures by which the NHS handles information about patients and employees, in particular personal identifiable information. The NHS Information Governance Framework is supported by an information governance toolkit and the annual submission process provides assurances to the CCG, other organisations and to individuals that personal information is dealt with legally, securely, efficiently and effectively. The Chief Finance Officer (CFO) is the Executive Lead on the Governing Body for Information Governance (IG) and also the Senior Information Risk Owner (SIRO). However, whilst the CCG have an interim CFO, the Director of Integrated Governance is the designated SIRO. The Caldicott Guardian is a GP and governing body member. The Information Governance Steering Group meets bi-monthly. 66

69 Throughout 2015/16 we have worked to ensure compliance with the Information Governance Toolkit and continued to develop all aspects of information governance, improved processes for mapping of information flows of personal data, understood the risks associated with records, and adopted Information Governance policies and procedures. The current IG pass rate is at 66% (Level 2) which confirms the Accredited Safe Haven (ASH) status for the CCG. Information Governance Polices have been adopted and approved by the Governing Body and issued to all CCG staff. All staff, including temporary staff are expected to undertake the Information Governance Training on a yearly basis as a mandatory requirement. There are processes in place for incident reporting and investigation of Serious Incidents. The CCG has put in place information risk assessment and management procedures and these have been fully embedded within the CCG. Information Breaches During 2015/16 there were no Serious Incidents relating to of information breaches / data security. We have processes for the reporting and investigation of information breaches. This year, reported information breaches were: 0 serious incidents (categorised as 3-5) 11 minor incidents (categorised as 1-2) Six were CCG-owned issues related to employed staff and five were NHS England. None of the issues were reportable nationally. Review of economy, efficiency & effectiveness of the use of resources The CCG prepares its budgets in accordance with NHSE planning guidance based on an operational plan which is assured by NHSE. In this respect the CCG is noted to have met expectations that the budget will or will not meet statutory targets. For the financial year ending 31 March 2016 the CCG prepared a surplus plan that met NHSE requirements. In respect of major acute budgets, we are supported in agreeing value for money (VFM) contracts by the South East Commissioning Support Unit (SECSU) and for non-acute contracts it has in-house commissioning skills to ensure maximum value for money. Individual budgets are managed by commissioning personnel, who on a monthly basis review financial performance at contract and sub-contract level. Budgets are monitored and reported monthly on the basis of financial information provided by the CSU. The financial and activity variances are discussed at the Finance, Performance and QIPP (FPQ) Committee which is a sub-committee of the Governing Body, which in turn reviews the Financial Performance Report. Overall for 2015/16, External Audit are required to issue a conclusion on whether the CCG has put in place proper arrangements for securing, economy, efficiency and effectiveness in its use of resources. One single criterion is set for auditors to evaluate; 67

70 In all significant respects, the audited body had proper arrangements to ensure it took properly informed decisions and deployed resources to achieve planned and sustainable outcomes for taxpayers and local people. This is supported by three sub-criteria as below: 1. Informed decision making 2. Sustainable resource deployment 3. Working with partners and other third parties. 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. Capacity to Handle Risk The Capacity to Handle Risk is clearly described within the Risk Management Framework. Leadership is given to the risk management process through the roles and responsibilities set out within the strategy from Chief Officer, Directors, Associate Directors, Lead Managers with specific remits for risk, patient safety and compliance through to all staff. Staff are trained or equipped to manage risk in a way appropriate to their authority and duties. The Datix system is established and utilised across the organisation in risk management. The Greenwich CCG Risk Management Framework is available on the CCG intranet under the Risk Management page. All staff will be encouraged to access this and familiarise themselves with the strategy whilst developing an understanding of what is expected of them in line with risk management within the CCG. To enable the Integrated Risk Management Framework to be fully implemented, training sessions and workshops will be set up for managers, staff and clinical professionals. The sessions will include: 1. Introduction to and refresher training for risk management and governance 2. As part of the induction process for all new governing body members 3. The provision of appropriate resources to provide Governing Body development on risk management. Our staff have attended embedded learning events with providers to ensure shared learning and good practice in regard to serious incidents. Our CCG culture is such that it encourages openness, transparency and candour throughout the system about matters of concern. This is in line with the recommendations from the Francis Report (Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry 2013). Where risk is created by deliberate failure to adhere to policy or acting of professional codes of conduct, action may be taken against individuals under the disciplinary committee. We foster a risk aware culture shared by all in the services in putting the patients first. To support the culture of listening, learning and responding within the organisation, the CCG will: 1. Be open and fair 68

71 2. Approach all incidents, complaints and issues fairly and equally 3. Ensure transparency in the review of incidents and complaints and other issues and transfer the learning both internally and externally 4. Ensure all staff are aware of this strategy and processes and all other associated policies that complement robust risk management and internal control within the CCG. 5. Support and advise staff with matter relating to risk management 6. Provide relevant training and information resources 7. Acknowledge reports received and provide feedback on actions and decisions to demonstrate that the CCG has listened 8. Ensure there is a framework through which staff can raise concerns, malpractice and impropriety in a supportive manner 9. Respond to gaps in policy and processes to improve outcomes, experience and the overall management of 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 annual audit letter and other reports. Our assurance framework provides me with evidence that the effectiveness of controls that manage risks to the clinical commissioning group achieving its principles objectives have been reviewed. I have been advised on the implications of the result of my review of the effectiveness of the system of internal control by the Governing Body, the Audit Committee and Quality Committee, if appropriate and a plan to address weaknesses and ensure continuous improvement of the system is in place. Greenwich CCG recognises that risk management processes are continually evolving and the systems must be reviewed in light of changes in the CCG s environment, operations, best practice, guidance and legislation. In light of this, the Risk Management Framework is reviewed annually. 69

72 Head of Internal Audit Opinion Following completion of the planned audit work for the financial year for the clinical commissioning group, the Head of Internal Audit issued an independent and objective opinion on the adequacy and effectiveness of the clinical commissioning group s system of risk management, governance and internal control. The Head of Internal Audit concluded that: Our internal audit service has been performed in accordance with KPMG's internal audit methodology which conforms to Public Sector Internal Audit Standards (PSIAS). As a result our work and deliverables are not designed or intended to comply with the International Auditing and Assurance Standards Board (IAASB), International Framework for Assurance Engagements (IFAE) or International Standard on Assurance Engagements (ISAE) PSIAS require that we comply with applicable ethical requirements, including independence requirements, and that we plan and perform our work to obtain sufficient, appropriate evidence on which to base our conclusion. Roles and responsibilities The 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 (AGS) is an annual statement by the Accountable Officer, on behalf of the Governing Body, setting out: how the individual responsibilities of the Accountable Officer are discharged with regard to maintaining a sound system of internal control that supports the achievement of policies, aims and objectives; the purpose of the system of internal control as evidenced by a description of the risk management and review processes, including the Assurance Framework process; and the conduct and results of the review of the effectiveness of the system of internal control including any disclosures of significant control failures together with assurances that actions are or will be taken where appropriate to address issues arising. The Assurance Framework should bring together all of the evidence required to support the AGS. The Head of Internal Audit (HoIA) is required to provide an annual opinion in accordance with PSIAS, based on and limited to the work performed, on the overall adequacy and effectiveness of the CCG s risk management, control and governance processes (i.e. the system of internal control). This is achieved through a risk-based programme of work, agreed with Management and approved by the Audit Committee, which can provide assurance, subject to the inherent limitations described below. The purpose of our HoIA 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 system of internal control. This opinion will in turn 70

73 assist the Governing Body in the completion of the AGS and may also be taken into account by other regulators to inform their own conclusions. The opinion does not imply that the HoIA has covered all risks and assurances relating to the CCG. The opinion is substantially derived from the conduct of risk-based plans generated from a robust and Management-led Assurance Framework. As such it is one component that the Governing Body takes into account in making its AGS. A further component will be the assurances provided on the operation of the systems of internal control the service organisations which provide financial services on behalf of the CCG during 2015/16 as follows: NHS South East Commissioning Support Unit (Deloitte); NHS Shared Business Service (Grant Thornton); and McKesson: NHS Electronic Staff Records (PwC). Assurances on the operation of these systems will be provided by ISAE3402 Service Auditor Reports issued by the internal auditors of these organisations. Opinion Our draft opinion is set out as follows: basis for the opinion; overall opinion; and commentary. The basis for forming our draft opinion is as follows: 1. An assessment of the design and operation of the underpinning Assurance Framework and supporting processes; and 2. An assessment of the range of individual assurances arising from our risk-based internal audit assignments that have been reported in year. This assessment has taken account of the relative materiality of these areas. Our draft opinion based for the period 1 April 2015 to 22 February 2016 is that: significant assurance with improvements required assurance can be given on the overall adequacy and effectiveness of the CCG s framework of governance, risk management and control. Commentary The commentary below provides the context for our draft opinion and together with the draft opinion should be read in its entirety. Our draft opinion covers the period 1 April 2015 to 22 April 2016 inclusive, and is based on the four audits we completed during the period. We share this draft head of internal audit opinion for information at this stage. Our final opinion will be updated to include the findings from the ISAE3402 Service Auditor Reports and our remaining 2015/16 reviews. The design and operation of the Assurance Framework and associated processes Overall our review found that the Assurance Framework in place is founded on a systematic risk management process and provides appropriate assurance to the Governing Body. 71

74 The Assurance Framework reflects the organisation s key objectives and risks and is reviewed on a regular basis by the Governing Body. The range of individual opinions arising from risk-based audit assignments contained within our risk-based plan that have been reported throughout the year We issued no no assurance opinions in respect of our 2015/16 assignments. We have provided three significant assurance with minor improvement opportunities opinions on Budgetary Control and Financial Management, Information Governance and Adult Safeguarding, and one partial assurance with improvements required opinion for our review on Risk Management Deep Dive. The Risk Management Deep Dive review had two high priority recommendations over QIPP planning, monitoring and reporting and controls over contract management. Both recommendations have been accepted by Management and actions are in place to respond to the matters. The draft head of internal audit opinion will be updated once the programme of work has been finalised. KPMG LLP Chartered Accountants London 22 April 2016 During the year, Internal Audit issued the following audit reports which identified governance, risk management and/or control issues which were significant to the organisation: Data Quality Restrictions on the use of data by commissioners have made it difficult for the CCG to link and synthesize data; which has also presented problems for the validation of invoices. The validation process for identifiable data uses information downloaded from SUS by SECSU which is in turn downloaded to the CCG from the SECSU data warehouse environment. The CCG uses this data to challenge providers on the usage and cost of Greenwich patients using healthcare services, but is reliant on the quality of this data. The CCG has retained its ASH status for 2016/17 and is able to continue accessing identifiable data in this way and through the HSCIC approved Controlled Environment for Finance (CEfF). Business Critical Models The key business critical models on which the Governing Body relies are (i) in-year financial forecasts, (ii) medium-term financial planning and 72

75 (iii) financial evaluation and forecasting of quality led savings schemes. These models are the responsibility of the Chief Finance Officer and operated by the Finance, management & planning team and the QIPP planning, delivery and monitoring group. The governance of these models is delegated from the Governing Body to the Finance Performance & QIPP Committee. Quality assurance on these models has been sought, and received, by (i) expert external review and (ii) the internal audit programme. The supplier of our information and computer technology (ICT) functions is South East London CSU. Business intelligence is provided in house by CCG Officers. Business critical models in use within ICT are subject to a number of quality assurance processes which link into the overall framework and management commitment to quality. There is transparency and management oversight over models and data sources used to make business critical and strategic decisions, with scrutiny within the IG and senior management committees (through which Greenwich CCG receives assurance). In addition, a governance process is implemented whereby an internal peer review process is supported by robust document control, ownership and accountability. Data inputs and outputs are regularly validated, with senior management responsible for an overall sense check before decisions are approved. Business critical models in use within BI include processes which supports the identification and maintenance of a list of all business critical models and a schedule for periodic review. Qualified and experienced personnel exercise professional scepticism over the outputs from key models and organisational use of data. These processes are subject to review by internal auditors, who review management information data and process owners, and external auditors, whose work covers the quality assurance processes of financial models. NHS England recognises the importance of quality assurance across the full range of its analytical work. In partnership with analysts in the Department of Health we have developed an approach that is fully consistent with the recommendations in Sir Nicholas Macpherson's review of quality assurance of government models. The framework includes a programme of mandatory workshops for NHS England analysts, which highlights the importance of quality assurance across the full range of analytical work. For business critical models, where an error would have a significant reputational, financial or patient care impact, we have agreed with the Department of Health a joint approach that audits the quality assurance strategy of the models. This is overseen by a joint committee of experienced analysts. The Macpherson Report on the review of quality assurance (QA) of Government Analytical Models set out the components of best practice in QA making eight key recommendations. In 2014/15, NHS Greenwich CCG, working with other commissioners in South East London, developed the South East London Commissioning Model, a business critical 73

76 analytical tool in modelling and appraising the impact of proposed changes in the local health economy over the next five years. The development of the model follows the principles set out in the Macpherson report with an identified Senior Responsible Officer, supported by a clear Governance Structure. The technical review group, chaired by the Bromley CCG Chief Finance Officer, draws upon multi-disciplinary specialist experience from all stakeholders, responsible for developing and using the model as well as providing quality assurance and peer review. This group is responsible for ensuring that there are effective processes underpinning the model, including appropriate guidance, documentation and training, as well as sharing best practice across disciplines and organisations. The QA framework in place for this model will be used for all future business critical models. Discharge of Statutory Functions Arrangements put in place by the clinical commissioning group and explained within the corporate governance framework have been developed with extensive expert external legal input, to ensure compliance with the all relevant legislation. That legal advice also informed the matters reserved for Membership Body and Governing Body decision and the scheme of delegation. In light of the Harris Review, the clinical commissioning group has reviewed all of the statutory duties and powers conferred on it by the National Health Service Act 2006 (as amended) and other associated legislative and regulations. As a result, I can confirm that the clinical commissioning group is clear about the legislative requirements associated with each of the statutory functions for which it is responsible, including any restrictions on delegation of those functions. Responsibility for each duty and power has been clearly allocated to a lead Director. Directorates have confirmed that their structures provide the necessary capability and capacity to undertake all of the clinical commissioning group s statutory duties. Responsibility for each duty and power has been clearly allocated to a lead Director. Directorates have confirmed that their structures provide the necessary capability and capacity to undertake all of the clinical commissioning group s statutory duties. Late in the financial year (March 2016) an unexpected cost pressure emerged concerning the funding of Oversees Visitors and expenditure has been made by Greenwich CCG which has not been matched by income to offset this. Therefore the agreed control total of 1% surplus has not been fully met by 924k. This position has been agreed with NHSE and they have been able to cover this from another source. The appropriate action has now been taken to address the management of Oversees Visitors in 2016/17. Greenwich CCG identified that it would have difficulty setting a budget in line with all NHS business rules in 2016/17 and appointed a Turnaround Director. A Financial Recovery Board has been established and the operational plan submitted for 2016/17 has been submitted in line with NHSE expectations set for Greenwich CCG which includes a deficit budget. 74

77 Conclusion Internal controls have been strengthened through the Turnaround arrangements with four programmes reporting into the Financial Recovery Board whose terms of reference have been approved by Greenwich CCG Governing Body. These are: a. QIPP Delivery b. Organisational Capability and Capacity c. Operational Planning for 2016/17 d. 2016/17 Contract Resolution within Affordable Envelopes The Financial Recovery Board reports directly to the Governing Body, as does the Finance, Performance and QIPP Committee for Assurance processes. Both of these ensure that appropriate actions are being taken and to the Governing Body so that they have a full oversight of progress in returning the organisation to full financial recovery. Annabel Burn Accountable Officer 23 May

78 Remuneration and staff report Remuneration Committee The Remuneration Committee comprises of four members and has met on one occasion during the past year. It is a joint committee held with Bexley CCG. The Chair of the committee is Bexley CCG vice chair Mr Keith Wood. A full list of the NHS Greenwich CCG members and their roles is below. Name Role Service Jim Wintour Greg Ussher Lay Member Dr Iyngarun Vanniasegarum Maggie Buckell Lay Member / Vice Chair (Audit and COI) Lay member (PPI) Secondary Care Doctor Registered Nurse In addition to the members listed above, the following CCG employees provided the committee with advice which was material to the committee s deliberations. Name Role Service Simon Hall Deputy Chief officer / Director of Strategy & Performance Advice The following persons who are not employees of the CCG also provided advice to the committee: Name Role Service Nick Mardsen Senior Human Resource Business Partner, NHS South London CSU Advice The South London Commissioning Support Unit provides HR advice and support to the CCG in accordance with an agreed Service Level Agreement. This includes advice and support to the Remuneration Committee including agreeing agendas with the Chair of the Committee and preparing and presenting papers at Committee meetings. The advice given to the Remuneration Committee is based on National Guidance and benchmarking information. The HR Business Partner is appointed by the CSU. 76

79 Remuneration Policy The Committee s deliberations are carried out within the context of national pay and remuneration guidelines, local comparability and taking account of independent advice regarding pay structures. Business expenses are reimbursed in accordance with the CCG policy based on national guidelines. There are no benefits in kind. Senior Managers Performance Related Pay The CCG does not have a policy of performance related pay for senior managers. Senior Managers Service contracts The CCG s policy concerning senior managers contracts is that they are permanent contracts, with a notice period of 3 months. There have been no termination payments in year or any awards to current or former members of the Governing Body or other senior manager. Should there be termination of contract liabilities in future, and none are planned, these would be in accordance with national NHS policy. Senior Managers Salaries and Allowances 2015/16 (audited) All members of the Governing Body are deemed to be individuals with significant financial responsibility during the financial year and are therefore regarded as senior managers. No other CCG senior managers have significant financial responsibility. 77

80 Name Title Salary & Fees Taxable Benefits Annual Performance Related Bonuses Long-term Performance Related Bonuses All Pension Related Benefits Total Salary & Fees Taxable Benefits Annual Performance Related Bonuses Long-term Performance Related Bonuses All Pension Related Benefits Annabel Burn Chief Officer Chris Costa Financial Year Financial Year Chief Finance Officer -until 30 November Total Simon Hall Nicola Moore Sam Jones Diane Jones Dr Ellen Wright Dr Eugenia Lee Dr Greg Ussher Dr Hany Wahba Dr Iyngaran Vanniasgarum Dr Nayan Patel Dr Rebecca Rosen Mr Jim Wintour Dr Ranil Perera Dr Krishna Subbarayan Maggie Buckell Deputy Chief Officer and Director of Strategy and Performance Director of Integrated Governance - Until 29 May Director of Delivery and Service Transformation - From 1 June Director of Integrated Governance - From 24 August Not Applicable Chair and GP Member of the NHS Greenwich CCG Governing Body - From 22 Oct GP Member of the NHS Greenwich CCG Governing Body - Until 1 August Lay Member on the NHS Greenwich CCG Governing Body GP Member of the NHS Greenwich CCG Governing Body -Chair until 17 Oct Secondary Care doctor on the NHS Greenwich CCG Governing Body GP Member of the NHS Greenwich CCG Governing Body GP Member of the NHS Greenwich CCG Governing Body - Until 1 August Lay Member on the NHS Greenwich CCG Governing Body GP Member of the NHS Greenwich CCG Governing Body - From 1 May GP Member of the NHS Greenwich CCG Governing Body - From 1 July Registered Nurse on the NHS Greenwich CCG Governing Body - From 8 January Dr Sylvia Nyame GP Member of the NHS Greewich CCG Governing Body - From 1 August Not Applicable Dr Sabah Salman GP Member of the NHS Greewich CCG Governing Body - From 1 August Not Applicable Ian Fisher Regina Shakespeare Interim Chief Financial Officer - From 01 December Interim Turnaround Director and Acting Director of Commissioning - From 03 Feburary Councillor David Gardner Local Authority Member Not Applicable Not Applicable Not Applicable Steve Whiteman Director of Public Health Not Applicable Mrs Yemisi Osho Sara Nelson Dr Junaid Bajwa Registered Nurse on the NHS Greewich CCG Governing Body - Until 19 June 2014 Not Applicable Registered Nurse on the NHS Greewich CCG Governing Body - From 20 Aug 2014 to 16 Jan 2015 Not Applicable GP Member of the NHS Greenwich CCG Governing Body- Until 30 May 2014 Not Applicable No Governing Body member, or any other manager, received any performance related pay or bonus, or taxable benefit. The pension benefit figure is based on the HMRC method for calculating the increase in the annual pension entitlement for deferred benefit schemes. It is not the same as the cost to the CCG of its contribution in respect of the individual concerned (the employer s contribution). 78

81 Pension Benefits Name Real Increase in pension at age 60 (bands of 2500) Real Increase in pension lump sum at age 60 (bands of 2500) T otal accrued pension at age 60 at 31 M arch 2016 (bands of 5000) Lump Sum at age 60 related to accrued pension at 31 March 2016 (bands of 5000) Cash equivalent T ransfer V alue at 31 March 2016 Cash equivalent T ransfer V alue at 31 March 2015 Real Increase in Cash E quivalent T ransfer V alue E mployer contribution to stakeholder pension Annabel Burn - Chief Officer Chris Costa - Chief Finance Officer Simon Hall - Deputy Chief Officer and Director of Strategy and Performance Nicola Moore - Director of Integrated Governance untill xx September Sam Jones - Director of Delivery and Service Transformation Diane Jones - Director of Integrated Governance - From 24 August NHS organisations are required to disclose the pension benefits for those persons disclosed as senior managers of the organisation, where the clinical commissioning group has made a direct contribution to a pension scheme. Due to the nature of clinical commissioning groups, some GPs have served as office holders of NHS Greenwich CCG. However, for GPs who work under a contract for services with the CCG, they are not considered to hold a pensionable post and so no pension disclosure is required. From 1 April 2013, NHS England became the employing agency for all types of GPs and pensions contributions have been made by NHS England. Where fees for service have been paid directly to GPs practice, the practice is the employing agency and not the CCG. Pay multiples (Audited) 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 Membership Body/Governing Body in the clinical commissioning group in the financial year 2015/16 was 112,500. (14/15 was 113,500) 79

82 This was 2.64 times the median remuneration of the workforce, which was 42,602. (14/15 was 2.98 and 38,075). In 2015/16 no employees received remuneration in excess of the highest-paid member of the Membership Body/Governing Body. Remuneration ranged from 16,000 to 112, 500 (2014/15 was 21,000 to 113,500). Total remuneration includes salary, non-consolidated performance-related pay, benefitsin-kind. It does not include severance payments, employer pension contributions and the cash equivalent transfer value of pensions. The figures in the Pensions Benefits 2015/16 table are to the nearest 500. Off payroll engagements Off-payroll engagements as of 31 March 2016, for more than 220 per day and that last longer than six months are as follows: Table x: Off-payroll engagements as of 31 March 2016, for more than 220 per day and that last longer than six months are as follows: Number The number that have existed: For less than one year at the time of reporting 11 For between one and two years at the time of reporting For between two and three years at the time of reporting For between three and four years at the time of reporting For four or more years at the time of reporting 7 3 n/a n/a Total number of existing engagements as of 31 March All existing off-payroll engagements, outlined above, have at some point been subject to a risk based assessment as to whether assurance is required that the individual is paying the right amount of tax and, where necessary, that assurance has been sought. Table x: For all new off-payroll engagements from 31 March 2016, for more than 220 per day and more than 6 months Number Number of new engagements, or those that reached six months in duration, between 1 April 2015 and 31 March 2016 Number of the above which include contractual clauses giving the clinical commissioning group the right to request assurance in relation to Income Tax and National Insurance obligations Number for whom assurance has been requested 0 Of which, the number:

83 - for whom assurance has been received 0 - for whom assurance has not been received 0 - that have been terminated as a result of assurance not being received 0 Number of off-payroll engagements of Governing Body members, and senior officials with significant financial responsibility, during the financial year Number of individuals that have been deemed Governing Body members, and senior officials with significant financial responsibility, during the financial year (this figure includes both off-payroll and on-payroll engagements) N/A N/A 81

84 Our staff Communicating and Engaging There are a number of ways in which the CCG communicates and engages with its staff. These include: Regular staff briefings these moved from monthly to twice weekly when the CCG went into Turnaround in February The briefings are shared on the intranet. Each directorate holds staff meetings, and all staff have a one to one meeting with their line manager. Participation in the national NHS Staff Survey in 2015 we have an agreed action plan based on the results of the Survey, which is coordinated by the staff health, safety and wellbeing group. The Growing Success programme started in 2015/16 following a series of staff engagement events looking at internal processes and identifying what was going well and not so well. An action plan was developed covering the following areas: communication; management; operational; training and induction; social, morale and health and wellbeing. During November 2015 we assessed progress against the action plan and the Staff Health and Wellbeing group RAG rated the plan. Good progress had been made against many of the areas, and the plan continues to be monitored. We will be holding staff events to increase engagement across all staff areas. Training and Development All staff are required to complete their Statutory & Mandatory training that has been provided both online via e-learning from Skills for Health and in-house. Training compliance is reported back to the CCG on a regular basis. All staff have regular 1:1s and we are working towards all staff having appraisals, objectives and Personal Development Plans (PDPs) in place. Employee Consultation Organisational Change is managed in accordance with the principles and procedures contained within the CCG's Organisational Change Policy. The CCG also informally communicates and consults with employees via regular staff briefings. Policy on Disabled Employees Disabled employees are protected under the "protected characteristics" of the Equality Act 2010, one of which is disability. The CCG will ensure that the requirements and reasonable adjustments necessary for employees with disabilities are taken into account during their employment and that people with disabilities are not discriminated against on the ground of their disability at any stage of the recruitment process or in their employment with the CCG. 82

85 The CCG's Sickness Absence Policy confirms that where an employee becomes disabled as a result of sickness, the CCG will make any necessary reasonable adjustments, as required, and in accordance with the Equality Act to enable the employee to return to work. The types of adjustments may include adjustments to work base, working hours, redeploying the employee to another suitable position and providing any necessary equipment to assist the employee to perform their role. Equalities for Staff The CCG promotes a working environment in which all parties and procedures relating to recruitment, selection, training, promotion and employment are free from unfair discrimination, ensuring that no employee or prospective employee is discriminated against, whether directly or indirectly on the grounds of age; disability; gender reassignment; pregnancy and maternity; race including ethnic or national origins, colour or nationality; religion or belief; sex (gender); sexual orientation; marriage and civil partnership; trade union membership; responsibility for dependents or any other condition or requirement which cannot be shown to be justifiable. Staff Composition Gov Body Clinical Lead Director Employee Grand Total Female Male Female Male Female Male Female Male Staff Numbers in 2015/16 Average FTE Average Headcount 83 Number of Senior Staff by Band Pay Band Total Band 4 7 Band 5 5 Band 6 4 Band 7 21 Band 8A 11 Band 8B 9 Band 8C 10 Band 8D 4 Band 9 3 Local Salary 14 Local VSM 3 Grand Total 91 83

86 Ethnicity of Staff in London compared with NHS Greenwich CCG Etnicicity breakdown - NHS Workforce (London Region) 3% 1% 4% 5% White Black or Black British 15% 18% 54% Asian or Asian British Mixed Chinese Any Other Ethnic Group Not Stated/Unknown Ethnicity Ethnicity breakdown for Greenwich CCG Unknown 6% Black 23% White 43% Asian 16% Mixed 6% Any other White background 6% The CCG ethnicity split compares favourably to the London NHS workforce. The CCG is committed to diversity and its obligation to be inclusive regarding job opportunities, encouraging people from all sections of the community to join the team. 84

87 Staff religious belief The chart reveals that Christianity is the religion practiced by most employees, however, undefined, not wishing to disclose and other, provides for inconclusive evidence of the breakdown by religion. Staff sexual orientation Gay 1% Bisexual 1% Sexual Orientation Lesbian 1% Undefined 25% Heterosexual 38% I do not wish to disclose my sexual orientation 34% According to the Office for National Statistics 1.6% of UK adults aged 16+ gave their sexual identity as lesbian, gay or bisexual in Public Health England are currently reviewing this, however, the percentages for Greenwich CCG are in line with the published data. 85

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