NHS Horsham and Mid Sussex Clinical Commissioning Group Annual Report and Accounts 2017/18

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1 NHS Horsham and Mid Sussex Clinical Commissioning Group Annual Report and Accounts 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group ANNUAL REPORT 2017/18 1

2 2 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

3 Contents Foreword from the Clinical Chair and Accountable Officer 4 Section 1: Performance Report A year in the life of the CCG 7 A year in performance 17 A year in quality and safety 29 A year in commissioning 37 Engaging people and communities 49 Reducing health inequalities 51 Health and wellbeing strategy 52 Sustainable development 53 Section 2: Accountability Report A year in governance 57 Members report 57 Statement of Accountable Officer s responsibilities 67 Governance statement 70 Remuneration and staff report 98 Parliamentary accountability and audit report 112 Section 3: Annual Accounts Finance report 113 Managing a challenging financial agenda 114 Annual accounts 2017/ Independent Auditor s Report 162 NHS Horsham and Mid Sussex Clinical Commissioning Group ANNUAL REPORT 2017/18 3

4 Foreword from Clinical Chair and Accountable Officer Welcome to the Horsham and Mid Sussex Clinical Commissioning Group (CCG) Annual Report 2017/18, which provides a detailed overview of our performance during the year and highlights some of the key improvements we have made to health and care services for the benefit of our local communities. It also draws out some of the difficulties and challenges we, like much of the NHS in England, are facing. One of the biggest challenges we have faced during the year has been financial stability and this was the dominant reason why the CCG was rated inadequate by NHS England in the annual assessment and placed in special measures. This was followed by a set of legal directions to formally oversee our recovery plan. The key areas for improvement in this plan are financial recovery, leadership and governance and a lot of work has taken place to begin the journey of improvement that we have to take. A robust and ambitious financial recovery plan has been developed, with the aim of achieving financial balance, and we recognise this will be a significant challenge as we finish the financial year with a deficit of 38.74m against a planned deficit of 13.0m. We are in a stronger position to achieve this as an organisation following the creation of the Central Sussex and East Surrey Commissioning Alliance at the beginning of This will allow us to work closely with the CCGs of Crawley, East Surrey, High Weald Lewes Havens and Brighton and Hove and presents an opportunity for us to share best practice, resources and expertise and to give us a greater voice in how we commission services. While we move in this direction, we will not let go of the value our strong clinical focus and local patient and community voices have on how we commission relevant and effective services for our population. We have made some really positive improvements to health and care services for our local population over the past year and have made progress in reviewing and redesigning numerous care pathways, This has included the launch of a new perinatal mental health service to support new and expectant parents, investment in an innovative early supported discharge rehabilitation service for stroke patients and their families, and the extension of the Time to Talk Health service, which offers talking therapies for people who are finding it difficult to cope with their long-term health conditions. 4 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

5 We also launched our town-based GP access hubs providing evening and weekend appointments, in order to free up more time in our practices for patients with long term, complex health conditions and to help ensure improved access to GP services for all patients in the face of rising need. We recognise we still have much to do, particularly in maintaining the sustainability of general practice, which will be a key focus for us in the year ahead, alongside our wider plans to ensure all services are more robust and sustainable. We have an ageing population with increasingly complex needs that has resulted in rising demand for GP care at a time when recruitment and retention of staff is difficult. Overcoming these issues requires multiple approaches, but we are starting to make an impact through projects such as more support for patient wellbeing in social prescribing, and a wider mix of skills and disciplines. We will now be looking to maintain and build upon the progress and improvements we have made over the last year, to continue to commission high quality and sustainable services for people living across Horsham and Mid Sussex. Dr Minesh Patel Clinical Chair Horsham and Mid Sussex CCG Adam Doyle Accountable Officer Central Sussex and East Surrey Commissioning Alliance NHS Horsham and Mid Sussex Clinical Commissioning Group ANNUAL REPORT 2017/18 5

6 Performance Report 6 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

7 A year in the life of the CCG This performance report provides a comprehensive overview of the work of Horsham and Mid Sussex CCG and an analysis of our performance during the year and our position at year end. It also describes how we have identified the risks and uncertainties facing the CCG and how we have managed them. Who we are and what we do NHS Horsham and Mid Sussex Clinical Commissioning Group (CCG) is responsible for planning and buying ( commissioning ) healthcare services for the people living across Burgess Hill, East Grinstead, Haywards Health, Horsham and the surrounding areas. The CCG is made up of the 23 GP practices in our area and is responsible for the health and wellbeing of nearly 240,000 people. We have a leadership team of local doctors, hospital consultants and nurses who are working alongside an experienced local management team to make sure that local services are providing the best possible care for local people. Each year we are allocated government money to spend on behalf of our population and our purpose is to improve the health of the people living in Horsham and Mid Sussex. As well as planning and buying services, we also monitor the quality of the majority of local NHS services covering: The care and treatment you may need in hospital and in the community; Prescribing; Mental health services; and Support and services for people living with learning disabilities. We are committed to ensuring that our public, patients and carers are at the heart of what we do. We aim to be an organisation that takes account of their views and experiences and use what we have heard to inform our plans and influence our commissioning of local health services. NHS Horsham and Mid Sussex Clinical Commissioning Group ANNUAL REPORT 2017/18 7

8 8 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

9 Central Sussex Commissioning Alliance The Central Sussex Commissioning Alliance is the creation of a unified management structure across four Clinical Commissioning Groups (CCGs) of central Sussex Brighton and Hove, High Weald Lewes Havens, Horsham and Mid Sussex and Crawley. The Alliance officially went live from January 2018 and is organised in two places the north place covering the area of Crawley and Horsham and Mid Sussex CCGs, and the south place covering the area of Brighton and Hove and High Weald Lewes Havens CCGs. There is a single Executive Team for the Alliance, with a single Accountable Officer for all four CCGs. In January 2018, it was agreed that East Surrey CCG would formally become a member of the Alliance from April and from this date it would be known as the Central Sussex and East Surrey Commissioning Alliance. The Alliance represents a joint way of working across the CCGs, which allows the organisations to commission services more effectively and efficiently. It has become increasingly clear that the CCGs have not been working as efficiently and effectively as they could have been. Since CCGs were formed in 2013, the demand on health and social care services has grown significantly and funding has not been able to keep pace with this growth. People are now living longer, and with increasingly complex needs, and health inequalities are increasing. By working at a larger scale, it is recognised that we will be able to streamline processes, avoid duplication and have consistency of quality in services across a larger area for our patients. The Alliance is not a formal merger of the organisations and the CCG Governing Bodies remain accountable for healthcare commissioning to meet the needs of their local populations. NHS Horsham and Mid Sussex Clinical Commissioning Group ANNUAL REPORT 2017/18 9

10 Sussex and East Surrey Sustainability and Transformation Partnership (STP) The CCGs of the Alliance are part of the Sussex and East Surrey Sustainability and Transformation Partnership (STP) and our local plans support the wider aims to improve health and social care services for our local populations. The STP is made up of 24 organisations, which include CCGs, local authorities and hospital, mental health and community trusts. By working together, we have the opportunity to ensure services remain sustainable and can cope with future challenges. The aims of the STP are to: Give patients a better experience by ensuring that all the partnership organisations and every part of the health and care system works closer together; Give every patient the same high standard of care by reducing variation of standards across the Sussex and East Surrey area; Make services able to cope with future challenges by working differently to be more effective and efficient; and Make sure we get best use of the resources available by reducing waste and duplication and ensuring that every organisation is working as efficiently as possible. The STP is a partnership, within which there are different place-based plans that focus on places and populations. The aim of these plans is to create new ways of working that will bring hospital, community, mental health, social care and GP services closer together and bring care closer to people s homes. 10 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

11 Key issues and risks No organisation operates without risks and effective management of these is a key function of the Executive Team. Following a review of our goals we identified the principal risks to delivering those goals. These are reviewed regularly alongside operational risks escalated from our management team. During 2017/18 our main areas of risk were as summarised below: Financial Risks Having started the year in a deficit position, the CCG identified principal risks in both achieving the statutory duty to break even, as well as in meeting our control target. Risks in financial forecasting were also identified. Risks to delivery of our efficiency savings projects were identified by specific programme and project. Reputational Effective engagement of patients and public in the design and delivery of services, and with our stakeholders in developing a transformed system of care, were identified as key risks to our operational delivery, delivery of improved outcomes for patients, ability to successfully introduce new services, compliance with guidance and our reputation. Operational Risks to achievement of operational standards by our commissioned providers were an area of significant risk to the CCG. These were analysed by workforce risks (acute, community and primary care), achievement of constitutional standards, capacity shortfalls and seasonal pressures. During the year the performance of our main provider of commissioning support services was identified as a risk to delivery of our objectives. Compliance During the year new risks were identified in meeting the requirements of the transforming care programme. In addition risks with respect to safeguarding, looked after children and meeting the mental health investment standard were identified and managed. NHS Horsham and Mid Sussex Clinical Commissioning Group ANNUAL REPORT 2017/18 11

12 We have taken a wide range of actions to minimise and manage these risks including: Improving our approach to financial management, reporting and forecasting; Improving our governance structures and processes; Working in partnership with CCGs in the Central Sussex and East Surrey Commissioning Alliance; Working to improve the resilience of the local health system; and Continuing our focus on the clinical effectiveness of services using RightCare data which benchmarks CCG performance. There is more detail about how we manage the risks facing us in the Annual Governance Statement. Going concern The annual accounts have been prepared on the going concern basis. During the year a report was issued to the Secretary of State for Health under Section 30 of the Local Audit and Accountability Act 2014 as a result of our financial deficit. Further information about the CCG s financial position is provided in the section: Financial summary below and in section three of this report: Managing a challenging financial agenda. Note 1.1 of the Annual Accounts provides additional information. Public sector bodies are assumed to be going concerns where the continuation of the provision of a service in the future is anticipated, as evidenced by inclusion of financial provision for that service in published documents. There is no evidence that that services provided by the CCG will cease in the future. The CCG has been given notification of a 5 year allocation, which is fixed to 2018/19 and indicative for the two following years and in addition has an operating plan agreed by NHS E, which provide evidence that going concern is an appropriate basis for the preparation of financial statements. The work of the CCG in developing a commissioning alliance with partner CCGs in Crawley CCG, Horsham and Mid Sussex CCG, High Weald Lewes Havens CCG and Brighton and Hove CCG does not indicate any intention to merge or close any of the statutory bodies. In addition the CCG has identified no threats to operational stability from finance or income that has not yet been approved and services will continue to be provided, which supports preparing the financial statements on a going concern basis. 12 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex NHS Commissioning Group

13 Financial summary Our financial performance for 2017/18 is set out in the annual accounts. In summary the CCG delivered a deficit of 38.74m against allocation and did not meet NHS business rules. A number of factors contributed to the deficit position in 2017/18. In response to a deteriorating financial position the CCG undertook a number of actions to manage this position including developing a Financial Recovery Plan to achieve financial balance over the next 3-5 years and implementing the recommendations of a financial governance review. As part of the Central Sussex Commissioning Alliance since January 2018 the CCG has been placed into formal turnaround by the new Executive Team along with all other Alliance CCGs. This has established a common approach to financial savings and a new set of financial controls to minimise expenditure. The six key themes underlying the 2017/18 out-turn deficit and variance to plan are: financial recovery diagnostic, which has been used to develop plans to address the financial deficit and reduce expenditure in line with allocation. This has been developed into a Financial Recovery Plan which indicates a timescale of up to five years for the CCG to manage annual expenditure in line with allocation. As in 2016/17, CCGs were asked to set aside a risk reserve at the start of this financial year to provide a buffer to offset any wider system pressures. For 2017/18 this was reduced to 0.5% of CCGs allocations. CCGs were able to release the full amount of the risk reserve as additional underspend in its year end reporting. For the purpose of year-end assessment of financial performance against target the release of the 0.5% system reserve will be excluded. This is reported in note 20 of the annual accounts. NHS England has placed the CCG under legal directions. As a consequence the CCG financial position is subject to greater scrutiny and approvals are required for significant contract awards and financial commitments. impact of transactions relating to the previous financial year; under-delivery on planned savings schemes; higher activity than assumed in budget plans; in year pressures relating to growth in complexity of acute care services unfunded increased costs of acute activity; and A provision for a receivable balance, in relation to contract payments to providers, that is doubtful in its recovery. The Governing Body notes that the underlying position indicates on-going risk because we will start the 2018/19 financial year with a forecast deficit for the year and a cumulative debt from prior years of 53.54m. Ensuring financial recovery The CCG s financial plan for 2017/18 recognised that it would not be able to meet its financial duties. The financial plan for the year was a deficit of 13.0m. During the year the CCG implemented a thorough and comprehensive A Financial Recovery Programme started in 2016/17 and will continue NHS Horsham and Mid Sussex Clinical Commissioning Group ANNUAL REPORT 2017/18 13

14 into 2018/19. The CCG will be required to deliver challenging and significant savings targets and make investments to deliver the transformational changes as set out in the Five Year Forward View. We will have submitted a draft Financial Recovery Plan to NHS England which demonstrates how we plan to stabilise our financial position in 2018/19 and take steps to reduce the deficit over the next five years. An updated Financial Recovery Plan will be submitted by 30 June The CCG currently has an NHSE control total which is a deficit of 20m in 2018/19. If this remains it would represent an improvement of nearly 19m compared to 2017/18. However the CCG is working across the Alliance health system to propose a systemwide balanced position. The CCG submitted an Operating Plan in agreement with NHS England that shows a planned deficit of 28.4m and savings of 11.2m. If the CCG is able to deliver this level of deficit it would receive Commissioner Sustainability Funding enabling an overall breakeven position to be achieved. In line with the Alliance turnaround board agreement, the approach to delivering this position will be by targeting a QIPP efficiency saving of 4% and identifying other savings on discretionary expenditure. improved outcomes for patients at an affordable cost. The plans are consistent with national planning guidance and contain broad assumptions about activity growth. In developing our savings plans, we aim to eliminate waste and duplication, ensure delivery of quality and innovation plans addressing demand and supply, ensure our contracting process is robust and only when these have been exhausted we will explore clinically effective commissioning and making difficult choices including the prioritisation of services and expenditure. Our financial report in section three carries more information. Our savings plan Our savings plan has been worked up from opportunities identified in tackling unwarranted variation, which are identified from national benchmarking data. We will focus on identifying and delivering savings by only commissioning proven and cost effective services. We will also put in place new ways of commissioning and paying for services that will incentivise 14 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex NHS Commissioning Group

15 Performance summary Every CCG is measured against national and local health priorities to ensure patients are receiving a high standard of care within key services. We are continuously assessed by the Department of Health and NHS England on a number of financial and performance measures, within various national standards and frameworks. These include the NHS Constitution and the NHS England Improvement and Assessment Framework (IAF), which rates CCGs on key areas. This year, the CCG received a rating of inadequate against the IAF, which was due to the performance of key services and the finances of the organisation. One area that has been particularly challenging has been in urgent care and specifically the performance of the Emergency Departments (A&E) at our local acute hospital Trust, Brighton and Sussex University Hospitals NHS Trust (BSUH). An increase in the number of people using the Departments has meant patients have had to wait longer than we would have liked to be seen, treated and either admitted or discharged. This was particularly challenging during the winter months, when the NHS experienced one of the busiest periods in its history. We have worked hard with all local health and social care organisations to ensure the safety and quality of services was maintained and a number of initiatives and improvements have been introduced. These aim to reduce the number of people going to A&E for treatment and make it easier for patients to leave hospital when they are ready, which frees up space for other patients who need hospital care. Another area we need to improve is the performance against the waiting times from GP referral to when the patient is treated. The national target is 18 weeks and this has not been achieved locally, mainly due to how busy our local hospital Trust has been. Additionally, over the winter NHS England asked hospitals to pause planned work in January 2018 to ensure they could focus on giving patients the urgent treatment they needed. As a result, waiting lists have developed and we are working very hard with BSUH and other CCGs to reduce these. We have paid for patients to be treated at other hospitals and providers to speed up their treatment but we recognise there is still work to do in this area. We also need to focus on improving some areas of performance for local cancer patients. There have been circumstances where some patients have had to wait longer than they should for treatment, particularly those being referred urgently for their first treatment. This is something we are working with providers to improve as our priority is to ensure all cancer patients receive the care they need in the quickest possible way. Historically the CCG has performed well in relation to patients waiting for diagnostic tests and have mainly met the national targets. However, the CCG has struggled to achieve the target over recent winter months, due to issues with equipment and winter pressures. We have achieved the target for people requiring psychological therapies services experiencing improvements to their condition. More information on the CCG s performance can be found on MyNHS: NHS Horsham and Mid Sussex Clinical Commissioning Group ANNUAL REPORT 2017/18 15

16 New GP hubs improves service for patients During the busy winter period, new GP hubs offering evening and weekend urgent and routine appointments were piloted throughout Horsham and Mid Sussex. Our local GP Practices reported that the scheme helped them to manage demand for appointments, especially allowing them to continue working with those with long term conditions and completing home visits. 16 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex NHS Commissioning Group

17 A year in performance How the CCG measures performance Horsham and Mid Sussex CCG monitors performance through a monthly Integrated Performance and Quality Report. This comprehensive report has been developed in line with the CCG s ambition to create a health intelligence system to ensure that timely, accurate and appropriate information is available to all relevant staff that will: Support the CCG in delivering its constitutional requirements; Provide an appropriate assurance framework to serve internal and external performance management regimes; and Inform how the CCG commissions and delivers services by understanding about the health (and social) care needs and wants of patients and their experience of the services they use. The report summarises performance and quality against the key areas of key performance indicators and operational standards outlined below and forms the basis of the NHS England assurance: NHS Constitution; CCG Operating Plan; Improvement and Assessment Framework (IAF); and NHS Outcomes Framework. It also contains other exceptional risks or issues at other providers. The bringing together of information, actions and risks allows the CCG to utilise this report at the monthly Quality and Performance Committee and at the Strategic Clinical Commissioning Group and Governing Body meetings. Specific risks against indicators are captured in programme risks registers and are also strategically reviewed through the board assurance framework (BAF). CCG performance rating The IAF was introduced by NHS England in It provides a framework of measures against which CCGs are assessed. Six areas were identified by NHS England and Public Health England as clinical priorities. They are listed in the table below along with the current rating for Horsham and Mid Sussex CCG. This is based on published data. A number of measures are issued annually and a number of them are three year rolling averages e.g. infant mortality figures. The annual assessment for 2015/16 was published 21 July The 2016/17 ratings have been published for three of the clinical priority areas (cancer, mental health and dementia). NHS Horsham and Mid Sussex Clinical Commissioning Group ANNUAL REPORT 2017/18 17

18 Clinical Priority Area CCG Overall Rating Diabetes Requires Improvement Learning Disabilities Requires Improvement Maternity Requires Improvement Cancer Good Mental Health Good Dementia Requires Improvement Each of the Clinical Priority Areas are included in the Integrated Performance and Quality Report and scrutinised as part of the performance governance process as described above. NHS Constitution The NHS Constitution establishes the principles and values of the NHS in England; it sets out the legal rights of patients, public and staff, and further pledges the NHS is committed to achieve and sets out the responsibilities of public, patients and staff. There are a number of core standards which we are measured against. The table below shows Horsham and Mid Sussex CCG performance against each of the NHS Constitution targets. 18 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex NHS Commissioning Group

19 CCG Performance against each of the NHS Constitution Targets Target / Measure Threshold HMS RTT and Diagnostics Period RTT 18 weeks Incomplete >= 92.0% 86.2% Mar-18 RTT 52+ week waiters 0 10 Mar-18 Diagnostics 6 weeks <= 1.0% 3.2% Mar-18 Cancer Cancer - 2 Week Wait >= 93.0% 93.6% Mar-18 Cancer - 2 Week Wait (Breast) >= 93.0% 95.1% Mar-18 Cancer - 31 Day First Treatment >= 96.0% 99.0% Mar-18 Cancer - 31 Day Surgery >= 94.0% 84.6% Mar-18 Cancer - 31 Day Drugs >= 98.0% 100.0% Mar-18 Cancer - 31 Day Radiotherapy >= 94.0% 100.0% Mar-18 Cancer - 62 Day GP Referral >= 85.0% 80.8% Mar-18 Cancer - 62 Day Screening >= 90.0% 100.0% Mar-18 Cancer - 62 Day Upgrade >= 86.0% 100.0% Mar-18 Urgent Care Percentage of patients to spent 4 hours or less in A&E >= 95.0% 91.5% Mar-18 Provider 1 SASH A&E Waiting Times >= 95.0% 90.7% Mar-18 Provider 2 BSUH A&E Waiting Times >= 95.0% 81.0% Mar-18 Mental Health and Dementia CPA 7 day follow-up >= 95.0% 96.9% Q4 2017/18 Dementia Estimated Diagnosis Rate >= 66.7% 70.1% Mar-18 IAPT roll-out >= 15% 4.1% Jan-18 IAPT Recovery >= 50% 55.1% Jan-18 IAPT Waiting Times - 6 Weeks >= 75% 97.0% Jan-18 IAPT Waiting Times - 18 Weeks >= 95% 99.0% Jan-18 Psychosis treated within two weeks of referral >= 50% 100.0% Mar-18 Routine Referrals to CYP EDS (4 Weeks) 95% (by 2020) 71.4% Q4 2017/18 Urgent Referrals to CYP EDS (1 Weeks) 95% (by 2020) 100.0% Q4 2017/18 Children wheelchair waits (18 weeks) >= 92% 73.3% Q4 2017/18 Infection Control MRSA 0 2 Mar-18 YTD C. Diff Mar-18 YTD E. Coli n/a 26 Mar-18 YTD CHC - cases with a positive Checklist have eligibility decision within 28 days >80% 45.0% Q4 2017/18 CHC - NHS CHC assessments take place in an acute hospital setting <15% 39.0% Q4 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group ANNUAL REPORT 2017/18 19

20 There are a number of NHS Constitutional targets where the CCG has not achieved the required standards. These are described in the sections below. Four-hour accident and emergency (A&E) standard The NHS Constitution standard states that 95 per cent of patients should be seen and either treated and discharged or admitted within a maximum four hours of arrival in A&E. Whilst this measure focuses on time spent in A&E, it is an excellent indicator of performance across a hospital. This is because where it is achieved it indicates good flow, bed management and timely discharge. This target is the primary indicator used to assess and report the performance of a trust in the national performance tables. Our local A&E department at the Princess Royal Hospital (PRH) in Haywards Heath (which is part of Brighton and Sussex University Hospitals NHS Trust (BSUH)) treats thousands of patients each year. The target set in the Operating Plan for 2017/18 for BSUH was to achieve 89 per cent target against the A&E standard by March Performance at PRH has been above this target for much of the year but has seen some deterioration over winter. Current performance is 88.7%. Another of our local Trusts is Surrey and Sussex Healthcare NHS Trust (SASH) in Redhill Surrey. Historically SASH performs well against the national 95% target but as with the national picture, winter pressures have resulted in a deterioration of performance. Current performance is 90.7%. 20 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex NHS Commissioning Group

21 Along with many other A&E departments across the country, PRH faces a huge challenge in trying to ensure staff see and treat patients as quickly as possible. A contributing factor to A&E performance is the volume of demand being seen at the Trusts, with PRH seeing a 5.6% growth in the number of A&E attendances compared to last year. The CCGs have been working closely with providers to ensure patients are assessed and treated by the right clinician at the right time improve our patients experience of Urgent care. These include: Additional GP Streaming in A&E; Significant system-wide focus on Delayed Transfers Of Care and stranded patient reductions; Daily system operational calls with all providers to ensure optimum flow out of hospital and use of the operational pressures system escalation framework (known as OPEL) to manage pressure. Continuation of Accountable Officer level twice weekly escalation calls; Implementation of a live bed management system to ensure that every bed is allocated as soon as it is vacated, improving flow, minimising pressure and improving ambulance handover and patient experience; Additional spot purchase beds commissioned and all escalation areas opened to support safe management of patient pathways; System-wide focus on supporting seven day flow with further development of our community responsiveness to support admission avoidance and early supported discharge; and GP practices commenced their extended access hubs across towns during December which has increased urgent access to primary care appointments. NHS Horsham and Mid Sussex Clinical Commissioning Group ANNUAL REPORT 2017/18 21

22 Referral to treatment (RTT) The NHS Constitution states that 92% of patients should wait no longer than 18 weeks from a GP referral to treatment. This is known as the 18 week RTT standard and it has not been met locally for the past three years. The CCG has been committed to meeting this standard during 2017/18; however this has proven a challenge. During this period the capacity at BSUH has not been sufficient to meet the demand which has resulted in a significant waiting list has developed. 22 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex NHS Commissioning Group

23 The winter period has also brought significant pressures with more resources being used to care for those people who are in urgent need. In addition, NHS England asked acute Trusts to pause planned care work for the whole of January which meant that fewer patients waiting for routine care could be treated. To assist performance improvement, we commissioned additional activity at SASH, which would enable reduction in the size of the backlog and in turn, improve the length of time that a patient waits for treatment. This activity commenced in quarter three and continued into quarter four. We have commissioned a range of providers, including other NHS and independent sector organisations, in order to maximise the choices patients have about where and when they received their healthcare. Despite this, the Trust is still facing challenges in meeting the 18 week standard in some specialties. This means that patients who have conditions associated with digestive diseases and neurology, for example, are waiting longer than 18 weeks for their treatment. We have been working with our colleagues at BSUH and neighbouring CCGs to improve a number of patient pathways. These actions include: Wider demand management strategy developed and business case now approved within CCGs with a phased implementation in March. The aim is to monitor referrals, reinforce adherence to clinical thresholds, support referrals in the NHS E-Referral service (ERS), promote advice and guidance and shared decision making; and Working on clinically effective commissioning to develop one process for managing clinical policies. NHS Horsham and Mid Sussex Clinical Commissioning Group ANNUAL REPORT 2017/18 23

24 Diagnostic waiting times The diagnostic waiting time standard states that no more than 1% of patients should wait longer than 6 weeks for a diagnostic test. During early 2017/18, the CCG consistently met this standard. However, over recent winter months both the CCG and BSUH who provide the majority of diagnostic tests for Horsham and Mid Sussex patients have struggled to maintain their performance. This has been attributed to the two scanners that BSUH have at their Princess Royal Hospital site experiencing a number of breakdowns during November and December meaning that the standard has not been met. The Princess Royal Hospital are in the process of having a new scanner installed which means patients will have timely access to the most modern CT scanning equipment. 24 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex NHS Commissioning Group

25 Cancer access The NHS Constitution standards for cancer treatment are: Patients should be seen by a specialist doctor within two-weeks of a referral by their GP for suspected cancer; Patients should be seen within 31 days from when a decision is made to treat; and Patients should be seen within 62 days from an urgent referral to the first definitive treatment for all cancers. NHS Horsham and Mid Sussex Clinical Commissioning Group ANNUAL REPORT 2017/18 25

26 The CCG s performance against the Two-Week Wait standard has been subject to fluctuation this year. Following a change in cancer referral guidance, we have seen growth in the number of 2 week referrals to our providers. Whilst the CCG generally performed well on the 31 day cancer standards, improvements were required on the 62 day wait from an urgent referral for suspected cancer to the first definitive treatment for all cancers. 26 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex NHS Commissioning Group

27 One of the challenges in achieving this standard is the relatively small number of patients on the pathway, therefore it may only take one patient breaching to cause the standard to be failed. In addition to this, many cases can be complex or transferred from another Trust which can also cause delays to the pathway. This is an area which Providers have been focusing on this year, as late inter -Trust transfers can be detrimental to the patient receiving treatment within the 62 days. Surrey and Sussex Cancer Alliance have outlined 5 high priority groups; Breast, Lung, Lower Gastrointestinal, Upper Gastrointestinal and Urology, to deliver system wide change. CCGs are working with Public Health colleagues to support programmes of prevention including addressing risk factors of smoking; excess weight, diet, inactivity and alcohol consumption through public health initiatives and strategies. We are also going to monitor the new national standard which is 28 days from referral to either a definitive diagnosis or cancer being ruled out. This will start in June NHS Horsham and Mid Sussex Clinical Commissioning Group ANNUAL REPORT 2017/18 27

28 Mental health access targets Delivery of the 50 per cent recovery target for improving access to psychological therapies (IAPT) services has been met within Horsham and Mid Sussex historically. More information on the CCG s performance can be found on MyNHS here: 28 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex NHS Commissioning Group

29 A year in quality and safety The delivery of high quality care is at the centre of the CCG s vision and values. We are dedicated to ensuring all commissioned services on behalf of the resident populations are of the highest quality and are delivered with respect and compassion and provide a positive patient experience. During 2017/18, to continue to ensure that quality, safety and safeguarding are at the forefront of the development of new services and to provide robust assurance of our patient services, the CCG Quality teams across the STP area have been aligned as one team, led by the Chief Nurse. The alignment of these teams will enable our staff to use their extensive clinical knowledge and skills to influence service providers and inform the commissioning cycle. This quality report describes the key responsibilities and work which has delivered improvements to quality and safety and outcomes for our population. Quality improvement Our vision for the CCG has always been to reach out to the communities we care for and our patient experience lay members have been reaching out to engage actively with the local communities. Our focus on quality has played an essential role in helping us to ensure that we commission safe, effective, services which provide our patients with the best possible experience of the NHS and we continue to work with our provider organisations to ensure that patients, their families and carers are treated with compassion, respect and dignity, in safe environments and protected from harm. We take an active part through a range of formal and informal reviews, discussions with service providers, use of contractual levers, and through the implementation of quality improvement plans. Additionally we work alongside a quality assurance framework that incorporates: Obtaining assurance of commissioned service quality; Monitoring quality performance against agreed standards and outcomes; Carrying out surveillance of safety, effectiveness, patient experience, leadership, culture and responsiveness (CQC Domains); and Use of the Commissioning for Quality and Innovation (CQUIN) payment framework to link to local quality improvement and transformational plans. NHS Horsham and Mid Sussex Clinical Commissioning Group ANNUAL REPORT 2017/18 29

30 The main CCG provider organisations are as listed below and the remainder of this report outlines the activities in the CCG during 2017/18 across the domains of Patient Safety, Patient Experience and safeguarding Adults and Children. The main CCG providers are: Surrey and Sussex Healthcare Trust; Brighton and Sussex University Hospital Trust; Sussex Community Foundation Trust; Queen Victoria Hospital; Sussex Partnership Foundation Trust; SECAmb 999/111; IC24; and Sussex MSK partnership. Serious incidents (SIs) The CCG discharges its duty for approving closure of SIs undertaken by providers, by commissioning a patient safety service that provides oversight and effective management of serious incidents for all providers. This includes the convening of a fortnightly serious incident scrutiny group meeting and includes membership of CCG quality teams from across the STP aligned teams. Each meeting is attended by either a Chief Nurse or Head of Quality and has a structured and standardised approach to ensuring standards are met by providers to undertake robust investigations, and identified actions are put in place that would either eliminate or minimise the chance of a similar event occurring again. Assurances that actions have been taken are followed up at monthly contractual quality review meetings. Infection prevention and control CCGs and provider organisations continue to have reduction targets for incidence of Clostridium difficile (CDI) infections in 2017/18. Surrey and Sussex Hospitals NHS Trust (SASH) have identified lessons to learn to improve patient care. There was significant evidence that lessons learned from previous years and recommendations developed by SASH, in addition to a management of diarrhoea project, have been implemented and have resulted in improved patient outcomes. There remains a zero tolerance approach nationally and locally for methicillin resistant Staphylococcus aureus blood stream infections (MRSA BSI) which continues to be investigated by providers and CCGs. A number of infectious outbreaks have affected the locality resulting in ward or bay closures within both acute and community inpatient beds, nursing homes. During an influenza outbreak, when appropriate, antivirals are given as prophylaxis treatment to high risk 30 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex NHS Commissioning Group

31 patients, residents and staff. In 2017/18 the uptake of staff and the public receiving the flu vaccination has improved from last year s trajectories. Reducing gram negative bacteraemia We are implementing a number of initiatives to achieve the Public Health England ambition target of reducing Healthcare associated gram negative bacteraemia by 50% by Plans include education programmes, awareness raising and support for care home staff and medicines management information for GP surgeries to reduce the use of antibiotics. Managing sepsis We have embarked on a comprehensive improvement plan to increase awareness of Sepsis in our acute and community care providers and GP practices in primary care; educated clinicians to recognize early the signs of sepsis and treat effectively using the National Early Warning Score (NEWS); ensure that Health Education England resources around sepsis are widely shared and used. We are establishing forums where learning from community acquired and hospital acquired infections is shared, jointly understood as a whole system and mitigated through improved practice, communications and clinical engagement. Workforce development Despite a growing workforce, NHS staff are under real pressure. The number and complexity of the patients they care for continues to increase. Some geographies and types of job are hard to recruit to. Further challenge arises from ongoing pay restraint and uncertainty for our international staff. Given these well understood pressures, frontline NHS staff say their experience at work continues to improve, with overall employee engagement scores now at a five-year high. One significant achievement for the team has been the production of a handbook for care workers in care homes and for home carers, called the Stop Look Care tool, which is an educational tool to support care staff undertaking the National Care Certificate, as well as being a reference guide for families and carers to increase awareness of health needs and identify when referrals may be needed if concerns are identified. This project was nearing completion in 2016/17 but this year has seen its implementation and early evaluation has confirmed it has prevented hospital admissions. It has attracted a significant amount of positive interest elsewhere in the country and several requests have been made from other CCGs for it to be replicated, and the team has presented it at regional and national forums. The plan for 2018/19 is to develop a Stop Look Care tool dedicated to mental health care. During the year the team has organised protected learning schemes for GP Practices with four internal and two larger external events. The subjects have been identified based on training needs identified by Practices, as well as CCG clinical strategies. A Primary Care Workforce Tutor supports the development of the workforce in general practice. NHS Horsham and Mid Sussex Clinical Commissioning Group ANNUAL REPORT 2017/18 31

32 Patient experience The CCG takes complaints very seriously and the Accountable Officer for the CCG reviews and responds, ensuring that they are aware of the issues and wider learning. The quality team ensures triangulation of information is shared across service providers, commissioners and external stakeholders. The Patient advice and liaison service (PALS) works on our behalf to gather patient s feedback on the services we commission. Each person s view is taken into account so we can ensure each patient s experience is an individual one, delivered to the highest appropriate standards that we all expect from healthcare. Safeguarding adults, children and looked after children All CCGs hold statutory responsibilities to ensure that the needs of children and adults at risk of abuse, or suffering abuse, are addressed in all the work that we undertake and commission on behalf of our population. Our Accountable Officer has overall responsibility for safeguarding, with our Chief Nurse fulfilling the role of executive lead for safeguarding. The safeguarding team covers the whole of West Sussex, working for NHS Coastal West Sussex CCG, NHS Horsham and Mid Sussex CCG and NHS Crawley CCG and works closely with West Sussex County Council (WSCC). Key updates for 2017/18: Successful and continued inclusion of Safeguarding Standards into the rigorous quality and safety systems and processes the CCGs use to monitor providers. This comprises an assurance tool, quarterly exception reporting, site visits and audit and has informed the quarterly reports to the Quality and Performance Committee; Continued work with the West Sussex Safeguarding Adults and Children Boards, multi-agency partners and subgroups, participating fully as members of the panels and authors of the reports, on behalf of the West Sussex CCGs, for all Serious Case Reviews, Safeguarding Adult Reviews, Domestic Homicide Reviews and Learning Reviews; There are five Serious Case Reviews in progress for children with agreement for a further SCR. Two SCRs have been published in the last six months and work is ongoing with the resulting action plans; Continued work with provider organisations to ensure action planning and monitoring of identified actions following Serious Case Reviews, Safeguarding Adult Reviews, Domestic Homicide Reviews and Learning Reviews; Engagement with providers regarding the Prevent agenda. Assurance work around the Prevent Duty and compliance with the March 2018 deadlines; Continued work with NHS England to fulfil the national safeguarding priority areas of Mental Capacity Act, Child Sexual Exploitation and Sexual Abuse, Domestic Abuse, Female Genital Mutilation, Prevent, Modern Slavery, Safeguarding Reforms, Neglect, Looked After Children, and Unaccompanied Asylum Seeking Children; 32 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex NHS Commissioning Group

33 Continued delivery and support for high quality safeguarding training and development within CCGs, provider organisations and primary care; Following the Wood Review and consultation for the updated Working Together statutory guidance (expected publication Spring 2018) it is anticipated that requirements within the updated document are likely to present significant challenges to CCGs in 2018/19; Funding was secured from NHSE for a full time Mental Capacity Act lead professional post for 2017/18. This post has worked across the health economy to offer advice and support, deliver training and raise awareness to increase compliance; working with providers and Primary Care; The Child Sexual Exploitation (CSE) specialist nurse role has been in post during 2017/18. This role has proved invaluable in enabling strong and trusting professional pathways to be developed and has enhanced the communication between agencies; The Missing and Exploitation Operational Group (MEOG) has met weekly to address concerns raised around individual children s risk of CSE at an operational level ensuring that the services provided are appropriate and skilled to support the individual child. Alongside this, a new Complex and High Risk Adolescent service is currently being piloted. This operational group of key partners (health, police and social care) has been developed to focus additional resources on those children for whom the risks continue to increase even with the support provided. Bespoke packages are created in order to meet their needs and reduce risk; In addition training has been provided over the past 12 months to raise the profile and understanding of CSE. Further review is to take place in 2018/19 of the STP 8 CCGs Safeguarding team and of the priorities to ensure sustainability, meeting CCG statutory duties, and to keep our local populations safe from harm; and There has been dedicated health resource in the Multi-Agency Safeguarding Hub (MASH). Nationally safeguarding activity is increasing and this is also reflected locally. NHS Horsham and Mid Sussex Clinical Commissioning Group ANNUAL REPORT 2017/18 33

34 order to meet the health needs for Looked After Children. With particular emphasis on the timeliness of initial health assessments and the health needs of Looked After Children placed in West Sussex by other local authorities. Looked after children The Statutory guidance for promoting the health of looked after children (DOH, DfE 2015) states that: Local Authorities, CCGs, NHS England and Public Health England must cooperate to commission health services for all children in their area; and CCGs and NHS England have a duty to cooperate with requests from local authorities to undertake health assessments and help them ensure support and services to looked-after children are provided without undue delay. The CCG is committed to improving services so that looked after children have access to consistent provision of quality assured services, which promotes the optimum health and wellbeing of the individual child and improves their health outcomes. During 2017/18 the designated professionals and CCG: Developed an action plan following the TIAA Audit of Looked After Children health provision within West Sussex, which highlighted some key areas for improvement; and Continued to develop services in line with the actions identified in There has been continued partnership work with West Sussex County Council (WSCC) and the West Sussex Safeguarding Children s Board (WSSCB). The Designated Professionals are also members of the Multi Agency Children Looked After Improvement Group (MACLAIG) which is a multi-agency partnership whose work plan is underpinned by the WSCC Children Looked After Strategy. Improving care for people with learning disabilities Every CCG quality team has key responsibility for implementing two national priorities: Transforming Care this is the programme of work to ensure that people residing in hospital settings, often out of the local area, are transferred to local services in the least possible restrictive settings. The CCG currently has no in-patients but continues to work collaboratively with our CCG colleagues across the STP landscape to ensure every patient has been transferred to local services. Undertaking mortality reviews for every person with a learning disability over the age of four years, known as the LeDeR programme. This programme went live for Sussex in September Three Local Area Contacts have been identified for Sussex and a bank of approximately 40 people has been trained to undertake mortality reviews. The 34 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex NHS Commissioning Group

35 findings and recommendations from reviews are reported to a Sussex steering group, chaired by the Chief Nurse for Crawley and Horsham and Mid Sussex CCGs, with the aim of informing commissioning and quality improvements to be made across the health and social care economy for people with learning disabilities Further information on services for people with learning disabilities can be found on page 48.. NHS Horsham and Mid Sussex Clinical Commissioning Group ANNUAL REPORT 2017/18 35

36 Mental health service for new mums During the year we commissioned a new community-based Specialist Perinatal Mental Health Service (SPMHS) for mums with severe mental health difficulties either now or in the past, during pregnancy or up to a year after birth. The service is provided by Sussex Partnership NHS Foundation Trust and provides weekly phone and face-to-face clinics at a range of different birthing, maternity and community sites. Clinics are led by consultant psychiatrists, specialist perinatal mental health practitioners or joint psychiatric and obstetric teams. 36 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex NHS Commissioning Group

37 A year in commissioning Our programmes Transforming primary and community care In 2017/18 as a CCG we have sought to further embed our work to develop new models of care, inspired by evidence from the National Vanguards Programme. We are clear that the development of locality care delivery hubs or Primary Care Homes, made up of groups of geographically contiguous general practice working in an integrated way with wider community based professionals, are central to the successful development of our emerging Integrated Care System and our STP vision to provide more care and services closer to patients homes. Our work is centred on delivery of four clinical priorities but tailored to meet the needs of local populations and circumstances in each of our five towns. Achievements and areas of progress in these priority areas include: Improving primary care access In November 2017 we opened up GP access hubs in each of our towns to provide a mix of additional in hours and some extended hours capacity over the busy winter period when it can be more challenging for patients to get a GP appointment. Initial evaluation has demonstrated that they are working well, have created much needed additional capacity in primary care, and are popular with practices and patients; and We have also sought to improve access to routine non-urgent care working with the MSK partnership to roll out self-referral to physiotherapy to all our towns. Improving continuity of care for patients with long term conditions We have introduced a revised specification with our community, mental health and social care providers for our multidisciplinary teams (MDT) that wrap around groups of general practice in each of our towns moving towards a population responsibility approach. This means that all patients with a risk of hospital admission above 50% will go on their caseload so GPs won t have to refer patients of concern and wait for an assessment they should already know them and have developed a care plan. We NHS Horsham and Mid Sussex Clinical Commissioning Group ANNUAL REPORT 2017/18 37

38 have introduced a daily huddle which allows general practice staff, pharmacists and wider community and MDT staff to dial in and discuss patients of concern on the day. The MDT will then coordinate the services required to support the patient and their carers. This is having a positive impact meaning fewer patients are being admitted to hospital when they didn t need to be; and We are bringing specialist support nearer to patients with some consultants developing local roles in the community, for example a respiratory consultant doing one session a week supporting reduction of COPD emergency admissions, linking in with GPs and specialist nurses. We have also established consultant mentoring arrangements for specialist heart failure and COPD nurses. Improving coordination for the most complex and frail patients Our MDT team is now providing more intensive coordination and support for the relatively small number of our most complex patients to help avoid hospital admission wherever possible and enable rapid discharge when they are admitted; These patients are being better supported by the responsive services team and specialist nurses who have refocused their efforts to provide rapid response helping patients to stay in their own homes wherever possible; and We have started a focused piece of work to define our end of life care strategy and dedicated workstreams around support for falls and care homes. Providing greater support for prevention and self-care We have sought to embed initiatives such as social prescribing which connects people to services and community resources; We have appointed Age UK voluntary sector link workers in the 4 MDTs in HMS to support patients who have non-medical needs which need to be addressed such as social isolation; and Supporting patients to have the knowledge, skills and confidence to manage their own condition through patient activation and building on the success of tailored health coaching in both CCGs. The model also helps address the workload and capacity challenges experienced in general practice and community-based health and care services by implementing a more coordinated service, improving patient experience and outcomes, with patients seeing the right professional at the right time based on their needs, while increasing the value of the NHS investment. We have been implementing a number of general practice specific measures during 2017/18 in recognition of the increasing challenges primary care faces with an ageing local population, living with chronic conditions alongside challenges in recruitment and retention of the primary care workforce. As well as looking to implement new model of care, we have begun to implement measures set out in the General Practice Forward View including: 38 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex NHS Commissioning Group

39 Initiating procurement of extended access to GP services, including at evenings and weekends, for 100% of the local population by 1 October 2018; Providing bespoke resilience support to individual vulnerable practices and supporting the development of a local federation of general practices to provide longer term resilience by working through working at scale; Providing training support for practices to improve workflow and workload and free up GP time to provide direct patient care; and Supporting practices to test out new roles to help address workforce and recruitment issues and pressures in more traditional roles bringing in more clinical pharmacists, paramedic practitioners and medical assistants. Improving mental health The financial year 2017/18 has been a very successful one in how the CCG has improved mental health and dementia services for the local population of Horsham and Mid Sussex. Working closely with many partners, and through a clear and challenging strategy to improve and transform services, we would like to highlight three areas of achievement. Firstly, performance of services. A large number of national targets and standards have been met and exceeded. These include: Ensuring people in need of urgent help are seen by a Mental Health professional inside 4 hours; Where someone s need is not urgent but waiting the standard 28 days would be too long, we have continued to focus on the significance of people being seen inside 5 days. This priority referral category target has been exceeded, meaning people are seen more quickly and more effective help can be mobilised earlier; Our Improving Access to Psychological Therapies service (IAPT ), called Time To Talk, has further improved through successfully bidding for an enhanced service, focusing on people who have long term conditions. Growing numbers of patients now benefit from having their physical health needs, such as diabetes, heart disease and COPD, treated in an integrated way with psychological support. Our local IAPT service remains in the top 10 services in England in helping people recover from common mental health problems like depression and anxiety; and The dementia diagnosis rate in Horsham and Mid Sussex CCG has exceeded the national target and at January, 2018 stands at 71.5%. This is the highest rate in the SE of England. There are a number of performance areas we wish to improve, including improving how people can more easily access urgent and crisis around the clock. NHS Horsham and Mid Sussex Clinical Commissioning Group ANNUAL REPORT 2017/18 39

40 Secondly, communicating and engaging with our local population and patient representative groups. This is incredibly important for us, and by talking with people about what type of preventative and early intervention support services they would find most helpful, this shaped the new targeted mental health service for people where a mental health difficulty first emerges or re-emerges in a primary care / community setting. This service is called Pathfinder and brings together a group of providers under a common cause of integrated, easily accessible support. This help is flexible to people s individual situation where interventions are effective in addressing the cause/s of escalating mental health difficulties, such as housing, employment, debt, and family issues. Thirdly, parity of esteem for mental health. In line with national requirements, and the increasing focus on the importance and priority of mental health, Horsham and Mid Sussex CCG has increased investment in key areas of mental health. This is not only to meet the nationally mandated requirement for CCGs to spend more on mental health, i.e., meeting the Mental Health Investment Standard, it is because our local population and clinicians say and know how important mental health support is to patient recovery, support and independence longer term. This focus, particularly integrating physical health and mental health, will continue to grow in future years. service, creation of the local maternity system transformation plan and focusing on managing demand for children s urgent care services. Perinatal mental health Horsham and Mid Sussex are the lead commissioners for the STP wide specialist community perinatal mental health service. The new service is commissioned to focus on the complex/moderate women who make up 5% of the women giving birth. The specialist service also provides training for services that work with women in the perinatal period. Along with the new service specialist perinatal mental health midwives and health visitors roles have been created to support women and disseminate best practice. Local maternity system We have been working with CCGs across the STP to produce our transformation plan of how we will meet the key recommendations of the Better Births Five year Forward View for Maternity Care. The focus of the transformation plan is to deliver care which is woman-centred in organisations which are well led and in cultures which promote innovation, continuous learning, and break down organisational and professional boundaries. Children young people and maternity The priorities for the children and maternity team for 2017/18 have been to implement the new specialist community perinatal mental health 40 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex NHS Commissioning Group

41 Children s urgent care Our urgent care project has been focusing on ensuring that children and young people access the most appropriate urgent care services for their needs. This included: Promotion of the new children s area of the Crawley Urgent Treatment Centre; East Grinstead GPs launched an initiative GP not A&E which provides same day GP appointments for under 5s; Holding urgent care assemblies to educate parents through their children about the alternatives to A&E; and Podcasts and videos being made available to parents promotion the urgent care pathways and promoting alternatives to A&E e.g. local pharmacies. Children s community services As part of plans to ensure that all patients receive the same children s community services we have changed the arrangements for Mid Sussex patients. Formerly children who were under the care of clinicians at Brighton and Sussex University Hospitals NHS Trust were seen by their nurses, and the remainder of children needing nursing support, in the community by Sussex Community Foundation Trust. This means that children will now have only one team providing their care. resulting in five main areas for change: The diagnosis pathway families reported long waiting times and confusion about the roles of professionals on the pathway; Support for families families told us that they would like more training, information and individual support before, during and after a diagnosis; Support in schools families were not confident that school staff were able to understand and manage challenging behaviours and some of the problems that young people with autism or ADHD may face in school; What if it s not autism/adhd families reported feeling excluded from support if their child was waiting for, or had not received a clear diagnosis; and Transition Families wanted to feel confident in transition, whether transition meant school to college, primary to secondary or life transitions such as adolescence, change in family circumstances e.g.: divorce, moving home. Neurodevelopment A detailed scoping exercise was undertaken to identify the main challenges for families on the neurodevelopmental pathway, NHS Horsham and Mid Sussex Clinical Commissioning Group ANNUAL REPORT 2017/18 41

42 Medicines management The medicines optimisation programme of work for 2017/18 has focused on supporting GP Practices in primary care. Our CCG pharmacy teams have engaged with prescribers in ensuring that policies and procedures are in place and that prescribers have the most up to date information to make prescribing decisions and optimise medicines for patients. The medicines management team have continued to develop the role of the pharmacist and pharmacy technician in primary care through the Community of Practice initiative for 2017/18. The pharmacists and technicians have supported the primary care multidisciplinary teams and the integrated response teams to manage the most vulnerable groups in the community. Our CCGs have started a polypharmacy project in collaboration with East Surrey CCG and the Academic Health Science Network. As we are living longer with more chronic and long-term diseases, it is becoming increasingly common for people to be prescribed many medicines; sometimes ten or more different types of medicines each day. We have been working together to develop a set of comparators to identify people who are potentially at risk from polypharmacy. To support this, we have recruited additional pharmacists to conduct medication reviews in care homes. The objectives for the polypharmacy project are: Improve patient outcomes and quality of life; Optimise medications ensuring all prescribed medication is appropriate and beneficial; Quantify cash releasing savings from reducing problematic polypharmacy; Reducing medicines waste; and Prevent/reduce hospital admissions. In addition to this, polypharmacy will support other CCG work programmes such as end of life, frail elderly and patients with long term conditions. The medicines management team have also worked with other CCG medicines management team to ensure that there is equity in patient care across a wider landscape to support the STP footprint. Within specialised commissioning services, we have reviewed and served notice on a number of legacy arrangements that fall outside of the national tariff exclusion list. Reporting of actual spend against budget has supported on-going budgetary management. The challenge process has been revised to ensure it is robust and standardised around providers, this work has been linked with finance and contracting to ensure credits are received back into the CCG. We have been working with providers to maintain assurance on adherence to NICE as well as increasing the utilisation of blueteq to provide an ongoing audit trail. The team have developed and supported a number of initiatives such as implementation of biosimilars, which have resulted in improved access to cost effective treatment options. With the development of the Central Sussex and East Surrey 42 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex NHS Commissioning Group

43 Commissioning Alliance, the high cost drug leads at the four CCGs have developed a centralised model for the management of high cost drugs including, the operational management of blueteq which is expected to go live in 2018/19. Technology to empower patients The NHS recognises that an integral part of building a health service fit for the needs of our population is harnessing the power of technology to empower our patients and make health services work better together. Last year we began to refine and implement our plans to deliver Digital Enablement: that is the ability for our IT systems to share patient information and work together. We are now beginning to deliver elements of this programme that will ensure our systems keep pace with the developing needs of our population. We have also been working closely over the last 12 months with our clinical workforce to better understand how technology can deliver real benefits to those delivering care and our planning for the next 12 months reflects heavily on a digitally enabled workforce. deliverables such the NHS E-Referral Service (ERS) with many specialties now enabled in ERS. We have also worked to improve our performance in relation to Patient Online which is the service that enables patients, among other things, to view their GP record. Cyber Security has featured heavily this year and remains a high priority for the CCG both in the development of our response plan and our defence. Our staff are the first line of defence in the fight against Cyber-crime and we have for the first time added Cyber Security awareness as part of our mandatory training. We will continue to raise awareness of this constantly evolving threat and will build on the training to ensure we have the right access to Cyber Security expertise within the CCG and through our strategic partners. There has been significant development this year with regards to our ability to use data to support our planning and commissioning. Working in partnership with Docobo we have been able to enhance the functions of the primary and secondary care information available in the risk stratification tool. Additional functionality has been created to: This year the CCG has become an early adopter of GP Connect. This vital stream of work is developing the infrastructure to enable real time sharing of patient information across clinical systems. This project is focused initially on the delivery of a read only record access view, with scope in the future to enable full read and write capability along with appointment booking. Understand highly frail patients and contributing risk factors; Correlate the potential of information to understand organ and function deterioration in patients potentially reaching end of life; and Integrate mental health data with primary and secondary care to understand whole patient needs and address both mental and physical health equally (parity of esteem). We have built strong relationships with the acute trusts locally to partner in the delivery of key NHS England The information is now being utilised to integrate it into pathways that provide collaborative conversations between NHS Horsham and Mid Sussex Clinical Commissioning Group ANNUAL REPORT 2017/18 43

44 primary, community, hospice and mental health providers to integrate care as well as early intervention initiatives that are aligned to strategies. Critical to our continued success are the partnerships that have formed across our health and care system. We have developed strong relationships through our Digital Steering Group and Programme Board and we are wholly committed to using our combined efforts and expertise to make a positive impact for our citizens. Key activities through the year have been: Digital enablement of GP hubs; Securing additional funding through the Estates and Technology and Transformation Fund process to deliver the Digital Roadmap; Development of a primary care clinical decision support tool; and Creation of an STP wide Information Sharing Protocol. Urgent care Urgent, same day and emergency care can often be fragmented and confusing for patients to navigate. During 2017/18 we continued to commission local services across a range of providers and pathways to provide easier navigation and simplified patient access routes into urgent care services. With an overarching aim to ensure patients in our local community receive the right urgent and emergency care in the right place by the right person at the right time. Through partnership working across acute, community, primary care and social care services we continued to build on our vision for truly integrated local urgent and emergency care. Over 2017/18 our urgent care schemes of work have supported the timely and continual improvement of admission pathways and processes. These include: Supporting new ambulance response times, conveyance pathways and alternatives to conveyance to A&E; Reviewing, developing and embedding ambulatory care and frailty pathways: and Promoting the use of the newly updated Crawley Urgent Treatment Centre and new Clinical Assessment Unit, Kingsfold and Pendleton units at East Surrey Hospital. The CCG is currently working with service providers to meet the new guidance on Urgent Treatment Centre standards and in partnership on the reduction in A&E attendances and non-elective admissions. At the front door of A&E at SASH and PRH the introduction of clinical streaming to a GP is designed to manage demand, reduce waiting times and improve the patient experience. We have also been working on schemes that support safe discharge of patients out of hospital and reduced delayed transfers of care. To achieve this we have worked in partnership with neighbouring CCGs, health, social care and voluntary sector providers to improve the patient s journey and flow from admission to discharge. A pilot scheme has commenced at SASH and PRH based on the Discharge to Assess D2A-Home First and trusted assessment model whereby full assessments of ongoing needs can take place in the patient s usual place of residence. The scheme closely links 44 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex NHS Commissioning Group

45 with the Hospital Rapid Discharge Team at Princess Royal Hospital and Integrated Discharge Team at East Surrey Hospital and multi-agency accelerated discharge events (MADE) to improve timely discharges. Centralisation of hyper-acute, acute stroke and early stroke rehabilitation services at Royal Sussex County Hospital and East surrey Hospital; and Throughout the year there has been a proactive focus on greater system resilience, escalation to manage capacity and demand and to meet the four hour standard of 95%. During the winter period the predicted seasonal spike resulted in increased demand for urgent and emergency care services, additional pressures have included managing flu outbreaks in some of our in-patient units. During winter we commissioned spot purchase nursing home beds to support discharges. Improved communication during system escalation has helped to forge greater partnership working across the locality. Stroke In the last year the redesign of stroke services for the CCG was driven by the need to improve the quality of services in line with local and ever more challenging national clinical standards. February 2017 saw the culmination of a comprehensive redesign of stroke services in the area incorporating: Creation in October 2017 of a new community based Responsive Service rehabilitation service 7 days a week, enabling early supported discharge for stroke patients; Improved access to highly specialised inpatient rehabilitation for those patients who require longer term rehabilitation. The Early Supported Discharge (ESD) Team received their first patients in October Since then the team are focusing on improving both the quality of care and the performance of the team, with reporting on performance indicators developed to monitor and evaluate the service. The team was established using experienced neurological therapy staff working within our Responsive Services team. The organisation of care was based on review of the evidence base. The aims of the service are to achieve patients/ carer outcomes as per evidence base by: Providing appropriate, patient centred rehabilitation at home; Facilitating early discharge home from the Acute Stroke Unit at both Brighton and Sussex University Trust and Surrey and & Susses Hospitals; Maximising rehabilitation within home environment and community; Providing a rehabilitation programme for approximately 6 weeks; and Centralisation of longer term inpatient community stroke rehabilitation services in a reprovisioned stroke ward at Crawley Hospital; Signposting to the voluntary services who can provide ongoing support for life after stroke, to minimise social isolation and loneliness. NHS Horsham and Mid Sussex Clinical Commissioning Group ANNUAL REPORT 2017/18 45

46 In addition the service supports patient flow by reducing transfers to inpatient rehabilitation beds in community hospitals and reducing length of stay for those mild to moderate stroke patients in hospital who are eligible for ESD. The benefits of the service for patients and their families are: Decreased length of stay in hospital improved mood, decreased anxiety for both the patient and their family and carers; Increased participation in rehab in own environment, assisting lifestyle changes and secondary prevention; and Increased integration back into the community. GP Practices in the area have continued to work on improving the identification of, and providing optimum treatment to, those patients who have Atrial Fibrillation, to reduce their risk of having a stroke. Planned care The priorities for the Planned Care Team for 2017/18 have been to manage demand for planned care services and ensure that pathways are clinically effective and delivered in a timely and affordable way, thereby reducing waiting times for patients. Demand management Our demand management programme has been focussed on reducing variation in GP referrals not always easily explained by different demographics, health needs or practice populations. During the first four months of the year we piloted a Clinical Peer Review scheme with all our GP practices and the findings of this helped to inform the Business Case for our Referral Assessment Service (RAS) which will go live in March. The aims of the service are to support consistent application of our commissioning policies and thresholds for treatment, promote the use of Advice and Guidance and patient shared decision making and the roll out of ERS. All of this means our patients will have access to the right planned care services at the right time, reducing Referral to Treatment Times for clinically appropriate referrals. Clinically effective commissioning programme (CEC) We also have been working very closely with our commissioning colleagues across the STP area to review and agree a common set of commissioning policies and thresholds. This will ensure that we only commission those services which have a strong clinical evidence base and frees up resources to be directed to the areas of highest priority. The review of CCG Clinical Policies is partially concluded and some changes have already been implemented this year. Further changes to pathway, thresholds and services will be introduced during 2018/19. The Programme also recommended an optimal referral process and the outputs of this work also informed our Demand Management programme. Streamlining patient pathways Our other priority for the year has been to implement new models of care that minimise face to face appointments and unnecessary steps in the patient pathway. We have also been working with providers to streamline patient 46 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex NHS Commissioning Group

47 pathways and address areas of unwarranted variation identified by national benchmarking data such as Right Care, Getting it Right First Time (GIRFT) and Doctor Foster. We have implemented a new cardiology pathway for angiograms with BSUH and a straight to test pathway for lower Gastro-Intestinal conditions. Advice and guidance We have been working with our provider organisations to implement an Advice and Guidance Service. This means that GPs will be able to access specialist advice, with guaranteed response times, prior to referring a patient for treatment. The benefits of this are that GPs are supported to make informed decisions and agree appropriate treatment plans, only those patients that need referral to hospital are referred, and relationships with consultants in secondary care are improved. Cancer The focus for cancer for this year has been around managing the performance of the acute trusts to ensure that people are treated in a timely manner and ensuring that the NG12 referral forms have been rolled out across the area. Patient transport service Patient Transport Service is a nonemergency service provided for medically eligible residents of Sussex who require support in getting to their appointments. The previous annual report summarised the operational challenges for that year and the decision to transfer the service from Coperforma to South Central Ambulance Service NHS Foundation Trust (SCAS). The contract itself is managed by NHS High Weald Lewes Havens CCG on behalf of all Sussex CCGs. The process is integrated through a Sussex wide Programme Board and a contract review process involving all the CCGs. The management of the contract for next year is currently under review. The 1 April 2017 saw the completion of transfer of all services over to SCAS; patient transfers and discharges having been transferred a month earlier. Significant pre-transfer preparation between SCAS and the CCG saw a relatively smooth and safe transfer. Additional resources were utilised in the first few months to ensure the service was maintained to a high standard. Although this resource level has now reduced to normal levels the performance has been maintained. The service model which utilises local quality sub-contractors has been maintained and built upon by SCAS and the operational and quality performance on the contract continues to show improvements. There are areas within the contract which the CCGs are keen to work with SCAS to improve further however the contract is in a substantially better position than it was in 2016/17. Furthermore, the most recent Health Watch report showed improved customer satisfaction in the reliability of the service. Integrating health and social care Joint commissioning The CCG continues to commission services in partnership with Coastal West Sussex CCG, Crawley CCG and WSCC. Joint commissioning is delivered and managed through the NHS Horsham and Mid Sussex Clinical Commissioning Group ANNUAL REPORT 2017/18 47

48 Joint Commissioning and Partnerships Directorate that works across partner organisations and includes: Mental Health services, Services for Learning Disabled adults, Community and Mental Health services for children and young people (outlined above), and The Better Care Fund. Joint Commissioning reports through the Joint Commissioning Strategy Group to the Health and Wellbeing Board, as well as to the three West Sussex CCGs and WSCC. Our partnership and joint commissioning arrangements across West Sussex are an important part of our journey towards Health and Social Care integration. We have many examples of jointly commissioned services delivering integrated care to patients and service users and strategic intent to develop further jointly commissioned, integrated services. This year, we have worked closely together as three CCGs and WSCC to establish our intent and define our high level joint commissioning strategy. We have agreed that there should be a West Sussex place within the STP, and with Health and Wellbeing Board support, we are working to scope new areas for collaboration and integration. We plan to move our intentions forward at pace through 2018/19, using the Better Care Fund to enable collaborative solutions to system wide issues. Learning disability for individually eligible customers. Increasing numbers of customers and costs of provision have placed considerable pressure on this service and presented challenges for providers to respond to increasing complexity of need and demand. Despite the volatility and vulnerability of the care market, the joint commissioning partnership has continued to support services that are integrated at the point of delivery for our Learning Disabled customers. Further information on services for people with learning disabilities can be found in the section A year in quality. West Sussex Better Care Fund The West Sussex Better Care Fund (BCF) footprint is a partnership across West Sussex CCGs and WSCC. In 2017/18 the pooled budget totalled 73.58m, which included funding for Maintaining Social Care, Care Act, Reablement, Carers and Disabled Facilities Grant. The West Sussex BCF programme is focused on three core areas of work of Crisis management, Long term conditions and Prevention, which align to the strategic direction of addressing a frailty plan overall without age boundaries. West Sussex was identified as an area of good practice and was involved in the national support offer through jointly delivering the Measuring Success Masterclasses; a national Webinar, and through engagement with the Social Care institute of Excellence. Services for Learning Disability (adults) are commissioned through a pooled budget with Coastal West Sussex CCG, Crawley CCG and WSCC. The pooled budget predominantly funds packages of care 48 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex NHS Commissioning Group

49 Engaging people and communities We have a duty to ensure the services we commission meet the needs of our local population, As such, we engage with and involve patients, carers and the public in our work in order to make sure the services we commission are responsive to need and deliver the best possible standards of care. Engagement in commissioning We have continued to ensure that we put the views of patients, carers and the public at the centre of our commissioning. We conducted a survey to gather the views of local residents on GP services extended access (offering care in the evenings and at weekends). This feedback has been used in conjunction with clinical expertise to shape availability of these services. Our commissioners worked with women and their families when implementing the Better Births action plan in addition to the launch of the Specialist Community Perinatal Service in September Commissioning Patient Reference Group (CPRG) The CPRG comprises representatives from GP practices, Healthwatch and local voluntary organisations. Members monitor and provide feedback on the CCG s engagement plans. The chair of this meeting is the Lay Member for Patient and Public Engagement, who is a voting member of the CCG Governing Body and other key CCG decision-making forums, and who champions the patient voice at all levels of the organisation. The Commissioning Patient Reference Group oversees many of our commissioning plans, and helps assure compliance as regards patient and public engagement. Patient Participation Groups (PPGs) We continue to develop PPGs to both support primary care and to gather wider patient views. The CCG has developed good links with PPGs via the CPRG, which helps to gather feedback to inform our ongoing commissioning work. Commissioners continue to work with relevant stakeholders and local forums to support understanding of urgent care advice and guidance for parents. We have distributed information and talked to local people at various forums about different urgent care options and how to access services appropriately. NHS Horsham and Mid Sussex Clinical Commissioning Group ANNUAL REPORT 2017/18 49

50 Our Horsham and Mid Sussex PPG members have explored meeting together within their towns (PPG localities), sharing good practice and working alongside their local health and wellbeing teams and developing local health and wellbeing events in Horsham and East Grinstead. Our Haywards Heath PPG members have also run shared information sessions groups. Communities/neighbourhoods and community engagement The CCG has formed closer links with our town and parish colleagues in working with Sussex and Surrey Association of Local Councils (SALC). This has enabled us to extend our reach to towns and parishes. Both the CCG and SALC have supported PPG localities with their health and wellbeing events, with some parishes kindly providing meeting rooms.we continue to reach out to our community by attending relevant forums including town summer festivals where we have had conversations with the community about accessing urgent care services appropriately. Engaging with diverse groups We know there are groups and communities who don t engage with us through our regular methods; over the past year we have strengthened our links with local groups, including those working with older people, black, Asian and minority ethnic (BAME) communities, children and young people, people with learning disabilities and those with sensory impairment. Our engagement with diverse groups is also guided by our Equality Impact Assessments, which highlight gaps in feedback from particular protected characteristic Keeping patients and the public informed We continue to develop and grow our Health Network, a virtual group of local people who have expressed interest in working with us through sharing views and becoming more closely involved, which not only informs commissioners about the views of those using local health and care services, but provides active engagement in our ongoing work. We use a wide variety of tools to keep patients and the public informed of our work and to promote involvement opportunities, including public websites, public newsletter (quarterly), Facebook, Twitter, YouTube, CPRG, media and the GP Practice Health Bulletin. In 2017/18 we have kept people informed about managing health via podcasts as well as targeted campaigns encouraging flu vaccination for children and pregnant women. This year the engagement team developed a fortnightly (electronic) Patient Round-up which includes short health and social care related updates, as well as updates and listings from our voluntary sector colleagues. This is sent to all Health Network members, PPG/CPRG members and our towns and parishes. 50 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex NHS Commissioning Group

51 Reducing health inequalities NHS Horsham and Mid Sussex compares well with similar communities elsewhere. The health of people in both Horsham and Mid Sussex districts is generally better than the England average. Both areas are one of the 20% least deprived districts/unitary authorities in England, however about 7% (1,800) of children in Mid Sussex and 8% (1,900) in Horsham, live in low income families. Life expectancy is 5.3 years lower for men and 4.2 years lower for women in the most deprived areas of Mid Sussex than in the least deprived areas. In Horsham life expectancy is 7.9 years lower for men and 7.5 years lower for women in the most deprived areas than in the least deprived areas. Overseeing equality and diversity The CCG has equality objectives which are monitored, reviewed and reported through the annual equality report. In 2017/18, the CCG embedded the newly formed Equality and Diversity working group to support the work to reduce inequalities. Members of this group come from all staff groups and include the CCG equality champions, patient engagement and governance teams. Other attendees include representatives from the West Sussex County Council Ethnic Minorities Group, Healthwatch, Public Health and the local Carers Group. This working group supports the CCG in working to reduce health inequalities. Equality and Diversity training is mandatory for all staff and is delivered face to face or online. An equality awareness week was held alongside the national campaign in May This allowed staff to have a greater understanding of equality and diversity and their role within the CCGs. The CCG has published its Equality Report which outlines the actions that the CCG is taking to address inequalities and the General Duty, placed on public authorities, as part of the Public Sector Equality Duty. A copy of the full report can be found on the CCG website. Equality and Impact Assessment Equality Impact Assessments (EIAs) demonstrate that an organisation is giving due regard to equality when developing and implementing changes to strategy, policy and practice. EIAs are completed as part of our commissioning processes; in total 6 EIAs have been submitted for quality review during 2017/18, which have been shared with our Equality and Diversity working group for comments and approval. The Equality Dashboard System 2 (EDS2) EDS2 is a framework that helps NHS organisations to improve the services they commission or provide for their local communities, it also considers health inequalities in our locality. EDS2 also provides evidence of better working environments, free of discrimination, for those who work for the NHS. For the EDS2 for the past year, we pulled on evidence from our event with children and young people, our work with women and their families to implement the Better Births action plan work with our Commissioning Patient Reference Group. Our EDS2 report can be found on our website. NHS Horsham and Mid Sussex Clinical Commissioning Group ANNUAL REPORT 2017/18 51

52 Engagement with our communities The engagement team actively promotes the CCGs Health Networks and strengthens links with groups by attending forums and stakeholder events, including older people, BAME communities, children and young people, those with learning disabilities, those with sensory impairments and carers groups. Good working relationships have been established with our Community Voluntary Service colleagues in Horsham and Mid Sussex, colleagues in West Sussex County Council (WSCC), West Sussex Alliance of Local councils, as well as the Community Development team at Horsham District Council and Young Horsham District Forum; these relationships help us to gather feedback from a range of groups and communities, which in turn helps us address health inequalities. One example of our work is the development of a number of initiatives to support parents and carers in dealing with childhood ailments. A group of clinicians, parents, and colleagues from education and social care co designed downloadable information, and developed a Podcast which provides advice for parents and carers if their child falls ill. Workforce Race Equality Standard (WRES) As an employer the CCG is exempt from publishing information relating to the protected characteristics of their employees due to the small size of the organisation (less than 150 staff). However the CCG has due regard for the workforce equality race standard and has policies in place and (available on the intranet) to support and protect staff from discrimination, harassment, bullying and victimisation. Health and wellbeing strategy We have two seats on the West Sussex Health and Wellbeing Board (HWB) which has been established as a statutory committee of West Sussex County Council and is the body responsible for leading on improving the co-ordination of commissioning across NHS, social care and public health services. The Board brings together elected council members, leaders from the NHS, social care and the voluntary sector to work together and support one another to improve the health and wellbeing of the local population and reduce health inequalities. A major responsibility is the development of the health and social care needs assessment referred to as the Joint Strategic Needs Assessment (JSNA). The JSNA identifies the health and wellbeing needs of the people of West Sussex and the results are used to inform local commissioning of services to create a more effective and responsive local health and care system. We consult regularly on a formal and informal basis with the HWB, its membership and its Chair. In particular, we consult with the HWB on our strategies and plans, and how these contribute to the delivery of the Health and Wellbeing Strategy for West Sussex. The discussion points over 2017/18 have included Better Care Fund, pharmaceutical needs assessment, wellbeing and resilience, care worker recruitment campaign and the Sustainability Transformation Plan. 52 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex NHS Commissioning Group

53 Sustainable development As an NHS organisation, and as a spender of public funds, we have an obligation to work in a way that has a positive effect on the communities for which we commission and procure healthcare services. Sustainability means spending public money well, the smart and efficient use of natural resources and building healthy, resilient communities. By making the most of social, environmental and economic assets we can improve health both in the immediate and long term, even in the context of the rising cost of natural resources. Spending money well and considering the social and environmental impacts is enshrined in the Public Services (Social Value) Act (2012). We acknowledge this responsibility to our patients, local communities and the environment by working hard to minimise our footprint. The majority of the environmental and social impacts are through the services we commission. Due to the nature of the building we occupy, we are unable to model our direct carbon footprint. In order to embed sustainability within our business, we have included it in our policies and processes. Our procurement policy includes requirements to include environmental and social impacts within service specifications. As an organisation that acknowledges its responsibility towards creating a sustainable future, we help achieve that goal by running awareness campaigns that promote the benefits of sustainability to our staff. Climate change brings new challenges to our business both in direct effects to the healthcare estates, but also to patient health. Examples of recent years include the effects of heat waves, extreme temperatures and prolonged periods of cold, floods, droughts etc. The organisation has identified the need for the development of a board approved plan for future climate change risks affecting our area. Events such as heatwaves, cold snaps and flooding are expected to increase as a result of climate change. To ensure that the CCG would continue to meet the needs of our local population during such events, we have Business Continuity Plans in place, but we recognise that we could do more with respect to climate adaptation. As a commissioning and contracting organisation, we will need effective contract mechanisms to deliver our ambitions for sustainable healthcare delivery. The NHS policy framework already sets the scene for commissioners and providers to operate in a sustainable manner. Crucially for us as a CCG, evidence of this commitment will need to be provided in part through contracting mechanisms. For commissioned services the sustainability comparator for our main providers is shown below. NHS Horsham and Mid Sussex Clinical Commissioning Group ANNUAL REPORT 2017/18 53

54 Organisation Name SDMP* On track for 34% reduction GCC+ Healthy travel plan Adaptation SD Reporting score Surrey and Sussex Healthcare NHS Trust Yes Target included but not on track to be met No Yes No Minimum Brighton and Sussex University Hospitals NHS Trust No No SDMP No No No Excellent Queen Victoria Hospital NHS Foundation Trust Sussex Partnership NHS Foundation Trust Sussex Community NHS Trust South East Coast Ambulance Service No No SDMP No No No Good Yes Yes Yes Target included but not on track to be met No Yes No Poor On track to No Yes No Excellent meet target Target included but not on track to be met *Sustainable Development Management Plan +Good Corporate Citizen No Yes Yes Minimum While not being able to directly measure carbon emissions, outlined below are some of the key areas in which we have taken action: Travel: We can improve local air quality and improve the health of our community by promoting active travel (e.g. walking or cycling) to our staff, through our providers and to the patients and public that use the services we commission. Every action counts and we are a lean organisation trying to realise efficiencies across the board for cost and carbon (CO 2 e) reductions. We support a culture for active travel to improve staff wellbeing and reduce sickness; Energy: The CCG lighting system is motion activated thus reducing energy use. The CCG regularly promotes amongst its staff the need to turn off all unused equipment, especially computers and monitors overnight. Photocopiers are procured via the Crown commercial service framework agreement and are specified for energy saving modes; Waste: We are part of the recycling and waste management processes commissioned for the whole of the Crawley Hospital site; 54 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex NHS Commissioning Group

55 Water: The CCG does not have the capability to measure its water use; and Resources: The CCG promotes effective use of resources and reducing printed materials. Organisation Name Building energy use Building energy use per FTE Water Water use per FTE Percent high cost waste Waste cost increase Surrey and Sussex Healthcare NHS Trust 0-10% decrease 3.1 >20% increase 45.3 >89% high cost >20% increase Brighton and Sussex University Hospitals NHS Trust 0-10% decrease % decrease 34.5 >89% high cost >20% increase Queen Victoria Hospital NHS Foundation Trust >10% increase % decrease 18.5 >97% high cost >20% increase Sussex Partnership NHS Foundation Trust >10% decrease % increase 28.4 >75% high cost >20% decrease Sussex Community NHS Trust 0-10% decrease 0.6 >20% increase 8.1 <=75% high cost >20% increase South East Coast Ambulance Service TRUST >10% decrease 1.3 >20% decrease 5.2 <=75% high cost >20% increase More information on these measures is available here: Performance Report Signed By Adam Doyle Accountable Officer: Adam Doyle Date: 24 May 2018 NHS Horsham and Mid Sussex Clinical Commissioning Group ANNUAL REPORT 2017/18 55

56 Accountability Report 56 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

57 A year in governance Members report The CCG membership is comprised of each of the 23 GP practices within the boundaries of Horsham and Mid Sussex CCG. Each practice is grouped into one of the CCG s four towns or communities within the CCG: Burgess Hill, East Grinstead, Haywards Heath and Horsham, The table below shows the practices which make up the membership of the CCG. Practice name Courtyard Surgery Holbrook Surgery Orchard Surgery Park Surgery Riverside Surgery Rudgwick Medical Centre The Village Surgery The Brow Medical Centre Cowfold Crawley Down Health Centre Cuckfield Medical Practice Address London Road Horsham, RH12 1AT Bartholomew Way Horsham, RH12 5JL Lower Tanbridge Way Horsham, RH12 1PJ Albion Way Horsham, RH12 1BG 48 Worthing Road Horsham, RH12 1UD Station Road Rudgwick, RH12 3HB Station Road Southwater, RH13 9HQ The Brow Burgess Hill, RH15 9BS The Surgery, St Peters Close Cowfold, RH13 8DN Branch Surgery: Partridge Green Surgery, Oakleigh Partridge Green, RH13 8HX Bowers Place, Crawley Down, RH10 4HY Branch Surgeries: West Hoathly Surgery West Hoathly, RH19 4QF and Turners Hill Surgery, The Ark Turners Hill, RH10 4RA Glebe Road Cuckfield, RH17 5BQ Branch Surgery:The Vale Surgery Haywards Heath, RH16 4SY ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 57

58 Dolphins Practice The Nightingale Primary Care Centre, Butlers Green Road Haywards Heath, RH16 4BN Judges Close Surgery High Street East Grinstead, RH19 3AA Lindfield The Medical Centre, High Street Lindfield, RH16 2HX The Meadow Surgery Temple Grove, Gatehouse Lane Burgess Hill, RH15 9XN Mid Sussex Health Care The Health Centre, Trinity Road Hurstpierpoint, BN6 9UQ Branch Surgeries: Ditchling Health Centre, Lewes Road Ditchling, BN6 8TT and Hassocks Health Centre, Windmill Avenue Hassocks, BN6 8LY Moatfield Surgery St Michaels Road East Grinstead, RH19 3GW Newtons Practice The Health Centre, Heath Road Haywards Heath, RH16 3BB Northlands Wood Practice 7 Walnut Park Haywards Heath, RH16 3TG Ouse Valley Practice Dumbledore Primary Care Centre, London Road Handcross, RH17 6HB Branch Surgery: Gilletts Surgery, Deanland Road Balcombe, RH17 6PH Park View Health Partnership Sidney West Primary Care Centre, Leylands Road Burgess Hill, RH15 8HS Ship Street Surgery Ship Street East Grinstead, RH19 4EE Silverdale Practice 4 Silverdale Road Burgess Hill, RH15 0EF Branch Surgery: The Avenue Surgery, 283 London Road Burgess Hill, RH15 9QU Details of the CCG s governance structures can be found in the constitution on the website at: Details of the membership and attendance at committees are outlined in the annual governance statement. This includes the Audit Committee, which is a key part of the oversight and assurance functions of the CCG. 58 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

59 Our Governing Body Our Governing Body oversees the decisions that the CCG makes about local health services, ensuring our activities meet the best standards of quality for the local population. As at 31 March 2018, the members of the Governing Body were as shown below. Details of members during the year can be seen on page 64 and in the remuneration report. CCG Clinical Chair Dr Minesh Patel served throughout period Dr Patel qualified at the University of London in 1991 and has been a GP for 18 years and a GP Partner at Moatfield Surgery, East Grinstead since He is the Clinical Chair of Horsham and Mid-Sussex CCG. Dr Patel is the Chair of the STP Clinical Board. He is an Executive Member of the National Association of Primary Care and also the Clinical Lead responsible for the current Sussex-wide Stroke Services Transformation Programme. CCG Accountable Officer Adam Doyle- from 1 January 2018 Adam Doyle is Accountable Officer for the Central Sussex Commissioning Alliance, which is made up of the CCGs of Brighton and Hove, Crawley, High Weald Lewes Havens, as well as Horsham and Mid Sussex. He took up his post on 1 January Prior to that Adam was the Chief Accountable Officer for Brighton and Hove CCG. Adam started his career as a physiotherapist and has held a number of senior healthcare roles over the past ten years. Before working in Sussex, Adam was the Chief Accountable Officer at NHS Merton CCG in London, where he worked from its establishment in Prior to this, Adam was the Director of Private Care and Community Services at The Royal Marsden NHS Foundation Trust. ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 59

60 Strategic Director of Finance Mark Baker from 1 January 2018 Mark Baker is a qualified accountant who has been a Director of Finance for a Surrey CCG since August He was previously Director of Finance at Sussex Police from 2009 to 2016 leading on finance, estates, fleet management and procurement. Prior to this he was Deputy Head of Finance at Surrey County Council covering corporate finance functions and projects. Earlier in his career Mark undertook a variety of finance roles in local authorities in Surrey and Hampshire including social care, education and children's services. Mark fulfils the required role of Chief Finance Officer on the Governing Body. Clinical Director Dr David McKenzie - served throughout period Dr McKenzie is Co-Chair of the CCG Locality Group Meeting representing Horsham and GP practice representative for Rudgwick Surgery. He qualified from Otago University in New Zealand in 2000 and has worked in the UK since He initially worked in a surgical rotation, but he retrained as a GP from 2009.He is Co-Chair of the Locality Group, Clinical Lead responsible for adult functional mental health, and Chair of the Horsham GP Forum, and sits on the Finance and Contacting Committee and the Strategic Clinical Commissioning Group. Clinical Director Dr Karen Eastman - served throughout period Clinical Director member for the Governing Body and Strategic Clinical Commissioning Group since April She is also the Sussex and East Surrey STP Lead for unwarranted clinical variation, a GP Partner at The Brow Medical Centre in Burgess Hill and a GP with Special Interest in Pain Management. With a passion for high quality, person centred and innovative patient care and services, Dr Eastman became involved in Practice Based Commissioning in 2005 and now leads the integration of Right Care, Getting it Right First Time and Clinically Effective Commissioning to understand and address unwarranted clinical variation in pathways of care. She is a RCGP Champion for collaborative Care and Support Planning and has been a GP since ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

61 Clinical Director Dr Stephen Bellamy - served throughout period Dr Bellamy is Mid Sussex Chair of the Locality Group and a member of the Delivery Group and the Commissioning Patient Reference Group. He is a GP at Ship Street Surgery and has been a GP in East Grinstead since 1991, having completed his training in Worthing and Shoreham. He was involved in administering the GP-run Out Of Hours Co-Operative between 1996 and Clinical Director Dr Riz Miarkowski - served throughout period Dr Miarkowski is a GP practice representative for Park View Surgery on the Locality Group and member of the Delivery Group. He has also been a member of the Clinical Policy and Medicines Approval Panel since it formed in July He is senior partner in Park View Health Partnership in Burgess Hill, where he has been a partner since He was previously on the Mid Sussex PCT PEC in , and has been GP Prescribing Lead for Mid Sussex from 2008 until His current main clinical areas of interest include Pro-active Care and Medicines Management. Clinical Director Dr Terry Lynch - served throughout period A Clinical Director from April 2017, Terry Lynch has been working as a GP partner and GP trainer in Hassocks since He has worked for the CCG since 2013 on several clinical projects including the development of dementia, stroke and end of life care services. ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 61

62 Clinical Director Dr Mark Lythgoe - served throughout period Dr Lythgoe is GP practice representative for Judges Close Surgery on the Locality Group, and a member of the Delivery Group and the Quality and Performance Committee. He has also been a member of the Clinical Policy and Medicines Approval Panel since it formed in July Dr Lythgoe, a GP Trainer, has worked in East Grinstead since 2002 and was involved in Practice Based Commissioning before the formation of CCGs. Independent Nurse Sally Thomson - served throughout period Sally runs a consultancy business that focuses upon quality of patient care in a variety of ways and expert witness work. She has a breadth of experience across nursing in both the NHS voluntary and independent sector and is on the nursing register as a general and mental health nurse. She has experience of nurse education as principal lecturer, worked nationally as Director of Policy for a professional organisation and has been a Director of Nursing in the NHS. Secondary Care Clinician Dr Hugh McIntyre - served throughout period Dr McIntyre was appointed as consultant physician at East Sussex Healthcare Trust (ESHT) in He has held various clinical lead roles in Medicine including as Trust Medical Director for Strategy. He is an Hon. Clinical Reader in Medicine at BSMS and a Fellow of the Royal College of Physicians, European Society of Cardiology and Royal Society of Arts. He has developed a nationally recognised integrated heart failure service with national and international publications, and has contributed to international and NICE guidelines. Dr McIntyre is a member of the South East Clinical Senate Council and is Chair of the NICE Quality Standards 62 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

63 Lay Member for Governance Adrian Brown - served throughout period Adrian is Chair of the Audit Committee and Remuneration Committee, Chair of the Clinical Policy and Medicines Approval Panel and Chair of the Individual Funding Requests Panel. Following a career in the international engineering and construction industry where he held a number of board level positions including Commercial Director and Group Managing Director, he was instrumental in delivering the first acute PFI hospital for the NHS. Adrian was previously Chairman of Surrey and Sussex NHS Trust and Justice of the Peace. Lay Member for Patient and Public Engagement Simon Chandler - served throughout period Simon is a professional Engineer and Programme Manager who spent 25 years in Unilever in the UK and overseas before joining the Strategy and Operations team of a leading Professional Services firm. The last seven years in this role he spent coordinating the Public Sector Health team in the UK. He is particularly interested in innovation and the future opportunities of using innovative technology to improve the management of health conditions. He has been a resident of Horsham for the past 20 years. Lay Member Primary Care John Steele from 1 January 2018 John Steele is a retired senior civil servant with a career in criminal justice and has wide experience of strategic and financial management. Following retirement he was the Chair of the Sussex Probation Board and then the Surrey and Sussex Probation Trust for seven years. He has been the lay member for the Primary Care Commissioning Committee since 2015 and is a member of the Audit Committee. ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 63

64 Composition of the Governing Body during the year (alphabetic order) Name Position Contract/Sessions Mark Baker Dr Stephen Bellamy Adrian Brown Simon Chandler Adam Doyle Dr Karen Eastman Geraldine Hoban Dr Terry Lynch Dr Mark Lythgoe Dr Hugh McIntyre Dr David McKenzie Dr Riz Miarkowski Dr Minesh Patel Strategic Director of Finance (Joint with Brighton and Hove CCG, High Weald Lewes Havens CCG, and Crawley CCG) Locality Group Chair/GP Member of the Governing Body Lay Member (Governance) Also co-opted to Crawley CCG Lay Member (PPE) and Vice Chair of the Governing Body Accountable Officer (Joint with Brighton and Hove CCG, High Weald Lewes Havens CCG, and Crawley CCG) Clinical Director/GP Member of the Governing Body Accountable Officer for NHS Horsham and Mid Sussex CCG. Joint appointment with NHS Crawley CCG for the period 1 October 2017 to 31 December Managing Director North from 1 January Clinical Director/GP Member of the Governing Body Clinical Director/GP Member of the Governing Body Secondary Care Clinician (joint appointment with NHS Crawley CCG) Clinical Director/GP Member of the Governing Body Clinical Director/GP Member of the Governing Body CCG Clinical Chair Appointed 1 January Current term of office 1 April 2015 to 31 March Current (second) term of office 24 July 2015 to 23 July Current (second) term of office 1 October 2016 to 30 September Appointed 1 January Current term of office 1 April 2015 to 31 March Appointed 1 November Governing Body member until 31 December Current term of office 1 April 2017 to 31 March Current term of office 1 April 2015 to 31 March Current term of office 1 August 2016 to 31 March Current term of office 1 April 2017 to 31 March Current term of office 1 April 2016 to 31 March Current term of office: 1 April 2016 to 31 March John Steele Lay Member Primary Care Appointed 1 January Current term of office to 31 March Sally Thomson Barry Young Independent Nurse (joint appointment with NHS Crawley CCG) Chief Finance Officer for NHS Horsham and Mid Sussex CCG (Joint with NHS Crawley CCG). Chief Finance Officer (North) from 1 January 2018 Current (second) of office 24 July 2015 to 23 July Appointed 1 April Governing Body member until 31 December Senior managers who are members of the CCG decision making bodies but not GB Members Rachel Harrington Director of System Transformation Previously Chief Operating Officer Appointed 1 February ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

65 Emergency preparedness resilience and response The Civil Contingencies Act 2004 (CCA) and the NHS Act 2006 (NHSA) (as amended) place responsibilities on the CCG in relation to Emergency Preparedness, Resilience and Response (EPRR) as described below. The CCA defines CCGs as a Category 2 responder organisation. This means the CCG has a legal obligation to support, co-operate and share information with other responding organisations in planning for and responding to emergencies. Section 252A of the NHSA requires that CCGs take appropriate steps to prepare for and respond to emergencies. In this regard, I can confirm that NHS Horsham and Mid Sussex CCG has in place suitable plans enabling the CCG to respond to major and emergency incidents as they may arise. These plans are consistent with the NHS England Emergency Preparedness Framework and are regularly reviewed and exercised. The NHSA 2006 requires NHS England to establish processes to monitor and seek assurance that each CCG is properly prepared for dealing with emergencies. In order to ensure that CCGs are meeting their responsibilities under CCA and the NHSA, NHS England has created a framework for EPRR, including a robust annual assurance process under which NHS organisations are obliged to demonstrate their compliance. This process identifies a series of core standards for EPRR against which commissioner and provider organisations are assessed. As a commissioner of services, CCGs use these core standards to seek assurance from service providers and in turn provide assurance to NHS England that the CCG, and its Local Health Economy, are meeting their obligations in relation to EPRR. Under the last annual assurance process, concluded in October 2017, NHS Horsham and Mid Sussex CCG was assessed as Substantially compliant with the NHS England National Core Standards for EPRR. The CCG s providers of clinical services, in accordance with CCA, NHSA and the terms of the NHS Standard Contract, have their own responsibilities in respect of EPRR for which the CCGs seek assurance. The seven CCGs in Sussex collectively sought assurance from our provider organisations against the national core standards. For the most part the Sussex CCGs were assured that the providers were adequately meeting their EPRR responsibilities. ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 65

66 However, where it was evident that a provider has not met the required standard they will continue to work with their local CCG, meeting regularly throughout the year, to improve their performance against the national core standards. As the Accountable Officer for NHS Horsham and Mid Sussex CCG I have chosen to delegate the responsibility for EPRR to an Accountable Emergency Officer (AEO), responsible for ensuring that the CCG is compliant with its obligations. The AEO or their deputy represents the CCG at the Local Health Resilience Forum, taking a strategic coordinated view of EPRR activity amongst health organisations in Sussex. Geraldine Hoban, Managing Director North, has been appointed AEO for the CCG, supported by Adrian Brown, Lay Member for Governance, and CCG staff with responsibilities for EPRR. Personal data related incidents There have been no personal data related incidents formally reported to the Information Commissioner s Office. Register of interests The CCG keeps a register of interests and a register of gifts and hospitality on its website. The register for the Governing Body and Senior Managers (as defined in the remuneration report) for the year can be found on our website here: nhs.uk/about-us/how-we-work/ Statement of disclosure to auditors Each individual who is a member of the CCG at the time the Members Report is approved confirms: So far as the member is aware, there is no relevant audit information of which the CCG s auditor is unaware that would be relevant for the purposes of their audit report; and The member has taken all the steps that they ought to have taken in order to make him or herself aware of any relevant audit information and to establish that the CCG s auditor is aware of it. Modern Slavery Act NHS Horsham and Mid Sussex CCG fully supports the Government s objectives to eradicate modern slavery and human trafficking but does not meet the requirements for producing an annual Slavery and Human Trafficking Statement as set out in the Modern Slavery Act ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

67 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 Accountable Officer to be the Accountable Officer of NHS Horsham and Mid Sussex CCG. The responsibilities of an Accountable Officer are set out under the National Health Service Act 2006 (as amended), Managing Public Money and in the Clinical Commissioning Group Accountable Officer Appointment Letter. They include responsibilities for: The propriety and regularity of the public finances for which the Accountable Officer is answerable; For keeping proper accounting records (which disclose with reasonable accuracy at any time the financial position of the Clinical Commissioning Group and enable them to ensure that the accounts comply with the requirements of the Accounts Direction); For safeguarding the Clinical Commissioning Group s assets (and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities); The relevant responsibilities of accounting officers under Managing Public Money; Ensuring the CCG exercises its functions effectively, efficiently and economically (in accordance with Section 14Q of the National Health Service Act 2006 (as amended)) and with a view to securing continuous improvement in the quality of services (in accordance with Section14R of the National Health Service Act 2006 (as amended)); and Ensuring that the CCG complies with its financial duties under Sections 223H to 223J of the National Health Service Act 2006 (as amended). Under the National Health Service Act 2006 (as amended), NHS England has directed each Clinical Commissioning Group to prepare for each financial year financial statements in the form and on the basis set out in the Accounts Direction. The financial statements are prepared on an accruals basis and must give a true and fair view of the state of affairs of the Clinical Commissioning Group and of its net expenditure, changes in taxpayers equity and cash flows for the financial year. ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 67

68 In preparing the financial statements, the Accountable Officer is required to comply with the requirements of the Group Accounting Manual issued by the Department of Health and in particular to: Observe the Accounts Direction issued by NHS England, including the relevant accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis; Make judgements and estimates on a reasonable basis; State whether applicable accounting standards as set out in the Group Accounting Manual issued by the Department of Health have been followed, and disclose and explain any material departures in the financial statements; and Prepare the financial statements on a going concern basis. To the best of my knowledge and belief, and subject to the disclosures set out below, I have properly discharged the responsibilities set out under the National Health Service Act 2006 (as amended), Managing Public Money and in my Clinical Commissioning Group Accountable Officer Appointment Letter. The CCG is subject to legal directions issued by NHS England which can be found here: I also confirm that: As far as I am aware, there is no relevant audit information of which the CCG s auditors are unaware, and that as Accountable Officer, I have taken all the steps that I ought to have taken to make myself aware of any relevant audit information and to establish that the CCG s auditors are aware of that information; and 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. Disclosures: Adam Doyle During the year a report was issued to the Secretary of State for Health under Section 30 of the Local Audit and Accountability Act 2014 as a result of our financial deficit; and Adam Doyle Accountable Officer 24 May ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

69 Communities of Practice improving care for patients During the year we have progressed the development of Communities of Practice, which is a new way of working to ensure care is built around patients in our communities. The initiative aims to provide patients a more personalised, consistent relationship with a team of care professionals, who work together to make the most of the range of skills they possess. By working in this way, we will be able to better tackle the workload and workforce challenges in our GP and community care services, as well as keep people out of hospital if they can be cared for well at home. ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 69

70 Governance statement Introduction and context NHS Horsham and Mid Sussex CCG is a body corporate established by NHS England on 1 April 2013 under the National Health Service Act 2006 (as amended). The clinical commissioning group s statutory functions are set out under the National Health Service Act 2006 (as amended). The CCG s general function is arranging the provision of services for persons for the purposes of the health service in England. The CCG is, in particular, required to arrange for the provision of certain health services to such extent as it considers necessary to meet the reasonable requirements of its local population. As at 1 April 2017, the CCG was not subject to any directions from NHS England, (issued under Section 14Z21 of the National Health Service Act 2006). However following an assessment of the CCG as inadequate against the National CCG Improvement and Assurance Framework, legal directions came into effect from 13 November The CCG ended the year with a financial deficit of 38.74m which resulted in a section 30 referral by our external auditors to the Secretary of State. The legal directions focus on 4 key areas. Production of a credible financial recovery plan; Commissioning of a capability and capacity review and production of an improvement plan that addresses the recommendations of the review; Undertaking a review of its governance arrangements and developing a plan for the implementation of the recommendations of the Governance Review; and Requirement to notify NHS England of the need to make any appointments to its Executive Team or its next tier of management. The full directions can be found on the NHS England website here: ctions-for-nhs-horsham-and-mid-sussexclinical-commissioning-group/ The CCG continues to work closely with NHSE to address the issues identified that led to legal directions and special measures, and to achieve financial recovery. I was appointed as the CCG s Accountable Officer with effect from 1 January 2018, having previously held the same post at NHS Brighton and Hove CCG throughout 2017/18. Indeed, from the 1 January 2018, as part of the development of the Central Sussex Commissioning Alliance (hereafter referred to as the Alliance ), I became Accountable Officer for the four CCGs that at that point comprised the Alliance (NHS Brighton and Hove CCG, Crawley CCG, High Weald Lewes Havens CCG and Horsham and Mid Sussex CCG). The Alliance represents a way of working across a larger commissioning footprint, which allows the organisations to plan and ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 70

71 commission services more effectively and efficiently. The work we do and how we plan future services are part of the wider plans to improve health and social care for our populations. I have, with the support of the Governing Body and the previous Accountable Officer, (now Managing Director North for the Alliance), taken a number of actions during the period since my appointment and until the end of the financial year in order to ensure I have not only effectively discharged my duties but which have been designed to move the CCG forward and address the key aspects of the legal directions. Collectively, these actions have given me a greater degree of assurance than would otherwise have been possible had those actions not been taken and which I have been able to reference as part of this Governance Statement. They will be further progressed in 2018/19. Financial governance review I have reviewed the financial governance review undertaken by RSM UK Consulting LLP during March This was commissioned with the advice and support of NHS England, in conjunction with Crawley CCG and in the light of the deteriorating financial situation at that time. The review made recommendations with respect to a number of weaknesses in the CCG s financial governance and control culture. A full action plan was prepared by the senior team responding to the recommendations and reviewed by the Audit Committee. The CCG Membership Group also received a paper which summarised those recommendations which had potential implications for the CCG Constitution at their June 2017 meeting and agreed to a revamp and review of the committee structure (this is described in more detail later in this governance statement). The July 2017 Governing Body formally approved these revised arrangements. Improvement and assurance plan Building on this earlier review work and further to the legal directions received by the CCG, a comprehensive Improvement and Assurance Plan has been developed in January 2018 to address the key areas of improvement identified through assurance meetings with NHS England, reporting against the national improvement and assessment framework as well as the requirements outlined in the legal directions. This Improvement and Assurance Plan has been taken forward by the senior team and there has been some progress made on its implementation. External review of governance commissioned In the months preceding my new role with Horsham and Mid Sussex CCG, and with the support of the Governing Body and the previous Accountable Officer, I commissioned an external review of governance across Horsham and Mid Sussex CCG and the other CCGs comprising the Alliance, in February 2018 following a competitive tendering process. This external review of governance will report in May The independent consultants appointed to undertake this work have a strong track record of undertaking CCG governance reviews across the country. The external review will provide a clear understanding of the baseline position on the governance of Horsham and Mid Sussex CCG and the other CCGs comprising the Alliance. It was welcomed by the Governing Body of Horsham and Mid Sussex CCG, the ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 71

72 Governing Bodies of the other CCGs comprising the Alliance, and me, as an opportunity to see how effective the CCG s governance arrangements are, what is working well within them and what areas require further attention and focus. The review will also make recommendations on how the Alliance could work effectively and efficiently and realise the benefits of collaborative working, whilst maintaining the statutory independence of the CCGs, and consider whether other more far-reaching governance changes could lead to better outcomes. Internal and external audit Upon my appointment, I have, with the newly appointed Strategic Director of Finance for the Alliance, reviewed each and every internal audit report undertaken between April 2017 and December 2017 and met with the CCG s internal auditors to not only discuss those reports and their key findings but to also discuss progress in addressing internal audit findings and review the overall internal audit plan for 2017/18. Upon my appointment, I have, with the newly appointed Strategic Director of Finance for the Alliance, also met with the Trust external auditors to seek their independent perspective on the governance of the CCG during the period between April 2017 and December 2017 and discuss with them their overall audit plan for 2017/18. Financial turnaround Given the challenging financial position of all the CCGs that comprise the Central Sussex and East Surrey Commissioning Alliance, the Strategic Chief Finance Officer for the Alliance and I agreed with the Clinical Chairs to place all of the CCGs within the Alliance, including East Surrey CCG, into financial turnaround. This is a necessary action to ensure the appropriate level of focus and application across our organisations to manage expenditure and establish and deliver a clear plan to work within the available resources. This will help us co-ordinate the approach to financial recovery and balance across the CCGs. The key steps in this approach are: Establish a Turnaround Board which will include the CCG Chairs and meet on a fortnightly basis to scrutinise plans and delivery of actions to establish financial control and budget in-line with plan; Experienced consultants will lead the planning and delivery of financial recovery for all the Alliance CCGs, reporting directly to me; QIPP programmes across all Alliance CCGs will be managed collectively; We will have immediate spending controls where any discretionary expenditure will require executive approval; All changes to establishment and recruitment to posts (temporary or permanent) are to be signed off by Alliance Executive Team; Budget holders are to have monthly meetings with the finance team in the last week of each month and sign off forecasts, variations and budget planning assumptions; and Review of finance reporting processes. Objective setting I have also worked closely with the Governing Body and wider leadership of the CCG to reset the CCG s objectives and key work priorities. These have been 72 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

73 developed to ensure a high degree of consistency across the Alliance and were accepted by the Governing Body in March Through these objectives and key work priorities the CCG is able to concentrate on how it will proceed over the coming year and how it will work with its Governing Body staff and membership as it works towards achieving its objectives. Staff engagement In order to embed our new of working across the Alliance, I held a conference for all staff across all the CCGs in the Alliance in February 2018 where we agreed as an Alliance how these values would be embedded and lived throughout all the CCGs that comprise the Alliance. Memorandum of Understanding The CCGs that are part of the Alliance, including Horsham and Mid Sussex CCG, are separate statutory bodies working with shared management team and arrangements since 1 April 2018 are governed by a Memorandum of Understanding, which has been formally approved by the Governing Body of Horsham and Mid Sussex CCG and the other Alliance CCGs. The purpose of this Memorandum of Understanding is to further formalise working arrangements, to protect each organisation and allow them to hold each other to account. It will ensure that our Alliance operates effectively to collaboratively commission consistent and high quality services and work in partnership on other strategic areas to achieve the best outcomes for patients across the whole area, whilst maintaining a local focus. Conclusion This work alongside the assurances I have received from the outgoing Accountable Officer and Chief Finance Officer has given me a degree of assurance which I have been able to reference as part of this governance statement for Horsham and Mid Sussex CCG. The rest of this Governance Statement needs to be read within the context of all the above. The CCG continues to work closely with NHSE to address the issues identified that led to legal directions and special measures, and to achieve financial recovery. Scope of responsibility As Accountable Officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of the clinical commissioning group s policies, aims and objectives, whilst safeguarding the public funds and assets for which I am personally responsible, in accordance with the responsibilities assigned to me in Managing Public Money. I also acknowledge my responsibilities as set out under the National Health Service Act 2006 (as amended) and in my Clinical Commissioning Group Accountable Officer Appointment Letter. I am responsible for ensuring that the clinical commissioning group is administered prudently and economically and that resources are applied efficiently and effectively, safeguarding financial propriety and regularity. I also have responsibility for reviewing the effectiveness of the system of internal control within the clinical commissioning group as set out in this governance statement. ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 73

74 Governance arrangements and effectiveness The main function of the Governing Body is to ensure that the group has made appropriate arrangements for ensuring that it exercises its functions effectively, efficiently and economically and complies with such generally accepted principles of good governance as are relevant to it. The main features of the governance of Horsham and Mid Sussex CCG are described below. The CCG membership body: Locality Group In accordance with the Health and Social Care Act 2012, the CCG was formed as a membership organisation with the constituent GP practices as its members. The composition of the membership is outlined in the accountability report. Clinical commissioning has been developed around the principle of clinical leadership, which is demonstrated in CCGs by their status as membership bodies. The membership voice in NHS Horsham and Mid Sussex CCG is expressed through the Locality Group. The Locality Group is made up of the statutory GP practice representative or nominated GP deputy from each practice (voting) and a practice manager representative from each locality (Horsham and Mid Sussex), the lay member Chair of the Commissioning Patient Reference Group, two other lay members representing each locality and a pharmacist (all nonvoting). The Locality Group may also invite other individuals, including professional advisers, to attend meetings periodically if required, although such individuals will not have voting rights. The Locality Group met 6 times during 2017/18. The frequency of the Locality Group was changed following agreement early in the year to meet 6 times per year rather than 12 times to enable more focused work on clinical pathways. The Locality Group also agreed to there being Town Based Discussions to take place monthly to focus on relevant topics for that locality, however must also provide the opportunity to take forward: Model of improved/extended access to primary care; Managing variations making practice use of practice pack data to establish town priorities and actions to rectify and; Delivery of the various work streams set out in the GP Forward View. Locality Group has also agreed the CCG s operational structure, including the governance for the CCG meetings and the shared management for the CCG in line with the Central Sussex and East Surrey Commissioning Alliance. The Governing Body The CCG Governing Body has responsibility for ensuring good governance arrangements and as well as its main function the membership has assigned the following specific duties to the Governing Body: Leading the setting of vision and strategy; Approving the annual strategic commissioning plans; Approving the annual budget; Monitoring performance against plans and providing assurance of strategic risk; Ensuring that the registers of interest are reviewed regularly, and updated as necessary; and Ensuring that all conflicts of interest or potential conflicts of interest are declared and appropriate management plans are in place. 74 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

75 The Governing Body meets formally in public. The Governing Body also meets informally to discuss matters that arise and to give an opportunity for development and training. This is part of an ongoing process which will be further strengthened through the organisational development activities of the Commissioning Alliance. As a clinically led organisation it is important for us to have clinical leadership which represents the views of our membership at the most senior level and the constitution of the CCG provides for strong clinical representation and the Governing Body and committees of the CCG. All Governing Body members and senior managers have annual appraisals. During the course of the year there have been some changes in the Governing Body. The CCG formalised its arrangements for compliance with statutory guidance on managing conflicts of interest by appointing its Associate Lay Member of the Primary Care Commissioning Committee to also be a member of the Governing body. As described above the Accountable Officer changed on 1 January 2018, but continuity has been provided through the continued involvement of Geraldine Hoban as Managing Director North for Horsham and Mid Sussex and Crawley CCGs. The Strategic Director of Finance for the Commissioning Alliance, Mark Baker, took the statutory role of Chief Finance Officer on the Governing Body from 1 January The CCG is working with its membership to further strengthen lay member involvement through formalisation of existing co-option arrangements. Committees The CCG and the Governing Body have established committees for the running of CCG business and details of these governance structures can be found in the CCG Constitution on the CCG s website at: uk During 2017/18 the CCG implemented the recommendations from its Financial Governance review which recommended a change in structures so as to improve financial scrutiny and control. As a result the CCG changed its committee structures, working initially in shadow form pending formal approval of the constitution changes by NHS England in November The CCG has a shared management team with Horsham and Mid Sussex CCG and moved to holding its Governing Body meetings in common to reduce duplication and provide further resilience in its operations. Committees work in common unless otherwise indicated. The table below shows the revised structure and the remainder of this section describes the committees in more detail. Each committee has terms of reference describing its membership and scope of its authority. ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 75

76 NHS Crawley CCG NHS Horsham and Mid Sussex CCG Combined Governance Structures Two statutory bodies with shared management team June 2017 CCG Membership Crawley CCG Membership Horsham and Mid Sussex Governing Bodies Two statutory bodies meeting in common Remuneration and Nominations committee Audit Committee Quality and Performance Committee Finance and Contracting Committee Two Primary Care Commissioning Committees Delivery Programme Board Strategic Clinical Commissioning Committee Strategic Information Governance Group (not in common ) Commissioning Patient Reference Groups Crawley & Horsham and Mid Sussex Audit Committee The Audit Committee reviews the CCG s governance and internal control principles. The Committee ensures that an appropriate relationship with both internal and external auditors is maintained. Its terms of reference require it to ensure a comprehensive system of internal control that underpins the effective, efficient and economic operation of the CCG. The Governing Body co-opted the Lay Member for Governance from Crawley CCG to the Governing Body and in this capacity she acted as a member of the Horsham and Mid Sussex Audit committee with the Horsham and Mid Sussex Lay member acting as joint Chair of the Audit Committees meeting in common for both CCGs. During the course of the year the Audit Committee reviewed the work and findings of the external and internal auditors, considering the implications of, and management response to their work. The Committee satisfied themselves that the organisation has taken appropriate steps to meet the new conflicts of interest guidance, be in line with the whistleblowing guidance and that procurement processes are reviewed and lessons are learnt. The Audit Committee undertook a self- assessment during 2018 using a new format. Five questionnaires were completed which included both internal and external audit. This highlighted the need for transparent reporting back to Governing Body and ensuring sufficient time is given at governing body meetings, the need for better membership training and development, and indicated the need to review meeting agenda planning to ensure meetings are not over-long. 76 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

77 Finance and Contracting Committee Since May 2017, the Finance and Contracting Committee have subjected the CCG s financial reporting to scrutiny and review. This has included reports and presentations on the Financial Recovery Plan and at its meetings in January and February 2018 reviewed in-depth the medium term financial recovery plan which was signed off for initial submission to NHS England by the Governing Body on 20 February In implementing the financial governance review the Committee have overseen some improvements in financial reporting. This has included improving the forecasting methodology, the content, presentation and timeliness of financial reporting and strengthening the methodology and governance for setting and signing off annual budgets, aligned to clear framework of accountability, risk identification and mitigations. In addition to this the Lay Chairs have had regular updates with the Chief Finance Officer on the current financial position. Remuneration and Nomination Committee The Committee comprises the following governing body members: the Lay Member for Governance, the Lay member for Patient and Public Engagement (PPE), the Independent Secondary Care Clinician and the Independent Nurse. The Chair of the Committee is usually the Lay Member for Governance except when the remuneration of the Lay Members is being discussed, at which point one of the independent clinicians takes the chair. The Committee is quorate if any two members are present, and a member of the Committee is not permitted to be present if their remuneration is being discussed. The Committee has met no less than twice a year, as provided in its terms of reference. The CCG contracts with a CSU under a service level agreement to deliver HR services. This includes provision of specialist HR advice to its Remuneration Committee. The Committee therefore has access to, and takes advice from, a named HR Principal Associate, employed by the CCG s HR provider; SCW CSU. Specialist advice covered employment law, NHS terms and conditions, the interpretation of NHS England remuneration guidance for CCGs and the provision of benchmarking information relating to local and regional CCG Governing Bodies. The service worked with the CCG s Head of Governance to ensure appropriate reference was made to the CCG s Constitution where necessary. The Committee was satisfied that the advice received was objective and independent due to the factual nature of the data provided and the service provider had no other association or involvement with the CCG Officers or Senior Employees. As part of the development of the Central Sussex and East Surrey Commissioning Alliance, a Remuneration and Nominations Committees in Common covering NHS Brighton and Hove CCG, Crawley CCG, High Weald Lewes Havens CCG and Horsham and Mid Sussex CCG met for the first time on the 17 October Delivery Group and Strategic Clinical Commissioning Group (SCCG) The CCG membership previously delegated operational responsibilities to the Delivery Group, in early 2017/18, following the financial governance review, the CCG structures were reviewed and the responsibilities of the Delivery Group ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 77

78 aligned more appropriately. Those functions of the Delivery Group with respect to developing and recommending a clinical commissioning strategy to the Governing Body, informed by the Locality Group, and the Clinical Patient Reference Group, were assigned to the Strategic Clinical Commissioning Group. As a clinically led group the SCCG has principal responsibilities for developing and overseeing the necessary programme and project arrangements to effectively inform the development of clinical strategy and to oversee production of the operating plan in response to national guidelines, local priorities and the joint strategic needs assessment (JSNA), ensuring clinical ownership of the plans. The group review clinical benchmarks and outcome data to inform clinical strategy. The SCCG provide the Governing Body with an overview of the commissioning activity of the CCG and its effectiveness. The Committee decides which strategies to recommend to the Governing Body for approval and raises performance concerns. Delivery Programme Board The Delivery Programme Board has been established by the Governing Body to drive and assure the delivery of the 2017/18 Financial Recovery Plans and QIPP Programmes and to design and drive the delivery of future year s QIPP Programmes. The board meets weekly and a key responsibility during the financial year has been to oversee the production of the medium term FRP developed in response to the CCG directions. Scrutiny of QIPP delivery is undertaken monthly and new schemes business cases are approved within delegated financial limits or recommended to Finance and Contracting Committee for sign off. Quality and Performance Committee Following the CCG s governance review the Quality and Clinical Governance Committee was refreshed and renamed to the Quality and Performance Committee. It performs a key function in allowing the organisation to have oversight and assurance of service quality and patient safety issues and is chaired by the Governing Body Independent Nurse. The Committee meets monthly and receives an in-depth quality report, escalating issues to the Governing Body where appropriate. Key concerns for the Committee during 2017/18 have been outlined in the performance report section A year in quality and safety on page 29. Primary Care Commissioning Committee From 1 April 2017, NHS Horsham and Mid Sussex CCG assumed delegated responsibility for primary care commissioning. A Primary Care Commissioning Committee (PCCC) was already in place and the CCG Constitution and the Terms of Reference for this committee were amended to reflect to additional delegated responsibilities. In 2017/18 the PCCC met six times. During this time the Committee reviewed locally commissioned services around anticoagulation, prescribing, complex patients and diabetes. The terms of reference were amended to reflect the new conflict of interest guidance, with a smaller membership and with GP members acting in an advisory rather than voting capacity. In December 2017, the Associate Lay member appointed to serve on the PCCC as part of managing conflicts of interest was also appointed to the Governing Body to lead on primary care matters. 78 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

79 Sustainability and Transformation Partnership Arguably, one of the most significant areas of cross-ccg working is the Sustainability and Transformation Partnership (STP). All NHS health organisations and local authority organisations that commission and provide health and care in Sussex and East Surrey have put aside their usual boundaries and come together to work to create an ambitious local plan to achieve a vision of a sustainable health and care system built around the needs of our local populations. Sussex and East Surrey is one of 44 geographical STP footprints in England who have been asked to produce a longterm plan outlining how local health and care services will evolve, improve and continue over the next five years. In July 2017 NHS E published an STP progress dashboard giving an initial baseline view of STPs work. Sussex and East Surrey were rated in category 4 as needing most improvement. STP footprints are locally defined, based on natural communities, existing working relationships, patient flows and take account of the scale needed to successfully deliver all health and care services. STP footprints are not statutory bodies, but collective discussion forums which aim to bring together health and care leaders to support the delivery of improved health and care based on the needs of local populations. They do not replace existing local bodies, or change local accountabilities. During 2017/18 the CCG has ensured visibility of STP finances at the Finance and Contracting Committee and the work of the STP has regularly been updated at the CCG Governing Body. Central Sussex and East Surrey Commissioning Alliance As I stated at the opening of this governance statement, a very important contextual development in 2017/18 has been the creation of the Central Sussex and East Surrey Commissioning Alliance in September 2017, which brings together Brighton and Hove CCG, Crawley CCG, High Weald Lewes Havens CCG, Horsham and Mid Sussex CCG and East Surrey CCG. By developing the Alliance, the commissioning functions that need to be managed only once will be managed at greater scale across our five CCGs. This will free up local teams to more rigorously deliver for the local population and support the transformation of local care systems. It will maximise the use of resources and improve patient outcomes. The dual goals of our Alliance are to: Take control of and lead our system by being stronger commissioners to deliver better outcomes for our population; and Enable the development of new local models of care (e.g. accountable care systems) By developing our Alliance we aim to: Provide stronger traction with the providers of healthcare for our population; Provide clarity for providers through a single commissioning voice; Free-up local teams to allow them to give more focus to business as usual and integration; Share and spread clinical service improvements through collaboration; Accelerate the pace of delivering transformational change and new local models of care; ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 79

80 Streamline processes and stop duplication across the five CCGs that could be done once; Better use the limited specialist skills and talent; and Provide more effective organisational development at scale. The Alliance involves the formation of a unified management structure across the five CCGs and will involve the five CCGs being organised into two places north and south. The north place will be made up of the area covered by Crawley, Horsham and Mid Sussex and East Surrey CCGs, while the south will cover the area of High Weald Lewes Havens and Brighton and Hove CCGs. The Executive Team for the Alliance will include a Joint Accountable Officer for all five CCGs, a North Managing Director and a South Managing Director. Much of the preparatory work is complete and the unified management structure has been agreed across the five CCGs. Most of the alliance directors formally commenced their roles on 2 January and have begun the process of aligning the work streams across the partner organisations. Our intention is that the Central Sussex and East Surrey Commissioning Alliance will commence in full on 1 April As the Accountable Officer for Horsham and Mid Sussex since 1 January 2018 as well as the other CCGs that comprise the Alliance, I have ensured that the development of the Alliance is guided by a number of key governance principles: The Alliance CCGs signed up to an initial Memorandum of Understanding which guided the work of the Alliance from September to December 2017 and a further more developed Memorandum of Understanding was approved by all Governing Bodies to cover the period from January to March 2018 before a more formal Memorandum of Understanding is approved to guide the work of the Alliance during 2018/19; There had been full visibility of the work of the Alliance at Governing Body meetings; and The development of an Alliance level risk register has ensured that all key risks are captured and effectively managed. UK Corporate Governance Code NHS Bodies are not required to comply with the UK Code of Corporate Governance. However, we have reported on our corporate governance arrangements by drawing on best practice available, including those aspects of the of the UK corporate governance code we consider to be relevant to the CCG. For the financial year ended 31 March 2018 and up until the date of signing this statement, we have complied with the provisions of the Code as would be expected of a CCG. Leadership The CCG is headed by an effective Governing Body which is collectively responsible for the long-term success of the CCG. There is a clear division of responsibilities between the running of the Governing Body and the executive responsibility for the running of the CCG s business. No one individual has unfettered powers of decision and decision making powers are clearly governed by the CCG s Standing Orders and Prime Financial Instructions. 80 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

81 During 2017/18, the CCG further enhanced the Governing Body independent scrutiny through the appointment of a third lay member to the Governing Body. Effectiveness The Governing Body and its committees have the appropriate balance of skills, experience, independence and knowledge to enable them to discharge their respective duties and responsibilities effectively. There is an on-going programme of training and development and training sessions in 2017/18 have included a specific focus on financial reporting in response to our financial governance review. Arrangements for appointments to key roles are outlined in the CCG constitution and in the case of the Accountable Officer, Chair and Chief Finance Officer subject to the NHS England appointments process. The CCG directions mean that no senior or executive appointment can be made without NHS England approval. Executive members of the Governing Body set objectives annually and their performance is reviewed by the Accountable Officer. Governing Body papers are supplied in a timely manner, with minimum timescales for receipt of papers set out in the CCG s Constitution and committee terms of reference. Governing Body papers are prepared with information in a form and of a quality appropriate to enable the Governing Body to discharge its duties. Accountability The Governing Body considers that it presents a balanced and understandable assessment of the CCG s position and prospects. The CCG management of risk and arrangements for the Audit Committee are outlined elsewhere in the governance statement. The CCG does not have shareholders but is accountable to the public for its activities. The CCG engaged patients, stakeholder organisations and the public in planning its objectives; particularly when considering larger scale service changes where it had a duty to consult. See elsewhere in this annual report for more details on patient and public engagement. Relations with stakeholders and member practices Whilst the CCG does not have shareholders, the organisation is accountable to the public and its stakeholders. The CCG involves patients, the public and stakeholders at every level of the organisation from statutory lay members on the governing body to patient representatives on committees and groups. Patients, the public and stakeholder organisations are encouraged to attend formal Governing Body meetings and the Annual General Meeting. The CCG, via the CCG Clinical Chair and Locality Group Chairs, has an ongoing dialogue with its member practices based on the mutual understanding of objectives. The Governing Body as a whole has the responsibility for ensuring that a satisfactory dialogue with member practices takes place. The CCG uses a variety of methods to engage and communicate with its member practices, including a regular newsletter to practices and regular meetings of the Locality Group. ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 81

82 Discharge of statutory functions In light of recommendations of the 1983 Harris Review, the clinical commissioning group has reviewed all of the statutory duties and powers conferred on it by the National Health Service Act 2006 (as amended) and other associated legislative and regulations. As a result, I can confirm that the clinical commissioning group is clear about the legislative requirements associated with each of the statutory functions for which it is responsible, including any restrictions on delegation of those functions. Responsibility for each duty and power has been clearly allocated to a lead Director. Directorates have confirmed that their structures provide the necessary capability and capacity to undertake all of the CCG s statutory duties. Risk management arrangements and effectiveness The CCG recognises that risk management is an integral part of good management practice and to be most effective it must be embedded within the organisations culture. The CCG has a comprehensive Risk Strategy and Management Policy that outlines the CCG approach to risk management and its vision in relation to assurance systems. The Risk Strategy and Risk Management Policies were combined, updated and agreed by Audit Committee in October This policy aims to; Ensure structures and processes are in place to support the assessment and management of risk throughout the CCG; Achieve a culture that encourages all staff to identify and control risks which may adversely affect the operational ability of the CCG; Assure the public, patients and, staff and partner organisations that the CCG is committed to managing risk appropriately; and Promotes a holistic approach to risk management. The CCG has a responsibility to ensure that it is effectively governed in accordance with best practice. Every activity that the CCG undertakes or commissions others to undertake on its behalf, brings with it some element of risk that has the potential to threaten or prevent the organisation achieving its objectives. The CCG risk management processes are designed to ensure that risks are identified, assessed, controlled, and when necessary, escalated. These main stages are carried out through: Clarifying objectives; Identifying risks to the objectives; Defining and recording risks; Completion of the risk register and identifying actions; and Escalation of risks. The risks to which the CCG are specifically exposed are identified by various routes, including: Internal methods such as complaints, identification through equality analyses, audits, QIPP related risks, project risks and monitoring the quality of commissioned services; External methods - national reports, new legislation, surveys, reviews of partnership working; and Liaison through practice visits, locality meetings, GP Forums and patient engagement forums. ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 82

83 Each programme has a risk register which is reviewed and managed by the Programme Directors and Clinical Directors at the programme boards. The consequences of some risks, or the action needed to mitigate them, can be such that it is necessary to escalate the risk to a higher management level. When programme risks are assessed as having significant risk to the CCG s corporate goals, they are escalated to the corporate risk register. The same principle is in place for escalation from a team risk register to the Programme Risk Register. Programmes identify risks through various routes including equality analyses, feeding back to the Commissioning Patient Reference Group where a patient and public perspective of risk is highlighted and lessons learnt from other programmes and services previously commissioned. Risk Management by the Governing Body is underpinned by a number of systems of control. The Governing Body reviews risk principally through the following three related mechanisms:. The Board Assurance Framework (BAF) sets out the strategic objectives, identifies risks in relation to each strategic objective along with the Service Goals controls in place and assurances available on their operation; The CCG corporate risk register is the corporate high level operational risk register used as a tool for managing risks and monitoring actions and plans against them. Used correctly it demonstrates that an effective risk management approach is in operation within the organisation; and The Audit Committee and other Governing Body committees exist to provide scrutiny and assurance of the robustness of risk processes and to support the Governing Body. The Governing Body is responsible for determining the nature and extent of the significant risks it is willing to take in achieving its strategic objectives. The BAF provides the Governing body with assurance through an overview of the risks identified for each of the five objectives, the actions in place to mitigate the risks and the trend over time, and brings together a review of initial performance triangulated with data from the national CCG assurance framework. There are responsible leads identified for each of the five strategic objectives listed in the table below. Care designed for the needs of the population Transformation and Integration High Quality and Sustainable Care Organisational Goals Be an effective Organisation Sustainable finances ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 83

84 The BAF and corporate risk register are updated on an ongoing basis with a formal review undertaken monthly. This formal review is led by the Governance Team who meet with each risk owner to review changes in the controls and assurances and progress against actions agreed since the previous review. Following each monthly review, the overall risk profile is then considered by the executive management team and Quality, Finance and Strategic Clinical Commissioning Group Committees in order to agree the corporate risks being managed by the CCG. This view is then reported to the Governing Body to enable them to consider their own assessment of the risks in question. The corporate risk register is reviewed as a standing item at the Audit Committee. The Audit Committee s focus is on providing assurance to the Governing Body that the agreed system is robust and being appropriately applied. The CCG has determined a risk appetite which sets the level at which the CCG is prepared to tolerate the risk, although the risk appetite is not necessarily static and may change depending on the circumstances. The Governing Body is responsible for risk decision making by determining if a risk can be tolerated or if further action (treat, transfer or terminate) is required. To treat or mitigate is in practice the most common response, achieved by taking action to reduce the probability of the risk occurring or by reducing the impact. This enables the CCG to continue with the activity/objective but with controls and actions in place to maintain the risk at an acceptable level. It may be appropriate to tolerate the risk without any further action. To transfer a risk is usually taken to transfer a financial risk or pass the risk to an insurer. However, there is also the opportunity to agree to transfer risks to a partner organisation in a joint project, but it is important that all parties are clear to the exact extent of each partner s liability and responsibility for the risk. The formal creation of the Central Sussex and East Surrey Commissioning Alliance from the 1 April 2018 affords the opportunity to further review and strengthen our risk management arrangements, drawing on best practice. This work will of course need to be considered alongside and be informed by, the findings from the externally commissioned review across all the CCGs that comprise the Alliance and which was commissioned in February 2018 and which will report its findings in May Capacity to handle risk The Accountable Officer has overall responsibility for ensuring that an effective risk management system is in place and the governance lead has delegated responsibility for managing the development and implementation of risk systems. The Strategic Director of Financer is answerable to the Accountable Officer and is responsible for ensuring (and reporting to the Governing Body and Audit Committee) that systems and structures are in place for the effective management of financial risk and organisational controls. The CCG s Clinical Directors each have an identified portfolio of clinical responsibilities. They oversee the management of risks to programme delivery, working with the Executive Team and heads of department, all of whom are accountable for the management of risks related to their areas of responsibility. Staff are supported to manage risk as appropriate to their level of authority and duties and the CCG policies and procedures are available on the CCG s website. There is a programme of mandatory training for staff that includes equality and diversity, fire safety, 84 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

85 information governance, health and safety, manual handling and safeguarding children and adults. The risk management strategy outlines the process for assessing risks and the CCG uses a Risk Matrix for calculating risk scores. Risks are categorised as financial, reputational, operational and compliance risks. Risks are also linked to one or more sections of the Governing Body Assurance Framework and the Corporate Goals. In 2017/18 there were three risk management training sessions that were available to all CCG staff. There was an extra risk management training session that was conducted specifically for the Primary Care Community Development team. Risk Management training is available to all staff and can be conducted at a team level on request. Risk assessment The CCG recognises that it is impossible to eliminate all risk and that the aim of risk management it to mitigate risks using control measures and an action plan. As part of risk assessment, risks are given an initial risk score and a target risk score. The target risk score represents the level of risk that remains after existing control measures and actions have been taken into account; it is the level of risk that is acceptable to the CCG. At year end, the corporate risk register identified 17 risks where the level of risk remains significant (12 or above). These relate to financial and contractual performance issues (4), Primary Care Community Development (2), Quality (2), Urgent Care (4), Mental Health (4) and 1 risk relating to the delivery of clinical outcomes across all programmes. Other corporate risks are described on page 11 Key issues and risks. Other sources of assurance Internal control framework A system of internal control is the set of processes and procedures in place in the clinical commissioning group to ensure it delivers its policies, aims and objectives. It is designed to identify and prioritise the risks, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically. The system of internal control allows risk to be managed to a reasonable level rather than eliminating all risk; it can therefore only provide reasonable and not absolute assurance of effectiveness. The CCG has an Integrated Governance Framework (available at which describes the CCG s systems and processes for: Managing clinical and non-clinical risk; Ensuring they are commissioning for quality; Managing financial risk; Managing information risk; Ensuring they are operating within the law and adhering to appropriate legislation; Building robust corporate governance within their own structures; and Emergency preparedness, resilience and response. Governing Body arrangements, including the Governing Body Assurance Framework, are outlined above. Financial controls are outlined in more detail in the annual accounts. The CCG has adopted a set of Standing Orders (Annex C of the Constitution) and Standing Financial Instructions/ Prime Financial Policies (Annexes D and E of the ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 85

86 Constitution) as well as more detailed financial policies approved by the Audit Committee and a detailed financial scheme of delegation. Continuing Healthcare Services for the CCG are hosted by NHS Coastal West Sussex CCG under a Memorandum of Understanding. During 2017/18 the Head of Continuing Healthcare at NHS Coastal and West Sussex CCG has attended the Quality and Performance Committee to provide information and assurance of the service being provided. The Governing Body receives assurance that the organisation and commissioned providers are meeting the defined set of standards across domains of performance, safety, quality and patient experience through the Integrated Performance, Delivery and Quality Report (PDQ) that is presented to Strategic Clinical Commissioning Group, Quality and Performance Committee and the Governing Body. The PDQ consists of a review of and exception reporting on performance and quality issues in key areas of provider activity. Annual audit of conflicts of interest management The revised statutory guidance on managing conflicts of interest for CCGs (published June 2016) requires CCGs to undertake an annual internal audit of conflicts of interest management. To support CCGs to undertake this task, NHS England has published a template audit framework. The annual internal audit of conflicts of interest was carried out in December 2016 and found to be reasonable assurance. Five recommendations were made and actions plans put in place to address these. The CCG carries out a Conflicts of Interest Indicator quarterly self-assessment as part of the adherence to the new conflict of interest guidance. Since the new guidance was published there have been no conflict of interest breaches. Data quality A range of data is made available to the Governing Body. The Integrated Performance, Delivery and Quality Report provides assurance to the Governing Body and the Quality and Performance Committee that the organisation and commissioned providers are meeting the quantitatively defined set of standards across the domains of performance, safety, quality and patient experience. The data received by the Governing Body and the committees of the CCG is continuously reviewed and the contents of reports are refreshed regularly to ensure that suitable information is available to the CCG s committees. Throughout the year the data outputs from the CSU and the in-house business intelligence team are checked and any outlying or unexpected values are questioned. The reports are further checked against other available data sources such as NHSE reports, Better Care Value indicators and Public Health data. In response to the Financial Governance review undertaken in 2017, there has been a significant improvement in the timeliness and format of financial reporting, which is overseen by the Finance and Contracting Committee. The annual contract model is built on Secondary User Service (SUS) and Service Level Agreement (SLAM) data. We continue to work with our providers to reconcile SUS data to their contract monitoring. We have included a Data Quality Improvement Plan (DQIP) within the contract with both Surrey and Sussex Hospitals Trust and Brighton and Sussex University Hospitals NHS Trust to improve data quality in a number of areas. 86 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

87 Information governance The NHS Information Governance Framework sets the processes and procedures by which the NHS handles information about patients and employees, in particular personal identifiable information. The NHS Information Governance Framework is supported by an information governance toolkit and the annual submission process provides assurances to the clinical commissioning group, other organisations and to individuals that personal information is dealt with legally, securely, efficiently and effectively. We place high importance on ensuring that there are robust information governance systems and processes in place to help protect patient and corporate information. We have established an information governance management framework and have developed information governance processes and procedures in line with the information governance toolkit. We have ensured all staff undertake annual information governance training. To support legislative changes as a result of the new General Data Protection Regulation (GDPR) law, NHS Digital have made changes to data sharing processes applying an approval process to Data Privacy Impact Assessments (DPIA s). We have been working closely with teams to streamline the DPIA process for future use. There are processes in place for incident reporting and investigation of serious incidents. We have completed an information risk assessment of the data held and managed by the organisation, and reviewed Information Governance management procedures throughout the year. In March 2018 the CCG submitted a Satisfactory rated Information Governance Toolkit, (Version 14.1) achieving 81% compliance for the year 2017/18. This achievement is an increase from 68% achieved for IG Toolkit Version 14 for the year 2016/17. The submission was audited by TIAA Ltd (internal auditors) to provide independent assurance that the evidence provided was robust. This assessment received substantial assurance. The CCG will be working closely with service partners, and all directorates to align practices to the new, GDPR compliant, Data Security and Protection Toolkit (DSP Toolkit) due for release in April The role of Senior Information Risk Owner in the CCG is assigned to a senior executive who takes ownership of the organisation s information risks and acts as advocate for information risk to the CCG s Audit Committee and Governing Body. The role of the Caldicott Guardian in the CCG is assigned to the Clinical Chair, who has particular responsibilities for protecting the confidentiality of patients and service users information and enabling appropriate information sharing. The role of Data Protection Officer (DPO) for the organisation has been assigned to an identified role within the Finance directorate, and upon recruitment, will enable the organisation to fulfil data security responsibilities in relation to new General Data Protection (GDPR), and Data Protection Bill 18 legislation. As part of the annual IG review, policy, procedure and guidance documents were reviewed and updated to reflect changes in relevant legislation, structures and/or guidelines. All documents were approved by the Audit Committee. There are processes in place for the reporting of information incidents and investigation of serious information incidents. The CCG has developed its information risk assessment and ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 87

88 management procedures in order to focus on embedding an information risk culture throughout the organisation. To date, the CGG has received no level 1 or above Serious Incident Requiring Investigation reports, however we continue to monitor both root and cause of low level IG breaches to inform training needs and potential operational review. Business critical models The CCG recognises the principles reflected in the Macpherson report as a direction of travel for business modelling in respect of service analysis, planning and delivery. An appropriate framework and environment is in place to provide quality assurance of business critical models within the clinical commissioning group CCG business-critical models primarily rely on activity and finance data produced by the South Central and West Commissioning Support Unit (CSU) which is assured through their own processes. The CCG reviews CSU data regularly and its use is checked internally by the Executive Team and externally through audit of key systems and processes. The output of business-critical models is validated by NHS England through their assurance process of the CCG. Third party assurances In 2017/18, the CCG commissioned support services from the following Commissioning Support Units (CSUs): South Central and West (SCW CSU) provide Human Resources, Financial, Business Intelligence, Information Governance, Complaints and Freedom of Information; North East London (NEL CSU) provides Information Technology services; and Individual Funding Requests and clinical policies support (following the merger of SE CSU into NEL CSU). The CCG obtains assurance regarding CSU provided services through Service Auditor Reporting. Service Auditor Reporting is undertaken by an independent auditor (Deloitte) to review the key business process controls of a service organisation and to give an opinion on whether control activities are designed and operating effectively for control objectives to be achieved. The CSUs provide the CCG with letters outlining the scope and findings of the audits and these, together with CCG management controls for monitoring the performance of the CSU, provide coverage for a significant portion of the year in relation to CSU activities. The service auditor report Type 2 report for 1 March 2017 to 31 August 2017 provided assurance of SCW CSU s controls during the period and this report identified four control exceptions, resulting in the qualification of three control objectives. It also identified a number of areas where controls did not operate for the full period This report covered payroll, financial ledger, accounts payable, accounts receivable, financial reporting, treasury and cash management and non-clinical procurement. An action plan has been provided by the CSU, which includes 3 actions relating to HR and 1 relating to procurement. The final report for the period 1 September 2017 to 31 March 2018 gave a qualified opinion for two control objectives relating to payroll and staff changes. SCW CSU has implemented an action plan to address the issues identified. The CCG receives activity and finance data produced from SCW CSU which is assured through their own processes. The CCG also employs its own analysts who review the data and reports provided by CSU and may comment on their accuracy. The CCG also has its own processes for checking the quality of information received by third parties, recognising the importance 88 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

89 of reliable information, both in terms of commissioning services and efficient management of the CCG s day-to-day business and resources. Where the CCG relies on third party providers for example NHS Digital who provide IG training modules, payroll (provided by ESHT), then built into the contract are mechanisms regarding assurances that the CCG requires throughout the life of the contract. The contract with the CSU is monitored by senior managers within the CCG and any issues reported to the senior management team. Control issues The CCG notes a significant control issue relating to its financial position in 17/18. The CCG position moved from a planned deficit of 13.0m to an actual deficit of 38.74m at year end and in light of this deterioration in our financial status, and in response to our legal directions the CCG commissioned independent pieces of work to address the deficit and to understand how the challenged position had arisen and inform the development of a credible plan to help the CCG move forward. Actions included: Development of comprehensive medium term financial recovery plan which was presented to NHS England in February 2018; RSM UK Consulting LLP undertook a financial governance review in May 2017 which resulted in a comprehensive action plan, including initiation of a Finance and Contracting Committee; and In February 2018 Price Waterhouse Coopers (PWC) consultancy, were asked to undertake a review of the CCG s governance, capacity and capability process in alignment with the Commissioning Alliance CCGs. This was initiated with the support of NHSE to understand the challenges and opportunities facing the CCG in order to inform recovery through Legal Directions. Review of economy, efficiency and effectiveness of the use of resources The Accountable Officer has responsibility for reviewing the effectiveness of the system of internal control within the clinical commissioning group. As described above, the membership has delegated authority to the Governing Body and to the Strategic Clinical Commissioning Group to act effectively, efficiently and economically. The Quality and Performance Committee oversees provider performance management across the CCG and the Delivery Programme Board oversees QIPP development and CCG performance and delivery. Finance and Contracting Committee oversee financial performance, including scrutiny of financial planning and ensuring transparency of underlying assumptions in building financial plans and budgets. During 2017/18 there has been additional scrutiny of financial planning and in-year performance monitoring through the appointment of an interim Turnaround Director, providing an independent assessment of the CCG plans. To deliver our deficit control total the CCG had an ambitious QIPP programme and the delivery of savings is always a key component of the assurance given to the Governing Body on the effective use of resources. In July 2017 the CCG developed a financial recovery Plan (FRP) to deliver additional savings. Despite this the CCG position deteriorated as noted above. ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 89

90 The CCG s 2017/18 financial plans required 5.8% QIPP savings and the planning assumptions taken directly from those used in the Sussex and East Surrey STP planning process. The STP has been classified as one of the most financially challenged STPs in the country. This highlights the wider difficult financial situation in which the CCG is operating. The main contributors to the CCG s increased deficit over their budget has been a continued increase in acute spend and QIPP under delivery. The CCG has also been impacted by negotiations with regulators and providers on main acute contracts for 2018/19, which was the main contributor to the movement in the deficit from the month 10 forecast of 31.6m to the final outturn of 38.74m. The CCG achieved 4% QIPP ( 11.4m), against the original plan of 5.8% ( 17.1m). This represents a strong performance in absolute terms compared to previous years but still produced a budget shortfall of 5.7m. The significant factor behind the under-performance is that QIPP targets were not adequately underpinned by implementation plans capable of delivering in-year savings. This lack of robustness of the assumptions and plans underpinning the FRP and budget have been highlighted as two of the key contributing factors of the CCGs deteriorating financial position in 2017/18. The CCG now carries forward a cumulative deficit of 53.54m into the 2017/18 financial year. In line with 2016/17, we anticipate an adverse economy, efficiency and effectiveness conclusion from external audit due to our in year and underlying deficit position. and economically and this includes receiving and processing all recommendations made by internal audit. Formal reports on financial performance are presented at every Governing Body meeting and Finance and Contracting Committee meeting. The CCG rating against the Quality of Leadership indicator of the CCG Improvement and Assessment Framework 2016/17, reported on MyNHS was red. The CCG has addressed this in a number of ways and a key theme of the improvement and assurance plan is leadership, which is monitored through the Executive Team with oversight of the Audit Committee. Delegation of functions The CCG has not delegated decision making on any aspects of its expenditure or functions. Where it works collaboratively with partners, decisions still need to be taken in a CCG decision making committee. A formal Memorandum of Understanding exists between the CCGs in the Central Sussex and East Surrey Commissioning Alliance. The CCG has formal Section 75 agreements in place with West Sussex County Council and neighbouring CCGs in West Sussex. These arrangements are monitored through the Joint Commissioning Strategic Group (JCSG) and through the provisions of the Section 75 agreement. This includes arrangements for the Better Care Fund and JCSG monitor performance and budget reports monthly. The Audit Committee has been delegated responsibility for providing assurance that the CCG is acting effectively, efficiently 90 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

91 Counter fraud arrangements The CCG has the support of a specialist Counter Fraud Service, which reports to the Chief Finance Officer (North) and Audit Committee. The service undertakes both proactive work to detect abuse or fraud, as well as investigates suspicions of fraud. There is a full set of policies and procedures in place and contact information via posters on staff notice boards and fraud newsletters. During 2017/18 the activities of the fraud service included: Thematic reviews into purchasing cards and personal health budgets; Fraud Awareness presentations to all staff and members; Registration concerns at GP surgeries; Supporting the CCG completing their Self Review Tool (SRT) to evidence how the CCG approaches and tackles fraud, this is required annually by NHS England and NHS Counter Fraud Authority; Updating the Fraud Bribery and Corruption Policy / Parallel sanctions policies; Monitoring the National Fraud Initiative for the CCG; Issuing a staff Fraud Survey, which will provide benchmarking against other CCG clients; and Issuing national and local Fraud Alerts to the CCG and GP Practices. 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: The overall Head of Internal Audit Opinion for 2017/18 is Reasonable Assurance, except for the CCG s ability to deliver their planned financial control total. I am satisfied that sufficient internal audit work has been undertaken to allow me to draw a reasonable conclusion as to the adequacy and effectiveness of the CCG's risk management, control and governance processes. In my opinion the CCGs have adequate and effective management, control and governance processes to manage the achievement of its objectives, except for delivery of their planned financial control total. ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 91

92 During the year, Internal Audit issued the following audit reports: Area of Audit Level of Assurance Given Cyber security (carried forward from ). Workforce QIPP Locally commissioned service monitoring Conflicts of interest Critical Financial Assurance Financial Accounting & Non- Pay Expenditure Information Governance toolkit parts 1 and 2. Critical Financial Assurance - Payroll Assurance Framework and Risk Management Public Website Management (draft reporting stage) Business Continuity Limited Reasonable Limited / Reasonable Assurance No opinion assigned. Reasonable Reasonable Part 1 no opinion assigned Part 2 Substantial Reasonable Reasonable Reasonable Reasonable There were two areas reviewed by internal audit where it was assessed that the effectiveness of some of the internal control arrangements provided limited' assurance. Recommendations were made to further strengthen the control environment in these areas and the management responses indicated that the recommendations had been accepted. With respect to cyber security, the Audit Committee has overseen the implementation of many of the recommendations throughout the year and has escalated the issue of risk appetite v. costs to the Central Sussex and East Surrey Commissioning Alliance. The CCG will monitor completion of all actions through the Audit Committee. Review of the effectiveness of governance, risk management and internal control My review of the effectiveness of the system of internal control is informed by the work of RSM UK Consulting LLP financial governance review in May 2017, internal auditors, executive managers and clinical leads within the clinical commissioning group who have responsibility for the development and maintenance of the internal control framework. I have drawn on performance information available to me. My review is also informed by comments made by the external auditors in their annual audit letter and other reports. Our BAF provides me with evidence that the effectiveness of controls that manage risks to the clinical commissioning group achieving its principal objectives have been reviewed. 92 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

93 I have been advised on the implications of the result of this review by: The Governing Body; The Audit Committee; Finance and Contracting Committee; Quality and Performance Committee; Delivery Programme Board; Internal audit; and External Consultants appointed to review the CCG s governance. This has been a challenging year for the CCG, having seen significant changes to the organisation s leadership through development of the Central Sussex and East Surrey Commissioning Alliance and having entered legal directions in November I have put in place a series of actions to address these issues which are discussed in more detail in the introduction and context to the governance statement. Conclusion The weakness in financial control evidenced by our declared deficit is described above. During 2017/18 the CCG has improved its systems of internal control through the changes introduced in its governance structures, with a specific focus on financial governance. I have noted that the Head of Internal Audit Opinion stating that the CCG can take reasonable assurance included the exception that the CCG was unable to deliver its planned control total. In 2018/19, working with colleagues in the Central Sussex and East Surrey Commissioning Alliance the CCG will further strengthen its governance structures and financial controls building on the Head of Internal audit finding that there is a generally sound system of internal control, designed to meet the organisation s objectives, and that controls are generally being applied consistently. Measures will be taken to strengthen these, informed by the recommendations of the commissioned governance review. The factors described in this statement have given me increased assurance which I have been able to reference as part of this governance statement and these systems of internal control will be further improved during 2018/19. Adam Doyle Adam Doyle Accountable Officer 24 May 2018 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 93

94 Governing Body attendance Name Position Attended / Eligible to attend Mark Baker Strategic Director of Finance (from ) 3/3 Stephen Bellamy Locality Group Chair 8/10 Adrian Brown Lay Member Audit 9/10 Simon Chandler Lay Member PPE and Vice Chair 8/10 Adam Doyle Accountable Officer (from ) 3/3 Karen Eastman Clinical Director 7/10 Rachel Harrington Chief Operating Officer (to ) Director of System Transformation 4/7 Geraldine Hoban Accountable Officer (to ) Managing Director North (from ) 10/10 Terry Lynch Clinical Director 10/10 Mark Lythgoe Clinical Director 5/10 Hugh McIntyre Secondary Care Clinician 8/10 David McKenzie Clinical Director 8/10 Riz Miarkowski Clinical Director 5/10 Minesh Patel Clinical Chair 9/10 John Steele Lay member (from ) 3/3 Sally Thomson Independent Nurse 7/10 Chief Finance Officer (GB member to Barry Young ) 7/7 Audit Committee voting members Name Position Attended / Eligible to attend Adrian Brown Chair 6/6 Simon Chandler Lay Member 5/6 Dr Matthew Greenwood CCG Member Representative 5/6 94 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

95 Delivery Group/Strategic Clinical Commissioning Group As of April 2017, the Horsham and Mid Sussex Delivery Group was still in place. As of May 2017, the Strategic Clinical Commissioning Group superseded the Delivery group, although voting members remained the same. The below table reflects the attendance of members at the Delivery Group meeting in April 2017 and the Strategic Clinical Commissioning Group from May 2017 onwards. Name Position Attended / Eligible to attend Stephen Bellamy Locality Group Co Chair 7/12 Karen Eastman Locality Group Co Chair 9/12 Rachel Harrington Director of System Transformation 8/12 Accountable Officer (to ) 7/12 Geraldine Hoban Managing Director North (from ) Julia Layzell Head of Quality 6/12 Terry Lynch Clinical Director 12/12 Mark Lythgoe Clinical Director 7/12 David McKenzie Clinical Director 9/12 Riz Miarkowski Clinical Director 5/12 Minesh Patel Clinical Chair 8/12 Barry Young Chief Finance Officer (North) 7/12 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 95

96 Horsham and Mid Sussex Locality Group Practice Attended The Brow Medical Centre 6 / 6 Courtyard Surgery 4 / 6 Cowfold Medical Group 5 / 6 Crawley Down Health Centre 4 / 6 Cuckfield Medical Practice and Vale Surgery 5 / 6 Dolphins Practice 4 / 6 Holbrook Surgery 3 / 6 Judges Close Surgery 6 / 6 Lindfield Medical Centre 6 / 6 The Meadows Surgery 5 / 6 Mid Sussex Healthcare 4 / 6 Moatfield Surgery 4 / 6 Newtons Practice 6 / 6 Northlands Wood Practice 6 / 6 Orchard Surgery 6 / 6 Ouse Valley Practice 4 / 6 Park Surgery 5 / 6 Park View Health Partnership 5 / 6 Riverside Surgery 1 / 6 Rudgwick Medical Centre 5 / 6 Ship Street Surgery 4 / 6 Silverdale Practice 4 / 6 Village Surgery 6 / 6 96 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

97 Horsham and Mid Sussex Primary Care Commissioning Committee Primary Care Commissioning Committees - Advisory Members As of May 2017 there was a change to the Terms of reference of this committee to ensure compliance with national guidance. GPs are welcomed as advisory members of the Primary Care Commissioning Committee to ensure sufficient clinical input. This allows GP participation in strategic discussions on primary care issues, subject to appropriate management of conflicts of interest. Advisory members are: GP member of the Governing Body or their nominated deputy; and Two other CCG member representatives which may include a practice manager Name Position Attended / Eligible to attend Stephen Bellamy / Mark Lythgoe GP Governing Body Member 1/1 Adrian Brown Governing Body Lay Member (Audit) 4/6 Simon Chandler Governing Body Lay Member (PPE) - Chair 6/6 Matt Greenwood GP Member 1/1 Sheryl Knight GP Member 0/1 Julia Layzell/ Sally Thomson Head of Quality/ Independent Nurse John Steele Lay Member - Vice Chair 5/6 Barry Young Chief Finance Officer (North) 3/6 3/6 Remuneration and Nominations Committee Name Position Attended / Eligible to attend Adrian Brown Lay Chair 4/4 Simon Chandler Governing Body Lay Member 3/4 Hugh McIntyre Secondary Care Clinician Sally Thomson Independent Nurse 2/4 Barry Young* Chief Finance Officer (North) 1/2 *Served as a co-opted member where conflicts of interest needed to be managed. As part of the development of the Central Sussex and East Surrey Commissioning Alliance, a Remuneration and Nominations Committees in Common covering NHS Brighton and Hove CCG, Crawley CCG, High Weald Lewes Havens CCG and Horsham and Mid Sussex CCG met for the first time on the 17 October 2017, this committee is included in the above table. 2/4 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 97

98 Remuneration and staff report Remuneration report Remuneration Committee The Remuneration Committee is a formally appointed committee of the Governing Body. It has delegated authority from the Governing Body to determine the terms and conditions of engagement, remuneration including fees, allowances and the appropriate administration of pension contributions for senior employees on the Governing Body and from the Membership via the Constitution, to determine the remuneration, including allowances, for members of the Governing Body who are officers. The information in the Remuneration Report that is subject to external audit, includes: The table of salaries and allowances of senior managers and related narrative notes on pages 100 to 104; The table of pension benefits of senior managers and related narrative notes on pages 102 to 104; and The narrative disclosure of pay multiples on page 105; Employee staff numbers outlined in note 3.2 to the Accounts and on page 107 The Committee is appointed by the CCG from amongst its Lay and Independent Governing Body Members and comprises the Lay Member for Governance, the Lay member for Patient and Public Engagement (PPE), the Independent Secondary Care Clinician and the Independent Nurse. The Chair of the Committee is usually the Lay Member for Governance except when the remuneration of the Lay Members is being discussed, at which point one of the independent clinicians takes the chair. The Committee is quorate if any two members are present, and a member of the Committee is not permitted to be present if their remuneration is being discussed. The Committee has met no less than twice a year, as provided in its terms of reference. Details of Remuneration Committee membership and attendance is shown in the annual governance statement. The CCG contracts with a Commissioning Support Unit (CSU) under a service level agreement to deliver HR services. This includes provision of specialist HR advice to its Remuneration Committee. The Committee therefore has access to and takes advice from a named HR Lead, employed by the CCG s HR provider; South, Central and West CSU (SCW). Specialist advice covered employment law, NHS terms and conditions, the interpretation of NHS England remuneration guidance for CCGs and the provision of benchmarking information relating to local and regional CCG Governing Bodies. The work of the Remuneration Committee and decisions made The Committee has worked to its agreed annual work plan over the past year and has reached decisions on the following: 98 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

99 The 2017/18 annual review of the remuneration of its Governing Body, with reference to the nationally agreed pay award, appropriate benchmarking and the prevailing financial situation of the CCG; As part of Pensions Act 2008, selection of NEST; the government approved pension scheme for the auto enrolment of staff who are not eligible to enrol on the NHS pension scheme; and The re appointment of Lay members through an established governance process for a second tenure. In reaching decisions, the Committee was provided with relevant benchmarking and up to date guidance from its specialist HR provider to ensure all decisions are robust. Policy on the remuneration of senior managers The definition of senior manager within the guidance is: Those persons in senior positions having authority or responsibility for directing or controlling the major activities of the CCG. This means those who influence the decisions of the entity as a whole rather than the decision of individuals, directorates or departments. For the purposes of this report, this definition has been taken to include employee and officer voting members of the Governing Body and all members of the Central Sussex Commissioning Alliance Executive Team. In Horsham and Mid Sussex CCG this also includes the Director of System Transformation (previously Chief Operating Officer) who has acted as the nominated deputy of the Accountable Officer. The Accountable Officer has confirmed that the definition of senior manager does not extend beyond this and that regular (but non-voting) attendees at the Governing Body and strategic Clinical Commissioning Group are covered by nationally negotiated NHS Pay scales and are disclosed via the employee benefits table in these annual accounts. The CCGs that are part of the Central Sussex Commissioning Alliance (NHS Horsham and Mid Sussex CCG, NHS Crawley CCG, NHS Brighton and Hove CCG and NHS High Weald Lewes Havens CCG) are separate statutory bodies working with shared management team and arrangements since 1 January 2018 are governed by a Memorandum of Understanding. Where a senior manager and member of the Governing Body works across more than one CCG, the appropriate proportion of remuneration is reported and their total remuneration across both CCGs is shown separately in order to ensure full disclosure. Remuneration of very senior managers The CCG has a number of individuals where total remuneration (when prorated) exceeds 150,000pa. The CCG is satisfied that this remuneration is reasonable based on the benchmarking data and analysis undertaken by the Remuneration Committee. ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 99

100 Senior manager remuneration (including salary and pension entitlements) Salary Disclosure Table / /17 Name and Title Salary (bands of 5,000) Salary (bands of 5,000) (note 6) (note 6) Dr Minesh Patel, CCG Chair Adam Doyle Accountable Officer from (Note 1) 5-10 n/a Mark Baker Strategic Director of Finance from (Note 1) Geraldine Hoban Managing Director North from (Note 1 and Note 10) From shared appointment with Crawley CCG Wendy Carberry Managing Director South from (Notes 1 and 11) Terry Willows Director of Corporate Affairs from (Notes 1 and 12) Glynn Dodd, Programme Director of Commissioning Reform (Note 1) Sarah Valentine, Director of Commissioning and Performance from (note 2) Allison Cannon, Director of Quality and Chief Nurse from (Notes 2 and 13) Barry Young, Chief Finance Officer for NHS Horsham and Mid Sussex CCG (Note 3) Rachel Harrington, Director of System Transformation (previously Chief Operating Officer) (Note 3) From 1 April 2017 this was a joint post with Crawley CCG. Dr Karen Eastman, Clinical Director/GP Member of the Governing Body Dr Nick Barrie, Clinical Director/GP Member of the Governing Body to Dr Mark Lythgoe, Clinical Director/GP Member of the Governing Body Dr Riz Miarkowski, Clinical Director/GP Member of the Governing Body Dr Terry Lynch, Clinical Director/GP Member of the Governing Body from Dr Simon Dean, Clinical Director/GP Member of the Governing Body to n/a n/a 5-10 n/a 5-10 n/a 0-5 n/a 5-10 n/a n/a n/a n/a ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

101 Dr Stephen Bellamy Clinical Director/GP Member of the Governing Body Dr David McKenzie, Clinical Director/GP member of the Governing Body from Adrian Brown, Lay Member (Governance) of the Governing Body n/a Simon Chandler, Lay Member (PPE) of the Governing Body John Steele, Lay Member Primary Care (from ) (note 5) Dr Hugh McIntyre, secondary care clinician (from ) (Note 4) 0-5 n/a Sally Thomson, Independent Nurse (Note 4) Salary Disclosure Table - 2 For the joint appointments, total salary is shown. All pension related benefits are calculated with respect to total for the joint appointment Salary (Bands of 5,000) 2017/ /17 All pension Total Salary All pension related related benefits benefits (Bands of 2,500) (Bands of 5,000) (Bands of 5,000) (Bands of 2,500) Total (Bands of 5,000) (Note 7) (Note 7) Adam Doyle (Note 1) n/a n/a n/a Mark Baker (Note 1) n/a n/a n/a Wendy Carberry (Note 1 and 11) n/a n/a n/a Terry Willows, (Note 1 and 12) n/a n/a n/a Glynn Dodd (Note 1) n/a n/a n/a Sarah Valentine (note 2) n/a n/a n/a Allison Cannon (Note 2 and 13) n/a n/a n/a Rachel Harrington (Note 3) Geraldine Hoban (Note 1) Barry Young (note 3) ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 101

102 Name and title Pension Disclosure Table (1 of 2) Real increase in pension at pension age (bands of 2,500) Real increase in pension lump sum at pension age (bands of 2,500) Total accrued pension at pension age at 31 March (bands of 5,000) Lump sum at pension age related to accrued pension at 31 March (bands of 5,000) 2017/18 Cash Equivalent Transfer Value at 1 April Real increase in Cash Equivalent Transfer Value Cash Equivalent Transfer Value at 31 March previous year Employer's contributio n to stakeholder pension (Note 9 ) (Note 9) (Note 9) (Note 8) Adam Doyle (Note 1) Mark Baker (Note 1) Terry Willows, (Note 1 & 12) Glynn Dodd (Note 1) Sarah Valentine (note 2) Allison Cannon (Note 2 & 13) Rachel Harrington Geraldine Hoban (Note1) Barry Young (note 3) , ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

103 Adam Doyle (Note 1) Mark Baker (Note 1) Wendy Carberry (Note 1 & 11) Terry Willows, (Note 1) Glynn Dodd (Note 1) Sarah Valentine (note 2) Allison Cannon (Note 2 & 13) Rachel Harrington, (Note 3) Geraldine Hoban, (Note 1) Barry Young, as above Pension Disclosure Table (2 of 2) Real increase in pension at pension age (bands of 2,500) (Note 9 ) Real increase in pension lump sum at pension age (bands of 2,500) (Note 9) Total accrued pension at pension age at 31 March (bands of 5,000) Lump sum at pension age related to accrued pension at 31 March (bands of 5,000) 2016/17 Cash Equivalent Transfer Value at 1 April Real increase in Cash Equivalent Transfer Value (Note 9) Cash Equivalent Transfer Value at 31 March previous year Employer's contribution to stake-holder pension (Note 8) n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a (0-2.5) (0-2.5) (0-2.5) Notes relating to tables Note 1: Appointed to the CSCA executive team from 1 January 2018 and a shared post with Brighton and Hove CCG, High Weald Lewes Havens CCG and Crawley CCG). The total salary for the joint appointment is as shown in salary disclosure table 2; this is a part year effect for 2017/18. In salary disclosure table 2 and the pension disclosure table, all pension related benefits are calculated with respect to total for the joint appointment, except for the employer pension contribution. The Alliance percentage split agreed is 37% Brighton and Hove CCG, 20% High Weald Lewes Havens CCG 28% Horsham & Mid Sussex CCG and 15% Crawley CCG. Note 2: Joint appointment to the 8 CCGs in the STP (Brighton and Hove CCG, High Weald Lewes Havens CCG, Coastal West Sussex CCG, East Surrey CCG, Eastbourne Hailsham and Seaford CCG, Hastings and Rother CCG and Crawley CCG). The total salary for the joint appointment is as shown in in salary disclosure table 2; this is a part year effect for 2017/18. In salary disclosure table 2 and the pension disclosure table, all pension related benefits are calculated with respect to total for the joint appointment, except for the employer pension contribution. The STP percentage split agreed is 15.7% Brighton and Hove CCG, 8.4% High Weald Lewes Havens CCG 11.1% Horsham & Mid Sussex CCG, 6.5% Crawley, 27.7% CCG Coastal West Sussex CCG, 8.9% East Surrey CCG, 10.8% Eastbourne Hailsham and Seaford CCG and 10.9% Hastings and Rother CCG. Note 3 Joint appointment with NHS Crawley CCG.The total salary for the joint appointment is as shown in in salary disclosure table 2. In salary disclosure table 2 and the pension disclosure table, all pension related benefits are calculated with respect to total for the joint appointment, except for the employer pension contribution. The MOU between Crawley and Horsham and Mid Sussex CCGs is ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 103

104 for 36% of the salary cost to be recharged from Horsham and Mid Sussex CCG (the employer) to NHS Crawley CCG. Note 4: Joint appointment with NHS Crawley CCG The total remuneration for the joint appointment is in the salary band range of ( 000). The MOU between Crawley and Horsham and Mid Sussex CCGs is for 36% of the salary cost to be recharged from Horsham and Mid Sussex (the employer) to NHS Crawley CCG. Note 5 Joint appointment with NHS Crawley CCG The total remuneration for the joint appointment is in the salary band range of 0-5 ( 000). The MOU between Crawley and Horsham and Mid Sussex CCGs is for 36% of the salary cost to be recharged from Horsham and Mid Sussex (the employer) to NHS Crawley CCG. Note 6: There are nil entries for taxable benefits, annual performance related bonuses, long term performance related bonuses and all pension related benefits for those senior managers shown in salary disclosure table 1 except for employees of the CCG. (See salary disclosure table 2 and pension table for pension related benefits for employees). Note 7: All Pension Related Benefits: This will apply to those receiving pension contributions only. The amount included here comprises all pension related benefits, including: The cash value of payments (whether in cash or otherwise) in lieu of retirement benefits; and, All benefits in year from participating in pension schemes. For defined benefit schemes, the amount included here is the annual increase in pension entitlement determined in accordance with the 'HMRC' method. In summary, this is as follows: Increase = ((20 x PE) +LSE) - ((20 x PB) + LSB) less employee contributions Where: PE is the annual rate of pension that would be payable to the director if they became entitled to it at the end of the financial year; PB is the annual rate of pension, adjusted for inflation, that would be payable to the director if they became entitled to it at the beginning of the financial year; LSE is the amount of lump sum that would be payable to the director if they became entitled to it at the end of the financial year; and, LSB is the amount of lump sum, adjusted for inflation, that would be payable to the director if they became entitled to it at the beginning of the financial year. Note 8 This is the CCGs contribution to the employee s pension at a rate of 14.3% of the employee s salary for those within the NHS Pension scheme. Lay members, the Governing Body independent nurse and secondary care consultant remuneration are non-pensionable and therefore there are no entries in respect of pensions for these members. The Clinical Directors are office holders of the CCG and are self-employed GPs. The employment status is an 'off payroll worker' but in accordance with HMRC guidance they are deemed 'office holders' of the organisation requiring the organisation to deduct income tax and national insurance at source. The practitioner pension information cannot be obtained by the CCG in respect of CETV or lump sum.as the role carried out by the GPs at the CCGs will only form a part of their overall work, it is also considered inappropriate to disclose information on CETV or lump sum even if the CCGs were party to the information. Note 9: The inflation applied to the accrued pension, lump sum (where applicable) and CETV is the percentage (if any) by which the Consumer Prices Index (CPI) for the September before the start of the tax year is higher than it was for the previous September. For 2017/18 the difference in CPI between September 2015 and September 2016 was 1%. Therefore for transfers and benefit calculation purposes in 2017/18 CPI is 1%. Applying this inflation adjustment to the 31 March 2017 value has in some cases resulted in an adjusted value which exceeds the 31 March 2018 value. Note 10: Appointed Accountable Officer for Horsham and Mid Sussex CCG until Joint Appointment with NHS Crawley CCG to Appointed Managing Director North in the Alliance executive team from Note 11: Member of the CSCA Executive but remuneration is with Brighton & Hove CCG and High Weald Lewes Havens CCG. Note 12: Seconded from NHS England; Pension disclosure information not available from host organisation. Note 13: Role is Sussex wide and on NHS Hastings and Rother CCG payroll: Pension disclosure information not available from host organisation. 104 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

105 Cash equivalent transfer values A cash equivalent transfer value (CETV) is the actuarially assessed capital value of the pension scheme benefits accrued by a member at a particular point in time. The benefits valued are the member s accrued benefits and any contingent spouse s (or other allowable beneficiary s) pension payable from the scheme. A CETV is a payment made by a pension scheme or arrangement to secure pension benefits in another pension scheme or arrangement when the member leaves a scheme and chooses to transfer the benefits accrued in their former scheme. The pension figures shown relate to the benefits that the individual has accrued as a consequence of their total membership of the pension scheme, not just their service in a senior capacity to which disclosure applies. The CETV figures and the other pension details include the value of any pension benefits in another scheme or arrangement which the individual has transferred to the NHS pension scheme. They also include any additional pension benefit accrued to the member as a result of their purchasing additional years of pension service in the scheme at their own cost. CETVs are calculated within the guidelines and framework prescribed by the Institute and Faculty of Actuaries. Real increase in CETV This reflects the increase in CETV that is funded by the employer. It does not include the increase in accrued pension due to inflation or contributions paid by the employee (including the value of any benefits transferred from another scheme or arrangement). Exit packages, including special (non-contractual) payments There have been no exit packages including special (non-contractual) payments or other departures in any of the following categories. Voluntary redundancies including early retirement contractual costs; Mutually agreed resignations contractual costs; Early retirements in the efficiency of the service contractual costs; Contractual payments in lieu of notice; Exit payments following Employment Tribunals or court orders; and Non-contractual payments requiring HMT approval. Pay multiples Reporting bodies are required to disclose the relationship between the remuneration of the highest paid member in their organisation and the median remuneration of the organisation s workforce. The banded remuneration of the highest paid member in NHS Horsham and Mid Sussex CCG in the financial year 2017/18 was ( 000) (2016/17: ( 000)). The full time equivalent (FTE) value for the highest member remuneration is ( 000) (2016/17, ( 000)). This was 5.0 times (2016/17: 4.1) the median remuneration of the workforce, which was 45,519 (2016/17: 43,751). The increase in pay multiples is due to a number of posts within the CCG filled on an interim basis with consultants; especially with the assurance of the Financial Recovery Programme. ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 105

106 In 2017/18, six employees received remuneration in excess of the highest-paid member. Remuneration (calculated on a full time equivalent basis) ranged from ( 000) (2016/17: ( 000)). Staff Report The CCG started the year with a shared management team with Crawley CCG which enabled us to work efficiently and effectively with limited management allowance resources. All employees are treated for payroll purposes as NHS Horsham and Mid Sussex CCG employees. During the year the CCG agreed to work as part of an alliance of CCGs and the executives of the Alliance are hosted for employment purposes by Brighton and Hove CCG. As noted earlier in the Performance report, the Alliance officially went live from January 2018 and is organised in two places. There is a single Executive Team for the Alliance, with a single Accountable Officer for all four CCGs, as outlined below. An asterisk denotes executives that are voting members of the Horsham and Mid Sussex CCG Governing Body. All executives may attend Governing Bodies in a non-voting capacity. 4 CCG Chairs Joint Accountable Officer Adam Doyle * Managing Director North Geraldine Hoban Managing Director South Wendy Carberry Strategic Director of Finance Mark Baker * Programme Director - Commissioning Glynn Dodd Joint Director of Corporate affairs Terry Willows Director of Contracts and Performance (STP) Sarah Valentine Chief Nurse (STP) Allison Cannon In order to realise the efficiencies of working in alliance across the CCGs, the team structures below executive level are being reviewed and revised to align staff more effectively. During 2017/18 a period of discussion and consultation with staff has begun and fully revised staff structures will be completed during 2018/19. Number of senior managers, staff numbers and composition Staff details disclosed are permanently employed staff with a permanent (UK) employment contract with the CCG and includes the relevant CCG share of any 106 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

107 shared posts. The Governing Body members composition is shown below. In addition there is one (one female) nominated deputy for a voting member, who is defined as a senior manager for the purposes of the remuneration and staff report. The table below shows the staff composition by band. This includes those GPs working as clinical leads, and paid through the payroll, but who are not employees or officers. Female Male Total Headco unt in 2017/18 Average WTE Headco unt in 2017/18 Sum of Average WTE Headco unt in 2017/18 Sum of Average WTE Governing Body Chair Accountable Officer/Managing Director Strategic Finance Director Chief Finance Officer Clinical Directors Lay Members Governing Body Total Employees of the CCG Band Band Band Band Band Band 8A Band 8B Band 8C Band 8D Band Very Senior Managers Clinical Leads Employees Total Grand Total ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 107

108 Staff Costs The table below shows the total employee benefits. 2017/18 Employee Benefits 2017/18 total Admin Programme Total Perm Other Total Perm Other Total Perm Other Employee Benefits Salaries and wages 4,861 4, ,184 2, ,677 2, Social Security Costs Employer contribution to NHS Pension Scheme Net Employee Benefits 5,694 5, ,676 2, ,018 2, /17 Employee Benefits 2016/17 total Admin Programme Total Perm Other Total Perm Other Total Perm Other Employee Benefits Salaries and wages 3,632 3, ,225 2, ,408 1, Social Security Costs Employer contribution to NHS Pension Scheme Net Employee Benefits 4,452 4, ,769 2, ,685 1, Sickness absence data Sickness absence rates for the calendar year to December 2017, show average days lost per FTE employee of 6.2 days (4.0 in 2016/17), equating to sickness absence rate of 2.78% (1.78% in 2016/17). The underlying figures have been converted to the Cabinet Office measurement base by applying a factor of 225/365 to convert from calendar days to working days lost. Because of the shared management team (with all employee payments made through NHS Horsham and Mid Sussex CCG) the figure shown is combined with NHS Crawley CCG. There is a sickness absence policy in place and support in managing absence is provided by a human resources service. 108 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

109 Staff policies The CCG in discharging its obligation as a responsible employer has HR policies, procedures and practices in place that are inclusive of diversity and equal treatment of its workforce. Each policy is equality impact assessed for the effect on different groups protected from discrimination by the Equality Act (2010) to ensure the policy is fully effective for all target groups. The CCG operates under the Disability Confident Scheme principles by ensuring candidates who declare a disability and meet the minimum requirements for a vacancy, are interviewed. HR advise recruiting managers appropriately, as all applications are anonymous until shortlisting for interview has been completed. The CCG works with its HR provider to ensure training and development is accessible to all staff and where appropriate will seek the advice of Occupational Health specialists. The CCG is a member of a Sussex wide Health and Safety Committee which enables the CCG to discharge its responsibility for the safety and wellbeing of its workforce. Trade Union facilities Senior managers and the HR leads in the CCG meet formally with recognised Trade Union representatives and engage with staff through this mechanism. The CCG is a relevant public sector employer as defined by the Trade Union (Facility Time Publication Requirements) Regulations 2017 and has one full time employee serving the shared management team of both Crawley CCG and Horsham and Mid Sussex CCG to report, who spent 1% to 50% of their working hours on facility time representing less than 1% of total pay bill. Expenditure on consultancy During the year the CCG spend on consultancy services was 1,336,000 ( 997,000 in 2016/17) as can be seen in note 4 of the Annual Accounts. The increase in consultancy charges is mainly due to cover of CCG substantive posts and additional resource engaged to support and assure the turnaround project of the CCG ( 367k) and to charges for expenditure incurred across Sussex and East Surrey relating to Sustainable Transformation Plans (STP) and Place Based Plans 86k [2016/17 87k]. Off-payroll engagements Off-payroll engagements are defined as those at rates of more than 220 per day and lasting more than six months. In this category there have been a number of engagements with individuals undertaking interim roles for the CCG, outlined below. The majority of these roles are shared with NHS Crawley CCG as part of the shared management arrangements. ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 109

110 Off-payroll engagements longer than 6 months For all off-payroll engagements as at 31 March 2018, for more than 220 per day and that last longer than six months: Number Number of existing engagements as of 31 March Of which, the number that have existed: for less than one year at the time of reporting 4 for between one and two years at the time of reporting 1 for between 2 and 3 years at the time of reporting for between 3 and 4 years at the time of reporting for 4 or more years at the time of reporting In 2017/18 a business case approval process via weekly executive meeting has been implemented for all changes to the CCGs establishment; including recruitment of interims. New off-payroll engagements For all new off-payroll engagements between 01 April 2017 and 31 March 2018, for more than 220 per day and that last longer than six months: Number of new engagements, or those that reached six months in duration, between 1 April 2017 and 31 March 2018 Number of new engagements which include contractual clauses giving NHS Horsham and Mid Sussex CCG the right to request assurance in relation to income tax and National Insurance obligations Number Number for whom assurance has been requested 6 Of which: assurance has been received 6 assurance has not been received - engagements terminated as a result of assurance not being received ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

111 Off-payroll engagements / senior official engagements For any off-payroll engagements of Board members and / or senior officials with significant financial responsibility, between 01 April 2017 and 31 March Number of off-payroll engagements of board members, and/or senior officers with significant financial responsibility, during the financial year Total no. of individuals on payroll and off-payroll that have been deemed board members, and/or, senior officials with significant financial responsibility, during the financial year. This figure should include both on payroll and off-payroll engagements ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 111

112 Parliamentary accountability and audit report NHS Horsham and Mid Sussex CCG is not required to produce a Parliamentary Accountability and Audit Report. Disclosures on remote contingent liabilities, losses and special payments, gifts, and fees and charges are included as notes in the Financial Statements of this report at note 19 of the financial statements. An audit certificate and report is also included in this Annual Report at page 162. Accountability Report Signed By Adam Doyle Accountable Officer: Adam Doyle Date: 24 May ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

113 Finance Report ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 113

114 Managing a challenging financial agenda Overall summary of the financial position NHS Horsham and Mid Sussex CCG delivered a deficit of 38.74m in 2017/18. The key results are: The CCG delivered a greater deficit than planned (planned deficit 13.0m; actual deficit of 38.74m), against a Revenue Resource Limit of m; The financial deficit triggered a Section 30 report to the Secretary of State from the CCG s external auditors; Cash was managed within the resource limits available; and The CCG, as a result of its many joint working arrangements, stayed within its running cost target of per head of population, restricting costs to per head. Finance report In 2017/18 the CCG was required to set the financial plan in accordance with the planning requirements laid down by NHS England; the CCG agreed a planned deficit of 13.0m. This plan included a low level of contingencies and reserves, and a challenging savings target and demand management plan to limit growth in activity. The CCG faced a number of financial pressures in 2017/18 leading to an increase in deficit above plan. These included: Continuing high levels of activity in acute hospitals, and at Surrey and Sussex Healthcare NHS Trust in particular; Impact of transactions relating to prior year; Growth in activity higher than forecast and growth in average cost of care at acute hospital settings; Failure to fully identify and deliver QIPP savings targets; Unfunded increased costs of acute activity; and A provision for a receivable balance, in relation to contract payments to providers, that is doubtful in its recovery. As in 2016/17, CCGs were asked to set aside a risk reserve at the start of this financial year to provide a buffer to offset any wider system pressures. For 2017/18 this was reduced to 0.5% of CCGs allocations. CCGs were able to release the full amount of the risk reserve as additional underspend in its year end reporting. For the purpose of year-end assessment of financial performance against target the release of the 0.5% system reserve will be excluded. This is reported in note 20 of the annual accounts. 114 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

115 Quality, Innovation, Productivity and Prevention (QIPP) The NHS as a whole has to improve efficiency to offset the rising cost of healthcare from new technologies, population growth, inflation and other pressures. A national programme is now well established to release savings by improving quality, driving innovation in healthcare, improving productivity and preventing illhealth. The CCG plan for 2017/18 included a savings target of 17m (6% of allocation). This is significantly above the CCG national average for delivery over the last three years. The actual delivery of savings was 11.5m (67% of plan). Running costs Each CCG is set a limit on how much it can spend on its administrative and management costs. The running costs threshold approximates to per head of population, and we were able to manage our business within this limit with a running cost of per head of population. The CCG manages its running cost allowance as efficiently as possible through significant joint working with Crawley CCG in particular, and also with East Surrey CCG and other Sussex CCGs. Looking ahead The financial prospects for 2018/19 and subsequent years remain challenging, with significant savings targets to be met and rising demand for services, coupled with an ageing population with more complex health needs. The CCG will be the furthest away from its funding target, sometimes known as the fair shares target, compared to other local CCGs by 2018/19. The CCG s funding allocation broadly flat-lines in terms of distance from target and has been calculated as -2.97% (under) target at the end of 2018/19 The CCG has received an additional allocation of 9.7m in 2018/19 but this does not match the forecast growth in activity or new cost pressures. The CCG has produced a financial plan for 2018/19 in line with the guidance produced by NHS England. The CCG s current plans do not deliver the statutory financial duty of breakeven in 2018/19 or the NHS England control total of a deficit of 20m in year. The CCG is developing saving plans to meet this control total and will provide an updated Financial Recovery Plan to NHSE by 30 June The CCG submitted an Operating Plan in agreement with NHS England that shows a planned deficit of 28.4m and savings of 11.2m. ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 115

116 Annual Accounts 2017/ ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

117 NHS Horsham and Mid Sussex CCG Annual Accounts Contents Statement of Comprehensive Net Expenditure for the Year Ended 31 March Statement of Financial Position as at 31 March Statement of Changes in Taxpayers Equity for the Year Ended 31 March Statement of Cash Flows for the Year Ended 31 March Notes to the financial statements Accounting Policies Other Operating Revenue Employee Benefits & Staff Numbers Operating Expenses Better Payment Practice Code Operating Leases Property, Plant and Equipment Trade & Other Receivables Cash & Cash Equivalents Trade & Other Payables Provisions Contingencies Capital Commitments Financial Instruments Operating Segments Pooled Budgets Related Party Transactions Events after the end of the reporting period Losses and Special Payments Financial Performance Duties ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 117

118 Statement of Comprehensive Net Expenditure for the Year Ended 31 March Note Income from Sale of Goods and Services 2 (1,833) (2,150) Other Operating Income 2 (591) (190) Total Operating Income (2,424) (2,340) Staff Costs 3 5,706 4,452 Purchase of Goods and Services 4 330, ,051 Provision Expense 4 (72) 464 Other Operating Expenditure 4 7, Total Operating Expenditure 343, ,021 Comprehensive Net Expenditure for the year ended 31 March 2018 Of which: 341, ,681 Administration Income and Expenditure Employee Benefits 4 2,688 2,767 Operating Expenses 4 1,947 2,025 Other Operating Revenue 2 (25) (134) Net Administration Costs before Interest 4,610 4,658 Programme Income and Expenditure Employee Benefits 4 3,018 1,685 Operating Expenses 4 336, ,544 Other Operating Revenue 2 (2,399) (2,206) Net Programme Expenditure before Interest 336, ,023 The notes on pages 122 to 161 form part of this statement. Surplus / Deficit for Year Total Admin Programme PCDCC* The CCG's performance for the year ended 31 March 2018 is as follows: Total Net Operating Cost for the Financial Year 341,479 4, ,359 27,510 Revenue Allocation 302,739 4, ,442 28,312 (Under)/Overspend Against Revenue Resource Limit (RRL) 38,740 (375) 39,917 (802) * PCDCC Primary Care Delegated Co-Commsioning 118 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

119 Statement of Financial Position as at 31 March March March 2017 Note Total Non-Current Assets Current Assets: Trade and Other Receivables 8 27,692 26,571 Cash and Cash Equivalents Total Current Assets 27,736 26,861 Total Assets 28,030 27,026 Current Liabilities Trade and Other Payables 10 (25,643) (22,602) Provisions 11 (253) (546) Total Current Liabilities (25,896) (23,148) Non-Current Assets plus/less Net Current Assets/Liabilities 2,134 3,878 Non-Current Liabilities Provisions Total Non-Current Liabilities - - Assets Less Liabilities 2,134 3,878 Financed by Taxpayers Equity General Fund 2,134 3,878 Total Taxpayers' Equity: 2,134 3,878 The notes on pages 122 to 161 form part of this statement. The financial statements on pages 118 to 161 were approved by the Governing Body on 24 th May 2018 and agreed on its behalf by: Accountable Officer: Adam Doyle ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 119

120 Statement of Changes in Taxpayers Equity for the Year Ended 31 March March March 2017 General General fund fund Balance as at the Start of the Financial Year 3,878 (876) Changes in NHS Clinical Commissioning Group Taxpayers Equity for Net Operating Expenditure for the Financial Year (341,479) (284,681) Net Recognised NHS Clinical Commissioning Group Expenditure for the Financial Year (341,479) (284,681) Net Funding* 339, ,435 Balance as at the End of the Financial Year 2,134 3,878 *The Net funding represents the cash drawdown received from NHS England. The notes on pages 122 to 161 form part of this statement. 120 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

121 Statement of Cash Flows for the Year Ended 31 March Note Cash Flows from Operating Activities Net operating expenditure for the financial year (341,479) (284,681) (Increase)/decrease in trade & other receivables 8 (1,121) (10,356) Increase/(decrease) in trade & other payables 10 3,015 5,512 Provisions utilised 11 (222) (407) Increase/(decrease) in provisions 11 (72) 747 Net Cash Inflow (Outflow) from Operating Activities (339,879) (289,185) Cash Flows from Investing Activities (Payments) for property, plant and equipment 7 (103) (28) Net Cash Inflow (Outflow) from Investing Activities (103) (28) Net Cash Inflow (Outflow) before Financing (339,982) (289,213) Cash Flows from Financing Activities Net Funding Received 339, ,435 Net Cash Inflow (Outflow) from Financing Activities 339, ,435 Net Increase (Decrease) in Cash & Cash Equivalents 9 (246) 222 Cash & Cash Equivalents at the Beginning of the Financial Year Cash & Cash Equivalents (including bank overdrafts) at the End of the Financial Year Note: Capital Payables balances from Note 8- Trade & Other Payables are included within the (Payments) for property, plant and equipment of the Statement of Cash Flow not within Increase/ (decrease) in trade & other payables. The notes on pages 122 to 161 form part of this statement. ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 121

122 Notes to the financial statements 1 Accounting Policies NHS England has directed that the financial statements of clinical commissioning groups shall meet the accounting requirements of the Group Accounting Manual issued by the Department of Health. Consequently, the following financial statements have been prepared in accordance with the Group Accounting Manual issued by the Department of Health. The accounting policies contained in the Group Accounting Manual follow International Financial Reporting Standards to the extent that they are meaningful and appropriate to clinical commissioning groups, as determined by HM Treasury, which is advised by the Financial Reporting Advisory Board. Where the Group Accounting Manual permits a choice of accounting policy, the accounting policy which is judged to be most appropriate to the particular circumstances of the clinical commissioning group for the purpose of giving a true and fair view has been selected. The particular policies adopted by the clinical commissioning group are described below. They have been applied consistently in dealing with items considered material in relation to the accounts. 1.1 Going Concern These accounts have been prepared on the going concern basis; despite the issue of a referral to the Secretary of State for Health under Section 30 of the Local Audit and Accountability Act Public sector bodies are assumed to be going concerns where the continuation of the provision of a service in the future is anticipated, as evidenced by inclusion of financial provision for that service in published documents. Where a clinical commissioning group ceases to exist, it considers whether or not its services will continue to be provided (using the same assets, by another public sector entity) in determining whether to use the concept of going concern for the final set of Financial Statements. If services will continue to be provided the financial statements are prepared on the going concern basis. The following is clear evidence that the Clinical Commissioning Group meets the requirements as set out in the Group Accounting Manual issued by the Department of Health: The Clinical Commissioning Group was established on the 1st April 2013 as a separate statutory Body The Clinical Commissioning Group has an agreed constitution which it is operating to for the governance of its activities; The Clinical Commissioning Group has a notified allocation from NHS England to and an indicative allocation to ; The Clinical Commissioning Group has a notified Control Total from NHS England in The Clinical Commissioning Group has an agreed plan for and NHS England have agreed to provide cash funding as required. The Clinical Commissioning Group is part of the Central Sussex and East Surrey Commissioning Alliance and is working to achieve a combined Control Total. 1.2 Accounting Convention These accounts have been prepared under the historical cost convention modified to account for the revaluation of property, plant and equipment, intangible assets, inventories and certain financial assets and financial liabilities. 122 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

123 1.3 Movement of Assets within the Department of Health Group Transfers as part of reorganisation fall to be accounted for by use of absorption accounting in line with the Government Financial Reporting Manual, issued by HM Treasury. The Government Financial Reporting Manual does not require retrospective adoption, so prior year transactions (which have been accounted for under merger accounting) have not been restated. Absorption accounting requires that entities account for their transactions in the period in which they took place, with no restatement of performance required when functions transfer within the public sector. Where assets and liabilities transfer, the gain or loss resulting is recognised in the Statement of Comprehensive Net Expenditure, and is disclosed separately from operating costs. Other transfers of assets and liabilities within the Department of Health Group are accounted for in line with IAS 20 and similarly give rise to income and expenditure entries. 1.4 Pooled Budgets Where the clinical commissioning group has entered into a pooled budget arrangement under Section 75 of the National Health Service Act 2006 the clinical commissioning group accounts for its share of the assets, liabilities, income and expenditure arising from the activities of the pooled budget, identified in accordance with the pooled budget agreement. If the clinical commissioning group is in a jointly controlled operation, the clinical commissioning group recognises: The assets the clinical commissioning group controls; The liabilities the clinical commissioning group incurs; The expenses the clinical commissioning group incurs; and, The clinical commissioning group s share of the income from the pooled budget activities. If the clinical commissioning group is involved in a jointly controlled assets arrangement, in addition to the above, the clinical commissioning group recognises: The clinical commissioning group s share of the jointly controlled assets (classified according to the nature of the assets); The clinical commissioning group s share of any liabilities incurred jointly; and, The clinical commissioning group s share of the expenses jointly incurred. 1.5 Critical Accounting Judgements & Key Sources of Estimation Uncertainty In the application of the clinical commissioning group s accounting policies, management is required to make judgements, estimates and assumptions about the carrying amounts of assets and liabilities that are not readily apparent from other sources. The estimates and associated assumptions are based on historical experience and other factors that are considered to be relevant. Actual results may differ from those estimates and the estimates and underlying assumptions are continually reviewed. Revisions to accounting estimates are recognised in the period in which the estimate is revised if the revision affects only that period or in the period of the revision and future periods if the revision affects both current and future periods Critical Judgements in Applying Accounting Policies The following are the critical judgements, apart from those involving estimations (see below) that management has made in the process of applying the clinical commissioning group s accounting policies that have the most significant effect on the amounts recognised in the financial statements: ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 123

124 Accounting for Accruals Various methods are used for calculating different types of accruals. They include: Trend analysis Expert judgement of Finance Managers Supplier statements Formulaic approach based upon historic cost information Provisions A provision is recognised when the CCG has a legal or constructive obligation as a result of past events and it is probable that an outflow of economic benefits will be required to settle an obligation. In addition to widely used estimation techniques, judgement is required when determining the probable outflow of economic benefits. Any estimates have been made in line with IAS 37: Provisions, Contingent Liabilities and Contingent Assets. Provision for Impairment of Receivables Management will use their judgement upon assessment of outstanding receivables to decide when to write-off revenue or to provide against the probability of not being able to collect a debt. Considering age of receivable, progress of the debt recovery process etc. Classification of Equipment and Property Leases between Finance and Operating Judgements have been made regarding identification of leases and whether risks and rewards of ownership pass to the lessee under lease arrangements. These judgements have been made in accordance with accounting standards IAS 17 Leases and IFRIC 4 Determining Whether an Arrangement Contains a Lease Key Sources of Estimation Uncertainty The following are the key estimations that management has made in the process of applying the clinical commissioning group s accounting policies that have the most significant effect on the amounts recognised in the financial statements: Current Assets Included in the receivables balance are a number of prepayments and accrued income. These may inevitably require an element of estimation. The CCG is required to identify that the appropriate spend is reported within the current year having assessed most appropriate forecasting methodology; for example using transaction analysis, activity analysis and historical trend analysis etc. Where estimates have been applied, the CCG has adhered to guidance stipulated in the Group Accounting Manual issued by the Department of Health. Payables Trade payables include a number of NHS and non-nhs accruals which will require an element of judgement. The CCG is required to identify that the appropriate spend is reported within the current year having assessed most appropriate forecasting methodology; for example using transaction analysis, activity analysis and historical trend analysis etc. Where applicable, the CCG adheres to guidance set out in the Group Accounting Manual issued by the Department of Health and relevant financial standards. Prescribing Accrual Prescribing information is sent to the CCG monthly in arrears by NHS Business Services Authority (NHSBSA). This is always at least two months behind the current month. Each month, the CCG has to estimate the year to date expenditure including at the year end based on the last set of available data including forecast information; this forecasting assumption is enhanced by the expertise of the CCG Medicines Management Team. At the 124 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

125 year end, the CCG will be estimating prescribing expenditure based on 10 months data, but with information about profiling and extrapolated trends. Non-Contract Activity Non-Contract Activity is traditionally behind in being relayed, by the nature of the activity. The CCG has made an estimate of the likely uninvoiced value of the NCAs and accrued for them. The assessement is made based on historical invoicing patterns, notified accrual invoices and provider activity information. Clinical Work in Progress This relates clinical work being carried out by the providers which is in progress at year-end and not yet invoiced. The CCG, through discussion with providers, has made a judgement to whether the work in progress should be included in the accounts, based upon materiality. The work in progress is calculated based upon cost of treatment, the number of patients being treated, and the proportion of days in progress against average length of treatment. Contract Monitoring Several of the CCG s contracts with provider Trusts are relatively straightforward as block payments are agreed at the start of the year. However, contracts with acute providers can be complex and information in relation to performance on the contracts may not be fully available when the accounts are being prepared. Negotiations take place with the provider Trusts at year-end and payments / accruals for any over and under-performance are agreed. The CCGs position will be based on Activity trends and known performance challenges to the contract. NHS agreements are binding once made reducing the risk of bad debts/spurious accruals. The process is facilitated by an NHS Agreement of Balances (AoB) process at year end whereby respective debit/credit balances between NHS bodies are reconciled on a national level. In line with the Financial Recovery Plan, the CCG has increased its challenge of delivery by providers against the performance measures in agreed contracts. The calculation of any recovery of under-performance in relation to these challenges carries an element of estimation and accruals for these are included in trade and other receivables. This therefore creates an uncertainty within the financial statements; and whilst individual items may not be material, they could be material in aggregate if the outcome of any future mediation were to go predominantly against the CCG. 1.6 Revenue Revenue in respect of services provided is recognised when, and to the extent that, performance occurs, and is measured at the fair value of the consideration receivable. Where income is received for a specific activity that is to be delivered in the following year, that income is deferred. 1.7 Employee Benefits Short-term Employee Benefits Salaries, wages and employment-related payments are recognised in the period in which the service is received from employees, including bonuses earned but not yet taken. The cost of leave earned but not taken by employees at the end of the period is recognised in the financial statements to the extent that employees are permitted to carry forward leave into the following period, unless deemed immaterial Retirement Benefit Costs Past and present employees are covered by the provisions of the NHS Pensions Scheme. The scheme is an unfunded, defined benefit scheme that covers NHS employers, General Practices and other bodies, allowed under the direction of the Secretary of State, in England ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 125

126 and Wales. The scheme is not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities. Therefore, the scheme is accounted for as if it were a defined contribution scheme: the cost to the clinical commissioning group of participating in the scheme is taken as equal to the contributions payable to the scheme for the accounting period. For early retirements other than those due to ill health the additional pension liabilities are not funded by the scheme. The full amount of the liability for the additional costs is charged to expenditure at the time the clinical commissioning group commits itself to the retirement, regardless of the method of payment. 1.8 Other Expenses Other operating expenses are recognised when, and to the extent that, the goods or services have been received. They are measured at the fair value of the consideration payable. Expenses and liabilities in respect of grants are recognised when the clinical commissioning group has a present legal or constructive obligation, which occurs when all of the conditions attached to the payment have been met. 1.9 Property, Plant & Equipment Recognition Property, plant and equipment is capitalised if: It is held for use in delivering services or for administrative purposes; It is probable that future economic benefits will flow to, or service potential will be supplied to the clinical commissioning group; It is expected to be used for more than one financial year; The cost of the item can be measured reliably; and, The item has a cost of at least 5,000; or, Collectively, a number of items have a cost of at least 5,000 and individually have a cost of more than 250, where the assets are functionally interdependent, they had broadly simultaneous purchase dates, are anticipated to have simultaneous disposal dates and are under single managerial control; or, Items form part of the initial equipping and setting-up cost of a new building, ward or unit, irrespective of their individual or collective cost. Where a large asset, for example a building, includes a number of components with significantly different asset lives, the components are treated as separate assets and depreciated over their own useful economic lives Valuation All property, plant and equipment are measured initially at cost, representing the cost directly attributable to acquiring or constructing the asset and bringing it to the location and condition necessary for it to be capable of operating in the manner intended by management. All assets are measured subsequently at valuation. Land and buildings used for the clinical commissioning group s services or for administrative purposes are stated in the statement of financial position at their re-valued amounts, being the fair value at the date of revaluation less any impairment. Revaluations are performed with sufficient regularity to ensure that carrying amounts are not materially different from those that would be determined at the end of the reporting period. Fair values are determined as follows: Land and non-specialised buildings market value for existing use; and, Specialised buildings depreciated replacement cost. 126 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

127 HM Treasury has adopted a standard approach to depreciated replacement cost valuations based on modern equivalent assets and, where it would meet the location requirements of the service being provided, an alternative site can be valued. Properties in the course of construction for service or administration purposes are carried at cost, less any impairment loss. Cost includes professional fees but not borrowing costs, which are recognised as expenses immediately, as allowed by IAS 23 for assets held at fair value. Assets are re-valued and depreciation commences when they are brought into use. Fixtures and equipment are carried at depreciated historic cost as this is not considered to be materially different from current value in existing use. An increase arising on revaluation is taken to the revaluation reserve except when it reverses an impairment for the same asset previously recognised in expenditure, in which case it is credited to expenditure to the extent of the decrease previously charged there. A revaluation decrease that does not result from a loss of economic value or service potential is recognised as an impairment charged to the revaluation reserve to the extent that there is a balance on the reserve for the asset and, thereafter, to expenditure. Impairment losses that arise from a clear consumption of economic benefit are taken to expenditure. Gains and losses recognised in the revaluation reserve are reported as other comprehensive income in the Statement of Comprehensive Net Expenditure Subsequent Expenditure Where subsequent expenditure enhances an asset beyond its original specification, the directly attributable cost is capitalised. Where subsequent expenditure restores the asset to its original specification, the expenditure is capitalised and any existing carrying value of the item replaced is written-out and charged to operating expenses Depreciation, Amortisation & Impairments Freehold land, properties under construction, and assets held for sale are not depreciated. Otherwise, depreciation and amortisation are charged to write off the costs or valuation of property, plant and equipment and intangible non-current assets, less any residual value, over their estimated useful lives, in a manner that reflects the consumption of economic benefits or service potential of the assets. The estimated useful life of an asset is the period over which the clinical commissioning group expects to obtain economic benefits or service potential from the asset. This is specific to the clinical commissioning group and may be shorter than the physical life of the asset itself. Estimated useful lives and residual values are reviewed each year end, with the effect of any changes recognised on a prospective basis. Assets held under finance leases are depreciated over their estimated useful lives. At each reporting period end, the clinical commissioning group checks whether there is any indication that any of its tangible or intangible non-current assets have suffered an impairment loss. If there is indication of an impairment loss, the recoverable amount of the asset is estimated to determine whether there has been a loss and, if so, its amount. Intangible assets not yet available for use are tested for impairment annually. A revaluation decrease that does not result from a loss of economic value or service potential is recognised as an impairment charged to the revaluation reserve to the extent that there is a balance on the reserve for the asset and, thereafter, to expenditure. Impairment losses that arise from a clear consumption of economic benefit are taken to expenditure. Where an impairment loss subsequently reverses, the carrying amount of the asset is increased to the revised estimate of the recoverable amount but capped at the amount that would have been determined had there been no initial impairment loss. The reversal of the impairment loss is credited to expenditure to the extent of the decrease previously charged there and thereafter to the revaluation reserve. ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 127

128 1.11 Leases Leases are classified as finance leases when substantially all the risks and rewards of ownership are transferred to the lessee. All other leases are classified as operating leases The Clinical Commissioning Group as Lessee Property, plant and equipment held under finance leases are initially recognised, at the inception of the lease, at fair value or, if lower, at the present value of the minimum lease payments, with a matching liability for the lease obligation to the lessor. Lease payments are apportioned between finance charges and reduction of the lease obligation so as to achieve a constant rate on interest on the remaining balance of the liability. Finance charges are recognised in calculating the clinical commissioning group s surplus/deficit. Operating lease payments are recognised as an expense on a straight-line basis over the lease term. Lease incentives are recognised initially as a liability and subsequently as a reduction of rentals on a straight-line basis over the lease term. Contingent rentals are recognised as an expense in the period in which they are incurred. Where a lease is for land and buildings, the land and building components are separated and individually assessed as to whether they are operating or finance leases The Clinical Commissioning Group as Lessor Amounts due from lessees under finance leases are recorded as receivables at the amount of the clinical commissioning group s net investment in the leases. Finance lease income is allocated to accounting periods so as to reflect a constant periodic rate of return on the clinical commissioning group s net investment outstanding in respect of the leases. Rental income from operating leases is recognised on a straight-line basis over the term of the lease. Initial direct costs incurred in negotiating and arranging an operating lease are added to the carrying amount of the leased asset and recognised on a straight-line basis over the lease term Cash & Cash Equivalents Cash is cash in hand and deposits with any financial institution repayable without penalty on notice of not more than 24 hours. Cash equivalents are investments that mature in 3 months or less from the date of acquisition and that are readily convertible to known amounts of cash with insignificant risk of change in value. In the Statement of Cash Flows, cash and cash equivalents are shown net of bank overdrafts that are repayable on demand and that form an integral part of the clinical commissioning group s cash management Provisions Provisions are recognised when the clinical commissioning group has a present legal or constructive obligation as a result of a past event, it is probable that the clinical commissioning group will be required to settle the obligation, and a reliable estimate can be made of the amount of the obligation. The amount recognised as a provision is the best estimate of the expenditure required to settle the obligation at the end of the reporting period, taking into account the risks and uncertainties. Where a provision is measured using the cash flows estimated to settle the obligation, its carrying amount is the present value of those cash flows using HM Treasury s discount rate as follows: Timing of cash flows (0 to 5 years inclusive): Minus 2.42% (previously: minus 2.70%) Timing of cash flows (6 to 10 years inclusive): Minus 1.85% (previously: minus 1.95%) Timing of cash flows (over 10 years): Minus 1.56% (previously: minus 0.80%) When some or all of the economic benefits required to settle a provision are expected to be recovered from a third party, the receivable is recognised as an asset if it is virtually certain 128 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

129 that reimbursements will be received and the amount of the receivable can be measured reliably. A restructuring provision maybe recognised when the clinical commissioning group has developed a detailed formal plan for the restructuring and has raised a valid expectation in those affected that it will carry out the restructuring by starting to implement the plan or announcing its main features to those affected by it. The measurement of a restructuring provision includes only the direct expenditures arising from the restructuring, which are those amounts that are both necessarily entailed by the restructuring and not associated with ongoing activities of the entity Clinical Negligence Costs NHS Resolution operates a risk pooling scheme under which the clinical commissioning group pays an annual contribution to the NHS Litigation Authority which in return settles all clinical negligence claims. The contribution is charged to expenditure. Although the NHS Litigation Authority is administratively responsible for all clinical negligence cases the legal liability remains with the clinical commissioning group Non-clinical Risk Pooling The clinical commissioning group participates in the Property Expenses Scheme and the Liabilities to Third Parties Scheme. Both are risk pooling schemes under which the clinical commissioning group pays an annual contribution to NHS Resolution and, in return, receives assistance with the costs of claims arising. The annual membership contributions, and any excesses payable in respect of particular claims are charged to operating expenses as and when they become due Continuing healthcare risk pooling In a risk pool scheme was introduced by NHS England for continuing healthcare claims, for claim periods prior to 31 March Under the scheme clinical commissioning group contribute annually to a pooled fund, which is used to settle the claims Contingencies A contingent liability is a possible obligation that arises from past events and whose existence will be confirmed only by the occurrence or non-occurrence of one or more uncertain future events not wholly within the control of the clinical commissioning group, or a present obligation that is not recognised because it is not probable that a payment will be required to settle the obligation or the amount of the obligation cannot be measured sufficiently reliably. A contingent liability is disclosed unless the possibility of a payment is remote. A contingent asset is a possible asset that arises from past events and whose existence will be confirmed by the occurrence or non-occurrence of one or more uncertain future events not wholly within the control of the clinical commissioning group. A contingent asset is disclosed where an inflow of economic benefits is probable. Where the time value of money is material, contingencies are disclosed at their present value Financial Assets Financial assets are recognised when the clinical commissioning group becomes party to the financial instrument contract or, in the case of trade receivables, when the goods or services have been delivered. Financial assets are derecognised when the contractual rights have expired or the asset has been transferred. Financial assets are classified into the following categories: Financial assets at fair value through profit and loss; Held to maturity investments; ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 129

130 Available for sale financial assets; and, Loans and receivables. The classification depends on the nature and purpose of the financial assets and is determined at the time of initial recognition Loans & Receivables Loans and receivables are non-derivative financial assets with fixed or determinable payments which are not quoted in an active market. After initial recognition, they are measured at amortised cost using the effective interest method, less any impairment. Interest is recognised using the effective interest method. Fair value is determined by reference to quoted market prices where possible, otherwise by valuation techniques. The effective interest rate is the rate that exactly discounts estimated future cash receipts through the expected life of the financial asset, to the initial fair value of the financial asset. At the end of the reporting period, the clinical commissioning group assesses whether any financial assets, other than those held at fair value through profit and loss are impaired. Financial assets are impaired and impairment losses recognised if there is objective evidence of impairment as a result of one or more events which occurred after the initial recognition of the asset and which has an impact on the estimated future cash flows of the asset. For financial assets carried at amortised cost, the amount of the impairment loss is measured as the difference between the asset s carrying amount and the present value of the revised future cash flows discounted at the asset s original effective interest rate. The loss is recognised in expenditure and the carrying amount of the asset is reduced through a provision for impairment of receivables. If, in a subsequent period, the amount of the impairment loss decreases and the decrease can be related objectively to an event occurring after the impairment was recognised, the previously recognised impairment loss is reversed through expenditure to the extent that the carrying amount of the receivable at the date of the impairment is reversed does not exceed what the amortised cost would have been had the impairment not been recognised Financial Liabilities Financial liabilities are recognised on the statement of financial position when the clinical commissioning group becomes party to the contractual provisions of the financial instrument or, in the case of trade payables, when the goods or services have been received. Financial liabilities are de-recognised when the liability has been discharged, that is, the liability has been paid or has expired Other Financial Liabilities After initial recognition, all other financial liabilities are measured at amortised cost using the effective interest method, except for loans from Department of Health, which are carried at historic cost. The effective interest rate is the rate that exactly discounts estimated future cash payments through the life of the asset, to the net carrying amount of the financial liability. Interest is recognised using the effective interest method Value Added Tax Most of the activities of the clinical commissioning group are outside the scope of VAT and, in general, output tax does not apply and input tax on purchases is not recoverable. Irrecoverable VAT is charged to the relevant expenditure category or included in the capitalised purchase cost of fixed assets. Where output tax is charged or input VAT is recoverable, the amounts are stated net of VAT. 130 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

131 1.21 Losses & Special Payments Losses and special payments are items that Parliament would not have contemplated when it agreed funds for the health service or passed legislation. By their nature they are items that ideally should not arise. They are therefore subject to special control procedures compared with the generality of payments. They are divided into different categories, which govern the way that individual cases are handled. Losses and special payments are charged to the relevant functional headings in expenditure on an accruals basis, including losses which would have been made good through insurance cover had the clinical commissioning group not been bearing its own risks (with insurance premiums then being included as normal revenue expenditure) Joint Ventures Material entities over which the clinical commissioning group has joint control with one or more other parties so as to obtain economic or other benefits are classified as joint ventures. Joint ventures are accounted for using the equity method. Joint ventures that are classified as held for sale are measured at the lower of their carrying amount or fair value less costs to sell Joint Operations Links to Note 16. Joint operations are activities undertaken by the clinical commissioning group in conjunction with one or more other parties but which are not performed through a separate entity. The clinical commissioning group records its share of the income and expenditure; gains and losses; assets and liabilities; and cash flows Accounting Standards That Have Been Issued But Have Not Yet Been Adopted The DH Group accounting manual does not require the following Standards and Interpretations to be applied in These standards are still subject to FREM adoption and early adoption is not therefore permitted. IFRS 9: Financial Instruments ( application from 1 January 2018) IFRS 14: Regulatory Deferral Accounts ( not applicable to DH groups bodies) IFRS 15: Revenue for Contract with Customers (application from 1 January 2018) IFRS 16: Leases (application from 1 January 2019) IFRS 17: Insurance Contracts (application from 1 January 2021) IFRIC 22: Foreign Currency Transactions and Advance Consideration (application from 1 January 2018) IFRIC 23: Uncertainty over Income Tax Treatments (application from 1 January 2019) The application of the Standards as revised would not have a material impact on the accounts for , were they applied in that year. Note re the adoption of IFRS 9: The value of the CCGs Non NHS Recievables outstanding as at 1 st April 2018 is 314k therefore the expected credit loss is immaterial. ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 131

132 2 Other Operating Revenue Total Admin Programme Total Prescription Fees and Charges Education, Training and Research Non-Patient Care Services to Other 1,832-1,832 2,117 Bodies 2 Other Revenue Total Other Operating Revenue 2, ,399 2,340 *Additional Information provided for these notes below. Admin Revenue is revenue received that is not directly attributable to the provision of healthcare or healthcare services. Revenue arose totally from the supply of services. The Clinical Commissioning Group (CCG) receives no revenue from the sale of goods. Revenue in this note does not include cash received from NHS England, which is drawn down directly into the bank account of the CCG and credited to the General Fund. Prescription Fees and Charges 1 In the CCG recieved more rebates from pharmaceutical companies, 259k [ : 39k] Included within the Non-patient Care Services to Other Bodies 2 is 1,022k [ : 1,777k] relating to s117 income from West Sussex County Council; part of the Joint Commissioning Unit s75. Other Revenue 3 includes 153k for contributions from Schools for the Special School Nursing scheme and 50k funding for West Sussex Adult Talking Therapies Business Case ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

133 3 Employee Benefits & Staff Numbers 3.1 Employee Benefits Total Permanent Employees Total Other '000 '000 '000 Employee Benefits Salaries and Wages 4,861 4, Social Security Costs Employer Contributions to NHS Pension Scheme Apprenticeship Levy Gross Employee Benefits Expenditure 5,706 5, Total Permanent Employees Total Other '000 '000 '000 Employee Benefits Salaries and Wages 3,632 3, Social Security Costs Employer Contributions to NHS Pension Scheme Gross Employee Benefits Expenditure 4,452 4, Average number of whole time equivalent people employed Total Permanently employed Other Total Total Under a Memorandum of Understanding, there is a shared management team between NHS Horsham and Mid-Sussex CCG and NHS Crawley CCG. Staff are paid by NHS Horsham and Mid-Sussex CCG who then recharge NHS Crawley CCG on a net accounting basis. The average number of people employed above reflects the 64% of shared management whole time equivalents for NHS Crawley CCG and also adjusted for employees shared with other local CCGs. The disclosure incorporates the CCGs share of establishment changes as a result of being within the Central Sussex Commissioning Alliance from the 1 st January 2018 the CCG ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 133

134 3.3 Pension costs Past and present employees are covered by the provisions of the NHS Pensions Scheme. Details of the benefits payable under these provisions can be found on the NHS Pensions website at The Scheme is an unfunded, defined benefit scheme that covers NHS employers, GP practices and other bodies, allowed under the direction of the Secretary of State, in England and Wales. The Scheme is not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities. Therefore, the Scheme is accounted for as if it were a defined contribution scheme: the cost to the NHS Body of participating in the scheme is taken as equal to the contributions payable to the scheme for the accounting period. In order that the defined benefit obligations recognised in the financial statements do not differ materially from those that would be determined at the reporting date by a formal actuarial valuation, the FReM requires that the period between formal valuations shall be four years, with approximate assessments in intervening years. An outline of these follows: Accounting valuation A valuation of scheme liability is carried out annually by the scheme actuary (currently the Government Actuary s Department) as at the end of the reporting period. This utilises an actuarial assessment for the previous accounting period in conjunction with updated membership and financial data for the current reporting period, and is accepted as providing suitably robust figures for financial reporting purposes. The valuation of the scheme liability as at 31 March 2018, is based on valuation data as 31 March 2017, updated to 31 March 2018 with summary global member and accounting data. In undertaking this actuarial assessment, the methodology prescribed in IAS 19, relevant FReM interpretations, and the discount rate prescribed by HM Treasury have also been used. The latest assessment of the liabilities of the scheme is contained in the report of the scheme actuary, which forms part of the annual NHS Pension Scheme Accounts. These accounts can be viewed on the NHS Pensions website and are published annually. Copies can also be obtained from The Stationery Office Full actuarial (funding) valuation The purpose of this valuation is to assess the level of liability in respect of the benefits due under the schemes (taking into account recent demographic experience), and to recommend contribution rates payable by employees and employers. The last published actuarial valuation undertaken for the NHS Pension Scheme was completed for the year ending 31 March The Scheme Regulations allow for the level of contribution rates to be changed by the Secretary of State for Health, with the consent of HM Treasury, and consideration of the advice of the Scheme Actuary and employee and employer representatives as deemed appropriate. The next actuarial valuation is to be carried out as at 31 March 2016 and is currently being prepared. The direction assumptions are published by HM Treasury which are used to complete the valuation calculations, from which the final valuation report can be signed off by the scheme actuary. This will set the employer contribution rate payable from April 2019 and will consider the cost of the Scheme relative to the employer cost cap. There are provisions in the Public Service Pension Act 2013 to adjust member benefits or contribution rates if the cost of the Scheme changes by more than 2% of pay. Subject to this employer cost cap assessment, any required revisions to member benefits or contribution rates will be determined by the Secretary of State for Health after consultation with the relevant stakeholders. 134 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

135 For , employers contributions of 431k ( : 426k) were payable to the NHS Pension Scheme at the rate of 14.3% of pensionable pay. These costs are included in the NHS pension line of note 3.1. As part of the Memorandum of Understanding between NHS Crawley CCG and NHS Horsham and Mid Sussex CCG the pension contributions are paid over by NHS Horsham and Mid Sussex CCG on behalf of NHS Crawley CCG. The scheme s actuary reviews employer contributions, usually every four years and now based on HMT Valuation Directions, following a full scheme valuation. The latest review used data from 31 March 2012 and was published on the Government website in June ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 135

136 4 Operating Expenses Gross Employee Benefits Employee Benefits excluding Governing Body Members Restated Note Total Admin Programme Total ,993 2,320 2,673 4,028 Governing Body Members Total Gross Employee Benefits 3 5,706 2,688 3,018 4,452 Other Costs Services from other CCGs and 1, ,490 NHS England 1 Services from Foundation Trusts 2 79,622-79,622 73,109 Services from Other NHS Trusts 3 118, , ,779 Purchase of Healthcare from Non- 48,199-48,199 48,235 NHS Bodies 4 Purchase of Social Care Chair and Lay Members Supplies and Services Clinical Supplies and Services General 6 13, ,306 7,171 Consultancy Services 7 1, , Establishment Transport ,557 Premises ,714 Impairments and reversals of 7,305-7,305 receivables 9 Audit Fees Other Non-Statutory Audit Expenditure - Other Services Prescribing Costs 34,443-34,443 34,112 Pharmaceutical Services General Ophthalmic Services GPMS/APMS and PCTMS 10 30,455-30,455 3,397 Other Professional Fees excl Audit Legal Fees Education and Training Provisions 11 (72) - (72) 464 CHC Risk Pool Contributions Other Expenditure Total Other Costs 338,197 1, , ,569 Total Operating Expenses 343,903 4, , ,021 *Additional Information provided for these notes below. Admin Expenditure is expenditure incurred that is not a direct payment for the provision of healthcare or healthcare services. 136 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

137 Notes on Operating Expenses Within the expenditure lines of the financial statements the CCG is recognising 6,556k relating to impact of prior year accruals. This is where the accruals calculated using the best information available at the time are exceeded by costs when the actual activity was reconciled. The majority is within the NHS expenditure lines relating to Acute provider activity. 000 Services from other CCGs and NHS England 1 (98) Services from Foundation Trusts 2 3,836 Services from Other NHS Trusts 3 2,476 Purchase of Healthcare from Non-NHS Bodies Purchase of Social Care Other Revenue [Note 2] (83) 6,556 The most significant movement in the CCGs Expenditure position relates to the transfer of responsibility of Primary Care Co-Commissioing. This relates to the movement in the operating expenditure of 27,510k including: 000 Purchase of Healthcare from Non-NHS Bodies GPMS/APMS and PCTMS 10 26,720 27,506 Prior Year Restatement Services from Foundation Trusts 2 /Supplies and Services General 5 Pro-Active Care contribution reported with Sussex Community NHS Foundation Trust in ; refining reporting in allocated this with West Sussex County Council, ( 2,134k) [ : ( 3,820k)]. This material change was restated in the comparative values to align spend. Services from Foundation Trusts 2 /Transport 8 From April 2017 the Patient Transport Service across Sussex was managed by South Central Ambulance Service NHS Foundation Trust (SCAS) at 2,465k [ : 1,557k]. Consultancy 7 The increase in consultancy charges is mainly due to cover of CCG substantive posts and additional resource engaged to support and assure the Turnaround project of the CCG 367k. Also charges for expenditure incurred across Sussex & East Surrey relating to Sustainable Transformation Plans (STP) and Place Based Plans 86k [ : 87k]. Impairments and reversals of receivables 9 : In the CCG has provided for a Provider receivable balance, in relation contract payments to providers, that are doubtful in its recovery; 7,305k. An independent audit will take place in to assure this value and test the accounting assumptions within the contract. Provisions 11 Negative provision relates to the reversal of the provision identified in to de-risk the impact of potential movements in expected outturn with our local providers, CHC Risk Pool Contributions 12 The CCG is no longer required to contribute to the risk pool as previously requested by NHSE. ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 137

138 Notes on Operating Expenses continued Governing Body Members 13 the increase in the Governing Body is in the main a movement from Employee Benefits excluding Governing Body Members as a result of reviewing the share of the members role with Governing Body responsibility. GPMS/APMS and PCTMS 10 Stands for General Practice Medical Services/Alternative Provider Medical Services and Primary Care Trust Medical Services. Note 4.2 Limitation on auditor's liability The limitation on auditors' liability for external audit work is 2m. 5 Better Payment Practice Code Measure of Compliance Number 000 Number 000 Non-NHS Payables Total Non-NHS Trade Invoices Paid in the Year 7, ,258 6, ,153 Total Non-NHS Trade Invoices Paid within Target 7, ,230 6, ,374 Percentage of Non-NHS Trade Invoices Paid within Target 97.93% 98.13% 97.79% 97.63% NHS Payables Total NHS Trade Invoices Paid in the Year 2, ,902 3, ,446 Total NHS Trade Invoices Paid within target 2, ,819 3, ,676 Percentage of NHS Trade Invoices Paid within Target 97.55% 99.31% 98.82% 99.36% The Better Payment Practice Code requires the CCG to aim to pay all valid invoices by the due date or within 30 days of receipt of a valid invoice, whichever is later. The target percentage to be reached is 95% and in the CCG achieved this across all measures. 138 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

139 6 Operating Leases 6.1 As lessee The operating lease relates to the rental of office buildings and void space from NHS Property Services Payments recognised as an Expense Land Buildings Other Total Total Payments recognised as an expense Minimum lease payments ,650 Total ,650 Whilst our arrangements with NHS Property Services Limited fall within the definition of operating leases, rental charge for future years has not yet been agreed. Consequently this note does not include future minimum lease payments for the arrangements. 7 Property, Plant and Equipment Assets under construction and payments on account 000 Cost or Valuation at 01 April Addition of Assets Under Construction and Payments on Account 129 Cost/Valuation At 31-March Depreciation 01-April Charged during the year - Depreciation at 31-March Net Book Value at 31-March Purchased 293 Total at 31-March Economic Lives Minimum Life (years) Maximum Life (Years) Plant and Machinery 1 10 Information Technology 1 5 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 139

140 8 Trade & Other Receivables Current Current 31 March March NHS Receivables: Revenue 1 1,032 1,498 NHS Prepayments NHS Accrued Income 3 5,839 3,262 Non-NHS Receivables: Revenue 336 4,515 Non-NHS Prepayments 4 14,150 8,117 Non-NHS Accrued Income 5 13,184 8,695 Provision for the Impairment of Receivables 6 (7,305) - VAT Other Receivables 6 2 Total Trade & Other Receivables 27,692 26,571 Within Non-NHS Accrued Income 5 is a receivable balance of 7,305k [ : 7,220k] and included in Non-NHS Prepayments 4 is a prepayment of 6,917k [ : 7,003]; both linked to Care Unbound (formally Brighton and Hove Integrated Care Service) for the MSK Service relating to the contract transitional arrangements. Also within Non-NHS Accrued Income is 4,137k relating to Contract reconciliation payments made on account to Care Unbound. The share of the contract reconciliation payments relating to NHS Crawley CCG 2,891k and NHS Brighton & Hove CCG 789k are within NHS Accrued Income 3. Provision for the Impairment of Receivables 6 In the CCG has provided for a Provider receivable balance, in relation to contract payments to providers, that is doubtful in its recovery; 7,305k. An internal audit will take place in to assure this value and test the accounting assumptions within the contract. Included in the NHS Accrued Income 3 balance is 885k with NHS High Weald Lewes Havens CCG with regards to the outstanding action on the parent company guarantee submitted as part of a non-emergency patient transport services (PTS) contract. NHS prepayments 2 of 163k [ : 147k] relates to the Maternity Pathway prepayment with Surrey and Sussex Healthcare NHS Trust. Included in the NHS Receivables: Revenue 1 balance is 794k with neighbouring Sussex CCGs relating to recharges between CCGs; includes 400k with NHS Crawley CCG. Non-NHS Accrued Income 5 includes the s117 recharge accrual to West Sussex County Council 1,022k [ : 0k]. 140 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

141 8.1 Receivables past their due date but not impaired 31 March March By up to Three Months 232 3,508 By Three to Six Months (2) 15 By more than Six Months 293 1,227 Total 523 4,750 0k of the amount above has subsequently been recovered since 31 March Provision for impairment of receivables DH Group Bodies Non DH Group Bodies Balance at 01 April Amounts Written Off During the Year Amounts Recovered During the Year - - (Increase) Decrease in Receivables Impaired - (7,305) Transfer (to) from Other Public Sector Body - - Balance at 31 March (7,305) 9 Cash & Cash Equivalents Balance at 1 April Net change in year (246) 222 Balance at 31 March Made up of: Cash with the Government Banking Service Cash in Hand Cash and Cash Equivalents as in Statement of Financial Position ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 141

142 10 Trade & Other Payables Current Current 31 March March NHS Payables: Revenue 1 7,448 6,361 NHS Payables: Capital NHS Accruals 2,992 5,242 Non-NHS Payables: Revenue 3,752 6,227 Non-NHS Accruals 2 10,167 3,946 Non-NHS and Other WGA Payables: Capital Non-NHS Deferred Income Social Security Costs Tax Other Payables Total Trade & Other Payables 25,643 22,602 Other payables include 290k outstanding pension contributions at 31 March 2018 [ K]. From this includes practitioner payovers as part of the CCGs responsibilities under Delegated Primary Care co-commissioning. There are no liabilities shown above that are due in future years under arrangements to buy out the liability for early retirement over 5 years (31 March 2017: 0). Also included in the NHS balances is 1,435k [ : 937k] for Partially Completed Spells. The NHS Payables 1 include 2,999k [ 945k ] for Surrey and Sussex Healthcare NHS Trust; majority of which is the Final Contract balance for Also 1,274k [ 0k: ] with Sussex Community NHS Foundation Trust for final contract balance and property recharges. The Non-NHS Accruals 2 balance includes a Prescribing accrual of 5,224k [ : 5,115k]. Also 761k for accruals relating to payments to the CCG member practices; including Locally Enhanced Services reconciliation payments. The CCG has Accruals relating to Primary Care CoCommissioning within Non-NHS Accruals 2 of 1261k [ : 0k] 142 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

143 11 Provisions Current Non-Current Current Non-Current 31 March March March March Legal Claims Continuing Care Other Total Total Current and Non-Current Legal Continuing Other Total claims Care Provisions Balance at 1 April Arising during the year Utilised during the year - (222) - (222) Reversed unused - - (283) (283) Balance at 31 March Expected timing of cash flows: Within one year Between one and five years After five years Balance at 31 March The CCG, in association with NHS Coastal West Sussex CCG and NHS Crawley CCG, has entered into a Memorandum of Understanding (MoU) for the provision Continuing Health Care. The agreement is accounted for under net accounting rules. Each CCG reflects in their own accounts the CHC provisions in respect of the MoU. The 217k shown above represents the CCG's share of the continuing health care provision. Continuing care provisions relate to retrospective claims identified for periods after 1 April For information on the legal provision refer to note 12 Contingencies. ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 143

144 12 Contingencies The seven Sussex CCGs are jointly taking legal steps to enforce the terms of a parent company guarantee submitted as part of a non-emergency patient transport services (PTS) contract which was terminated with effect from 31st March The case is being supported by NHS High Weald Lewes Havens CCG s (the host CCG s) solicitors who are currently engaged in negotiations with the parent company who provided the guarantee. The process is ongoing but may result in court proceedings At this stage, it is not possible to give an accurate quantification of the precise financial consequences of the legal steps initiated but it is considered that these will not have a material impact on the future reported financial position of the CCGs. 13 Capital Commitments 31 March March 2017 Note Property, Plant and Equipment Total Financial Instruments 14.1 Financial Risk Management International Financial Reporting 7: Financial Instrument: Disclosure requires disclosure of the role that financial instruments have had during the period in creating or changing the risks a body faces in undertaking its activities. Because the clinical commissioning group is financed through parliamentary funding, it is not exposed to the degree of financial risk faced by business entities. Also, financial instruments play a much more limited role in creating or changing risk than would be typical of listed companies, to which the financial reporting standards mainly apply. The clinical commissioning group has limited powers to borrow or invest surplus funds and financial assets and liabilities are generated by day-to-day operational activities rather than being held to change the risks facing the clinical commissioning group in undertaking its activities. Treasury management operations are carried out by the finance department, within parameters defined formally within the clinical commissioning group s standing financial instructions and policies agreed by the Governing Body. Treasury activity is subject to review by the clinical commissioning group s internal auditors Credit Risk Because the majority of the clinical commissioning group s revenue comes from parliamentary funding, the clinical commissioning group has low exposure to credit risk. The maximum exposures as at the end of the financial year are in receivables from customers, as disclosed in the trade and other receivables note. 144 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

145 Liquidity Risk The clinical commissioning group is required to operate within revenue and capital resource limits agreed with NHS England, which are financed from resources voted annually by Parliament. The clinical commissioning group draws down cash to cover expenditure, from NHS England, as the need arises, unrelated to its performance against resource limits. The clinical commissioning group is not, therefore, exposed to significant liquidity risks Financial Assets Loans and Receivables Loans and Receivables 31 March March 2017 Note Receivables: NHS 8 6,872 4,760 Non-NHS 8 13,520 13,210 Cash at bank and in hand Other financial assets 6 2 Balance as at the End of the Financial Year 20,442 18, Financial Liabilities Other 31 March 2018 Other 31 March Payables: NHS 10 10,440 11,603 Non-NHS 10 14,599 10,848 Balance as at the End of the Financial Year 25,039 22,451 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 145

146 15 Operating Segments The clinical commissioning group consider they have two operating segments. Gross expenditure Income Net expenditure Total assets Total liabilities Net assets Commissioning of 301,942 (2,186) 299,756 27,583 (25,449) 2,134 Healthcare S75 Commissioning 41,961 (238) 41, (447) - 343,903 (2,424) 341,479 28,030 (25,896) 2,134 Horsham and Mid Sussex CCG has a Section 75 commissioning agreement between West Sussex County Council, Coastal West Sussex CCG and Crawley CCG for the joint commissioning and pooled funding of various services. Horsham and Mid Sussex CCG is the lead CCG for the Section 75 which accounts for more than 10% of the CCGs consolidated total and so is considered a separate operating segment. Reconciliation between Operating Segments and Statement of Comprehensive Net Expenditure 31 March Total net expenditure reported for operating segments 341,479 Reconciling items: - Total net expenditure per the Statement of Comprehensive Net Expenditure 341,479 Reconciliation between Operating Segments and Statement of Financial Position 31 March Total Assets Reported for Operating Segments 28,030 Reconciling Items: - Total assets per Statement of Financial Position 28, March Total Liabilities Reported for Operating Segments (25,863) Reconciling Items: - Total Liabilities per Statement of Financial Position (25,896) 146 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

147 16 Pooled Budgets NHS Horsham and Mid Sussex Clinical Commissioning Group is part of two section 75 s with Pooled Budget Arrangements in Both section 75s are accounted for as Joint Operations. Joint Commissioning Unit NHS Horsham and Mid Sussex Crawley Clinical Commissioning Group entered into a pooled budget with West Sussex County Council, NHS Crawley Clinical Commissioning Group and NHS Coastal West Sussex Clinical Commissioning Group. Under the arrangement funds are pooled under Section 75 of the NHS Act 2006 for the following services: Working Age Adults Mental Health and Older Age Mental Health (hosted by Horsham and Mid Sussex CCG), Learning Difficulties and Telecare (Hosted by West Sussex County Council). The accounting treatment in for the Joint Commissioning Unit pooled budget; as in previous years, is for Net values in all CCG Financial statements. The whole pool activity between the West Sussex County Council and the CCGs is proportioned (according to weighted Capitation income) out to West Sussex County Council and the CCGs to give net accounting in each of the Contributors accounts. Within the arrangement, there is a risk sharing agreement between the CCGs, whereby underspends and overspends are shared according to the CCG contributions. Section 75 for the Commissioning of Services and Pooled Funding of Various Services Mental Health Working Age and Older Age hosted by Horsham and Mid Sussex CCG on behalf of the Section 75 agreement Mental Health Working Age Pooled Memorandum Account for the period 01/04/17 to 31/03/18 Funding Cash Staff Other Grant Total NHS Horsham and Mid Sussex CCG 14,635, ,707 Total Funding (a) 14, ,707 (a) Expenditure West Sussex County Council 2,091 2,091 NHS 10, ,288 Non-NHS 2, ,468 Total Expenditure (b) 14, ,847 (b) Net under/(over) spend (a) - (b) (140) ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 147

148 Mental Health Older Age Pooled Memorandum Account for the period 01/04/17 to 31/03/18 Funding Cash Staff Other Grant Total NHS Horsham and Mid Sussex CCG 5, ,502 Total Funding (a) 5, ,502 (a) Expenditure Cash Staff Other Grant Total NHS 4, ,636 Non-NHS 1, ,046 Total Expenditure (b) 5, ,682 (b) Net under/(over) spend (a) - (b) (180) Telecare hosted by West Sussex County Council on behalf of the Section 75 agreement Telecare Memorandum Account for the period 01/04/17 to 31/03/18 Funding Cash Staff Other Grant Total NHS Horsham and Mid Sussex CCG Total Funding (a) Expenditure Mobile Response Installation and Monitoring Equipment Assistive Technology Training, IT and Administration Total Expenditure (b) Net under/(over)spend (a) - (b) ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

149 Children and Young People Aligned Budget Memorandum Account for the period 01/04/17 to 31/03/18 Funding Cash Staff Other Grant Total NHS Horsham and Mid Sussex CCG 4, ,084 Total Funding (a) 13, ,463 (a) Expenditure Cash Staff Other Grant Total Child and Adolescent Mental Health 1, ,940 Children s Community Services 2,101 2,101 Non-NHS Total Expenditure (b) 4, ,082 (b) Net under/(over) spend (a) - (b) 2 Children and Young People Aligned Budget has been added in 2017/18 for completeness of the Operating Segments identified in the Section 75 agreement. It was excluded in the previous year as it is an aligned budget rather than a pooled budget. Learning Disabilities hosted by West Sussex County Council on behalf of the Section 75 agreement Learning Disabilities Memorandum Account for the period 01/04/17 to 31/03/18 Cash Staff Other Grant Total Contributions as per Section 75 agreement NHS Horsham and Mid Sussex CCG 3, ,498 Total Funding 3, ,498 (a) Independent Sector 1, ,838 Community Support Supported Living 1, ,100 Other Commissioned Services WSCC inhouse services Total Expenditure 3, ,694 (b) Net under/(over) spend (a) - (b) (196) ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 149

150 Better Care Fund Also, in the CCG continued a Pooled arrangement under a section 75 of the NHS Act agreement with West Sussex County Council for the Better Care Fund. West Sussex County Council is the host of this arrangement. The principle of the BCF is a transition toward a healthier society supported by a more proactive care approach. The BCF utilises the section 75 agreement for Health and Social Care to use funding jointly. It is a mandated NHS England venture. The aim is to streamline care services for the population of West Sussex that are supported by the CCG's (NHS Coastal West Sussex CCG, NHS Crawley CCG and NHS Horsham and Mid Sussex CCG) and West Sussex County Council. The financial schedules are noted below. Committed Maximum Total Funding Contingency Funding Spend Grant Funding '000 '000 '000 '000 Disabled Facilities Grant 7,078 7,078 7,078 ibcf 11,358 11,358 11,358 18,436 18,436 18,436 Revenue Funding NHS Horsham and Mid Sussex CCG 9,472 3,760 13,232 13,228 NHS Crawley CCG 5,321 2,112 7,433 7,431 NHS Coastal West Sussex CCG 23,337 9,264 32,601 32,590 Total Revenue 38,130 15,136 53,265 53,249 WSCC additional contribution 1,878 1,878 1,878 Total Better Care Fund Budget 58,444 15,136 73,580 73,563 Underspend 17 For , the pool under spent by 17k in year, against Telecare BCF Scheme. The total expenditure was 58.4m of the 58.4m committed funds. The Contingency was agreed by all parties to be set as the risk share; in recognition of the trend in Non Elective Admissions. The Contingency was applied to the Urgent Care activity in excess of planned expenditure. 150 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

151 For the committed funding for BCF has increased to 58.4m, and schemes are in place for the delivery of this funding in West Sussex CCGs HMS Funding Share HMS Spend Share BCF Schemes Disabled Facilities Grant 7, Maintaining (Protecting) Social Care Services 16,798 4,148 4,148 Meeting Adult Social Care needs 1, Reducing pressures on the NHS hospital discharges 5, Supporting that the local social care provider network 4, Proactive Care / Communities of Practice 10,764 2,804 2,804 Falls Programme Support Care Homes Programme Support BCF Reablement 4,097 1,018 1,018 Dementia Wolfson (Docobo) Integrated Hospital Discharge Care Act Initiatives 2, Carers Advice, Information and Support 3, Carers Health Team Carers Support in Hospitals Social Care Reablement Telecare Community Equipment Improving Quality in Care Homes: Firefly Total Funds 58,444 9,472 9,472 Contingency Fund 15,136 3,760 3,756 Total Better Care Fund Budget 73,580 13,232 13,228 Underspend 4 Details of Better Care Fund can be found at ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 151

152 Purchase of Healthcare Related Party Transactions The clinical commissioning group is required to disclose all transactions in the year with any parties that are related to or connected with members of the Governing Body or members of key management staff. The following members of the Governing Body have declared an interest in the following organisations; these organisations are therefore regarded as related parties, and the details of the clinical commissioning group's transactions with these organisations are as follows: Details of related party transactions with individuals are as follows: Expenditure Type Payments to Related Party Receipts from Related Party Amounts owed to Related Party Amounts due from Related Party NHS England NHS Brighton & Hove CCG ,006 NHS Coastal West Sussex CCG NHS Crawley CCG ,453 NHS Eastbourne, Halisham & Seaford CCG NHS East Surrey CCG NHS Hastings & Rother CCG NHS High Weald Lewes Havens CCG ,008 Brighton and Sussex University 65, Hospitals NHS Trust Royal Surrey County Hospital NHS 2, Foundation Trust Surrey & Sussex Healthcare NHS 50,084-3, Trust Sussex Community NHS Foundation 30, Trust Moatfield Surgery 3, Dolphins Practice 3, Cuckfield Medical Practice 2, Ship Street Surgery 3, The Brow Medical Centre 2, Courtyard Surgery 2, Mid Sussex Health Care 5, Village Surgery, Southwater 2, Cowfold Surgery 1, Riverside Surgery 1, Park Surgery, Horsham 6, Silverdale 3, Crawley Down Health Centre PPG 2, The Meadows Surgery 2, Ouse Valley Practice 2, Northlands Wood Practice 1, Lindfield Medical Centre 3, Orchard Surgery 2, Holbrook Surgery, Horsham 3, Judges Close Practice 2, ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

153 Purchase of Healthcare Rudgwick Medical Centre 1, Park View Health Partnership 1, Newtons Practice 3, Care Unbound Ltd 16, ,809 Dorking Healthcare Integrated Care 24 Ltd 2, Sussex Community Dermatology Service 1, The Department of Health is regarded as a related party. During the year the clinical commissioning group has had a significant number of material transactions with entities for which the Department is regarded as the parent Department. The NHS organisations listed below are those where transactions over the year have exceeded 500k: NHS England NHS Brighton & Hove CCG NHS Coastal West Sussex CCG NHS Crawley CCG NHS High Weald Lewes Havens CCG Brighton & Sussex University Hospitals NHS Trust Epsom & St Helier University Hospitals NHS Trust Maidstone & Tunbridge Wells NHS Trust Surrey & Sussex Healthcare NHS Trust Sussex Community NHS Foundation Trust Guy's & St Thomas' NHS Foundation Trust King's College Hospital NHS Foundation Trust Royal Surrey County Hospital NHS Foundation Trust South Central Ambulance Service NHS Foundation Trust South East Coast Ambulance Service NHS Foundation Trust St George's University Hospitals NHS Foundation Trust Surrey & Borders Partnership NHS Foundation Trust Sussex Partnership NHS Foundation Trust Queen Victoria Hospital NHS Foundation Trust The Royal Marsden NHS Foundation Trust Type Payments to Related Party Receipts from Related Party Amounts owed to Related Party Amounts due from Related Party , , ,008 65, ,084-3, , , , , , , , , ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 153

154 University College London Hospitals NHS Foundation Trust Western Sussex Hospitals NHS Foundation Trust , NHS South Central & West CSU Service Support In addition, the clinical commissioning group has had a number of material transactions with other government departments and other central and local government bodies. Transactions with other Government Departments over the year which have exceeded 500k: Payments to Related Party Receipts from Related Party Amounts owed to Related Party Amounts due from Related Party West Sussex County Council NHS Property Services Ltd 13,124 1,639 1,665 1, ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

155 The list below highlights the relationships disclosed with the related party shown in Note 17 Related Party Transactions. Related Party Name Position(s) within CCG Relationship to Related Party Brighton & Hove CCG Brighton & Sussex University Hospitals NHS Trust Coastal West Sussex CCG. Crawley CCG Adam Doyle Allison Cannon Glynn Dodd Mark Baker Sarah Valentine Terry Willows Karen Eastman Rachel Harrington Allison Cannon Sarah Valentine Adam Doyle Glynn Dodd Mark Baker Accountable Officer Director of Quality and Chief Nurse Programme Director Of Commissioning Reform Strategic Director of Finance Director of Commissioning Director Of Corporate Affairs Clinical Director Director of System Transformation Director of Quality and Chief Nurse Director of Commissioning Accountable Officer Programme Director Of Commissioning Reform Strategic Director of Finance CCG is part of Central Sussex Commissioning Alliance, Member of Alliance Executive team Chief Nurse Eastbourne, Halisham & Seaford CCG, Hastings & Rother CCG, Coastal West Sussex CCG. - STP wide role and Executive of CSCA CCG is part of Central Sussex Commissioning Alliance, Member of Alliance Executive team CCG is part of Central Sussex Commissioning Alliance, Member of Alliance Executive team CCG is part of Central Sussex Commissioning Alliance, Member of Alliance Executive team and Role remit is STP wide CCG is part of Central Sussex Commissioning Alliance, Member of Alliance Executive team Brighton and Sussex University Hospital Trust GPwSI in Pain Management Spouse is part time clinical director for Kent Surrey and Sussex Patient Safety Collaborative and part time Obstetrician at BSUH Chief Nurse Eastbourne, Halisham & Seaford CCG, Hastings & Rother CCG, Coastal West Sussex CCG. - STP wide role and Executive of CSCA CCG is part of Central Sussex Commissioning Alliance, Member of Alliance Executive team and Role remit is STP wide CCG is part of Central Sussex Commissioning Alliance, Member of Alliance Executive team CCG is part of Central Sussex Commissioning Alliance, Member of Alliance Executive team CCG is part of Central Sussex Commissioning Alliance, Member of Alliance Executive team ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 155

156 Sarah Valentine Director of Commissioning CCG is part of Central Sussex Commissioning Alliance, Member of Alliance Executive team and Role remit is STP wide Terry Willows Director Of Corporate Affairs CCG is part of Central Sussex Commissioning Alliance, Member of Alliance Executive team Allison Cannon Director of Quality and Chief Nurse Chief Nurse Eastbourne, Halisham & Seaford CCG, Hastings & Rother CCG, Coastal West Sussex CCG. - STP wide role and Executive of CSCA Barry Young Chief Finance Officer/Chief Chief Finance Officer/Chief Finance Officer (North) is Finance Officer (North) joint management post with NHS Crawley CCG East Surrey CCG Adrian Brown Governance Lay Member Lay Member Governance, East Surrey CCG Carol Pearson Lay Member Governance Audit Committee Chair for East Surrey CCG Eastbourne, Halisham & Seaford CCG Allison Cannon Director of Quality and Chief Nurse Hastings & Rother CCG High Weald Lewes Havens CCG Sarah Valentine Allison Cannon Sarah Valentine Adam Doyle Allison Cannon Glynn Dodd Mark Baker Sarah Valentine Director of Commissioning Director of Quality and Chief Nurse Director of Commissioning Accountable Officer Director of Quality and Chief Nurse Programme Director Of Commissioning Reform Strategic Director of Finance Director of Commissioning 156 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group Chief Nurse Eastbourne, Halisham & Seaford CCG, Hastings & Rother CCG, Coastal West Sussex CCG. - STP wide role and Executive of CSCA CCG is part of Central Sussex Commissioning Alliance, Member of Alliance Executive team Chief Nurse Eastbourne, Halisham & Seaford CCG, Hastings & Rother CCG, Coastal West Sussex CCG. - STP wide role and Executive of CSCA CCG is part of Central Sussex Commissioning Alliance, Member of Alliance Executive team and Role remit is STP wide CCG is part of Central Sussex Commissioning Alliance, Member of Alliance Executive team Chief Nurse Eastbourne, Halisham & Seaford CCG, Hastings & Rother CCG, Coastal West Sussex CCG. - STP wide role and Executive of CSCA CCG is part of Central Sussex Commissioning Alliance, Member of Alliance Executive team CCG is part of Central Sussex Commissioning Alliance, Member of Alliance Executive team CCG is part of Central Sussex Commissioning Alliance, Member of Alliance Executive team and Role remit is STP wide

157 Terry Willows Director Of Corporate Affairs CCG is part of Central Sussex Commissioning Alliance, Member of Alliance Executive team NHS England Terry Willows Director Of Corporate Affairs Seconded From NHS England to CSCA Executive Royal Surrey County Hospital NHS Foundation Trust Surrey & Sussex Healthcare NHS Trust Dolphins Practice Carol Pearson Lay Member Governance Volunteer research assistant at Royal Surrey County hospital (including work funded by Ethicon on harmonic scalpel study from summer ) Hugh McIntyre GB Secondary Care Clinician Consultant Physician ESHT Jonathan (Sid) GP Practice Representative - Harrison Dolphins Practice GP Partner at Dolphins Practice Ship Street Surgery GP Practice Representative - Ship Stephanie Cook Street Surgery GP Partner at Ship Street Surgery Brow Medical Centre Lara Belle Clinical Lead GP Partner at The Brow Medical Centre Karen Eastman Clinical Director GP Partner at The Brow Medical Centre Courtyard Surgery GP Practice Representative - Mark Chopin Courtyard Surgery GP Partner at Courtyard Surgery Matt Greenwood GP Member of Audit Committee GP Partner at Courtyard Surgery Cuckfield Medical Practice GP Practice Representative - Susan Ferrier Cuckfield Medical Practice GP Partner at Cuckfield Medical Practice Angie Gurner GP Practice Representative - Cuckfield Medical Practice and The Vale Surgery GP Partner at Cuckfield Surgery Health Centre At Bowers GP Practice Representative - Place Dan Jefferies Crawley Down Health Centre GP Partner at Crawley Down Health Centre Holbrook Surgery GP Practice Representative - Hwa-Ion Liu Holbrook Surgery GP Partner at Holbrook Surgery Preet Singh Puri GP Practice Representative - Holbrook Surgery GP Partner at Holbrook Surgery Nadia Ziyada GP Practice Representative - Holbrook Surgery GP Partner at Holbrook Surgery Judges Close Surgery Mark Lythgoe Clinical Director GP Partner at Judges Close Practice ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 157

158 Lindfield Medical Centre Meadows Surgery Mid Sussex Health Care Sheryl Knight Alex Dombrowe Richard Cook Terry Lynch Terry Lynch GP Practice Representative - Lindfield Medical Centre GP Practice Representative - The Meadows Surgery GP Practice Representative - Mid Sussex Health Care Clinical Director/GP Member of the Governing Body Clinical Director/GP Member of the Governing Body 158 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group GP Partner at Lindfield Medical Centre GP Partner at The Meadows Surgery GP Practices representative at Horsham and Mid Sussex CCG GP Partner at Mid Sussex Health Care Mid Sussex Health Care is involved in medical research through the NHS run National Institute for Health Research (NIHR). Moatfield Surgery Stephen Bellamy Clinical Director Spouse employed at Moatfield Surgery Brodie Forrest GP Practice Representative - Moatfield Surgery GP Partner at Moatfield Surgery Minesh Patel Clinical Chair HMS CCG GP Partner at Moatfield Surgery Northlands Wood Surgery Elizabeth GP Practice Representative - Jenkins Northlands Wood Practice GP Partner at Northlands Wood Practice Huw Morris GP Practice Representative - Northlands Wood Practice Northlands Wood Practice Orchard Surgery Horsham GP Practice Representative - Chris Dawe Orchard Surgery GP Partner at Orchard Surgery Ouse Valley Practice GP Practice Representative - Ouse Katie Briggs Valley Practice Fertility LES (Local Enhanced Services) GP Janet GP Practice Representative - Ouse Hardingham Valley Practice GP Partner at Ouse Valley Practice Caroline Smith GP Practice Representative - Ouse Valley Practice GP Partner at Ouse Valley Practice Park Surgery GP Practice Representative - Park Provider of non obstetric ultrasound services through Steve Fisher Surgery park surgery Horsham David Holwell GP Practice Representative - Park Surgery GP Partner at Park Surgery John Steele Associate Lay Member Patient at Park Surgery, Albion Way

159 Park View Health Clinical Director/GP Member of the Partnership Riz Miarkowski Governing Body GP Partner at Park View Health Partnership Riverside Surgery GP Practice Representative - Matthew Davies Riverside Surgery GP Partner at Riverside Surgery Matt Greenwood GP Member of Audit Committee GP Partner at Riverside Surgery Rudgwick Medical Centre Clinical Director/GP Member of the David McKenzie Governing Body GP Partner at Rudgwick Medical Centre Ship Street Surgery Stephen Bellamy Clinical Director GP Partner at Ship Street Surgery Jean-Pierre Dias GP Practice Representative - Ship Street Surgery GP Partner at Ship Street Surgery Silverdale Practice (Burgess GP Practice Representative - Hill) Robert Denney Silverdale Practice GP Partner at Silverdale Practice Ian Holwell GP Practice Representative - Silverdale Practice GP Partner at Silverdale Practice Simon Plant GP Practice Representative - Silverdale Practice GP Partner at Silverdale Practice The Brow Medical Centre GP Practice Representative - The Mandy Claiden Brow Medical Centre GP Partner at The Brow Medical Centre The Vale Surgery Member Practice - The Vale Susan Ferrier Surgery GP Partner at The Vale Surgery Rob Harvey GP Practice Representative - GP Partner at Cuckfield Medical Practice and The Vale Cuckfield Medical Practice and Surgery The Vale Surgery Village Surgery Horsham Daphne GP Practice Representative - The Coutroubis Village Surgery GP Partner at The Village Surgery Matt Greenwood GP Member of Audit Committee Spouse is a Partner at Southwater Practice Care Unbound Ltd Allison Cannon Director of Quality and Chief Nurse Husband is Director of Primary Care Here Ltd Dorking Healthcare Ltd Karen Eastman Clinical Director Spouse is business director for Dorking Healthcare Integrated Care 24 Ltd Hugh McIntyre GB Secondary Care Clinician Senior Clinical Advisor to OOH unit Sussex Community Dermatology Service Lara Belle Clinical Lead Dermatology GPwSI ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 159

160 18 Events after the end of the reporting period The CCG has no events after the end of the reporting period to disclose. 19 Losses and Special Payments 19.1 Losses Total Number of Cases Total Value of Cases Total Number of Cases Total Value of Cases Number '000 Number '000 Administrative write-offs 2 7, Total 2 7, One of the items disclosed within the Losses and Special Payments disclosure relates to the provision for impairment of Provider receivables balance. This is in relation to contract payments to providers of 7,305k, for which there is some doubt over recovery;. Following advice from NHS England, this is being treated as a loss for accounting purposes only, and an independent audit will take place in to substantiate the true value of the debtor and also test the accounting assumptions within the contract Special Payments Total Number of Cases Total Value of Cases Total Number of Cases Total Value of Cases Number '000 Number '000 Extra contractual Payments Total ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group

161 NHS Act Section 223H (1) 223I (2) 223I (3) 223J(1) 223J(2) 223J(3) 20 Financial Performance Duties Clinical commissioning groups have a number of financial duties under the National Health Service Act 2006 (as amended). The clinical commissioning group s performance against those duties was as follows: Expenditure not to exceed income* Capital resource use does not exceed the amount specified in Directions Revenue resource use does not exceed the amount specified in Directions Capital resource use on specified matter(s) does not exceed the amount specified in Directions Revenue resource use on specified matter(s) does not exceed the amount specified in Directions Revenue administration resource use does not exceed the amount specified in Directions Duty Duty Target Performance Target Performance Achieved? Achieved? Yes/No Yes/No 305, ,032 No 272, ,021 No Yes Yes 302, ,479 No 269, ,681 No - - n/a - - n/a - - n/a - - n/a 4,985 4,610 Yes 4,988 4,658 Yes The CCG has not achieved all of its set performance duties for Note: For the purposes of 223H(1); expenditure is defined as the aggregate of gross expenditure on revenue and capital in the financial year; and, income is defined as the aggregate of the notified maximum revenue resource, notified capital resource and all other amounts accounted as received in the financial year (whether under provisions of the Act or from other sources, and included here on a gross basis). *The difference between the two figures is the CCG s deficit of 38,740k [ : 14,800k deficit] for the period as reported on the Statement of Comprehensive Net Expenditure on page 118. As advised by NHSE, the CCG s outturn before release of the 0.5% Non Recurrent Risk Reserve will be used for performance assessment purposes, this results in the deficit being 40,100k. The Financial performance targets above are produced on an in-year basis for but were on a cumulative basis in ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 161

162 INDEPENDENT AUDITOR S REPORT TO THE MEMBERS OF THE GOVERNING BODY OF NHS HORSHAM AND MID SUSSEX CLINICAL COMMISSIONING GROUP Opinion We have audited the financial statements of NHS Horsham and Mid Sussex Clinical Commissioning Group for the year ended 31 March 2018 under the Local Audit and Accountability Act The financial statements comprise the Statement of Comprehensive Net Expenditure, the Statement of Financial Position, the Statement of Changes in Taxpayers Equity, the Statement of Cash Flows and the related notes 1 to 20. The financial reporting framework that has been applied in their preparation is applicable law and International Financial Reporting Standards (IFRSs) as adopted by the European Union, and as interpreted and adapted by the HM Treasury s Financial Reporting Manual (the FReM) as contained in the Department of Health and Social Care Group Accounting Manual 2017/18 and the Accounts Direction issued by the NHS Commissioning Board with the approval of the Secretary of State as relevant to the National Health Service in England (the Accounts Direction). In our opinion, the financial statements: give a true and fair view of the financial position of NHS Horsham and Mid Sussex Clinical Commissioning Group as at 31 March 2018 and of its net operating costs for the year then ended; and have been properly prepared in accordance with the Health and Social Care Act 2012 and the Accounts Directions issued thereunder. Basis for opinion We conducted our audit in accordance with International Standards on Auditing (UK) (ISAs (UK)) and applicable law. Our responsibilities under those standards are further described in the Auditor s responsibilities for the audit of the financial statements section of our report below. We are independent of the clinical commissioning group (CCG) in accordance with the ethical requirements that are relevant to our audit of the financial statements in the UK, including the FRC s Ethical Standard and the Comptroller and Auditor General s (C&AG) AGN01, and we have fulfilled our other ethical responsibilities in accordance with these requirements. We believe that the audit evidence we have obtained is sufficient and appropriate to provide a basis for our opinion. Use of our report This report is made solely to the members of the Governing Body of NHS Horsham and Mid Sussex Clinical Commissioning Group in accordance with Part 5 of the Local Audit and Accountability Act 2014 and for no other purpose Our audit work has been undertaken so that we might state to the members of the Governing Body of the CCG those matters we are required to state to them in an auditor's report and for no other purpose. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the members as a body, for our audit work, for this report, or for the opinions we have formed. Page 162

163 Conclusions relating to going concern We have nothing to report in respect of the following matters in relation to which the ISAs (UK) require us to report to you where: the Accountable Officer s use of the going concern basis of accounting in the preparation of the financial statements is not appropriate; or the Accountable Officer has not disclosed in the financial statements any identified material uncertainties that may cast significant doubt about the Clinical Commissioning Group s ability to continue to adopt the going concern basis of accounting for a period of at least twelve months from the date when the financial statements are authorised for issue. Other information The other information comprises the information included in the annual report set out on pages 4 to 115, other than the financial statements and our auditor s report thereon. The Accountable Officer is responsible for the other information. Our opinion on the financial statements does not cover the other information and, except to the extent otherwise explicitly stated in this report, we do not express any form of assurance conclusion thereon. In connection with our audit of the financial statements, our responsibility is to read the other information and, in doing so, consider whether the other information is materially inconsistent with the financial statements or our knowledge obtained in the audit or otherwise appears to be materially misstated. If we identify such material inconsistencies or apparent material misstatements, we are required to determine whether there is a material misstatement in the financial statements or a material misstatement of the other information. If, based on the work we have performed, we conclude that there is a material misstatement of the other information, we are required to report that fact. We have nothing to report in this regard. Opinion on other matters prescribed by the Health and Social Care Act 2012 In our opinion the part of the Remuneration and Staff Report to be audited has been properly prepared in accordance with the Health and Social Care Act 2012 and the Accounts Directions issued thereunder. Matters on which we are required to report by exception We are required to report to you if: in our opinion the governance statement does not comply with the guidance issued by the NHS Commissioning Board; or we issue a report in the public interest under section 24 of the Local Audit and Accountability Act 2014; or we make a written recommendation to the CCG under section 24 of the Local Audit and Accountability Act We have nothing to report in these respects. Page 163

164 In respect of the following, we have matters to report by exception: Referral to the Secretary of State We refer a matter to the Secretary of State under section 30 of the Local Audit and Accountability Act 2014 because we have reason to believe that the CCG, or an officer of the CCG, is about to make, or has made, a decision which involves or would involve the body incurring unlawful expenditure, or is about to take, or has begun to take a course of action which, if followed to its conclusion, would be unlawful and likely to cause a loss or deficiency. On 2 May 2018 we made a referral to the Secretary of State under section 30a of the Local Audit and Accountability Act 2014 in relation to the CCG s outturn reported in 2017/18 spending 38.7 million in excess of the limits set under the National Health Service Act 2006 (as amended) section 223I (3) in breach of its statutory financial duties. Proper arrangements to secure economy, efficiency and effectiveness We report to you, if we are not satisfied that the CCG has put in place proper arrangements to secure economy efficiency and effectiveness in its use of resources. Basis for qualified conclusion The CCG reported a deficit of 38.7 million in its financial statements for the year ending 31 March 2018, thereby breaching its duty under the National Health Service Act 2006, as amended by paragraphs 223I (2) and (3) of Section 27 of the Health and Social Care Act 2012, to break even on its commissioning budget. The CCG set a deficit budget of 13 million for the year ended 31 March 2018, which worsened during the year. The CCG has not yet succeeded in addressing the underlying deficit in its budget and is forecasting a further deficit of 28.4 million for 2018/19. In November 2017, the CCG was placed under legal directions by NHS England, and has been required to carry out a further governance review. From 1 January 2018, the CCG is part of the Central Sussex and East Surrey Commissioning Alliance. A number of senior appointments have been made to support the transformation required, including the preparation of a robust financial recovery plan. However, these revised arrangements have not been in place for the whole year, and are not yet embedded and delivering significant demonstrable improvements in associated outcomes. The above factors are evidence of weaknesses in proper arrangements for sustainable resource deployment and informed decision making. Qualified conclusion (Adverse) On the basis of our work, having regard to the guidance issued by the Controller and Auditor General in August 2017, we are not satisfied that, in all significant respects, that NHS Horsham and Mid Sussex Clinical Commissioning Group put in place proper arrangements to secure economy, efficiency and effectiveness in its use of resources for the year ended 31 March Page 164

165 Responsibilities of the Accountable Officer As explained more fully in the Statement of Accountable Officer s Responsibilities set out on page 67, the Accountable Officer is responsible for the preparation of the financial statements and for being satisfied that they give a true and fair view and is also responsible for ensuring the regularity of expenditure and income. In preparing the financial statements, the Accountable Officer is responsible for assessing the Clinical Commissioning Group s ability to continue as a going concern, disclosing, as applicable, matters related to going concern and using the going concern basis of accounting unless the Accountable Officer either intends to cease operations, or have no realistic alternative but to do so. As explained in the Annual Governance Statement the Accountable officer is responsible for the arrangements to secure economy, efficiency and effectiveness in the use of the CCG's resources. We are required under Section 21(1)(c) of the Local Audit and Accountability Act 2014 to be satisfied that the CCG has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources. Section 21(5)(b) of the Local Audit and Accountability Act 2014 requires that our report must not contain our opinion if we are satisfied that proper arrangements are in place. Auditor s responsibilities for the audit of the financial statements Our objectives are to obtain reasonable assurance about whether the financial statements as a whole are free from material misstatement, whether due to fraud or error, and to issue an auditor s report that includes our opinion. Reasonable assurance is a high level of assurance, but is not a guarantee that an audit conducted in accordance with ISAs (UK) will always detect a material misstatement when it exists. Misstatements can arise from fraud or error and are considered material if, individually or in the aggregate, they could reasonably be expected to influence the economic decisions of users taken on the basis of these financial statements. A further description of our responsibilities for the audit of the financial statements is located on the Financial Reporting Council s website at This description forms part of our auditor s report. Scope of the review of arrangements for securing economy, efficiency and effectiveness in the use of resources We have undertaken our review in accordance with the Code of Audit Practice, having regard to the guidance on the specified criterion issued by the Comptroller and Auditor General in August 2017, as to whether the CCG had proper arrangements to ensure it took properly informed decisions and deployed resources to achieve planned and sustainable outcomes for taxpayers and local people. The Comptroller and Auditor General determined this criterion as that necessary for us to consider under the Code of Audit Practice in satisfying ourselves whether the CCG put in place proper arrangements for securing economy, efficiency and effectiveness in its use of resources for the year ended 31 March We planned our work in accordance with the Code of Audit Practice. Based on our risk assessment, we undertook such work as we considered necessary to form a view on whether, in all significant respects, the CCG had put in place proper arrangements to secure economy, efficiency and effectiveness in its use of resources. Page 165

166 We are required under Section 21(1)(c) of the Local Audit and Accountability Act 2014 to be satisfied that the CCG has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources. Section 21(5)(b) of the Local Audit and Accountability Act 2014 requires that our report must not contain our opinion if we are satisfied that proper arrangements are in place. We are not required to consider, nor have we considered, whether all aspects of the CCG s arrangements for securing economy, efficiency and effectiveness in its use of resources are operating effectively. Report on Other Legal and Regulatory Requirements Qualified Regularity opinion We are responsible for giving an opinion on the regularity of expenditure and income in accordance with the Code of Audit Practice prepared by the Comptroller and Auditor General as required by the Local Audit and Accountability Act 2014 (the "Code of Audit Practice"). We are required to obtain evidence sufficient to give reasonable assurance that the expenditure and income recorded in the financial statements have been applied to the purposes intended by Parliament and the financial transactions conform to the authorities which govern them. In our opinion, in all material respects the expenditure and income reflected in the financial statements have been applied to the purposes intended by Parliament and the financial transactions conform to the authorities which govern them, except for the 38.7 million expenditure in excess of statutory limits. We referred this matter to the Secretary of State on 2 May 2018 under section 30a of the Local Audit and Accountability Act Certificate We certify that we have completed the audit of the accounts of NHS Horsham and Mid Sussex Clinical Commissioning Group in accordance with the requirements of the Local Audit and Accountability Act 2014 and the Code of Audit Practice. Helen Thompson Helen Thompson (Key Audit Partner) Ernst & Young LLP (Local Auditor) Southampton 25 May 2018 The maintenance and integrity of the NHS Horsham and Mid Sussex Clinical Commissioning Group web site is the responsibility of the members; the work carried out by the auditors does not involve consideration of these matters and, accordingly, the auditors accept no responsibility for any changes that may have occurred to the financial statements since they were initially presented on the web site. Legislation in the United Kingdom governing the preparation and dissemination of financial statements may differ from legislation in other jurisdictions. Page 166

167 ANNUAL REPORT 2017/18 NHS Horsham and Mid Sussex Clinical Commissioning Group 117

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