Agenda and Papers. NHS West Kent Clinical Commissioning Group Governing Body Meeting. Tuesday 27 th June 2017 At 1.30pm

Agenda and Papers for the NHS West Kent Clinical Commissioning Group Governing Body Meeting To be held on Tuesday 27 th June 2017 At 1.30pm at The Village Hotel, Forstal Road, Maidstone, Kent ME14 3AQ Page 1 of 176

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Notice is hereby given of the meeting of the NHS West Kent CCG Governing Body meeting to be held on Tuesday 27 th June 2017, at 1.30 pm 3.00 pm, at The Village Hotel, Forstal Road, Maidstone, Kent ME14 3AQ This meeting will be held in public. Questions from the public The Chairman will take questions from the public relating to items on the agenda or other aspects of the CCG business. A G E N D A Part 1 Chairman is Dr Bob Bowes *Papers for approval Time Agenda no. Agenda Item Lead Required Action 1.30pm 107/17 Questions from the public Chair TO DISCUSS 1.35pm 108/17 Welcomes and Introductions Chair TO NOTE 109/17 Apologies for Absence Chair TO NOTE 110/17 Quorum Chair TO NOTE 111/17 Declaration of Members Interests *112/17 Minutes from the previous meeting held on 23 rd May 2017 113/17 Actions arising from the previous meeting held on 23 rd May 2017 114/17 Matters Arising from the meeting held on 23 rd May 2017 not covered elsewhere on the agenda Chair Chair Chair Chair TO NOTE FOR APPROVAL Pages 6-15 TO DISCUSS AND NOTE Pages 16-17 TO DISCUSS AND NOTE Page 3 of 176

Chief Member Reports and Strategy and Policy Papers 1.40pm 115/17 Chairman s Report Chair ORAL REPORT 1.50pm 116.1/17 Chief Officer s Report Chief Officer ORAL REPORT 2.10pm 116.2/17 Wannacry Cyber Attack 117/17 Annual Report & Accounts Update 2016/17 Chief Information Officer Chief Finance Officer Pages 18-26 FOR INFORMATION Pages 27-62 2.20pm 118/17 Equality Delivery System Chief Nurse FOR INFORMATION Pages 63-93 Performance and Assurance Reports 2.30pm 119/17 Quality & Safety Update Dr Meriel Wynter FOR INFORMATION Pages 94-98 2.40pm 120/17 Integrated Performance Report Chief Finance Officer FOR INFORMATION Pages 99-133 Reports from sub-committees 2.50pm 121/17 Clinical Strategy Group Report and Minutes Dr Sanjay Singh FOR INFORMATION Pages 134-144 122/17 Finance and Performance Committee Report and Minutes Dr Garry Singh FOR INFORMATION Pages 145-155 123/17 Primary Care Commissioning Committee Report and Minutes 124/17 Governing Body Forward Planner Alistair Smith Chair FOR INFORMATION Pages 156-167 FOR INFORMATION Pages 168-176 125/17 Any other business Chair Finish 3.00pm Resolution: That representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity Page 4 of 176

on which would be prejudicial to the public interest. Date of the next meeting: Tuesday 25 th July 2017, 1.30-3.30pm, The Village Hotel, Maidstone Dates of Future Meetings: Tuesday 22 nd August 2017, 1.30-3.00pm, Hadlow Manor Hotel Tuesday 26 th September 2017, 1.30-3.30pm, Hadlow Manor Hotel Tuesday 31 st October 2017, 1.30-3.00pm, The Village Hotel, Maidstone Page 5 of 176

DRAFT MINUTES of the NHS West Kent CCG Governing Body Meeting Held in Public Meeting held on Tuesday 23 rd May 2017 at 13.30 hrs At the Hadlow Manor Hotel, Maidstone Road, Tonbridge, Kent, TN11 OJH Date of Approval: Present: Dr Bob Bowes Ian Ayres Dr Andrew Cameron Dr David Chesover James Hedges Reg Middleton Dr Andrew Roxburgh Dr Stefano Santini Alistair Smith Sue Southon Dr Meriel Wynter Dr Garry Singh Dr Sanjay Singh Dr Nick Cheales Dr Katie Collier Mr Nic Goodger Caroline Becher Chair Accountable Officer GP Governing Body Member GP Governing Body Member Lay Member for Governance Chief Finance Officer GP Governing Body Member GP Governing Body Member Lay Member, Chair of the Primary Care Commissioning Committee Lay Member for Patient and Public Engagement GP Governing Body Member GP Governing Body Member GP Governing Body Member GP Governing Body Member GP Governing Body Member Secondary Care Clinician Independent Nurse In attendance: Adam Wickings Richard Segall Jones Kofo Abayomi Paula Wilkins Gail Arnold Dr Tony Jones Observing: Tony Broadrick Apologies: Dr Tim Palmer Chief Operating Officer, Delivery Company Secretary Deputy Company Secretary (Minutes) Chief Nurse Chief Operating Officer, Transformation GP Governing Body Member Patient Participation Group Chair GP Governing Body Member Page 6 of 176

84/17 Questions from the public There were no questions from the public. 85 17 Welcomes and Introductions The Chair welcomed all to the meeting. 86/17 Apologies for Absence Apologies for absence were noted. 87/17 Quorum The Chair confirmed that the meeting was quorate. 88/17 Declaration of Members Interests No declarations were received above those already recorded in the CCG Register of Interest. 89/17 Minutes of the previous meeting held on 25 th April 2017 The Minutes of the previous meeting held on Tuesday 25 th April 2017 were approved as an accurate record of the meeting. 90/17 Actions arising from the previous meeting held on 25 th April 2017 The Chair noted the action updates provided, as detailed in the action log. In regards to the Chief Officer s action, Mr Ayres confirmed that there was a Sevenoaks District Health Action Team, chaired by Hayley Brooks, Head of Housing and Health. There was also the Health Liaison Board (chaired by Cllr Pat Boseley), which is a member Board looking at health related topics as referred from Member s Housing and Health Advisory Committee (advisory committee of the Cabinet, chaired by the Portfolio Holder for Housing and Health Cllr Michelle Lowe). Mr Ayres would commence engagement after the purdah period. 91/17 Matters Arising from the meeting held on 25 th April 2017 not covered elsewhere on the agenda There were no matters arising from the meeting held on 25 th April 2017. 92/17 Chairman s Report The Chair informed the Governing Body that a proposal would be put to the CCG membership to vote/agree in principle the establishment of a Joint Committee with Kent and Medway CCGs on the consultation of stroke services. The task of the Group is to be the Page 7 of 176

configuration of stroke services in Kent and Medway. It was noted that no work would be done prior to the formation of the Group. The Governing Body noted the Chair s update that the West Kent Improvement Board had its inaugural meeting and explained that the Group was a forum of the CCG, providers and partners to discuss and oversee the direction and implementation of the Sustainability and Transformation Plan (STP) in West Kent. The Governing Body noted and congratulated Dr Collier on the news that she was expecting a baby later in the year. Further to this, the Governing Body agreed that on this occasion, there was no need to have a bye election for an interim replacement whilst Dr Collier was on maternity leave. The Governing Body NOTED the Chair s verbal report. 93/17 Chief Officer s Report Mr Ayres provided an oral update on the following: The Governing Body noted Mr Ayres s update that his position as Accountable Officer at East Surrey CCG had come to an end and would resume back at West Kent CCG from the 1 st of June. Mr Ayres thanked the Governing Body for their support and patience during the period. Mr Ayres informed the Governing Body of the outcomes of the recent NHS ransomware attack and it was noted that there was no significant impact on Kent and Medway CCGs. Mr Ayres formally thanked members of staff that worked hard during the period to ensure the smooth operations of the CCG. Care Plan Management System (CPMS) update The paper formed part of the Chief Officer s report and was presented by Mr Brownless, Chief Information Officer. The report was taken as read and content noted. Mr Brown highlighted that there were now 7,200 care plans on CPMS with 730 registered clinical users and 54 out of 60 West Kent practices had signed up to the system. It was noted that work was in progress to increase usage. The Governing Body was assured that practices yet to sign up would be engaged with and encouraged to sign up to CPMS. The Governing Body noted the key achievements since inception i.e. data feeding into the system and Organisations that were being engaged to include their data on the system. Mr Brownless reported on progress with the organisations his team were engaging with to sign up to CPMS. Following from the CPMS Improvement Board meeting earlier in the day, there was now an estimated start date with MTW which was placed around the end of July. Page 8 of 176

The following comments were raised by Governing Body members: - Concerns on successful engagement with the six practices that were yet to sign up to CPMS. - Whether benefit realisation can be demonstrated and the need for quality audit of the system. The coming benefits realisation meetings would be able to feed back to the GB in due course. - The Governing Body/CCG to decide that CPMS was the means by which MDT would function and how to handle lack of engagement from the remaining six practices not signed up to CPMS and agree a way forward. The Governing Body NOTED the Chief Officer s oral report and the Care Plan Management Systems update. 94.1/17 Annual Report & Accounts Update 2016/17 Mr Middleton informed the Governing Body that the draft annual report and accounts had been submitted to NHS England at the required time and was currently being reviewed by the CCG s external auditors (KPMG) for external audit opinion. It was noted that there were a number of transactions relating to primary care co-commissioning that required testing before concluding the audit. KPMG had communicated that they were experiencing challenges extracting source information from the provider (Capita). Mr Middleton reported that the CCG had provided most of the necessary documentation to external audit however some transactions still needed to be evidenced. Assurance was provided to the Governing Body that external audit unqualified approval opinion was anticipated to be provided on the CCG s accounts. Furthermore the CCG was in a position to demonstrate value for money. It was noted that the external audit process would be followed by the Audit Committee sign off meeting. 94.2/17 Delegation of Authority to the CCG and Accountable Officer to sign off Annual Reports and Accounts Mr Segall Jones informed the Governing Body that it was anticipated that the Audit Committee would be presented with the final annual report and accounts at its meeting on the 24 th of May for scrutiny and sign off. However as a precautionary measure and in the event that issues arose from the draft submissions to NHS England, Mr Segall Jones sought Governing approval to delegate authority to the CCG Chair and Accountable Officer to sign off the final report on behalf of the Governing Body. It was noted that the Audit Committee had already been delegated this function. The Governing Body NOTED the update and delegated authority to the CCG Chair and Accountable Officer to sign off the annual report and accounts. Page 9 of 176

95/17 Revised Corporate Governance Policies (Conflicts of Interest Policy, Gifts & Hospitality and Sponsorship Policy and Procurement Policy) Introducing the paper, Mr Segall Jones informed the Governing Body that the proposed updated policies were for Governing Body approval following recommendations from the management of conflicts of interest guidance issued by NHS England in September 2016 and February 2017 respectively. It has since been established that the recommendations were mandatory for all CCGs to implement. This was a way of NHS England enabling the CCGs to fulfil their corporate governance obligations under the Act. Furthermore the guidance was issued primarily because of the increasing numbers of CCGs taking on delegated cocommissioning of primary medical care. The Audit Committee had previously reviewed and debated the aspects of the guidance issued and where appropriate adopted for recommendation changes to the CCG policies and processes so that we are in line with national requirements. The Governing Body noted that there was now a requirement for an annual audit review of the CCG s arrangements regarding conflicts of interest management and CCGs are further required to be in line with national requirements to be able to get a good assurance rating from the internal auditors. Mr Segall Jones explained that changes to the policies were reflected in track mark ups, further commentaries were added for clarity. Comments and questions were invited from the Governing Body. Mr Smith commented on the procurement policy by referring to the values relating to section 12 procurements needed to go through certain routes and stated that this needed clarity i.e. whether it meant lifetime value rather than yearly value. Mr Segall Jones responded that he was not clear on this requirement and would be seeking expert opinion. (Action: Mr Segall Jones). The Governing Body approved the proposals and changes to the Conflicts of Interests, Gift, Hospitality and Sponsorship and Procurement Policies. 96/17 360 Degree Stakeholder Survey Results 2017 Mr Segall Jones presented the result of the 360 degree stakeholder survey 2017 to the Governing Body which highlighted improvements and slippages from the previous year. Mr Hedges commented that feedback from clinicians indicated that there was a gap in what the clinicians perception of what the CCG was doing and the reality. This point was discussed and it was agreed that the Chair would write an adjunct to the next newsletter to address clinician comments from the last survey. Mr Ayres added that there were challenging times ahead for the CCG due changes in the NHS and advised the importance of open and transparent communication with stakeholders. Page 10 of 176

Mr Goodger enquired whether the survey defined precisely what the CCG does. The Chair responded that the survey was designed before the era of co-commissioning and did not cover all areas of CCG work. It was agreed that the CCG would design and carry out its own version of the stakeholder survey in order to get maximum benefit. Dr Cameron stated that the general opinion from the patch meetings was the lack of collaborative working between the patches and the CCG and advised a more collaborative approach from the CCG in order to make the relationship successful. Dr Sanjay Singh pointed out that a two way approach was required to make the relationship work, however patients were the focus of collaborative working above other reasons. Dr Jones added that workforce views also needed to be taken on board. From the above discussion, it was agreed that better and open communication of plans was required from the CCG and it was requested that GP Governing Body members champion the above message at cluster meetings. 97/17 Targeted and Specialist Mental Health Service for Young Children and Young People Procurement Outcome Introducing the paper, Mr Ayres provided a background, the need for the exercise and highlighted stages of the procurement. Mr Ayres highlighted stages of the procurement process and informed the Governing Body of the preferred bidder and it was noted that the service was scheduled to commence in the autumn. The report still anonymised the bidders including the preferred bidder due to the purdah period. Further to discussions of the above, the Governing Body approved the award of the contract to provider A. 98/17 West Kent CCG Quality Report The Report was taken as read and content noted. Dr Meriel Wynter outlined the following key areas: The Quality report for the current reporting period was more detailed than the previous month with all Governing Body feedback from April meeting reflected in the report. Outcomes of the serious incidents/never events meeting with the quality team of MTW were noted. One of the issues was under consideration by MTW as to whether to be categorised as a serious incident or never event. Page 11 of 176

A new quality reporting format was being developed similar to the CQC format. The format would be tested at a Governing Body meeting shortly. The following comments were raised and discussed: Ms Southon raised the following questions 1) clarification on the term never events and how it was treated. Ms Wilkins confirmed that it was a categorisation and treated in the same way and process. 2) details concerning the G4S issue. It was noted that a fuller report on the matter would be available shortly, in the interim the CCG Quality team were providing the support on the reporting format. 3) outcomes of SecAmb CQC inspection. It was noted that Ms Wilkins was awaiting the inspection report. Mr Hedges referred to complaints emerging from KMPT patient experience relating to lack of service provided and failure to adhere to care plan agreed with patients and enquired what the reasons were for this situation. Ms Wilkins was not in a position to provide an answer and agreed to look into the matter for detailed feedback (Action: Paula Wilkins). Mr Smith sought confirmation whether the primary care dashboard was launched on the 1 st of May. Dr Wynter and Ms Wilkins were currently not sighted on the completed dashboard and agreed to follow up the matter. (Action: Dr Wynter/Paula Wilkins). In response to Mr Goodger s query on whether there was a register to track serious incidents Ms Wilkins stated that information was recorded on the STEIS system and also kept on the CCG database, there were plans to link the database with providers and planned collaborative working with other CCGs in this area. It was noted that providers were requested to review trends and themes. Furthermore the quality team was scheduled to do a yearly review which would be reinforced by the work of the national quality team. The Governing Body noted the report and looked forward to the new reporting format. 99/17 & 100/17 Corporate Risk Register & Board Assurance Framework (BAF) The corporate risk register and BAF items were presented together by Mr Segall Jones. It was noted that the CCG corporate risk register and BAF were moderated by the Chief Officer prior to Audit Committee scrutiny. The key highlights from Audit Committee discussion were around how the BAF risks linked with the Sustainability and Transformation Plan (STP) risks and more importantly whether the CCG strategic goals were still relevant in view of recent changes in the NHS. The Governing Body noted the updates on the corporate risk register and feedback following Audit Committee review and recommendations. The following points were raised for discussion: Page 12 of 176

Mr Smith highlighted that the BAF risks were identified against the achievement of Mapping the Future, however it appeared that the Governing Body did not have a mechanism for monitoring how the CCG was performing against Mapping the Future. Therefore this presented a gap in control. The Chair explained that the Local Care plan to a larger extent would address issues identified in Mapping the Future. The plan would therefore provide the necessary assurance to the Governing Body. In reference to Mr Segall Jones observations on whether the CCG strategic goals aligned with STP, the Chair stated that STP risks from a West Kent perspective needed to be clarified, clearly articulated and assessed. In addition, the CCG strategic goals would need to be refreshed and redrafted in light of the STP as a matter of priority. As a result of the above discussion, it was agreed that that the CCG strategic goals would be reviewed by July and the risks to be refreshed by autumn. (Action: Ian Ayres/Company Secretary/SET). Dr Jones mentioned that there were risks around workforce such as retention, recruitment, workload/capacity pressure and challenges currently not reflected on the corporate risk register or the BAF. Mr Ayres commented that there were on-going discussions regarding whether the real challenges of implementing the STP went beyond the issue of finance and included workforce. It appeared from these discussions that sufficient level attention had not been given to workforce challenges across the system. Mr Ayres also supported the need for a more comprehensive risk analysis of workforce pressures and impact on the system. The Local Care plan would need to identify workforce requirements; detailed plans around workforce and the risk register would reflect the risks around achievement of the plan in this area. The Chair highlighted that the second risk on the BAF mentioned workforce in relation to specific commissioning plans and not to the extent of primary care. The Chair recommended that an additional risk be added following from the workforce discussion. (Action: Richard Segall Jones/Kofo Abayomi). The Governing Body noted the Corporate Risk Register and Board Assurance Framework. 101/17 West Kent CCG Integrated Performance Report (IPR) The report was taken as read and content noted. Mr Middleton highlighted the following for the reported period: There was no finance reporting within the IPR for this period. The year- end had been closed and it was anticipated that a positive outcome would be achieved from the annual report and accounts sign off meeting. Furthermore there was insufficient data to report on month 1 performance, this would change from next month. Page 13 of 176

In terms of NHS constitutional standards, there was improvement in A&E performance in comparison to the period in West Kent when the standards were lower than national targets across England. The CCG had now improved to an average position over the last few weeks. Slight decline in cancer standards with 27 of 104 patients not commencing treatment within the national constitutional standard. Adverse movement in cancer 2 week standard performance but as indicated in the report, this was driven by provider performance (Medway Foundation Trust). Dementia diagnosis rate had not improved as anticipated. Improvements are required across the constitutional standards in the new financial year to reflect the ambitions of the planning process agreed with NHS England. In addition to the above impacting patient experience, it had also affected the CCG in earning quality premiums income. Therefore the CCG s efforts to improve against a range of quality standards were negated by the CCG s failure to achieve constitutional standards. The Finance and Performance Committee have however requested a report on the capability to achieve the quality standard for 2018/19 with the view of earning quality premiums for that year. The Chair of the Finance and Performance Committee would be overseeing this process. The following were highlighted during the discussion: Dr Garry Singh highlighted that although the CCG was not achieving the constitutional standards, the CCG was still in line with national targets. He stressed the need to work with providers for improvements on constitutional standards. Mr Ayres made a clarification on page 308 of the report (Ambulance Waiting Times) regarding reference to Deloitte working with SECAmb and explained that Deloitte was commissioned by Commissioners across Kent, Surrey and Sussex to carry out an economic analysis of money that went into the ambulance service in regards to performance and benchmarked against other ambulance providers, The report was now completed and would be presented to the Commissioners shortly. Ms Collier commented on the dementia diagnosis, the figure for April indicated the right direction; however the chart on page 311 did not show all the practices. Mr Middleton agreed to correct this error in future reports. The Chair also recommended that the charts reflect rates for clarity purposes. Since this information was no longer offered, the Chair requested that the information be benchmarked against demographics. Dr Garry Singh Page 14 of 176

responded that this had been carried out and discussed at the Finance and Performance Committee. 102/17 Clinical Strategy Group Report The report was taken as read and contented noted. 103/17 Finance and Performance Committee Minutes The report was taken as read and content noted. 104/17 Audit Committee Report and Minutes The report was taken as read and content noted. 105/17 Governing Body Forward Planner The Governing Body forward planner was noted. 106/17 Any other business There was no other business. The Chair thanked everyone for their attendance and closed the meeting at 15.30 hrs. Date of next meeting: Tuesday 27 th June 2017 at 13.30 hrs The Village Hotel, Maidstone. Page 15 of 176

Actions of West Kent CCG Governing Body Meeting date Action No (in accordance with agenda no) Action 28/02/2017 24/17 Questions from the public - Cllr Davison mentioned a HAG (Health Advancement Group) Sevenoaks district meeting and asked who should be aware of this meeting at the CCG and whether the Edenbridge proposal had been presented to them. Mr Ayres advised Cllr Davison that he would liaise with Sevenoaks Council to establish more detail. 23/05/2017 95/17 Revised Corporate Governance Policies (Conflicts of Interest Policy, Gifts & Hospitality and Sponsorship Policy and Procurement Policy) : Mr Smith commented on the procurement policy by referring to the values relating to section 12 procurements needed to go through certain routes and stated that this needed clarity i.e. whether it meant lifetime value rather than yearly value. Mr Segall Jones responded that he was not clear on this requirement and would be seeking expert opinion. Date of completion Responsibility Ian Ayres Richard Segall Jones Progress and outcome Mr Ayres at the last meeting reported that he had established contact at HAG and engagement would commence after the purdah period. Page 16 of 176

Meeting date Action No (in accordance with agenda no) Action 23/05/2017 98/17 Quality Report: Mr Smith sought confirmation whether the primary care dashboard was launched on the 1 st of May. Dr Wynter and Ms Wilkins were currently not sighted on the completed dashboard and agreed to follow up the matter. 23/05/2017 99/17 &100/17 Corporate Risk Register and Board Assurance Framework: It was agreed that that the CCG strategic goals would be reviewed by July and the risks to be refreshed by autumn. Date of completion Responsibility Dr Wynter/Paula Wilkins Ian Ayres/SET Progress and outcome 23/05/2017 99/17 & 100/17 Corporate Risk Register and Board Assurance Framework: The Chair highlighted that the second risk on the BAF mentioned workforce in relation to specific commissioning plans and not to the extent of primary care. The Chair recommended that an additional risk be added following from the workforce discussion. Richard Segall Jones / Kofo Abayomi All risks on the BAF will be refreshed including addition of a workforce risk by the next reporting period. Page 17 of 176

Wannacry Cyber Attack Briefing for Governing Body This paper is for: Assurance and information Recommendation: The Governing Body is asked to note the Lessons that have been identified from the Wannacry Cyber Attack in May 2017. For further information or for any enquiries relating to this report please contact: Andrew Brownless, Chief Information Officer, Andrew.brownless@nhs.net, 01732 375230 Date: 27 th June 2017 Reporting Officer: Andrew Brownless Agenda Item: 116/17 Lead Director: Reg Middleton Version: 1 Report Summary: On May 12 at approximately 15:00 hrs the CCG was notified by the commissioning support unit (CSU) that that the NHS had come under attack by the Wannacry ransomware computer virus. A ransomware attack is one that encrypts files on a victim s computer and then offers the victim the opportunity to purchase a de-encryption key so that they can recover the data. This paper provides a summary of the attack, the impact on west Kent CCG, the steps that the CCG took during the attack and to recover. The paper also details lessons that have been learnt as a result of the attack and identifies a number of next steps to mitigate against the impact of any future cyber-attacks. Page 18 of 176 West Kent CCG Front Sheet

FOI status: This paper is disclosable under the FOI Act Strategic objectives links: Board Assurance Framework links: G. Organisational competence Giii): Failure to ensure adequate internal controls and business processes could result in the CCG being unable to undertake its day to day business. Links to the implementation of the local digital roadmap and the aim of achieving a paperless NHS by 2020 Identified risks & risk management actions: Resource implications: Legal implications including equality and diversity assessment Equality and diversity assessment Management of Conflicts of Interest Public and Patient Engagement/Impact on patient services Detailed in the report None identified at this stage None Has an equality assessment been undertaken? Yes (please append the action plan to this paper) Will be necessary if for either Decision or Approval Not applicable None identified No impact on patient services Report history: Appendices No previous versions None Next steps: Next Steps are detailed within the report Page 19 of 176 West Kent CCG Front Sheet

Wannacry Cyber Attack Briefing for the Governing Body June 2017 Page 20 of 176 Patient focused, providing quality, improving outcomes

Introduction On May 12 at approximately 15:00 hrs the CCG was notified by the commissioning support unit (CSU) that that the NHS had come under attack by the Wannacry ransomware computer virus. A ransomware attack is one that encrypts files on a victim s computer and then offers the victim the opportunity to purchase a de-encryption key so that they can recover the data. This paper provides a summary of the attack, the impact on west Kent CCG, the steps that the CCG took during the attack and to recover. The paper also details lessons that have been learnt as a result of the attack and identifies a number of next steps to mitigate against the impact of any future cyber-attacks. Cybersecurity A cyber-attack is defined as any type of offensive manoeuvre, by nation-states, individuals, groups or organisations that targets computer information systems, infrastructure, networks and / or personal computer devices by various means of malicious acts usually originating from an anonymous source that either steals, alters or destroys a specified target by hacking into a susceptible system. The following are all types of cyber-attacks; Viruses a self-replicating program that attach itself to another program or file in order to reproduce Worms a self-sustaining program that replicate across a network Trojan horse malicious code embedded in a legitimate program The Wannacry ransomware crypto worm attack was a worldwide cyberattack which targeted computers running Microsoft windows by exploiting vulnerability in MS Windows Server Message Block (SMB). The attack began on Friday, 12 th May 2017 and within a day was reported to have infected more than 230,000 computers in over 150 countries. In addition to the NHS, it was reported that Telefonica, FedEx and Deutsche Bahn were also infected. The initial spread of Wannacry was halted by the fortuitous discover of a kill switch in the Wannacry source code, however, it should be noted that, subsequently versions of the crypto locker have been detected that lack the kill switch. Computer system can be protected against cyberattacks by Ensuring that the operating system on them is kept up-to date They are running an effective anti-virus tool which has up to date virus definitions loaded End user training is also a key component in cyber security, for example reminding user that they should not click on links or open files in emails that they are not expecting. NHS West Kent Clinical Commissioning Group Page 21 of 176 Page 2 of 7

Disaster recovery procedures are also key, ensuring that data is backed-up regularly, so that it can be restored in the event of an attack. The CCG commissions North East London Commissioning Support Unit (NELCSU) to manage its corporate IT service and to provide IT service management to the 60 GP practices across west Kent Timeline of the attack The approximate timeline of the attack is summarised in the table below: Date 12 th May 2017 Approx. time Between 07:00 & 08:00 hrs Approx. 13:30 NHS came under attack by ransomware Wannacry First attacks reported from NHS Trust in NE England 13:30 West Kent practice contacted the CSU service desk to report that they had been attacked 15:15 CSU notified the CCG that a crypto locker attack was affecting a number of sites across Kent & Medway. CSU confirmed that communication had gone out to all users. 16:39 CCG sent message to all west Kent practice managers and lead GPs advising extra vigilance when opening emails 16:45 CCG staff advised to shut down laptops and PCs 16:55 Following further verbal advice from the CSU, CCG emailed practices to advise them to shut down all IT equipment and await further advice., practices were given the CIO s mobile phone number to contact for further advice 17:00 CareCERT 1 notification received from NHS Digital 17:00 CCG On-call manager briefed 19:20 CCG received confirmation from the CSU that all patches were in place and that practices could restart their machines in the 1 CareCERT is the cybersecurity information sharing portal provided by NHS Digital. As well as providing NHS bodies with Cybersecurity alerts, it hosts a repository of threat articles, white papers and best practice. All NHS organisations, including GP Practices, are encouraged to register with CareCERT so that they receive threat notification other alerts. NHS West Kent Clinical Commissioning Group Page 22 of 176 Page 3 of 7

morning. This message was relayed to a small number of practices who had made contact and who were running weekend clinics 20:30 Apparent that the situation was not getting worse in west Kent, no further contact with practices and no reports from MTW or other trusts of any infection. Trusts and CSU had established teams on standby should they be needed over the weekend. 13 th May 2017 14 th May various Contact with the CSU to ascertain the affected sites. Practices who made contact, advised that they could restart machines 15 th May 2017 7:00 am CCG primary care team made contact with each practice to advise them that they could restart machines 10:00 CSU engineers on site to restore PCs at affected practices 16 th May CSU provided reports showing machines that had been identified as having out of date anti-virus images. The users of these machines where asked to put their machines on the network so that the images could be updated. This process was repeated later in the week. Impact on West Kent The impact on west Kent was reasonably light; one practice had approximately half of its PCs infected by the Wannacry crypto locker worm. There was no infection reported from the CCG corporate users or from NHS Trusts that serve west Kent. The practice that was infected had their machines reimaged and restored on Monday 14 th May, however they had a number of residual problems Issues with reinstalling DocMan and their dictation software, these issues were resolved by calling in support from the system suppliers Loss of files that staff had been storing on the hard disks of the machines that were infected Inability to scan from their photocopier and save the scanned image on the network, this is the SMBv1 issue described below NHS West Kent Clinical Commissioning Group Page 23 of 176 Page 4 of 7

A number of other practices also lost the ability to scan from photocopiers; this is because the CSU had, under advice from NHS Digital, switched off SMBv1 as it contained vulnerabilities. Whilst SMBv2 was available this was not supported by the copiers affected. A small number of practices have patient check-in terminals based on windows XP hardware. XP is a discontinued and unsupported operating system and therefore poses a risk to network security. It is worth reinforcing the point that no clinical data was lost or compromised as a result of this attack. Lessons Learnt Whilst the impact across west Kent was on this occasion, reasonably light, there are still a number of lessons that practices, the CCG and the CSU can learn from the attack. The CSU have undertaken an incident debrief and NHS England have run a cyber-attack formal review and debrief. Neither of these reports are available at the time of writing but are expected to be informative and provide further guidance and advice. The CCG has identified lessons in the following categories IT related Communications Business continuity IT related lessons learnt The CCG had recently completed a PC refresh programme that meant that the vast majority of workstations were running Windows 7, a supported operating system. This minimised the risk of infection, it is recommended that the CCG should work with the CSU to use available funds to maintain this position. Each machine had antivirus software loaded, however, the virus definitions updates hadn t been applied consistently to each machine, the CCG should seek regular assurance from the CSU that anti-virus definitions are kept up to date on all devices It is apparent that some users in practices are storing documents on PC hard drives which are not backed up. Each practice should have access to a networked drive to store documents which has appropriate back-up arrangements. Perimeter security on the Kent community of interest network (COIN) seems to have helped protect the Trusts and a number of GP practices across Kent. This design should be considered when procuring the replacement for the COIN and N3 connections. A number of peripheral devices, photocopiers and patient check in systems have been shown to have the SMB v1 vulnerability. Typically these devices are the responsibility of practices, and whilst the CSU has helped practices to resolve issues, NHS West Kent Clinical Commissioning Group Page 24 of 176 Page 5 of 7

responsibility for the cost of upgrade and maintenance remain with individual practices. Practices should be encouraged to keep such devices under a maintenance contract or lease agreement which keeps the device up to date. Practices should also be encouraged to replace such devices when the equipment becomes obsolete or unsupported. Communications Lessons Learnt As a result of the fast moving situation, there was a perception of inconsistent messages received from the CSU and hence the instructions that the CCG passed on to practices. It should be acknowledged that messages were based on the best intelligence at the time that the message that was sent, however, in future the CCG should consider whether it is possible to triangulate messages before communicating to practices. In such circumstances, there is an inevitable tension between the need to take decisive steps and to avoid an inappropriate over reaction. There was a delay between when the NHS first became aware of the attack and the CCG and practices first being notified. The CCG should work with other agencies, including NHS Digital and the CSU to minimise such a delay in future. Once email had been shut down, the CCG had no easy way of contacting practices other than telephone calling individual practice switchboard. This issue was exacerbated by the fact that practices were closing as it was Friday evening. The CCG has now compiled a list of switchboard bypass numbers and has updated contact lists to include an emergency contact number for all practices. This contact list has now been put in the on-call pack as previously it was only held by the primary care team. The email from the CCG to practices included the mobile phone number for a single member of staff; whilst this was fine on this occasion, as this member of staff was able to respond to calls from practice over the weekend, this would not have been sustainable if the incident had lasted for much longer. It is recommended that such contact should be via the CCG s on call arrangements. There would be benefit in establishing a local network of IT Directors / CIOs to share experiences and to provide help and advice during such an incident. Business continuity lessons Learnt The on call manager was dependent on expert advice from the CSU and the CCG CIO over the weekend. Weekend coverage is not included in the CCG s agreement with the CSU and support was primarily provided on a goodwill basis. This would not be sustainable over a longer period. Consideration should be given to commissioning the CSU to provide contingency support. NHS West Kent Clinical Commissioning Group Page 25 of 176 Page 6 of 7

It was clear that practices that were running clinics over the weekend were dependent on having the clinical systems available. Fortunately this was possible during this incident, however, it is recommended that practices should assess whether their business continuity plans include adequate resilience in the eventuality of a long term clinical system outage. A number of practices are not registered on CareCERT, meaning that CareCERT alerts relating to the practice are directed to the CCG as the parent organisation this potentially introduces a delay in responding to and resolving a practice level cybersecurity alert. Practices should be encouraged to register on CareCERT. Next Steps A focus on cyber security is paramount, the CCG, CSU and practices should work on the assumption that another attack will hit the NHS at some point in the future and that the lessons learnt from the Wannacry attack in May 2017 should be applied to everyday clinical and business services. As the reports from NHS England and NELCSU become available, further steps should be taken to build in the learning from these reports. NHS West Kent Clinical Commissioning Group Page 26 of 176 Page 7 of 7

Annual report and accounts 2016-17 This paper is for: Information Recommendation: To note that the final Annual Report and Accounts for 2016/17 was approved by the CCG s Audit Committee (on the 24 th of May 2017) & the CCG s External Auditors, and submitted to NHS England and published on the CCG website in line with required timescales. For further information or for any enquiries relating to this report please contact: Richard Segall Jones, richard.segall-jones@nhs.net Reg Middleton, reg.middleton@nhs.net Reporting Officer: Richard Segall Jones, Company Secretary and Reg Middleton, Chief Finance Officer Lead Director: Ian Ayres, Accountable Officer/Chief Officer Report Summary: Date: 27 th June 2017 Agenda Item: 117/17 Version: FINAL As a statutory NHS body, NHS West Kent CCG was required to compile and submit a final Annual Report and Accounts (ARA) for 2016/17 to NHS England by 31 May 2017. The CCG s Audit Committee considered the draft ARA in detail at its meeting on 24 May 2017 and was pleased to note that the external auditors had issued an unqualified opinion on the accounts and an unqualified value for money opinion. The document has now been published on the CCG s website and can be viewed at: http://www.westkentccg.nhs.uk/about-us/our-plans-reports-and-strategies/ A summary overview of the annual accounts and the external auditor s ISA 260 report is attached to this paper. The CCG s Overarching Scheme of Reservation and Delegation allows for the approval of the ARA by the Audit Committee on behalf of the Governing Body and the Audit Committee Page 27 of 176 West Kent CCG Front Sheet

approved the ARA on 24 May 2017. This report is for information and the Governing Body is asked to note the approval of the ARA. As with previous years, a summary annual report has been produced and will be published in June. This version will be more decipherable to the CCG s public and stakeholders than the full report, to which the summary will link. FOI status: This paper is disclosable under the FOI Act Strategic objectives links: Board Assurance Framework links: Identified risks & risk management actions: Resource implications: Legal implications including equality and diversity assessment Equality and diversity assessment Management of Conflicts of Interest Public and Patient Engagement/Impact on patient services The ARA covers the CCG s performance against all its strategic objectives. Strategic Goal F (Robust Governance): Loss of control of corporate governance could result in the CCG acting ultra-vires and becoming subject to regulatory or legal action, with resultant harm to the CCG s reputation, influence and capability, as well as possible financial harm. The CCG risks damage to its reputation if it is unable to submit a final audited Annual Report and Accounts to the deadline set by NHS England N/A No adverse legal or equality and diversity implications are anticipated as a result of approving the Annual Report and Accounts Has an equality assessment been undertaken? Yes Not applicable for this purpose. N/A N/A Report history: Appendices Recommended for approval by the Audit Committee on 24 May 2017 Annual Accounts 2016/17 Overview External Audit ISA 260 Report Page 28 of 176 West Kent CCG Front Sheet

Next steps: Publication of full ARA and summary Annual Report on the CCG s website. Page 29 of 176 West Kent CCG Front Sheet

NHS West Kent CCG Annual Accounts 2016/17 Overview 20 June 2017 Page 30 of 176 Patient focused, providing quality, improving outcomes

NHS West Kent CCG Annual Accounts 2016-17 Core functions of the CCG The CCG has a range of core functions as set out in legislation commissioning functions and duties relating to CCGs finance governance cooperation Statutory Duties and Powers of the CCG in relation to finance The powers and duties that the CCG has in respect of finance is summarised in Appendix A. The performance against these duties is summarised in the statutory accounts in Note 22 (see below), which shows all targets being achieved. A key point to note is that the surplus is higher than the previous year. As set out in the 2016/17 NHS Planning Guidance, CCGs were required to hold a 1% reserve uncommitted from the start of the year, created by setting aside the monies that CCGs were otherwise required to spend non-recurrently. This was intended to be released for investment in Five Year Forward View transformation priorities to the extent that evidence emerged of risks not arising or being effectively mitigated through other means. In the event, the national position across the provider sector has been such that NHS England has been unable to allow CCGs 1% non-recurrent monies to be spent. Therefore, to comply with this requirement, NHS West Kent CCG has released its 1% reserve to the bottom line, resulting in an additional surplus for the year of 5.993m. This additional surplus will be carried forward for drawdown in future years. Page 31 of 176 2 P a g e

22 Financial performance duties NHS Clinical Commissioning Groups have a number of financial duties under the NHS Act 2006 (as amended). NHS West Kent Clinical Commissioning Group's performance against those duties was as follows: National Health Service Act Duty 2016-17 2016-17 2016-17 2015-16 2015-16 2015-16 Duty Duty Maximum Performance Achieved Maximum Performance Achieved 000s 000s? 000s 000s? 223H (1) Expenditure not to exceed income 617,950 606,375 Yes 538,190 532,626 Yes 223I (2) Capital resource use does not exceed the amount specified in Directions 49 49 Yes 1,547 1,547 Yes 223I (3) Revenue resource use does not exceed the amount specified in Directions 617,901 606,326 Yes 536,643 531,079 Yes 223J (1) Capital resource use on specified matter(s) does not exceed the amount specified in Directions 0 0 Yes 0 0 Yes 223J (2) Revenue resource use on specified matter(s) does not exceed the amount specified in Directions 58,802 * 55,857 Yes 0 0 Yes 223J (3) Revenue administration resource use does not exceed the amount specified in Directions 10,577 10,576 Yes 12,340 10,565 Yes * Delegated Co-Commissioning allocation 58,802 Less 1.5% contribution to headroom and contingency (882) Delegated Co-Commissioning operating budget 57,920 2016-17 2015-16 000 000 Surplus-Programme 5,581 3,789 Contribution towards national risk reserve 5,993 0 Surplus-Admin 1 1,775 Surplus-CHC Risk Pool 0 0 11,575 5,564 Highlights of Annual accounts A new highlight for the 2016/17 accounts is the introduction of Delegated Co- Commissioning for West Kent CCG, with the CCG taking on full responsibility for the commissioning of general practice services. Primary care co-commissioning is one of a series of changes set out in the NHS Five Year Forward View. It gives Clinical Commissioning Groups (CCGs) an opportunity to take on greater responsibility for general practice commissioning. It was introduced to support the development of integrated out-of-hospital services, based around the needs of local people. Co-commissioning is part of a wider strategy to join up care and could lead to a number of benefits for patients and the public including: Improved access to primary care and wider out-of-hospital services, with more services available closer to home High quality out-of-hospital care Improved health outcomes and reduced health inequalities A better patient experience through more joined up services The CCG was given an allocation of 58.8m in 2016/17 to fund the payments for Primary Care Co-Commissioning. Page 32 of 176 3 P a g e

Notes to the Accounts other key variances Note 2 Other Operating Revenue 1. Education, training and research-increase of 0.7m In 2016/17 the CCG took over the hosting of the GP staff training team. The GP staff training team are responsible for managing the top sliced levies taken from the GP contracts and arranging training. The increase in income is due to receipt of 386k LMC levies administered by the team and 50k CEPN seed funding. It also includes 318k from Health Education England, which is a higher amount than last year, due to the receipt of monies to support the development of GP Medical Assistants, GP Nursing and Workforce Development (CPD) Funding for 2016/17. 2. Non-patient care services to other bodies-increase of 0.4m The income from non-patient care services to other bodies came from two streams, the CYPMHS procurement project lead by West Kent CCG and the hosting of the GP staff training team, recharged to other CCGs. Both of these were new for 2016/17. Note 4 Employee benefits and staff numbers The CCG has recruited more staff (96 average staff employed 2016/17 & 82 average staff employed 2015/16) with 17% of staff being employed on a short term contract basis. This in turn has had the impact of increasing all employee benefits. We are working on a departmental split of the average number of people employed but taken as a snapshot comparing March 2016 to March 2017, 3 additional staff were employed in the GP staff training team, 3 in the Medicines Management team, 2 in CHC (who were previously interim) and 2 in Commissioning. Note 5 Operating expenses Significant variances in operating expenses expenditure between the financial years are explained below: 1. Services from other NHS Trusts-increase 15.7m 2.4m of the increase is due to the charges for High Drugs Costs, previously charged by Healthcare at Home, now being charged by Maidstone & Tunbridge Wells NHS Trust (MTW). In addition, there was an increase in activity from the previous year in the High Cost Drugs already charged by MTW of 2m. Page 33 of 176 4 P a g e

There was also an 11.3m increase in the value of the main SLA with Maidstone & Tunbridge Wells NHS Trust. 2. Services from other NHS bodies-decrease 0.6m This is due to the CCG no longer reporting the expenditure of Oxygen under this classification in line with guidance issued. This now appears under purchase of healthcare from non-nhs bodies. 3. Purchase of healthcare from non-nhs bodies-increase 11.2m The main driver for this increase is the growth in independent/private providers of healthcare services, largely in Acute and Mental Health, including 2.2m for the full year impact of Kent Institute of Medicine and Surgery (KIMS). 4. Supplies and services clinical-decrease 2.7m This is largely due to additional charges for High Drugs Costs now appearing under Services from other NHS Trusts (see note 1. above) 5. Supplies and services general-increase 0.5m This includes the contribution to the STP of 0.3m and 0.2m procurement costs incurred for Childrens and Young People Mental Health Services (CYPMHS). 6. Establishment-decrease 0.7m This is due to a reduction in IT costs and the benefit of the CPMS revenue funding, which was treated as a net recharge to expenditure. 7. Premises-increase 0.2m NHS Property Services Ltd. moved to market rents in 2016/17 and there is a full year effect of the CCG lease at Maidstone Hospital for the Primary Care Booking Service to replace the office space lost on the vacation of Station Road. The CCG received an allocation to assist with the impact of market rents. 8. Prescribing costs-decrease 1.6m Page 34 of 176 5 P a g e

This reflects the CCG s achievement of QIPP savings and the successful delivery of the Medicines Optimisation Scheme (MOS) in 2016/17. 9. GPMS/APMS and PCTMS-increase 55.5m This can be explained by the inclusion of Delegated Co-Commissioning expenditure of 55.8m and a reduction in Local Enhanced Services of 0.3m. 10. Education and training-increase 0.5m 0.4m of the increase in expenditure is due to additional training costs incurred as a result of the CCG hosting the GP staff training team (see Note 2 Other Operating Revenue). The balance is due to additional training costs under the Student Nurse Practice Placements training scheme. 11. Continuing Healthcare Risk Pool contributions-decrease 1.3m The decrease in the risk pool expenditure was directed by NHS England and is part of a national exercise to ensure that the National provision for Continuing Healthcare is appropriate at a national level. Note 6 Better Payment Practice Code The CCG s performance for the payment of valid invoices has improved for Non-NHS and NHS invoices. The impact of Tradeshift (electronic invoicing) has been a key factor to improve the performance of the payment of Non-NHS invoices. The CCG is in the top five CCGs in England for its use of e-invoicing. Note 10 Intangible non-current assets The additional costs in respect of the Care Plan Management System in 2016/17 have been treated as revenue expenditure. The CCG received revenue funding, rather than a capital allocation, from the Estates and Technology Transformation Fund, via NHS England. Therefore, the net book value of this asset as at 31 March 2017 is 2.42m compared to the opening net book value of 3.08m at 1 April 2016, due to the continued amortisation of the asset throughout 2016/17. Note 11 Trade and other receivables The receivables balance is 1,464 higher than at last year-end, largely due to the 1.2m invoice to NHS England for CPMS revenue funding being outstanding at 31 March 2017. Page 35 of 176 6 P a g e

Note 12 Cash and cash equivalents The CCG has managed its cash drawdown effectively by having only a 1,408 cash balance at the year end, after managing 605,612,000 of cash throughout the year (see cash flow statement). Note 13 Trade and other payables Other payables and accruals have increased from the prior year due to the inclusion of accruals for GP Co-Commissioning, which the CCG did not have in 2015/16. Note 14 Provisions/Note 15 Contingencies The provision, created in 2015/16 for NHS Continuing Healthcare (CHC) claims, was reversed unused in 2016/17. For 2016/17, since the backlog of claims has disappeared, a contingent liability only has been disclosed in respect of CHC claims. There remains a possible obligation to pay out further claims but payment is not probable and the amount cannot be measured reliably. Note 20 Related party transactions The CCG is reporting an increased number of related party transactions compared to the previous year. In addition to the required declarations for all organisations sharing the Department of Health as the parent, the CCG has included all GP practices where the expenditure is over 250k. Due to Delegated Co-Commissioning, almost all GP member practices are above this threshold this year and have therefore been included. The number of declarations of interest has also increased due to Co-Commissioning. SoCTE-Statement of Changes in Taxpayers Equity This in effect states that the taxpayer i.e. central government owes WKCCG 32.1m at the year end and will be utilised as part of the consolidation of central governments accounts. Page 36 of 176 7 P a g e

Appendix A Finance Powers and Duties of the CCG 8 P a g e Page 37 of 176

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External Audit Report 2016/17 NHS West Kent Clinical Commissioning Group 25 May 2017 Page 40 of 176

Content The contacts at KPMG in connection with this report are: Philip Johnstone Director Tel: 020 73112091 Philip.Johnstone@KPMG.co.uk Paul Cuttle Senior Manager Tel: 020 7311 2302 Paul.Cuttle@kpmg.co.uk Page Important notice 3 1. Summary 4 2. Financial Statements Audit 5 3. Value for Money 12 Appendices 16 1 Recommendations raised and followed up 2 Audit Differences 3 Audit Independence 4 Audit Quality Aleksandra Ivockina Assistant Manager Tel: 078 8368 570 Aleksandra.Ivockina@kpmg.co.uk We are committed to providing you with a high quality service. If you have any concerns or are dissatisfied with any part of KPMG s work, in the first instance you should contact Philip Johnstone, the engagement lead to the CCG, who will try to resolve your complaint. If you are dissatisfied with your response please contact the national lead partner for all of KPMG s work under our contract with Public Sector Audit Appointments Limited, Andrew Sayers (on 0207 6948981, or by email to andrew.sayers@kpmg.co.uk). After this, if you are still dissatisfied with how your complaint has been handled you can access PSAA s complaints procedure by emailing generalenquiries@psaa.co.uk, by telephoning 020 7072 7445 or by writing to Public Sector Audit Appointments Limited, 3rd Floor, Local Government House, Smith Square, London, SW1P 3HZ. 2017 KPMG LLP, a UK limited liability partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. Page 41 of 176 2 Document Classification: KPMG Confidential

Important Notice This report is presented under the terms of our PSAA engagement. Circulation of this report is restricted. The content of this report is based solely on the procedures necessary for our audit. This report is addressed to NHS West Kent Clinical Commissioning Group (the CCG) and has been prepared for your use only. We accept no responsibility towards any member of staff acting on their own, or to any third parties. The National Audit Office (NAO) has issued a document entitled Code of Audit Practice (the Code). This summarises where the responsibilities of auditors begin and end and what is expected from the CCG. External auditors do not act as a substitute for the CCG s own responsibility for putting in place proper arrangements to ensure that public business is conducted in accordance with the law and proper standards, and that public money is safeguarded and properly accounted for, and used economically, efficiently and effectively. Basis of preparation: We have prepared this External Audit Report (Report) in accordance with our responsibilities under the National Audit Office Code of Audit Practice (the Code) and the terms of our Public Sector Audit Appointments Ltd (PSAA) engagement. Purpose of this report: This Report is made to the CCG s Audit Committee in order to communicate matters as required by International Audit Standards (ISAs) (UK and Ireland), and other matters coming to our attention during our audit work that we consider might be of interest, and for no other purpose. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone (beyond that which we may have as auditors) for this Report, or for the opinions we have formed in respect of this Report. Limitations on work performed: We have not designed or performed procedures outside those required of us as auditors for the purpose of identifying or communicating any of the matters covered by this Report. The matters reported are based on the knowledge gained as a result of being your auditors. We have not verified the accuracy or completeness of any such information other than in connection with and to the extent required for the purposes of our audit. 2017 KPMG LLP, a UK limited liability partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. Page 42 of 176 3 Document Classification: KPMG Confidential

Section One Summary Financial Statements Audit We intend to issue an unqualified audit opinion on the accounts following the Governing Body adopting them and receipt of the management representations letter. We have completed our audit of the financial statements and formed our regularity opinion on whether, in all material respects, the expenditure and income have been applied to the purposes intended by Parliament and the financial transactions conform to the authorities which govern them. We have also read the content of the Annual Report (including the Remuneration Report) and reviewed the Annual Governance Statement (AGS). Our key findings are: There are no unadjusted audit differences, explained in section 2 and appendix 2. There are two non material AOB mismatches that the CCG agreed that the counterparty position is correct and intended to adjust its position. The CCG was advised it could used an off ledger adjustment column but the final version of the AOB toolkit does not allow it. Had this been known the CCG would have posted the correction in the audit adjustment window but is now unable to make the correction in the ISFE. Therefore there is no impact on our opinion of the financial statements or the consolidation schedules. We have agreed presentational changes to the accounts with Finance, mainly related to compliance with the Department of Health Group Manual for Accounts (GAM) 2016/17. We have read the annual report and have no matters to raise with you. We have reviewed the AGS and have no matters to raise with you. We have no matters to raise with you in relation to the regularity of transactions. Value for Money Based on the findings of our work, we have concluded that the CCG has adequate arrangements to secure economy, efficiency and effectiveness in its use of resources. Other Matters In auditing the accounts of a CCG, auditors have a responsibility to consider whether there is a need to issue a public interest report or whether there are any issues which require referral to the Secretary of State. There were no matters in the public interest that we needed to report or refer to the Secretary of State in 2016/17. We are required to certify that we have completed the audit of the CCG s financial statements in accordance with the requirements of the Code. If there are any circumstances under which we cannot issue a certificate, then we must report this to those charged with governance. There are no issues that would cause us to delay the issue of our certificate of completion of the audit. 2017 KPMG LLP, a UK limited liability partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. Page 43 of 176 4 Document Classification: KPMG Confidential

Section Two Financial Statements Audit We audit your financial statements by undertaking the following tasks: Accounts production stage Work Performed Before During After 1. Business Understanding: review your operations 2. Controls: assess the control framework 3. Prepared by Client Request (PBC): issue our prepared by client request 4. Accounting Standards: agree the impact of any new accounting standards 5. Accounts Production: review the accounts production process 6. Testing: test and confirm material or significant balances and disclosures 7. Representations and opinions: seek and provide representations before issuing our opinions We have completed the first six stages shown above and report our key findings below: 1. Business Understanding 2. Assessment of the control environment In our 2016/17 audit plan we assessed your operations to identify significant issues that might have a financial statements consequence. We confirmed this risk assessment as part of our audit work. We have provided an update on each of the risks identified later in this section. We have assessed the effectiveness of your key financial system controls that prevent and detect material fraud and error. We found that the financial controls on which we seek to place reliance are operating effectively. As part of our external audit work, we have considered the matters set out in ISAE 3402 Assurance Reports on Controls at a Service Organisation relating to the following organisations: NHS Shared Business Services: There are no issues from this work which we wish to raise with you. NHS South East CSU (noting the merger and change of name from 1 April 2017): The opinion was qualified due to two issues (credit note authorisation and VAT returns) but we are satisfied there is no impact on our audit approach. NHS Business Services Authority: There are no issues from this work which we wish to raise with you. NHS Digital: This report contained a qualified opinion. We performed additional substantive testing to give us assurance over this balance (see p.7). Capita PCSE: This report contained an adverse opinion. We performed additional substantive testing to give us assurance over this balance (see p.7). We have reviewed the work undertaken by TIAA, your internal auditors, in accordance with ISA610 and used the findings to inform our planning and audit approach. 2017 KPMG LLP, a UK limited liability partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. Page 44 of 176 5 Document Classification: KPMG Confidential

Section Two Financial Statements Audit 3. Prepared by client request 4. Accounting Standards 5. Accounts Production We produced this document to summarise the working papers and evidence we ask you to collate as part of the preparation of the financial statements. As with previous years we were provided with high quality documentation, which had been prepared by the first day of our site visits at both the interim and final accounts stages. We work with you to understand the changes to accounting standards and other technical issues. For 2016/17 there have not been any significant changes to the GAM, although the presentation of some element of your annual report and accounts have been clarified. We received complete draft accounts by 26 April 2017 in accordance with the Department of Health s deadline. As in previous years, we will debrief with the Finance team to share views on the final accounts audit. Hopefully this will lead to further efficiencies in the 2016/17 audit process. We thank the finance team for their co-operation throughout the visit which allowed the audit to progress and complete within the allocated timeframe. 6. Testing We have summarised the findings from our testing of significant risks and areas of judgement within the financial statements on the following pages. 7. Representations You are required to provide us with representations on specific matters such as your going concern assertion and whether the transactions in the accounts are legal and unaffected by fraud. We provided a draft of this representation letter to the Chief Finance Officer on 19 May 2017. We draw your attention to the requirement in our representation letter for you to confirm to us that you have disclosed all relevant related parties to us. This letter was tabled and agreed at the meeting of the Governing Body on 24 May 2017. We are required under ISA 260 to communicate to you any matters specifically required by other auditing standards to be communicated to those charged with governance; and any other audit matters of governance interest. We have identified the following other matter to report: The responsibility for a large proportion of the processing of payments to primary care providers is provided by two services organisations, NHS Digital and Capita PCSE. This is consistent with other CCGs who have taken on responsibility for delegated primary care commissioning. We received the service auditor reports from NHS Digital and Capita PCSE which contained a qualified opinion and an adverse opinion respectively. The Audit Committee should note the findings in these two reports, to assess whether the CCG has sufficient arrangements at a local level to ensure these payments are calculated and processed correctly. 2017 KPMG LLP, a UK limited liability partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. Page 45 of 176 6 Document Classification: KPMG Confidential

Section Two Financial Statements Audit To ensure that we have provided a comprehensive summary of our work, we have below and over the next two page set out: The results of the procedures we performed over primary care expenditure and the required risks of the fraudulent risk of revenue recognition and management override of control; The results of our procedures to review other areas of focus (Services from Foundation Trusts and other NHS Trusts); and Our view of the level of prudence you have applied to key balances within your financial statements. Significant audit risk PCC Account balances GPMS/APMS and PCTMS expenditure, Non-NHS Accruals, Related Parties Summary of findings We undertook the following audit procedures: 1. The main controls around the process exist at service organisations NHS Digital and Capita PCSE. The NHS Digital ISAE 3402 report contained a qualified opinion and the Capita PCSE report contained an adverse opinion. We have therefore not been able to place reliance on the service entity and instead have completed substantive testing as follows: Sample testing of the primary care balance to invoice or supporting evidence level; We assessed the level of expenditure against the allocated budget from NHSE to assess the completeness of the disclosure; We reviewed whether any payments had been made to practices outside of West Kent; We performed analysis over GMS payments to assess the accuracy of the weighted list size calculation; We reviewed transactions with members of the Governing Body who were also GPs at local practices as part of our work over the related parties disclosure. 2. We reviewed the year-end accrual made in respect of primary care expenditure; and 3. We assessed the governance structures in place over the use of primary care resources through reviewing the minutes of the Primary Care Co-Commissioning Committee, reviewing finance reports presented to the Primary Care Co-Commissioning Committee and reviewing the process for monitoring the primary care budget. We found that the Primary Care Co-Commissioning Committee provided scrutiny and challenge over Primary Care performance on a regular basis, there was engagement from NHS England and financial performance was monitored by the Committee and the Governing Body on a regular basis. We therefore concluded there are appropriate arrangements in place at the CCG for securing value for money in this regard. There are no issues arising from our testing that we wish to draw to our attention. 2017 KPMG LLP, a UK limited liability partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. Page 46 of 176 7 Document Classification: KPMG Confidential

Section Two Financial Statements Audit Risks that ISAs require us to assess in all cases Why Our findings from the audit Fraud risk from revenue recognition Fraud risk from management override of controls Professional standards require us to make a rebuttable presumption that the fraud risk from revenue recognition is a significant risk. Professional standards require us to communicate the fraud risk from management override of controls as significant because management is typically in a unique position to perpetrate fraud because of its ability to manipulate accounting records and prepare fraudulent financial statements by overriding controls that otherwise appear to be operating effectively. We have not identified any specific additional risks of management override relating to this audit. We recognise that the incentives in the NHS differ significantly to those in the private sector which have driven the requirement to make a rebuttable presumption that this is a significant risk. These incentives in the NHS include the requirement to meet regulatory and financial covenants, rather than broader financial reporting or share based management concerns. In our External Audit Plan 2016/17 we reported that we do not consider the fraud risk from revenue recognition to be a significant audit opinion risk for CCGs. As the CCG receives a revenue resource allocation from the Department of Health, and has very little direct income, there is unlikely to be an incentive to fraudulently recognise revenue. This is still the case. Since we have rebutted this presumed risk, there has been no impact on our audit work. Our procedures, including testing of journal entries, accounting estimates and any significant transaction outside the normal course of business, found no instances of fraud. 2017 KPMG LLP, a UK limited liability partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. Page 47 of 176 8 Document Classification: KPMG Confidential

Section Two Financial Statements Audit In our audit plan we also included the following area of focus: Other areas of focus Why Our findings from the audit Services from Foundation Trusts and other NHS Trusts NHS West Kent CCG actual expenditure in 2016/17 on services from Foundation Trusts and other NHS Trusts was approximately 377 million representing approximately 62% of its total expenditure on services. We reviewed the processes and controls in place for the management of the acute contracts and substantively tested a sample of invoices. We specifically considered any contract challenges, disputes or negotiations which could give rise to a difference in balances reported between NHS bodies at year end. We reviewed the NHS balances exercise and checked the reasons for any differences. We also tested any adjustments included in the NHS balances exercise made by the CCG. There are no matters from this work that we need to bring to your attention. 2017 KPMG LLP, a UK limited liability partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. Page 48 of 176 9 Document Classification: KPMG Confidential

Section Two Financial Statements Audit Judgements in your financial statements During the audit we have considered a number of significant judgements and estimates affecting the CCG this year and have summarised our findings below to give the Audit Committee a view as to whether we believe these judgements are reasonable and where within the acceptable range they sit: Level of prudence Audit difference Cautious Balanced Optimistic Audit difference Assessment of subjective areas Asset/liability class Current year Prior year Balance KPMG comment Accruals 18.67 (PY: 19.2m) Acceptable range 6.05m (PY:0.35m) of the accruals balance relates to NHS accruals. 12.62m (PY: 18.85m) of the accruals balance relates to non-nhs accruals. Our testing has not identified any issues to suggest that the accruals balance is unreasonable. 2017 KPMG LLP, a UK limited liability partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. Page 49 of 176 10 Document Classification: KPMG Confidential

Section Two Financial Statements Audit Regularity Opinion We are required to form a view on the regularity of the CCG s income and expenditure i.e. that the expenditure and income included in the CCG s financial statements has been applied to the purposes intended by Parliament and the financial transactions in the financial statements conform to the authorities which govern them. We have reviewed the CCG s expenditure and income and in our opinion, in all material respects, it has been applied to the purposes intended by Parliament and the financial transactions conform to the authorities which govern them. Annual report We have read the contents of the Annual Report (including the Accountability Report, Performance Report and AGS) and audited the relevant parts of the Remuneration Report. Based on the work performed: We have not identified any inconsistencies between the contents of the Accountability and Performance Reports and the financial statements. We have not identified any material inconsistencies between the knowledge acquired during our audit and the Accountable Officer s statements. The Accountable Officer confirms that the annual report and accounts taken as a whole are fair, balanced and understandable. The parts of the Remuneration Report that are required to be audited were all found to be materially accurate; and The AGS is consistent with the financial statements and complies with relevant guidance subject to updates as outlined within section three. Independence and Objectivity ISA 260 also requires us to make an annual declaration that we are in a position of sufficient independence and objectivity to act as your auditors. We have provided this declaration at Appendix 3. Audit Fees Our fee for the audit was 69,525 plus VAT ( 69,525 in 2015/16). This fee was in line with that highlighted within our audit plan agreed by the Audit Committee in January 2017. We have not completed any non-audit work at the CCG during the year. 2017 KPMG LLP, a UK limited liability partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. Page 50 of 176 11 Document Classification: KPMG Confidential

Section Three Value for Money For 2016/17 our value for money (VFM) work follows the NAO s guidance. It is risk based and targets audit effort on the areas of greatest audit risk. Our methodology is summarised below. We identified three significant VFM risks which are reported overleaf. VFM audit risk assessment No further work required Financial statements and other audit work Identification of significant VFM risks (if any) Assessment of work by other review agencies Specific local risk based work Continually re-assess potential VFM risks Conclude on arrangements to secure VFM VFM conclusion AGS review Regulatory review Other matters considered in risk assessment We reviewed the 2016/17 AGS and took into consideration the work of internal audit. We confirm that the AGS reflects our understanding of the CCG s operations and risk management arrangements. We considered the outcomes of relevant regulatory reviews (NHS England, CQC, etc.) in reaching our conclusion. We did not identify any further significant risks to our VFM conclusion as a result of this review. As part of our risk assessment we reviewed various matters, including: forecast financial position. current operational performance and provider relationships. planned v actual outturn. The Board Assurance Framework. Minutes of key Committee meetings, such as the Governing Body and the Primary Care Committee. 2017 KPMG LLP, a UK limited liability partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. Page 51 of 176 12 Document Classification: KPMG Confidential

Section Three Value for Money Value for money risks Below we set out our value for money risks and our audit response and findings. These are not significant risks as defined in ISA (UK and Ireland) 315 but areas of focus that we have considered to our inform our judgement. Value for money risk Why this risk is significant Our audit response and findings Informed decision making We will look for evidence to support our conclusion around: Acting in the public interest, through demonstrating and applying the principles and values of sound governance; Understanding and using appropriate and reliable financial and performance information (including, where relevant, information from regulatory/monitoring bodies) to support informed decision making and performance management; Reliable and timely financial reporting that supports the delivery of strategic priorities; and Managing risks effectively and maintaining a sound system of internal control. The CCG has a well established Governing Body and supporting committee structure that is established through its Constitution. Agendas are minutes are published for each Governing Body and Primary Care Commissioning Committee meeting. Sub-Committee minutes are appended to each set Governing Body papers published. Each Governing Body meeting includes a Chairman and Chief Officer report which summarises the high level issues impacting the CCG. Each meeting includes a Quality and Safety and Performance Report. These set out key provider performance and the key constitutional standards. The CCG has eight strategic goals and the risk to delivery of these is reported to the Board through the Board Assurance Framework. As outlined overleaf, the CCG scored a Green for quality of leadership and fully compliant for probity and corporate governance in the 2016/17 CCG Improvement and Assessment Framework. Furthermore, the CCG s Head of Internal Audit Opinion was that Reasonable Assurance can be given that there is a generally sound system of internal control, designed to meet the organisation s objectives, and that controls are generally being applied consistently. However, some weakness in the design and/or inconsistent application of controls, put the achievement of particular objectives at risk. Through this work, we identified no residual risks that affected our ability to form our VFM conclusion. As a result, we did not consider it necessary to perform further work in this area. 2017 KPMG LLP, a UK limited liability partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. Page 52 of 176 13 Document Classification: KPMG Confidential

Section Three Value for Money Value for money risk Why this risk is significant Our audit response and findings Sustainable resource development Regulator Review The current scrutiny framework from NHSE has been relatively light touch. CCGs have been held to account in regards to their financial position, but generally there has been little intervention in CCGs unless there are breaches of their authorisation. Financial resilience West Kent CCG has achieved its financial target of operating within its resource limit since inception. There are though a number of cost pressures West Kent CCG are experiencing, which were managed in 2016/17 but will continue to put pressure on the CCG in 2017/18. Regulatory Review As at 1 April 2017, the CCG is not subject to any directions from NHS England issued under Section 14Z21 of the National Health Service Act 2006. NHSE have changed the methodology for how they annually monitor CCGs. Under the old regime published in July 2016 the CCG s overall rating was good (one of the two CCGs in Kent to have that score. A new CCG Improvement and Assessment Framework has been subsequently issued. Of particular relevance, at the time of this report, West Kent CCG were rated as requires improvement primarily due to under delivery of key Constitutional Standards by their providers(4 hour A&E Access, 62 day Cancer diagnosis and treatment, Dementia Diagnosis Rate and Direct Access Diagnostics) but in relation to the well led and sustainability criteria: Green for quality of leadership (two of eight Kent CCGs with this score). Fully compliant for probity and corporate governance (six of eight Kent CCGs with this score). Amber for financial plan (one Kent CCG scored green) Amber for in year performance (no green in Kent) Financial resilience In 2016/17, the CCG achieved a financial surplus against its revenue budget of 11.6 million. This includes the 5.6million planned surplus for performance assessment purposes and the 6 million contribution towards national risk reserve. We note the CCG required the deployment of contingency and a range of actions during the year and that 2017/18 will be a challenge with 5m of QIPP currently unidentified but note the continued ability of the CCG to make savings and identify remedial action when required. Through this work, we identified no residual risks that affected our ability to form our VFM conclusion. As a result, we did not consider it necessary to perform further work in this area. 2017 KPMG LLP, a UK limited liability partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. Page 53 of 176 14 Document Classification: KPMG Confidential

Section Three Value for Money Value for money risk Why this risk is significant Our audit response and findings Working with partner and third parties Following the publication of the Five Year Forward View the importance of working effectively with commissioning organisations has increased further. Across Kent and Medway, the health and care system Clinical commissioning groups, providers and local authorities are working together to develop a Kent and Medway sustainability and transformation plan (STP), which will set out how local health and care services will transform and become sustainable over the next five years, building and strengthening local relationships and ultimately delivering the Five Year Forward View vision. We assessed the arrangements in place to assess how the CCG was working in partnership with other STP organisations and how the CCG was able to make informed decisions about its involvement in the STP. There are appropriate mechanisms in place at the CCG level to ensure that the Governing Body is aware of activity at the STP level, and is appropriately informed to make decisions about the CCG s involvement in the STP. There are mechanisms in place to ensure that all parties to the STP are appropriately informed, particularly in regard to budget monitoring and regulatory compliance. While the STP is clearly in its early stages there are already examples of the CCG working together with partners. The CCG and Maidstone and Tunbridge Wells NHS Trust (MTW) have signed a new type of agreement an Aligned Incentive Contract (AIC) which allows for a more collaborative approach in line with STP principles and has a mechanism for parties to work together towards the point where both can succeed in terms of living within available resources. Through this work, we identified no residual risks that affected our ability to form our VFM conclusion. As a result, we did not consider it necessary to perform further work in this area. 2017 KPMG LLP, a UK limited liability partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. Page 54 of 176 15 Document Classification: KPMG Confidential

Appendix 1 Recommendations raised and followed up The recommendations raised as a result of our work in the current year are as follows: Priority one: issues that are fundamental and material to your system of internal control. We believe that these issues might mean that you do not meet a system objective or reduce (mitigate) a risk. Priority rating for recommendations Priority two: issues that have an important effect on internal controls but do not need immediate action. You may still meet a system objective in full or in part or reduce (mitigate) a risk adequately but the weakness remains in the system. Priority three: issues that would, if corrected, improve the internal control in general but are not vital to the overall system. These are generally issues of best practice that we feel would benefit you if you introduced them. # Risk Issue, Impact and Recommendation Management Response / Officer / Due Date 1 Retention of declaration of interest evidence Accepted As part of our testing of related party transactions we requested evidence of The recommendation is accepted. Future quarterly updates of the Corporate declarations for decision making staff as defined by the NHSE Managing Conflicts Register of Interests will require an active return (even if a nil return) from all of Interest in the NHS guidance from February 2017. The CCG was unable to those on the register and all returns, including nil returns, will be filed and provide declarations for 2 individuals. accessible for scrutiny. The CCG has a generally well developed approach to managing conflicts of interest. However going forward, the CCG should ensure it has a robust process in place for monitoring the collection of declarations for decision making staff and storing these in an accessible location especially with the requirements for more regular updates in the future. Richard Segall Jones Company Secretary / Head of Corporate Services 2017 KPMG LLP, a UK limited liability partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. Page 55 of 176 16 Document Classification: KPMG Confidential

Appendix 2 Audit Differences We are required by ISA (UK and Ireland) 260 to communicate to the Audit Committee all unadjusted audit differences (including disclosure misstatements) identified during the course of our audit, other than those that we believe are clearly trivial. As part of our planning process we agreed a definition of trivial with you which reflected balances below 250K. In line with ISA (UK&I) 450 we request that you correct uncorrected misstatements. We are also required to report all adjusted audit differences that management has corrected but that we believe should be communicated to the Audit Committee to assist it in fulfilling its governance responsibilities. We did not identify any unadjusted audit differences that were above this threshold. Under UK auditing standards (ISA UK&I 260) we are required to provide the Audit Committee with a summary of adjusted audit differences (including disclosures) identified during the course of our audit. We did not identify any audit differences over the 250K threshold. 2017 KPMG LLP, a UK limited liability partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. Page 56 of 176 17 Document Classification: KPMG Confidential

Appendix 2 Audit Differences We are required to report any inconsistencies greater than 250,000 between the signed audited accounts and the consolidation data and details of any unadjusted errors or uncertainties in the data provided for intra-group and intra-government balances and transactions regardless of whether a CCG is a sampled or non-sampled component. We have provided details of the inconsistencies that we are reporting to the NAO as follows. Counter party Type of balance/ transaction Balance as per counter party ( 000) Balance as per CCG ( 000) Difference ( 000) Comments on Difference FRJ1-Guy's and St Thomas' NHS Foundation Trust Debtor 490 0 490 The CCG has provided appropriate information to support their balance. No further work required. FRPA-Medway NHS Foundation Trust Creditor 643 151 492 The CCG has provided appropriate information to support their balance. No further work required. FRYD-South East Coast Ambulance Service NHS Foundation Trust FRYY-Kent Community Health NHS Foundation Trust RXY-Kent and Medway NHS and Social Care Partnership Trust RWF-Maidstone and Tunbridge Wells NHS Trust RXY-Kent and Medway NHS and Social Care Partnership Trust RWF-Maidstone and Tunbridge Wells NHS Trust FRJ1-Guy's and St Thomas' NHS Foundation Trust Creditor 758 357 401 The CCG has provided appropriate information to support their balance. No further work required. Creditor 196 484 ( 288) The CCG has provided appropriate information to support their balance. No further work required. Debtor 346 0 346 The CCG has provided appropriate information to support their balance. No further work required. Creditor 15,688 9,103 6,585 The CCG has provided appropriate information to support their balance. No further work required. Expenditure 33,097 34,188 ( 1,091) The CCG has provided appropriate information to support their balance. No further work required. Expenditure 239,245 234,750 4,495 The CCG has provided appropriate information to support their balance. No further work required. Expenditure 12,555 12,156 399 The CCG has provided appropriate information to support their balance. No further work required. FRPA-Medway NHS Foundation Trust Expenditure 6,300 5,902 398 The CCG has provided appropriate information to support their balance. No further work required. 2017 KPMG LLP, a UK limited liability partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. Page 57 of 176 18 Document Classification: KPMG Confidential

Appendix 2 Audit Differences Counter party Type of balance/ transaction Balance as per counter party ( 000) Balance as per CCG ( 000) Difference ( 000) Comments on Difference CBA033-NHS England Expenditure 915 ( 653) 1,568 The total mismatch is 1,568k. The CCG agreed with the counterparty that they needed to amend their position by 1,490k and intended to adjust it. The CCG was advised it could use an off ledger adjustment column but the final version of the AOB toolkit does not allow it. Had this been known the CCG would have posted the correction in the audit adjustment window but is now unable to make the correction in ISFE. NCA-Non-contracted activity (for Agreement of Balances purposes) There is no impact on the financial statements or the accounts template as these reflect the correct position. Expenditure 0 1,104 1,104 The CCG agreed that the counterparty position is correct and intended to adjust its position. The CCG was advised it could used an off ledger adjustment column but the final version of the AOB toolkit does not allow it. Had this been known the CCG would have posted the correction in the audit adjustment window but is now unable to make the correction in ISFE. There is no impact on the financial statements or the accounts template as these reflect the correct position. 2017 KPMG LLP, a UK limited liability partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. Page 58 of 176 19 Document Classification: KPMG Confidential

Appendix 3 Audit Independence The purpose of this Appendix is to communicate all significant facts and matters that bear on KPMG LLP s independence and objectivity and to inform you of the requirements of ISA 260 (UK and Ireland) Communication of Audit Matters to Those Charged with Governance. Integrity, objectivity and independence We are required to communicate to you in writing at least annually all significant facts and matters, including those related to the provision of non-audit services and the safeguards put in place that, in our professional judgement, may reasonably be thought to bear on KPMG LLP s independence and the objectivity of the Engagement Lead and the audit team. We have considered the fees paid to us by the CCG for professional services provided by us during the reporting period. We are satisfied that our general procedures support our independence and objectivity. General procedures to safeguard independence and objectivity KPMG LLP is committed to being and being seen to be independent. As part of our ethics and independence policies, all KPMG LLP Audit Partners and staff annually confirm their compliance with our Ethics and Independence Manual including in particular that they have no prohibited shareholdings. Our Ethics and Independence Manual is fully consistent with the requirements of the Ethical Standards issued by the UK Auditing Practices Board. As a result we have underlying safeguards in place to maintain independence through: Instilling professional values, Communications, Internal accountability, Risk management and Independent reviews. We would be happy to discuss any of these aspects of our procedures in more detail. There are no other matters that, in our professional judgement, bear on our independence which need to be disclosed to the those charged with governance. Audit matters We are required to comply with ISA (UK and Ireland) 260 Communication of Audit Matters to Those Charged with Governance when carrying out the audit of the accounts. ISA 260 requires that we consider the following audit matters and formally communicate them to those charged with governance: Relationships that may bear on the firm s independence and the integrity and objectivity of the audit engagement lead and audit staff. The general approach and overall scope of the audit, including any expected limitations thereon, or any additional requirements. The selection of, or changes in, significant accounting policies and practices that have, or could have, a material effect on the CCG s financial statements. The potential effect on the financial statements of any material risks and exposures, such as pending litigation, that are required to be disclosed in the financial statements. Audit adjustments, whether or not recorded by the entity that have, or could have, a material effect on the CCG s financial statements. 2017 KPMG LLP, a UK limited liability partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. Page 59 of 176 20 Document Classification: KPMG Confidential

Appendix 3 Audit Independence Material uncertainties related to event and conditions that may cast significant doubt on the CCG s ability to continue as a going concern. Disagreements with management about matters that, individually or in aggregate, could be significant to the CCG s financial statements or the auditor s report. These communications include consideration of whether the matter has, or has not, been resolved and the significance of the matter. Expected modifications to the auditor s report. Other matters warranting attention by those charged with governance, such as material weaknesses in internal control, questions regarding management integrity, and fraud involving management. Any other matters agreed upon in the terms of the audit engagement. We continue to discharge these responsibilities through our attendance at Audit Committees, commentary and reporting and, in the case of uncorrected misstatements, through our request for management representations. Auditor Declaration In relation to the audit of the financial statements of the CCG for the financial year ending 31 March 2017, we confirm that there were no relationships between KPMG LLP and the CCG, its directors and senior management and its affiliates that we consider may reasonably be thought to bear on the objectivity and independence of the audit engagement lead and audit staff. We also confirm that we have complied with Ethical Standards in relation to independence and objectivity. Non-audit fees KPMG did not provide any non-audit services in the year to West Kent CCG. We have therefore not identified any threats to our independence which require mitigation through safeguards. 2017 KPMG LLP, a UK limited liability partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. Page 60 of 176 21 Document Classification: KPMG Confidential

Appendix 4 KPMG s Audit quality framework Audit quality is at the core of everything we do at KPMG and we believe that it is not just about reaching the right opinion, but how we reach that opinion. To ensure that every partner and employee concentrates on the fundamental skills and behaviours required to deliver an appropriate and independent opinion, we have developed our global Audit Quality Framework - Comprehensive effective monitoring processes - Proactive identification of emerging risks and opportunities to improve quality and provide insights - Obtain feedback from key stakeholders - Evaluate and appropriately respond to feedback and findings Strategy Commitment to continuous improvement Interim fieldwork Association with the right clients - Select clients within risk tolerance - Manage audit responses to risk - Robust client and engagement acceptance and continuance processes - Client portfolio management - Professional judgement and scepticism - Direction, supervision and review - Ongoing mentoring and on the job coaching - Critical assessment of audit evidence - Appropriately supported and documented conclusions - Relationships built on mutual respect - Insightful, open and honest two way communications - Technical training and support - Accreditation and licensing - Access to specialist networks - Consultation processes - Business understanding and industry knowledge - Capacity to deliver valued insights Debrief Performance of effective and efficient audits Statutory reporting Commitment to technical excellence and quality service delivery Clear standards and robust audit tools Recruitment, development and assignment of appropriately qualified personnel - KPMG Audit and Risk Management Manuals - Audit technology tools, templates and guidance - Independence policies - Recruitment, promotion, retention - Development of core competencies, skills and personal qualities - Recognition and reward for quality work - Capacity and resource management - Assignment of team members and specialists 2017 KPMG LLP, a UK limited liability partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. Page 61 of 176 22 Document Classification: KPMG Confidential

kpmg.com/socialmedia kpmg.com/app 2017 KPMG LLP, a UK limited liability partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. The KPMG name and logo are registered trademarks or trademarks of KPMG International. The information contained herein is of a general nature and is not intended to address the circumstances of any particular individual or entity. Although we endeavor to provide accurate and timely information, there can be no guarantee that such information is accurate as of the date it is received or that it will continue to be accurate in the future. No one should act on such information without appropriate professional advice after a thorough examination of the particular situation. Page 62 of 176 Document Classification: KPMG Confidential

West Kent CCG Equality Delivery System (EDS2) Report 2016/17 Title of Report: West Kent CCG Equality Delivery System Report (EDS2) 2016/17 This paper is for: Information Recommendation: To note - This report provides evidence of WK CCG EDS2 engagement and compliance to WK CCG statutory responsibilities in respect of Equality and Diversity. For further information or for any enquiries relating to this report please contact: Paula Wikins, Chief Nurse, Yasmin Mahmood E&D NELCSU Lead, & Sue Southon WKCCG Governing Body Lay member Date: 27 th June 2017 Reporting Officer: Paula Wilkins, Chief Nurse Agenda Item: 118/17 Lead Director: Paula Wilkins Chief Nurse Version: 1 Report Summary: As a public sector body, NHS West Kent Clinical Commissioning Group (WK CCG) has a statutory requirement to meet the legal duties as required within the Equality Act 2010. The EDS2 is a performance improvement tool that helps NHS organisations, such as WK CCG, to gather evidence to monitor its equality performance against 18 outcomes. The adoption of EDS2 allows WK CCG to deliver against its Public Sector Equality Duty in a planned manner, embedding equality and diversity into its day-to-day practices and sustaining a culture of transparency and continuous improvement. This report provides evidence of WK CCG EDS2 engagement and compliance to WK CCG statutory responsibilities in respect of Equality and Diversity. FOI status: This paper is disclosable under the FOI Act Strategic objectives links: Goal C: Improved health outcomes and reduced health inequalities Page 63 of 176 West Kent CCG Front Sheet

Board Assurance Framework links: Goal F: Robust Governance. Strategic Goal A&C: Failure to make the strategic changes needed to deliver Mapping the Future and the Sustainability and Transformation plan (STP) may result in a local healthcare system that - is unsustainable in the long term - is unable to ensure high quality accessible services for local people - does not deliver improved outcomes and reduced inequalities Goal F: Robust Governance Strategic Goal F: Loss of control of corporate governance could result in the CCG acting ultra-vires and becoming subject to regulatory or legal action, with resultant harm to the CCG s reputation, influence and capability, as well as possible financial harm Strategic Goal Gi): The CCG s failure to deliver the requirements of NHS England (including the quarterly CCG Improvement and Assessment Framework and the terms of the CCG s Authorisation) could result in the CCG losing its freedom to operate independently (or ultimately being de-authorised). Identified risks & risk management actions: Resource implications: Legal implications including equality and diversity assessment Equality and diversity assessment Management of Strategic Gii): If the actions, or perceived actions, of the CCG bring it into disrepute with its stakeholders and local people, the CCG could lose influence; its ability to make strategic change or to operate effectively could be compromised. Failure to comply with Statutory duty Equality Act 2010, Public Sector Equality Duty guidance (2011) and Equality Delivery System (EDS) for the NHS, 2012- National framework to assist the delivery of equality in the NHS. Equality and Diversity impact assessments on all commissioning intentions, and CSU support to Chief Nurse in delivering statutory duties. E& D CCG Working Group. CCG has a statutory duty to publish information to demonstrate their compliance with the Equality Duty, at least annually; and set equality objectives, at least every four years. Has an equality assessment been undertaken? Yes (please append the action plan to this paper) Will be necessary if for either Decision or Approval Not applicable (please indicate which senior manager agreed that an equality assessment was not required) N/A Page 64 of 176 West Kent CCG Front Sheet

Conflicts of Interest Public and Patient Engagement/Impact on patient services To assess its performance against the EDS2 goals, WK CCG held a series of engagement events between August 2016 and March 2017 with staff, service users, members of the public, Patient Participation Groups and Governing Body members. A stakeholder event was held on the 22 March 2017, where evidence gathered from providers and commissioners was discussed and assessed by representatives from Patient Participation Groups. Report history: Appendices Work completed by members of the EDWG includes the CSU Equality & Diversity Lead, the CCG Equality & Diversity Lead (the Acting Chief Nurse) and the CSU Engagement Lead. Other staff also contribute to the EDWG as required, such as HR and commissioning managers. The group feeds back and makes recommendations to the WK CCG Quality Committee. N/A Next steps: WK CCG s E & D Working Group will monitor and review the implementation of the EDS2 on an annual basis and regular progress updates will be provided to the WK CCG Quality Committee Page 65 of 176 West Kent CCG Front Sheet

West Kent CCG Equality Delivery System (EDS2) Report 2016/2017 This document is available in other languages, larger text and alternative formats on request from the organisation s office please see page 2 Patient focussed Providing quality Improving outcomes Page 66 of 176

Contents 1. The Equality Act 2010 page 3 2. The Refreshed Equality Delivery System (EDS2) page 3 3. EDS2 Implementation by West Kent CCG page 4 4. Goals 1 & 2 Stakeholder Engagement and Grading page 5 5. Goal 3 Staff Engagement and Grading page 8 6. Goal 4 Leadership Grading page 9 7. Improvement Plans page 10 8. Equality Objectives 2013-2017 page 11 9. Publishing the EDS2 Results page 12 10. Monitoring and Reviewing the EDS2 page 12 11. Comments and Feedback page 13 Appendix 1: Description of EDS2 Goals and Outcomes page 14 Appendix 2: Current Good Practice page 16 Appendix 3: Improvement Plans page 23 Appendix 4: Feedback from EDS2 workshops page 41 Appendix 5: EDS2 National Reporting Template page 48 Tables: 1. WK CCG s EDS2 Implementation Plan page 4 2. Grades for Goal 1 Outcomes page 5 3. Grades for Goal 2 Outcomes page 5 4. Grades for Goal 3 Outcomes page 6 5. Grades for Goal 4 Outcomes page 7 6. West Kent CCG s Equality Objectives 2013-17 page 8 This report was prepared by the (Equality, Diversity and Inclusion Manager, NHS North and East London Commissioning Support Unit. If you would like more information on this report, please contact the CCG Equality Lead or CSU Lead. Alison Brett Acting Chief Nurse NHS West Kent CCG Wharf House, Medway Wharf Road, Tonbridge, Kent, TN9 1RE Tel: 01732 375212 Email: alison.brett@nhs.net Yasmin Mahmood Equality, Diversity and Inclusion Manager NHS North and East London Commissioning Support Unit 1 Lower Marsh London SE1 7NT Tel: 07812 348197 Email: yasminmahmood@nhs.net 2 Page 67 of 176

1. The Equality Act 2010 As a public sector body, NHS West Kent Clinical Commissioning Group (WK CCG) has a statutory requirement to meet the legal duties as required within the Equality Act 2010. The general duty requires public bodies to show due regard to: Eliminating unlawful discrimination or any other conduct prohibited by or under the Act Advancing equality of opportunity between persons who share a protected characteristic and persons who do not share it. Fostering good relations between people who share a relevant protected characteristic and people who do not share it. There are nine protected characteristics covered by the Equality Act: Age, Disability, Gender re-assignment, Marriage and civil partnership, Pregnancy and maternity, Race including nationality and ethnic origin, Religion or belief, Sex (male/female), Sexual orientation. The specific duties require public bodies to publish relevant, proportionate information showing how they meet the Equality Duty by 31 January each year, and to set specific measurable equality objectives by 6 April every four years starting in 2012. Both general and specific duties are known as the Public Sector Equality Duties (PSED). 2. The Refreshed Equality Delivery System (EDS2) The adoption of EDS2 allows WK CCG to deliver against its Public Sector Equality Duty in a planned manner, embedding equality and diversity into its day-to-day practices and sustaining a culture of transparency and continuous improvement. The EDS2 is a performance improvement tool that helps NHS organisations, such as WK CCG, to gather evidence to monitor its equality performance against 18 outcomes (see Appendix 1 for detail) grouped under 4 goals outlined below: Goal 1: Improved health outcomes Goal 2: Improved patient access Goal 3: Representative and supported workforce Goal 4: Inclusive leadership To assess its performance against these goals, WK CCG held a series of engagement events between August 2016 and March 2017 with staff, service users, members of the public, Patient Participation Groups and Governing Body members. The assessment process for all four goals involved gathering an initial evidence baseline, which was reviewed and graded by different stakeholder groups. Performance was assessed using the grading methodology provided by NHS England where goals and outcomes could be graded as excelling, achieving, developing or undeveloped. The stakeholder engagement and assessment process is described below. Page 68 of 176 3

3. EDS2 Implementation by West Kent CCG The EDS2 Implementation Plan for WK CCG is given in Table 1 below. To guide and support the implementation of the EDS2 and to deliver fairer outcomes for patients, communities and staff, WK CCG has set up an Equality and Diversity Working Group (EDWG). Chaired by the Governing Body Lay Member for Patient and Public Engagement, the group has been meeting bi-monthly to monitor progress on the Equality & Diversity workplan. Members of the EDWG include the CSU Equality & Diversity Lead, the CCG Equality & Diversity Lead (the Acting Chief Nurse) and the CSU Engagement Lead. Other staff also contribute to the EDWG as required, such as HR and commissioning managers. The group feeds back and makes recommendations to the WK CCG Quality Committee. Table 1: West Kent CCG s 2016/17 EDS2 Implementation Plan Action Timescale Development of plan for EDS2 Goals 1-4 Assessment Complete in August 2016 Goal 3 Assessment - internal engagement grading Complete in September 2016 Goal 4 Independent Assessment (outcomes 4.1 and 4.2) Complete in January 2017 Goal 3 improvement plan developed for Goal 3 Complete in December 2016 Goal 4 Recommendations for Governing Body developed Complete in January 2017 Goals 1 & 2 Assessment with Patient and Public Complete in March 2017 representatives Goals 1 & 2 Service Improvement Plans developed with Complete in March 2017 commissioners/providers Approval of EDS2 Report and Reporting Template by the By June 2017 Governing Body WK CCG gathered extensive quantitative and qualitative evidence throughout 2016-2017 to assess its performance against the EDS2. The EDS2 has helped WK CCG to review its current equality performance and identify future priorities and actions, whilst being a vehicle for continuous dialogue with all key stakeholders patients, staff and the public. It has provided a means to illustrate how the organisation fulfils its responsibilities under the Equality Act 2010. 4. Goals 1 & 2 Stakeholder Engagement and Grading To grade Goals 1 & 2, described as Better Health Outcomes and Improved Patient Access and Experience, WK CCG selected and focussed on the following two commissioning priorities: Continence Service IAPT Primary Care Psychological Therapy Services 4 Page 69 of 176

A stakeholder event was held on the 22 March 2017, where evidence gathered from providers and commissioners was discussed and assessed by representatives from Patient Participation Groups. Participants discussed strengths and areas for improvement for both services and finalised grades for both. Grades for Goals 1 and 2 are given in Table 1 and 2 below: Table 2: Grades for Goal 1 outcomes Goal 1: Better Health Outcomes Outcome 1.1 Services are commissioned, procured, designed and delivered to meet the health needs of local communities 1.2 Individual people s health needs are assessed and met in appropriate and effective ways 1.3 Transitions from one service to another, for people on care pathways, are made smoothly with everyone well-informed 1.4 When people use NHS services their safety is prioritised and they are free from mistakes, mistreatment and abuse 1.5 Screening, vaccination and other health promotion services reach and benefit all local communities (N/A) Continence Service (A) (D) (D) (A) N/A IAPT Primary Care Psychological Service (A) (A) (A) (A) N/A Table 3: Grades for Goal 2 outcomes Outcome Continence Service IAPT Primary Care Psychological Services Goal 2: Improved Patient Access & Experience 2.1 People, carers and communities can readily access hospital, community health or primary care services and should not be denied access on unreasonable grounds 2.2 People are informed and supported to be as involved as they wish to be in decisions about their care 2.3 People report positive experiences of the NHS 2.4 People s complaints about services are handled respectfully and efficiently (D) (A) (D) (A) (A) (A) (A) (E) Grading Key: (U) ndeveloped People from all protected groups fare poorly compared with people overall OR evidence unavailable (D) eveloping People from only some protected groups fare as well as people overall. (A) chieving People from most protected groups fare as well as people overall. (E) xcelling People from all protected groups fare as well as people overall. 5 Page 70 of 176

Appendix 2 outlines current good practice as highlighted by the stakeholders during the Goals 1 & 2 assessment exercise. Appendix 3 includes the EDS2 service improvement plans for each of the above commissioning priorities. The plans, which are based on concerns highlighted during the engagement events, will be implemented by the respective commissioning managers in collaboration with providers in 2017-18. 5. Goal 3 Staff Engagement and Grading Goal 3 refers to: A representative and supported workforce and includes outcomes that focus on key areas across the employment practices. Goal 4 described as Inclusive leadership includes one outcome (4.3) that was graded together with goal 3 outcomes in collaboration with staff. Goal 3 outcomes were graded based on evidence gathered from the CCG s staff survey, available policies as well as the metrics of the Workforce Race Equality Standard (a tool consisting of 9 metrics introduced by NHS England in April 2015 to gauge and improve the current state of race equality within NHS organisations). A workshop was held as part of the CCG s staff forum in September 2017, where members discussed their experiences and agreed a grade for Goal 3 and Outcome 4.3. Grades for Goal 3 are given below: Table 4: Grades for Goal 3 outcomes Outcome 3.1 Fair NHS recruitment and selection processes lead to a more representative workforce at all levels. 3.2 The NHS is committed to equal pay for work of equal value and expects employers to use equal pay audits to help fulfil their legal obligations. 3.3. Training and development opportunities are taken up and positively evaluated by all staff. 3.4 When at work, staff are free from abuse, harassment, bullying and violence from any source. 3.5 Flexible working options are available to all staff consistent with the needs of the service and the way people lead their lives. 3.6 Staff report positive experiences of their membership of the workforce. Grade in 2015-16 Achieving Developing Achieving Developing Achieving Developing Grades for 2016-17 (D) U A D D A Grading Key: (U) ndeveloped Staff from all protected groups fare poorly compared with their numbers in the local population and/ or the overall workforce OR evidence unavailable. (D) eveloping Staff members from only some protected groups fare well compared with their numbers in the local population and/or the overall workforce. (A) chieving Staff members from most protected groups fare well compared with their numbers in the local population and/or the overall workforce. (E) xcelling Staff members from all protected groups fare well compared with their numbers in the local population and/ or the overall workforce. 6 Page 71 of 176

Appendix 2b outlines current good practice as highlighted by staff during the Goals 3 assessment exercise. Appendix 3b includes the improvement plan for Goal 3. The Company Secretary and Head of Corporate Services will oversee the implementation and will report to the Equality & Diversity Working Group. 6. Goal 4 Inclusive Leadership Goal 4 of the EDS2, also described as Inclusive Leadership, measures the extent to which a CCG s leadership demonstrates sustained commitment to equality and diversity. Goal 4 was assessed using evidence gathered from the CCG s leadership team, a review of 15 board papers across the year, the staff survey and staff workshop. Whilst outcomes 4.1 and 4.2 were independently assessed by Healthwatch Kent, outcome 4.3 was graded together with goal 3 outcomes during the staff engagement workshop. The overall grade for Goal 4 was assessed as ACHIEVING. Table 5 outlines the grades for Goal 4 outcomes. Table 5: Grades for Goal 4 outcomes Outcome 4.1 Boards and senior leaders routinely demonstrate their commitment to promoting equality within and beyond their Organisations 4.2 Papers that come before the Board and other major Committees identify equality-related impacts, including risks and say how these risks are to be managed 4.3 Middle managers and other line managers support their staff to work in culturally competent ways within a work environment free from discrimination. Grades in 2015-16 Developing Developing Developing Grades in 2016-17 (A) (A) (A) Grading Key: (U) ndeveloped 4.1 There are no examples of strong and sustained commitment. 4.2 None of the papers took account of equality-related risks and their management. (D) eveloping 4.1 Only some of the examples show a strong and sustained commitment. 4.2 Only some of the papers took account of equality-related risks and their management. (A) chieving 4.1 Many examples show a strong and sustained commitment. 4.2 Many of the papers took account of equality-related risks and their management. (E) xcelling 4.1 All of the examples show a strong and sustained commitment. 4.3 All papers took account of equalityrelated risks and their management. Appendix 2c outlines current good practice as highlighted by Healthwatch Kent and staff as part of the grading exercise. Appendix 3c includes the improvement plan for Goal 4. 7 Page 72 of 176

The Acting Chief Nurse will oversee the implementation with the support of the Equality & Diversity Working Group (EDWG). The Equality & Diversity Working Group welcomes any feedback on the delivery of the EDS2 and will use it to inform future events. 7. Improvement plans The agreed improvement plans for Goals 1 to 4 can be found in Appendix 3. These plans have been finalised after consultation with the relevant leads (the commissioning managers, the Company Secretary, and the Equality and Diversity Working Group (EDWG). The improvement plans will form part of WK CCG s commissioning and organisational development plans to ensure they are embedded in mainstream business and reviewed annually. The Equality & Diversity Working Group will monitor the implementation of these plans. 8. Equality Objectives 2013-2017 West Kent CCG s Equality Objectives for the period 2013-17 are given below. These objectives will be refreshed for the period 2017-21 by July 2017. The objectives have been mapped on to the EDS2 goals (and their respective action plans) as indicated below. Table 6: WK CCG Equality Objectives 2013-2017 mapped against EDS2 Goals Objective EDS2 Goal 1. Embed equality into operational Goal 1: Better Health Outcomes for All environment 2. Supporting the Development of Staff Goal 3: Representative and Supported Workforce 3. Review and improve information to ensure it is understandable and Goal 2: Improved Patient Access and Experience accessible to all groups 4. Improve access to services Goal 2: Improved Patient Access and Experience 5. Governing Body and Staff Leadership Goal 4: Inclusive Leadership of Equality and Diversity Ethos 6. Commissioning for diversity within West Kent CCG Goal 1: Better Health Outcomes for All Progress against the refreshed objectives will be reported in the Public Sector Equality Duty Report for 2017. Page 73 of 176 8

9. Publishing the EDS2 Results The full and summary version of this report will be published on the CCG s website after approval by the Governing Body in June 2017. 10. Monitoring and Reviewing the EDS2 WK CCG s EDWG will monitor and review the implementation of the EDS2 on an annual basis and regular progress updates will be provided to the WK CCG Quality Committee. The EDS2 framework has helped the CCG meet its public sector equality duty, which was reported in January 2017. 11. Comments and Feedback We welcome comments and feedback on the EDS2 Grades and Improvement Plan Report 2016-17. We would like to know how effective this scheme has been in promoting and delivering equality and welcome suggestions for improvement. Comments and feedback can be sent to the CCG Equality Lead or the CSU Lead (contact details can be found on page 2). Page 74 of 176 9

APPENDIX 1 Description of EDS2 Goals and Outcomes EDS2 Goal No. Outcome 1.1 Services are commissioned, procured, designed and delivered to meet the health needs of local communities 1.2 Individual people's health needs are assessed and met in appropriate and effective ways 1. Better Health Outcomes 1.3 1.4 Transitions from one service to another, for people on care pathways, are made smoothly with everyone well-informed When people use NHS services their safety is prioritised and they are free from mistakes, mistreatment and abuse 1.5 Screening, vaccination and other health promotion services reach and benefit all local communities 2. Improved patient access and experience 2.1 2.2 People, carers and communities can readily access hospital, community health or primary care services and should not be denied access on unreasonable grounds People are informed and supported to be as involved as they wish to be in decisions about their care 2.3 People report positive experiences of the NHS 2.4 People's complaints about services are handled respectfully and efficiently 3. A representative and supported workforce 3.1 Fair NHS recruitment and selection processes lead to a more representative workforce at all levels Page 75 of 176

3.2 The NHS is committed to equal pay for work of equal value and expects employers to use equal pay audits to help fulfil their legal obligations 3.3 Training and development opportunities are taken up and positively evaluated by all staff 3.4 When at work, staff are free from abuse, harassment, bullying and violence from any source 3.5 Flexible working options are available to all staff consistent with the needs of the service and the way people lead their lives 3.6 Staff report positive experiences of their membership of the workforce 4. Inclusive leadership 4.1 4.2 Boards and senior leaders routinely demonstrate their commitment to promoting equality within and beyond their organisations Papers that come before the Board and other major Committees identify equality-related impacts including risks, and say how these risks are to be managed. 4.3 Middle managers and other line managers support their staff to work in culturally competent ways within a work environment free from discrimination. 11 Page 76 of 176

APPENDIX 2 Current Good Practice 2a Current Good Practice on Goals 1 and 2 Primary Care Improving Access to Psychological Therapy Service Outcome 1.1 Services are commissioned, procured, designed and delivered to meet the health needs of local communities 1.2 Individual people's health needs are assessed and met in appropriate and effective ways 1.3 Transitions from one service to another, for people on care pathways, are made smoothly with everyone well-informed 1.4 When people use NHS services their safety is prioritised and they are free from mistakes, mistreatment and abuse 2.1 People, carers and communities can readily access hospital, Good practice identified Service currently meeting & exceeding national targets. Service has inclusive aims and intentions and assessments are thorough and individually tailored. Clear protocols in place for transition out of IAPT. Flexibility of referral at 17+ years of age and meeting national standards on follow-ups on completing sessions. Presence of mental health action groups (MHAG) and other patient groups involved in service design has helped to minimise safety risks. Service currently meeting and exceeding national standards. Page 77 of 176

community health or primary care services and should not be denied access on unreasonable grounds 2.2 People are informed and supported to be as involved as they wish to be in decisions about their care 2.3 People report positive experiences of the NHS 2.4 People's complaints about services are handled respectfully and efficiently This criteria is embedded in all providers individual assessments and follow ups. Friends and Family Test (FFT) scores received from largest providers and patient experience questionnaires and MHAG. Clear and robust complaints handling process in place. Complaints handled quickly and individual issues resolved 13 Page 78 of 176

Continence Service Outcome 1.1 Services are commissioned, procured, designed and delivered to meet the health needs of local communities 1.2 Individual people's health needs are assessed and met in appropriate and effective ways Good practice identified Data reported on KPIs within service specification, including referrals (exceeded targets), clinical assessments within 30 days new patients, waiting times, urgent referrals and complaints resolved. Good patient education and engagement programme in place. Access to specialist health practitioners. Access to translators and interpreters. Access to nursing teams at community clinic. Urgent referrals met within 10 days usually it takes up to 30 days. High uptake of group sessions 1.3 Transitions from one service to another, for people on care pathways, are made smoothly with everyone well-informed Self-management care plans in place. Patients have option to self-referr. Communication between GPs and patients (within 5 days) Patients can access structured group programmes on discharge. 1.4 When people use NHS services their safety is prioritised and they are free from mistakes, mistreatment and abuse Compliance with health and safety legislation. Adherence to risk management protocols, safety checks, infection control and safeguarding. Good support for vulnerable patient and mental capacity. Access to same-sex chaperones and protocols relating to staff presence (such as a female member of staff accompanying a male member of staff). Patient Transport Service (PTS) available for eligible service users. 14 Page 79 of 176

2.1 People, carers and communities can readily access hospital, community health or primary care services and should not be denied access on unreasonable grounds 2.2 People are informed and supported to be as involved as they wish to be in decisions about their care PTS available for eligible patients. Services provided based on evidence of need. All patients have a care plan which identifies strengths and areas of improvement. Patients have access to support networks in the community. Information on services available in accessible formats. Hi-tech interpretation services available. Good satisfaction rates indication of good patient engagement. Access to patient education groups through the voluntary sector. 2.3 People report positive experiences of the NHS 98% patients rated the service good. 90% satisfaction rate achieved by service (over achieving). Nurses (input) to support patients to complete satisfaction surveys aim to achieve 100% satisfaction rates. Friends and Family Tests always available. DNA rate: 10% 2.4 People's complaints about services are handled respectfully and efficiently Two complaints in the last quarter no issues outstanding. 2b Current Good Practice on Goal 3 15 Page 80 of 176

Outcome Good practice identified 3.1 Fair NHS recruitment and selection processes lead to a more representative workforce at all levels Use of NHS Jobs process accessible, efficient and objective. Good rating for West Kent CCG on NHS Jobs. Use of balanced interview panels reduces bias (3 members 2 internal staff and 1 GP lead). 3.2 The NHS is committed to equal pay for work of equal value and expects employers to use equal pay audits to help fulfil their legal obligations Use of Agenda for Change standardised processes for pay and grading. 3.3 Training and development opportunities are taken up and positively evaluated by all staff Budget allocation for learning and development. Promotion of training opportunities internally and some opportunities for secondments and job shadowing. Staff able to attend relevant conferences. Support from leadership to pursue professional qualifications (CPD)/validation of qualification. 3.4 When at work, staff are free from abuse, harassment, bullying and violence from any source Complaints related to bullying and harassment taken seriously by senior managers. Leadership commitment to staff concerns demonstrated by the fact that Accountable 16 Page 81 of 176

Officer attends the staff forum. Training and awareness-raising on conflict management and team building. Organisation willing to act on results of last survey. 3.5 Flexible working options are available to all staff consistent with the needs of the service and the way people lead their lives 3.6 Staff report positive experiences of their membership of the workforce Good access to resources to facilitate flexible working such as laptops, smart phones, remote working facilities. Some managers supportive of flexible working. Friendly environment. Good leadership from Accountable Officer personal commitment demonstrated towards staff, approachable and professional. Access to good technology. Supportive and stable teams Good induction and on-boarding process and monthly staff briefings. Innovation encouraged. 2c Current Good Practice on Goal 4 Outcome Good practice identified 4.1 Boards and senior leaders routinely demonstrate their Excellent examples of leadership commitment to E&D for 2016/17 and plans for 2017/18. 17 Page 82 of 176

commitment to promoting equality within and beyong their organisations 4.2 Papers that come before the Board and other major Committees identify equality-related impacts including risks, and say how these risks are to be managed. Good commitment to equality and diversity demonstrated in a majority of the board papers reviewed. 11 of the 15 papers submitted included an equality analysis. 4.3 Middle managers and other line managers support their staff to work in culturally competent ways within a work environment free from discrimination. Access to mandatory and non-mandatory training to support cultural competency. Equality analysis (and training on it) has helped develop cultural competency. Diverse teams. 18 Page 83 of 176

APPENDIX 3 3a Improvement Plans for EDS2 Goals 1 & 2 *Status for Actions Below Explained: Red - Serious issues Amber Potential issues Green on track Blue accomplished (monitoring in place) EDS Goal Description of issue / area of improvement highlighted Source Mitigation / Reasonable Adjustment to make Responsible Lead /s & Timescale Status*: Red/ Amber/ Green/ Blue 1.1 More data needed with regards to patient satisfaction and usage of service. 1.2 More information needed on attendance of individual and group sessions and subsequent appointments and on effectiveness of service. 1.3 More data needed on effectiveness of treatment 1.3 KPI reporting more robust information on all aspects of service, such as how many selfreferrals take place and followup on telephonic consultations. EDS2 workshop EDS2 workshop EDS2 workshop EDS2 workshop Upon discussions with the provider it was advised that this data is captured within the meridian report. Actions as follows: Check meridian report to ensure data is captured (this is reported Monthly/Quarterly Check on numbers being reported and how reported Check that all KPI s are reported within the performance report Check that follow ups are telephone conversations this is reported already Look into the numbers and how often they are reported As part of Service specification review incorporate outcome measures and review KPI s to ensure they are reflecting what is required to be known Annabel Young 2 weeks Kim Morgan 1 month Kim Morgan & Rachel Parris 1 month Kim Morgan & Rachel Parris 1 month Included within meridian / performance report Check James numbers reporting Service Specification Review Service Specification Review with on Page 84 of 176

EDS Goal Description of issue / area of improvement highlighted Source Mitigation / Reasonable Adjustment to make Responsible Lead /s & Timescale Status*: Red/ Amber/ Green/ Blue 1.4 1.4 Transport links to sites how involved would patients be with their treatment if sites are not accessible by public transport? Access to sites needs to be verified through independent visits to location. 2.1 More information needed on intranet access 2.1 All sites are not easily accessible by public transport. 2.1 More data need on people completing treatment. EDS2 workshop EDS2 workshop EDS2 workshop EDS2 workshop EDS2 workshop Upon discussions with the provider it was advised that the sites are PDA compliant and have been set up based on patient accessibility. Patients are able to choose which clinic location they would like to go to and if they are housebound then home visits are undertaken. Actions as follows: Look into each clinic site to check accessibility by public transport Upon discussions with the provider it was advised that the sites are PDA compliant and have been set up based on patient accessibility. Patients are able to choose which clinic location they would like to go to and if they are housebound then home visits are undertaken. It was also advised that the intranet is a public facing website and is updated on a regular basis weekly/monthly where appropriate. Actions as follows: Look at intranet website to gain a further understanding on what information is out there As above (Look into each clinic site to check accessibility by public transport) Upon discussions with the provider, it was raised that patients complete their treatment in their own times, there is no set completion period, it is condition dependant. Actions as follows: Annabel Young 2 weeks Annabel Young 2 weeks Annabel Young 2 weeks Kim Morgan / Rachel Parris 1 month Review clinic sites locations and accessibility Visit intranet page to gain a further understanding on what is available Review clinic sites locations and accessibility Service Specification Review 20 Page 85 of 176

EDS Goal Description of issue / area of improvement highlighted Source Mitigation / Reasonable Adjustment to make Responsible Lead /s & Timescale Status*: Red/ Amber/ Green/ Blue 2.1 Need data on attendance rates at venues. 2.2 More robust information needed on patient experience and engagement. 2.2 Need statistics from patient surveys. 2.3 Need more nuanced data such as number of patient responses and Friends and Family Test results. EDS2 workshop EDS2 workshop EDS2 workshop EDS2 Workshop As part of Service specification review incorporate outcome measures and review KPI s to ensure they are reflecting what is required to be known Upon discussions with the provider it was advised that this data is captured within the meridian report. Actions as follows: Check meridian report to ensure data is captured (this is reported Monthly/Quarterly Check on numbers being reported and how reported Check that all KPI s are reported within the performance report As part of Service specification review incorporate outcome measures and review KPI s to ensure they are reflecting what is required to be known Actions as follows: As above (2.1) Upon discussions with the provider it was advised that this data is captured, however it was advised that the Friends & Family Test can be inconclusive. Compliments and Complaints are reported monthly within the KCHFT Performance report and the nature is Annabel Young/ Kim Morgan / Rachel Parris 1 month Kim Morgan & Rachel Parris 1 month Annabel Young 2 weeks Kim Morgan & Rachel Parris 1 month Included within meridian / performance report Service Specification Review Service Specification Review Included within meridian / performance report Service Specification Review 2.3 Need more information on how EDS2 Annabel Included within Page 86 of 176 21

EDS Goal Description of issue / area of improvement highlighted Source Mitigation / Reasonable Adjustment to make Responsible Lead /s & Timescale Status*: Red/ Amber/ Green/ Blue many compliments were received. 2.3 Need to assess impact of services on patients 2.4 More information needed on the nature of complaints and whether they were related to any of the protected characteristics. Workshop EDS2 Workshop EDS2 workshop captured. Actions as follows: As above (2.1) As above (2.3) Young 2 weeks Kim Morgan & Rachel Parris 1 month Annabel Young 2 weeks meridian / performance report Service Specification Review Included within meridian / performance report Primary Care IAPT Service EDS Goal 1.1 Description of issue / area of improvement highlighted Raising and monitoring awareness Source EDS2 workshop Mitigation / Reasonable Adjustment to make Promote service widely. Responsibl e Lead /s & Timescale Jacquie Pryke/Lead Provider Monthly Status: Red/ Amber/ Green/ Blue Reported on at monthly provider meeting 22 Page 87 of 176

EDS Goal 1.2 1.3 Description of issue / area of improvement highlighted Locations and venue, desirable to increase variety. Length of waits for onward referrals to secondary care this is an issue for KMPT - psychology step 4 services responsibility not IAPT Source EDS2 workshop EDS2 workshop Mitigation / Reasonable Adjustment to make Identify ways to promote telephonic and web-based services to increase accessibility?? Responsibl e Lead /s & Timescale Jacquie Pryke / Lead provider Monthly Referral management service N/A N/A Status: Red/ Amber/ Green/ Blue Reported on at monthly provider meeting 1.4 Encouraging service user feedback EDS2 workshop 2.1 Locations, desirable to increase variety 2.2 Encouraging feedback 2.3 Friends and Family Trust results from all providers EDS2 workshop EDS2 workshop EDS2 workshop Report data on service user feedback at agreed intervals ( Identify ways to promote telephonic and web-based services to increase accessibility Report service user feedback at agreed intervals (total nos., nos. reporting effectiveness of service, take-up monitored by protected characteristics etc. Report results from Friends and Family Tests at agreed intervals. Lead Providers Quarterly Jacquie Pryke / Lead Providers ongoing Lead Provider Quarterly Lead Provider Reported on at provider meeting Reported on at provider meeting Reported on at provider meeting Reported on at 23 Page 88 of 176

EDS Goal Description of issue / area of improvement highlighted Source Mitigation / Reasonable Adjustment to make Responsibl e Lead /s & Timescale Status: Red/ Amber/ Green/ Blue 2.4 EDS2 workshop Annually provider meeting 24 Page 89 of 176

3b Improvement Plan for EDS2 Goal 3 EDS Goal 3.1 Description of issue / area of improvement highlighted Feedback for unsuccessful candidates. Interview process formulaic and prescriptive - prevents candidates from presenting a range of perspectives. Transferable skills need to be considered. Source EDS2 workshop & WRES Action Plan Mitigation / Reasonable Adjustment to make 2016:Recruitment and selection training for staff undertaking interview panels is proposed, not yet delivered. A recruitment handbook for staff has been completed. Responsibl e Lead /s & Timsecale Company Secretary, to be reviewed in September 2017 Status: Red/ Amber/ Green/ Blue 3.2 Pay and grading clarification needed on how pay rises are agreed pay and grading methodology and benefits offered to all staff. EDS2 Staff workshop Methodology adopted for assessing pay scales Agenda for Change based on job descriptions. 2016:Work continues with human resources and Senior Exec Team to ensure due process observed when evaluating grading of posts. Non-monetary benefits offered to staff (free parking etc) Company Secretary, to be reviewed in September 2017 3.3 Staff need more information on non-mandatory courses. Line managers to be encouraged to allow staff time to complete non-mandatory courses. EDS2 Staff workshop & WRES feedback 2016: All staff had an appraisal and Personal development plan in place. A training needs assessment is proposed following the annual appraisal round due to be completed June 2017. Company Secretary, complete 25 Page 90 of 176

EDS Goal 3.4 3.5 Description of issue / area of improvement highlighted More internal mechanisms to respond to staff concerns. Need for an employee manual, which includes policies and procedures on reporting bullying and harassment. These need to be publicised internally. Training for interview panels people applying for manager positions need to be tested for their skills mix in managing diverse teams. Need to implement and promote a Speak Up Safely campaign. Need for an Employee Assistance Helpline and/or staff champions. Need for guidelines on flexible working and working from home. Need for more break-out area to Source EDS 2 staff workshop and WRES Action Plan Mitigation / Reasonable Adjustment to make 2016: The CCG staff policies and procedures are all available on the intranet. All staff are informed of changes via email. All policies relating to staff are taken to the Staff Forum for comment. Training and development sessions open to all staff are shared via email. Staff Forum set up to initiate staff champions in each department of the CCG. Recruitment and selection training for staff undertaking interview panels is proposed, not yet delivered. A recruitment handbook for staff has been completed. HR advice available readily from the Commissioning Support Unit 2016: Flexible working Policy review completed and Working from Home Policy developed with the Staff forum. Staff forum discuss opportunities for staff break out area Responsibl e Lead /s & Timsecale Company Secretary, complete Company Secretary complete Status: Red/ Amber/ Green/ Blue 26 Page 91 of 176

EDS Goal Description of issue / area of improvement highlighted encourage time-out. Source Mitigation / Reasonable Adjustment to make Responsibl e Lead /s & Timsecale Status: Red/ Amber/ Green/ Blue 3.6 High use of interims leads to loss of organisational memory/knowledge. Greater knowledge sharing within organisation. EDS2 workshop & WRES Action Plan 2016: Training and development results to identify more opportunities available for existing staff to develop (and retain). The CCG seeks to limit the use of interim staff, in certain circumstances this is unavoidable. Interims are required to hand over to existing staff on their departure to reduce the loss of organisational memory. Company Secretary complete 27 Page 92 of 176

3c Improvement Plan for EDS2 Goal 4 EDS Goal Description of issue / area of improvement highlighted Source Mitigation / Reasonable Adjustment to make Responsibl e Lead /s Status: Red/ Amber/ Green/ Blue 4.1 All members need to demonstrate clear examples of their commitment to diversity and inclusion, along with a statement of what change they were able to bring about. EDS2 External Assessme nt Governing Body members to be given examples of how they were able to bring about change or improvement in terms of equality and diversity. EDWG Guidance to be provided in June review in July 2017 4.2 West Kent CCG should aim to ensure all key board papers include an EA right at strategy inception stage EDS2 external assessme nt Checklist to be provided to governance team to ensure EAs have been completed for all key board papers. EDWG Review in July 2017 Key: Complete On Plan In discussion Not begun/at risk 28 Page 93 of 176

Chief Nurse s Quality and Safety Update Title of Report: Chief Nurse s Quality and Safety Update This paper is for: Information Recommendation: For the Governing Body to Note For further information or for any enquiries relating to this report please contact: Paula Wilkins, Chief Nurse Date: 27 th June 2017 Reporting Officer: Paula Wilkins Agenda Item: 119/17 Lead Director: Dr Meriel Wynter Version: 1 Report Summary: This report gives an update on quality and safety of West Kent CCG and provider agencies commissioned for the Governing Body. FOI status: This paper is disclosable under the FOI Act Strategic objectives links: Board Assurance Framework links: Identified risks & risk management actions: Strategic Goal D - Service quality and patient safety Service providers commissioned, and performance managed, to promote and support the highest standards of care, patient safety and patient experience. Strategic Goal D - Failures of clinical governance in the system could lead to: Less safe services; Failure to safeguard vulnerable individuals; or failure to deliver high quality care for patients resulting in poorer health outcomes for local people or actual patient harm. N/A Page 94 of 176 West Kent CCG Front Sheet

Resource implications: Legal implications including equality and diversity assessment Equality and diversity assessment Management of Conflicts of Interest Public and Patient Engagement/Impact on patient services N/A This document has taken into account Equality and Diversity best practice. Has an equality assessment been undertaken? Yes Not applicable For Information Only Conflicts of interest are declared and recorded at the Quality Committee The full quality report includes patient feedback reported by the providers. Report history: Appendices Standing report to Governing Body. N/A Next steps: N/A Page 95 of 176 West Kent CCG Front Sheet

Chief Nurse s Quality and Safety Update June 2017 1 Patient focused Providing quality, improving outcomes Page 96 of 176

Introduction The purpose of this report is to highlight pertinent issues with regards to the quality and safety of commissioned health services. However, it should be noted that a full quality report, reviewed by the quality committee, is presented bi-monthly to the Governing Body. This report will give an update of: Issues that are deemed as Red on the previous full quality report. Any actions to be addressed from the last Governing Body. Any new concerns that need to be brought to the attention of the Governing Body. Paula Wilkins Chief Nurse 2 Page 97 of 176

Maidstone and Tunbridge Wells Hospitals The Trust continues to closely monitor mortality rates through monthly the MTW mortality surveillance group (attended by the CCG Quality Team). A series of additional Serious Incident Panels have been convened to address the backlog of reports submitted for closure. The resulting action plans have been transferred to the Quality Review Group for ongoing monitoring. If the action plan is not progressing the SI will be reopened. SECAmb -South East Coast Ambulance Foundation NHS Trust CQC revisited SECAmb in May 2017, the report for which is awaited. Performance and Quality monitoring of SECAmb continues, a unified recovery plan is in place and monitoring is led by Swale CCG. The WKCCG quality team join a monthly teleconference with all Kent and Medway CCGs to provide feedback and updates on work stream progressions, development and actions taken and for all CCGs across the county to inform Swale CCG of issues within their locality. KMPT Clarity and further information regarding the themes of complaints received by KMPT is being sought and will be included in next month s full report. IC24 Following a meeting between the quality team and IC24 to discuss the reporting of required quality metrics, assurance has been forthcoming regarding the mandatory training for sessional GPs and other workforce data. G4S The quality team continue to work with G4S to support them to provide the required quality metrics, without which assurance is not possible. In response to a series of concerns being raised by patients, commissioners, other CCGs and other providers the quality team are in the process of planning a series of quality assurance visits to build a picture and gain assurance of the quality of the service being experienced by West Kent patients Primary Care Dashboard The primary care dashboard was successfully launched on 1st May as planned. A report on progress will be included in the full quality report. Quality Assurance Processes and Visits A systematic process for the evidence based categorisation of surveillance levels for providers, including primary care, is being developed by the quality team. This will inform the consistent planning of a schedule of visits for routine monitoring or enhanced monitoring. It will describe escalation and de-escalation of any quality concerns. 3 Page 98 of 176

Integrated Performance Report This paper is for: Information Recommendation: The Governing Body is asked to note the content of the report describing the CCG s constitutional and financial performance for May 2017. For further information or for any enquiries relating to this report please contact: Reg Middleton, Chief Finance Officer Date: 27 th June 2017 Reporting Officer: Reg Middleton Agenda Item: 120/17 Lead Director: Reg Middleton Version: 1 Report Summary: This report is provided to inform the Governing Body of current NHS West Kent CCG performance and to give assurance on the actions being taken by the CCG and partners to maintain or improve standards. FOI status: This paper is disclosable under the FOI Act Strategic objectives links: Board Assurance Framework links: Strategic Goal E: Deliver sustainable finances Strategic Goal F: Ensure robust governance Strategic Goal G: Organisational competence Strategic Risk E: Loss of control over provider activity and system finances could result in the CCG being unable to invest in service development and ultimately breaching its statutory duties. Strategic Risk F: Loss of control of corporate governance could result in the CCG acting ultra-vires and becoming subject to regulatory or legal action, with resultant harm to the CCG s reputation, influence and capability, as well as possible financial harm Strategic Risk Gi: The CCG s failure to deliver the April 2017 NHS West Kent CCG Page 99 of 176

requirements of NHS England (including the quarterly CCG Assurance Framework and the terms of the CCG s Authorisation) could result in the CCG losing its freedom to operate independently (or ultimately being de-authorised). Identified risks & risk management actions: Resource implications: Legal implications: Equality and diversity assessment: Management of Conflicts of Interest: Public and Patient Engagement/Impact on patient services: Report history: Appendices: Next steps: Not applicable Within existing resources N/A Has an equality analysis been undertaken? Yes Not applicable - this paper is for information only N/A N/A - Report for information only Monthly report to Governing Body Integrated Performance Report The Governing Body is asked to note the report April 2017 NHS West Kent CCG Page 100 of 176

Integrated Performance Report June 2017 Page 101 of 176 Patient focused, Providing quality, Improving outcomes. Page 1

Table of Contents Page Executive Summary 3 1 Overall Performance Status 4 2 Performance Commentary 5 3 Financial Performance 11 Appendices Appendix A Finance Dashboard 13 Appendix B Performance Charts 14 Appendix C CCG Improvement and Assurance Framework Indicator Set 21 Appendix D Activity against Plan (RTT) 24 Appendix E Activity Analysis Charts 26 Appendix F Quality Premium 32 Glossary 33 Page 102 of 176 Page 2

Executive Summary This report details operational performance for Month One (April) 2017/18 and Finance status as at Month Two (May 2017). Progress against the NHS England identified priority areas for West Kent proved challenging in 2016/17 and this has continued into Month One of 2017/18. The exception to this continues to be Diagnostic waiting times which achieved 99.4% of direct access diagnostic tests within 6 weeks significantly ahead of both national target and average National performance. The development of the new AIC contract with MTW supports a new approach to joint working to tackle both the financial challenge and delivery of core quality targets including key constitutional targets. The CCG is required to achieve an in-year break-even position on the balance of their allocation, excluding the cumulative historic underspend. The CCG forecasts at Month 2 that the planned inyear break-even position will be achieved. The financial plan includes 8m of net risk but it is anticipated that the Local System Envelope Approach review of budget areas will mitigate any risk that becomes realised throughout the year. The monitoring of the 23.49m QIPP programme for 2017/18 will be included in the performance report from next month but was the subject of a separate agenda item at the Finance & Performance Committee on the 21 st June 2017. Reg Middleton Chief Finance Officer NHS West Kent CCG Page 103 of 176 Page 3

1. Overall Performance Status WKCCG performance against key indicators in 2016/17 means that the Annual Assessment (yet to be published) is likely to be requires improvement with 3 out of 4 key constitutional targets not being met by the end of 2016/17 which has continued into April 2017. Financial performance to the end of month 2 indicates that the CCG is on track to achieve its year balance target. The urgent care indicators demonstrated further improvement in April against delayed transfers of care but Ambulance Category A response times continue to underperform and A&E 4 hour achievement fell slightly in April. Elective RTT achievement also continued its downward trend with just 87.3% of patients waiting less than 18 weeks. It should however be noted that the new elective dermatology provider, SCDS, has started to make a significant impact on this service slowing the downward trend. Page 104 of 176 Page 4

2. Performance Commentary Sections 2.1 to 2.4 detail the current performance for the 4 Constitutional standards that also form the gateway for achieving Quality Premium payments. Sections 2.5 to 2.8 give further details on other clinical priority areas that WKCCG are monitored against. Detailed performance charts and other information are shown at Appendix A. The overall Improvement and Assessment Framework is shown in Appendix B and activity graphs detailed in Appendix C. 2.1 Referral to Treatment (RTT) Waiting Times (Definition: Proportion of patients actively waiting 18 weeks or less from referral to commencement of hospital treatment.) The proportion of patients actively waiting less than 18 weeks for acute treatment was 87.3% in April compared to the National achievement of 89.9% and a requirement to achieve 92%. The numbers waiting more than 18 weeks increased in April from 3,340 to 3,518 including 7 reported over 52 week waiters. 32% of >18 week waiters are awaiting Orthopaedic Surgery, 11% Gynaecology treatment and 9% awaiting ENT care. Page 5 Page 105 of 176

2.2 A&E 4 hour Access Target MTW only (Definition: Percentage of patients that are admitted, transferred, or discharged from A&E within 4 hours of arrival) The total number of attendances in April 2017 was 13,543, an increase of 4.5% on the same month last year. There were 3,565 emergency admissions in the month, 12.1% higher than the same month last year. 30.7% of patients that attended a type 1 major A&E department required admission to hospital, which compares to 28.2% for the same month last year. This is slightly higher than the England average for April which was 27.9%. 87.0% of patients were seen within 4 hours in all A&E departments this month. This is below the 95% standard, lower than the national 90.5% achieved in month and lower than 91.6% for the same month last year. MTW has secured 645k capital funding to support A&E in preparing for the additional demands that winter brings. The investment will help MTW change the way patients are assessed so that they can receive the most appropriate medical care as quickly as possible. The scheme enables A&E to stream patients towards primary care based services where appropriate. Page 106 of 176 Page 6

2.3 62 Day Cancer Treatment Target (Definition: People with urgent GP referral having first definitive treatment for cancer within 62 days of referral) 71 out of 96 patients (74%) commencing cancer treatment in April 2017 did so within 62 days of urgent GP referral 11% below the national requirement to achieve 85%. 19 out of 25 breaches(76%) occurred at MTW with a further 2 at Medway FT and the remainder at tertiary sites. The cancer team, along with MTW and the new Kent & Medway Cancer Alliance, are working on a bid for transformation funding (submit by end September 2017) to include plans to improve diagnostic capacity and achievement of 62 day standard. 2.4 Ambulance Waiting Times Page 7 Page 107 of 176

55.4% of Red 1 calls and 50.6% of Red 2 calls for West Kent patients were responded to within 8 minutes by SECAmb in April. Overall for Kent & Medway SECAmb achieved 71.9% Red 1 and 56.8% Red 2 8 minute response rates. SECAmb conveyed 31,342 journeys in April which represents an increase of 1.5% compared to April 2016. Only 6.5% of calls to SECAmb result in closure based on telephone advice only which is the 3 rd lowest rate of telephone closure across all England s ambulance services and significantly lower than the 9.9% National average. In addition, SECAmb has the second highest ambulance dispatch rate not resulting in transportation to A&E 47.5% compared to National average of 37%. 2.5 2 Week Cancer Waits (Definition: 93% of urgent GP cancer referrals requests to be seen within 2 weeks of referral date) Performance fell from 86.3% in March 2017 to 85.1% in April below the national requirement of 93%. There were 185 breaches of the 2 week wait with 89(48.1%) reported Medway FT and 83(44.9%) at MTW. Medway breaches relate mainly to skin cancer referrals and should significantly improve over the first quarter as referrals increase to the new provider (SCDS) which is reporting no breaches. Breaches at MTW are driven by lower GI and Breast cancer screening. Page 8 Page 108 of 176

2.6 Delayed Transfers of Care (Definition: delayed days per occupied bed.) DTOC (Delayed Days per Occupied Bed) 8.5% 8.0% 7.5% 7.0% 6.5% 6.0% 5.5% 5.0% 4.5% 4.0% England MTW On average 41 beds at MTW were occupied in April with patients awaiting transfer/discharge to other services equivalent to 1,218 beddays. 13 beds (430 beddays) were due to patients awaiting nursing home placement; 13 beds (423 beddays) were due to patients awaiting residential or home care packages; 4 beds (129 beddays) were due to patients awaiting non-acute NHS transfers. 2.7 Direct Access Diagnostics (Definition: 99% of GP direct access diagnostic requests to be seen within 6 week of referral) 99.4% of patients waiting for direct access diagnostic tests waited less than 6 weeks in April 2017. This is ahead of the required threshold of 99% and compares favourably to 98.2% achieved nationally. 35 patients waited longer than 6 weeks with 11 waiting for ultrasound, 9 for an MRI, 4 for Urodynamics and 3 for CT. Page 9 Page 109 of 176

2.8 Dementia Diagnosis Rate (DDR) (Definition: Estimated Diagnosis rate for people with dementia Age 65+) Dementia diagnosis data for April 2017 is due to be published in July. Early intelligence of April s performance indicates performance will improve above 60% from the 59.4% recorded in March. Page 110 of 176 Page 10

3. Financial Performance 3.1 Financial Surplus 3.1.1 The cumulative historic underspend carried forward as at 31 March 2017 of 11.57m has been provided to the CCG as an allocation, to be recorded on a specific allocation code for NHS England purposes, and preserved. 3.1.2 Therefore, the CCG is required to achieve an in-year break-even position on the balance of their allocation, excluding the cumulative historic underspend. 3.1.3 It is essential that the CCG does all it can to achieve this position in 2017/18, as in past years. This avoids the additional scrutiny and reputational risk that accompanies failure to achieve the planned position. 3.1.4 The CCG forecasts at Month 2 that the planned in-year break-even position of 625.63m will be achieved. 3.2 Headroom 3.2.1 Consistent with previous years, the CCG is required to plan for investment of 1 percent of their allocation non-recurrently. For 2017/18, no more than 0.5 percent can be committed from the start of the financial year and the remaining 0.5 percent must be held in reserve as a contribution to the risk reserve until its release is authorised. 3.2.2 At M2 West Kent CCG has committed 0.57m of the available 0.5 percent headroom monies towards Primary Care Investments. 3.3 Month 2 Forecast Outturn 3.3.1 The CCG is currently making the following financial assumptions in reporting the Month 2 forecast position as being in line with plan: 2017/18 contract performance is based on M12 2016/17 activity data Contingency funds ( 3.1m) are phased equally throughout the financial year and will be utilised to mitigate any financial performance above plan. Risk reserve headroom monies ring fenced ( 2.77m) Page 11 Page 111 of 176

3.4 2017/18 CCG Financial Risks 3.4.1 The CCG is maintaining the financial risk assumptions at this stage as those submitted in the plan where an initial 21.41m was identified. This was risk adjusted to 11.61m based on a judgement of current year plans and activities that the CCG is progressing with as detailed below. 3.4.2 The above table highlights how the CCG is reporting financial risk to NHS England. At the present time the CCG can only mitigate 3.58m of risk (contingency 3.13m, contract reserves 0.45m). 3.4.3 This leaves a net risk of 8.04m which is rated by NHS England as being Amber as the CCG s plans does not reflect a full mitigation of financial risk issues. NB: Please see Appendix A for the Financial Performance Dashboard Page 112 of 176 Page 12

Appendix A: Finance Dashboard Page 13 Page 113 of 176

Appendix B: Performance Charts A&E Page 14 Page 114 of 176

Cancer 62 Day Pathway Page 15 Page 115 of 176

Dementia Diagnosis Rate (March Data) Across WKCCG there has been a net rise of just 8 (0.2%) 65+ registered dementia sufferers over the last 12 months. The monthly movement in reported 65+ dementia patients per practice shown on the table excludes those that have no change since February 2017. Practice Name Practice Code Dementia Diagnoses (aged 65+) Mar-2017 Dementia Diagnoses (aged 65+) Feb-2017 Movement in March BOROUGH GREEN MEDICAL PRACTICE G82120 105 100 5 ALBION PLACE MEDICAL PRACTICE G82017 68 65 3 WEST MALLING GROUP PRACTICE G82135 85 83 2 EDENBRIDGE MED PRACTICE G82019 64 63 1 SPELDHURST & GREGGSWOOD MEDICAL GROUP G82022 50 49 1 CLANRICARDE MEDICAL CENTRE G82025 81 80 1 WARDERS MEDICAL CENTRE G82059 138 137 1 MOTE G82076 51 50 1 ST ANDREWS MEDICAL CENTRE G82137 111 110 1 PHOENIX MEDICAL PRACTICE G82234 25 24 1 THE ORCHARD MEDICAL CENTRE G82751 23 22 1 AMHERST MEDICAL PRACTICE G82013 157 158-1 HILDENBOROUGH MEDICAL GROUP G82037 107 108-1 AYLESFORD MEDICAL CENTRE G82058 45 46-1 SNODLAND MEDICAL PRACTICE G82085 80 81-1 ALLINGTON CLINIC G82104 34 35-1 TOWN MEDICAL CENTRE G82110 62 63-1 ST JOHN'S MEDICAL PRACTICE G82205 56 57-1 NORTHUMBERLAND COURT G82604 59 60-1 WALLIS AVENUE G82641 47 48-1 WISH VALLEY SURGERY G82732 34 35-1 LONSDALE MEDICAL CENTRE G82768 61 62-1 SOUTH PARK MEDICAL PRACTICE G82888 35 36-1 TONBRIDGE MEDICAL GROUP G82042 90 92-2 NORTH RIDGE MEDICAL PRACTICE G82055 42 44-2 MARDEN MEDICAL CENTRE G82215 30 32-2 ORCHARD END G82733 27 29-2 COBTREE G82777 16 18-2 LENHAM G82093 79 82-3 THE COLLEGE PRACTICE G82099 148 151-3 WATERFIELD HOUSE SURGERY G82155 132 135-3 LANGLEY G82691 11 14-3 THE VINE MEDICAL CENTRE G82164 139 143-4 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 IAF Profile 61.00% 61.00% 61.00% 62.01% 62.01% 62.01% 63.00% 63.00% 63.00% 63.00% 63.00% 63.00% Actual 60.10% 59.50% 59.90% 59.70% 60.10% 60.30% 60.10% 61.20% 60.70% 60.50% 59.60% 59.40% Page 116 of 176 Page 16

Direct Access Diagnostics (Definition: 99% of GP direct access diagnostic requests to be seen within 6 week of referral) 6 Weeks Compliance and Waiting List Diagnostic Waits <6 Weeks Diagnostic Waiters Diagnostic Waits >6 Weeks Total Diagnosti c Waits 6 Weeks Compliance MRI 1044 9 1053 99.15% CT 645 3 648 99.54% Non Obstetric Ultrasound 1758 11 1769 99.38% Barium Enema 83 0 83 100.00% Dexa Scan 338 2 340 99.41% Audiology Assessments 857 0 857 100.00% Echocardiography 370 2 372 99.46% Electrophysiology 0 0 0 Peripheral Neurophys 108 1 109 99.08% Sleep Studies 43 0 43 100.00% Urodynamics 5 4 9 55.56% Colonoscopy 223 0 223 100.00% Flexi Sigmoidoscopy 101 0 101 100.00% Cystoscopy 91 3 94 96.81% Gastroscopy 281 0 281 100.00% Total 5947 35 5982 99.41% Page 17 Page 117 of 176

Delayed transfers of care N.B. June 2016 data was not submitted by MTW NHS Social Care Both Apr-16 58.1% 41.3% 0.7% May-16 56.1% 43.9% 0.0% Jul-16 48.7% 47.7% 3.6% Aug-16 60.2% 37.2% 2.5% Sep-16 56.6% 42.3% 1.1% Oct-16 55.1% 43.2% 1.7% Nov-16 51.1% 46.0% 2.9% Dec-16 60.0% 37.3% 2.7% Jan-17 60.0% 37.5% 2.5% Feb-17 58.6% 35.8% 5.6% Mar-17 58.8% 39.5% 1.7% Apr-17 62.1% 32.3% 5.6% 5.5% of all occupied bed days at MTW in April 2017 were occupied with patients that would have been better cared for out of hospital. This is 0.8% higher than the England position which was 4.7%. Page 18 Page 118 of 176

Ambulance Waiting Times Page 19 Page 119 of 176

Cancer 2 Week Pathway Breaches by Provider Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 YTD % Change from Apr-16 MAIDSTONE AND TUNBRIDGE WELLS NHS TRUST 81 85 100 72 62 51 59 47 47 46 39 58 83 83 2.5% -26.8% MEDWAY NHS FOUNDATION TRUST 16 21 132 111 108 126 89 28 3 27 48 111 89 89 456.3% -40.8% QUEEN VICTORIA HOSPITAL NHS FOUNDATION TRUST 11 2 1 5 0 1 1 1 5 4 0 2 9 9-18.2% 16.7% EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST 5 1 1 0 1 0 0 0 2 0 0 0 1 1-80.0% -56.3% KING'S COLLEGE HOSPITAL NHS FOUNDATION TRUST 1 0 0 0 1 0 0 2 0 0 1 0 0 0-100.0% 75.0% SUSSEX COMMUNITY DERMATOLOGY SERVICE 0 0 0 0 0 0 0 0 0 0 0 0 11 11 EAST SUSSEX HEALTHCARE NHS TRUST 0 0 0 0 0 1 0 0 0 0 0 1 1 1 133.3% THE ROYAL MARSDEN NHS FOUNDATION TRUST 0 1 0 1 0 0 0 0 0 0 0 0 0 0-100.0% GUY'S AND ST THOMAS' NHS FOUNDATION TRUST 0 0 0 0 0 0 0 1 0 0 0 0 1 1 ROYAL NATIONAL ORTHOPAEDIC HOSPITAL NHS TRUST 0 1 0 0 0 0 0 0 0 0 0 0 0 0-100.0% Total 114 111 234 189 172 179 149 80 57 78 89 172 195 195 71.1% 75.7% 6 Month change Compliance by Provider Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 YTD MAIDSTONE AND TUNBRIDGE WELLS NHS TRUST 91.0% 90.8% 90.4% 92.1% 93.2% 94.4% 93.8% 95.2% 94.9% 94.8% 95.7% 94.7% 91.2% 91.2% 0.2% MEDWAY NHS FOUNDATION TRUST 91.3% 89.0% 48.4% 48.6% 59.4% 42.2% 64.4% 88.1% 98.1% 82.1% 70.4% 24.0% 10.1% 10.1% -88.9% QUEEN VICTORIA HOSPITAL NHS FOUNDATION TRUST 81.0% 97.1% 98.2% 92.2% 100.0% 97.4% 98.1% 97.7% 91.7% 90.0% 100.0% 97.1% 85.2% 85.2% 5.2% EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST 66.7% 83.3% 94.1% 100.0% 90.9% 100.0% 100.0% 100.0% 83.3% 100.0% 100.0% 100.0% 93.8% 93.8% 40.6% KING'S COLLEGE HOSPITAL NHS FOUNDATION TRUST 85.7% 100.0% 100.0% 100.0% 92.9% 100.0% 100.0% 83.3% 100.0% 100.0% 80.0% 100.0% 100.0% 100.0% 16.7% SUSSEX COMMUNITY DERMATOLOGY SERVICE 93.5% 93.5% EAST SUSSEX HEALTHCARE NHS TRUST 100.0% 100.0% 100.0% 100.0% 80.0% 100.0% 100.0% 100.0% 100.0% 100.0% 80.0% 80.0% 80.0% -20.0% THE ROYAL MARSDEN NHS FOUNDATION TRUST 100.0% 50.0% 100.0% 66.7% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 0.0% GUY'S AND ST THOMAS' NHS FOUNDATION TRUST 100.0% 100.0% 100.0% 100.0% 100.0% 50.0% 100.0% 100.0% 100.0% 75.0% 75.0% ROYAL NATIONAL ORTHOPAEDIC HOSPITAL NHS TRUST 50.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% % Change from Apr-16 Trend Page 20 Page 120 of 176

Appendix C: CCG Improvement and Assessment Framework (IAF) The CCG IAF introduced in 2016-17 is composed of 60 indicators aligned to delivery of the Five Year Forward View. The IAF for 17/18 has yet to be published and so the following details the most up to date information available. Baseline assessment of clinical priority areas NHS West Kent CCG Clinical Priority Area Cancer Dementia Diabetes Overall Rating Needs Improvement Needs Improvement Top performing Indicator Ratings 53.0% 80.3% 70.0% 90.0% New of cases of cancer diagnosed at stage 1 and 2 as a proportion of all new cases of cancer diagnosed Of people with an urgent GP referral having first definitive treatment for cancer within 62 days of referral Of adults diagnosed with any type of cancer in a year who are still alive one year after diagnosis. 60.3 % 77.2% Estimated diagnosis rate for people with dementia Of responses,which were positive to the question "Overall, how would you rate your care?" of patients diagnosed with dementia whose care plan has been received a face-to-face review in the preceding 12 months 43.7% 9.9% 37.7% of people with diabetes diagnosed for less than a year who attended a structured education course of diabetes patients have achieved all the NICErecommended treatment targets of GP practices that participated in the National Diabetes Audit Page 21 Page 121 of 176

CCG Improvement and Assessment Framework S England Assessment for 2015-1 99J West Kent Good (2) Area No. Better Health Area Indicator Name Frequency Period Standard Last Data This Data Change 101a Smoking Maternal smoking at delivery Quarterly Q2 2016-17 TBC 10 10.5 102a Child obesity Percentage of children aged 10-11 classified as overweight or obese [Kent] Annual 2015-16 TBC 18.00% 29.60% 103a Diabetes Diabetes patients that have achieved all the NICE-recommended treatment targets: Three (HbA1c, cholesterol and blood pressure) for adults and one (HbA1c) for children Annual 2015/16 TBC 43.70% NA 103b People with diabetes diagnosed less than a year who attend a structured education course Annual 2015/16 TBC 9.90% NA 104a Falls Injuries from falls in people aged 65 and over per 100,000 population Annual 2015/16 TBC 2550 NA 105a Utilisation of the NHS e-referral service to enable choice at first routine elective referral Monthly Sep-16 TBC 28% 30% 105c Personalisation and choice Percentage of deaths which take place in hospital Rolling Annual Q2 2016-17 TBC 42.50% 43.44% 105d People with a long-term condition feeling supported to manage their condition(s) Annual 2015/16 TBC 65.30% 67.60% 107a Anti-microbial resistance: Appropriate prescribing of antibiotics in primary care Rolling Annual Oct-16 1.187 1.118 1.113 107b Anti-microbial resistance Anti-microbial resistance: Appropriate prescribing of broad spectrum antibiotics in primary care Rolling Annual Oct-16 <10 9.6 9.6 108a Carers Quality of life of carers Annual 2014/15 TBC 82.60% 81.80% Page 122 of 176 Page 22

Better Care 122a Cancers diagnosed at early stage Annual 2014 TBC 49.80% 53.00% 122b Cancer People with urgent GP referral having first definitive treatment for cancer within 62 days of referral Quarterly Q2 2016-17 85% 74.69% 80.26% 122c One-year survival from all cancers Annual 2013 TBC 69.20% 70.00% 122d Cancer patient experience Annual 2015 89% 90.00% NA 123a 123b 124b Mental Health Learning disability Improving Access to Psychological Therapies (IAPT) recovery rate People with first episode of psychosis starting treatment with a NICErecommended package of care treated within 2 weeks of referral (Early Intervention in Psychosis (EIP)) Proportion of people with a learning disability on the GP register receiving an annual health check Rolling Quarter Sep-16 50% 55.66% 55.39% Monthly Oct-16 50% 100.00% 100.00% Annual 2015 TBC 40% NA 125a Neonatal mortality and stillbirths Annual 2015 TBC 4.1 NA 125b Maternity Women's experience of maternity services 3 yearly 2015 TBC 83.6 NA 125c Choices in maternity services 3 yearly 2015 TBC 69.1 NA 126a Dementia Estimated diagnosis rate for people with dementia Monthly Mar-17 66.70% 59.60% 59.40% 127c Percentage of patients admitted, transferred or discharged from A&E within 4 hours Monthly Mar-17 95% 85.10% 89.60% Urgent and emergency 127d Ambulance waits (SECAmb Overall) Monthly Mar-17 75% 63.96% 63.85% care 127e Delayed transfers of care per 100,000 population Monthly Mar-17 TBC 1505 1409 128a Primary medical care Management of long term conditions Quarterly Mar-16 TBC 571.6 570.2 129a Elective access Sustainability Patients waiting 18 weeks or less from referral to hospital treatment (Incomplete Pathway) Monthly Mar-17 92% 88.10% 87.50% 141a Financial plan Annual 2016-17 Green Green Green Financial sustainability 141b In-year financial performance Quarterly Q2 2016/17 Amber Amber Amber 163a 163b Leadership Workforce engagement Staff engagement index on a 1 to 5 scale ( 5 good) Progress against workforce race equality standard (higher scores indicate higher differences, 0 indicates equality) Annual 2015 TBC 3.85 NA Annual 2015 TBC 0.3 NA 164a CCGs local relationships Effectiveness of working relationships in the local system Annual 2015 TBC 66% NA 165a Quality of leadership Quality of CCG leadership Quarterly Q2 2016/17 Green Green Green Page 23 Page 123 of 176

Appendix D: Activity against Plan (RTT) (March 2017) Page 124 of 176 Page 24

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Appendix E: MTW Real-time Activity Analysis Charts * Please note that GP referrals include the following specialties in the analysis; Obstetrics, Therapies and Oncology which are excluded on the MAR data. Page 126 of 176 Page 26

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Appendix F: Quality Premium WKCCG 2017/18 Quality Premium Tracker Registered pop: 480,000 No: Indicator Weighting / ( max) Key Metrics Early Cancer Diagnosis 17% Either: 1 ( 408k) 4% improvement of cancers diagnosed at stage 1 or 2 in 2017 calendar year compared to 2016, or (WKCCG Lead: Sally Allen) 60% of all cancers diagnosed at Stage 1 or 2 in 2017 calendar year. GP Access and Experience 17% As measured by the July 2018 publication either: 2 ( 408k) 85% of respondents having a good experience of making an appointment, or (WKCCG Lead: Priscilla Kankam) 3% improvement in reported good experience compared to July 2017 publication. Continuing Healthcare 17% Two part indicator, each worth 50%: 3 ( 408k) 80% of new referrals receive an eligibility decision within 28 days, and 4 5 6 (WKCCG Lead: Alison Brett) <15% of assessments occur in acute hospital setting. Mental Health (WKCCG Lead: Dave Holman) 17% Improve access to ChYPMHS in 17/18 achieving the greater of: ( 408k) =>14% increase in ChYP (0-18) starting treatment in NHS funded community services compared to 16/17, or 32% ChYP starting treatment in NHS funded community services when they need it. Reducing bloodstream infections (BSI) and inappropriate Bloodstream Infections 17% antibiotic prescribing in at risk groups. A three part target including: Reducing BSI across the whole health economy (45%), ( 408k) and Reduction in inappropriate antibiotic prescribing for UTIs in primary care(45%), and (WKCCG Leads: Priscilla Kankam & Sustained reduction in inappropriate prescribing in Alison Brett) primary care (10%). The percentage of COPD patients with a record of a forced Respiratory System 15% expiratory volume test (FEV1) in the preceding 12 months. To achieve 57% of the opportunity identified (10%/17.5% ) i.e., ( 360k) 5,395 COPD patients having a FEV1 recorded as reported by QOF return for 17/18. (WKCCG Lead: Rachel Parris) TOTAL 2,400k Gateway Requirements Current Achieve ment Forecast Achieve ment NHS Constitution Target Threshold Funding risk Value ( '000) RTT - Incomplete 92% Incomplete Standard 25% 600 N Y A&E Waits max: 4 hour wait in A&E (Q4) 25% 600 N Y Cancer waits - 62 days 62 days from urgent GP referral to treatment (Q4) 25% 600 N Y Cat A Red 1 Ambulance Calls Max: 8 minutes for Cat A red1 response (Q4) 25% 600 N Y Total 100% 2400 Total Adjustment based on Achievement -2400 0 Net QP claim 0 2400 Page 132 of 176 Page 32

Glossary Glossary of frequently employed NHS Terms A&E Accident and Emergency MCPs Multispeciality Community Providers BACS Bankers' Automated Clearing Services MRSA Methicillin-resistant Staphylococcus aureus BCF Better Care Fund MSA Mixed Sex Accommodation BPPC Better Payments Practice Code MTW Maidstone and Tunbridge Wells Hospitals NHS Trust C Diff Clostridium difficile NHS TDA NHS Trust Development Agency CCG Clinical Commissioning Group NHSE NHS England (formerly NHS Commissioning Board) Chaps Clearing House Automated Payment System NHSI NHS Improvement CQC Care Quality Commission NR Non Recurrent DTOC Delayed Transfers of Care PACS Primary and Acute Care Systems DDR Dementia Diagnosis Rate PROMs Patient Reported Outcome Measures EIP Early Intervention in Psychosis QIPP Quality, Innovation, Productivity and Prevention EKHUFT East Kent Hospitals University Foundation Trust RA Running Yearly Average EPRR Emergency preparedness, resilience and response RAG Red, Amber, Green 5YFV Five Year Forward View (NHS England strategy) RAP Recovery Action Plan GP General Practitioner RTT Referral to Treatment Guy s Guy's and St Thomas' NHS Foundation Trust RFT Internal NHS BACS payment HSMR Hospital Standardised Mortality Ratio SECAmb South East Coast Ambulance NHS Foundation Trust IAPT Increasing Access to Psychotherapy Treatment SECSU South East Commissioning Support Unit IPR Integrated Performance Report SHMI Summary Hospital-level Mortality Indicator JIB Joint Improvement Board SLAs Service Level Agreements KCHFT Kent Community Health Foundation Trust STP Sustainability and Transformation Plan KIMS Kent Institute of Medicine and Surgery STF Sustainability and Transformation Fund Kings King's College Hospital NHS Foundation Trust SUIs Serious Untoward Incidents KMPT Kent and Medway NHS and Social Care Partnership Trust YTD Year to Date LA Local Authority Page 33 Page 133 of 176

Reporting Committee Groups June 2017 This paper is for: Information Recommendation: To note report and minutes from the Clinical Strategy Group, Finance and Performance Committee and the Primary Care Commissioning Committee. For further information or for any enquiries relating to this report please contact: Dr Sanjay Singh (Chair, Clinical Strategy Group), Reg Middleton, (Chief Finance Officer), or Richard Segall Jones (Company Secretary) Reporting Officers: Dr Sanjay Singh (Chair, Clinical Strategy Group), Reg Middleton, (Chief Finance Officer), or Richard Segall Jones (Company Secretary) Lead Director: As Above Date: 27 th June 2017 Agenda Item: 121/17, 122/17 & 123/17 Version: FINAL Report Summary: This report provides an update to Governing Body on the items discussed at the Clinical Strategy Group, Finance and Performance Committee and the Primary Care Commissioning Committee. FOI status: This paper is disclosable under the FOI Act Strategic objectives links: All strategic objectives are served by the work of the above committees Board Assurance Framework links: Identified risks & risk management actions: Resource implications: Legal implications All BAF components are served by the work of the above committees. N/A N/A N/A NHS West Kent CCG Page 134 of 176

Equality and diversity assessment Management of Conflicts of Interest Has an equality analysis been undertaken? Yes Not applicable reports for information only N/A Public and Patient Engagement/Impact on patient services Report history: Appendices Next steps: N/A Report provided for information only Monthly report to Governing Body Report (and minutes) from the Clinical Strategy Group meeting on 13 th June 2017 (and 16 th May) respectively, report (and minutes) from the Finance and Performance Committee Meeting on 21 st June 2017 (and 17 th May 2017), and a report (and minutes) from the Primary Care Commissioning Committee on 20 th June 2017 (and 4 th April 2017) respectively. N/A NHS West Kent CCG Page 135 of 176

Clinical Strategy Group (CSG) report: June 2017 Dr Sanjay Singh Chief GP Commissioner Page 136 of 176 Patient focused Providing quality, improving outcomes

Dr Sanjay Singh Chief GP Commissioner, West Kent CCG The Clinical Strategy Group (CSG) met on Tuesday 13 th June 2017 and the following items were discussed. Chair s Report STP Listening Event The Chair informed the CSG that the STP listening event would be holding a series of events in July and August, where the CCG would present the local care plan led by the CCG Chair. West Kent CCG Local Care Plan presentation to the Carnall Farrar A meeting between the Governing Body and Carnall Farrar, who are working on the STP local care model, took place after the last Governing meeting in May. The Local Care plan was presented for discussion and there was confidence that both parties plans were aligned. Differences in opinions were further discussed which led to changes in the STP models. Investment case was also discussed at this meeting and it was noted that West Kent CCG was in the process of developing a business case for the investment in local care. West Kent Improvement Board The CSG noted that there was a new board (chaired by Dr Bowes) established comprising of system leaders of the CCG, providers and district councils with the aim of undertaking joint strategic planning and decision making. There are three sub groups of the board i.e. Local Care, Elective Care and Urgent Care. Terms of Reference for the board were being finalized. West Kent Local Care Implementation The Chair reported that the IT element of the local care was being rolled out to improve connectivity in GP practices in order to support the MDT. It was further noted that cluster leadership for local care specification was in progress and the dementia pilot was also progressing. Antibiotics Reduction Challenge Design and Learning Centre for Clinical & Social Innovation The CSG received a briefing paper from the Design and Learning Centre seeking West Kent CCG s active participation in the antibiotics reduction challenge with the Centre linking with the STP and the Kent Health and Wellbeing Board. Clinical Strategy 2 Group Governing Body report - July 2013 Page 137 of 176

The presentation was also an opportunity for West Kent CCG to inform how this should be taken locally and across West Kent and Medway and to gain an understanding of how the Design and Learning Centre can work with the CCG. There were discussions around the threat of antimicrobial resistance and challenges relating to how to reduce antibiotic prescribing by 60% and potential benefits. Potential solutions were also highlighted for discussion and CRP testing carried out in different community sites was the preferred approach. The CSG supported the travel of direction and agreed to explore innovative partnership workings with the Design and Learning Centre. West Kent Mental Health Pathway Redesign to Support Local Care The CSG received a paper for discussion on the proposed pathway mechanisms to allow the growth of mental health provision for the patient within Local care teams ensuring specialist advice is accessible in order to support both routine and more urgent patient care for suffering mental health illness while looked after within primary care. The proposals allowed patients who might have previously required referral to remain within local care and would further allow those already in recovery to access specialist advice as required, enhancing both recovery and preventing unnecessary escalation of care and health needs. CSG advised that the mental health pathway redesign is linked to the mental health STP workstream and members were asked to review the paper and provide feedback. Assurance Reports CSG noted the assurance reports. Clinical Strategy 3 Group Governing Body report - July 2013 Page 138 of 176

Present: DRAFT MINUTES OF THE CLINICAL STRATEGY GROUP (CSG) HELD ON TUESDAY 16 TH MAY 2017 IN THE MEDWAY ROOMS, WHARF HOUSE Approved: Tuesday 13 th June 2017 Dr Sanjay Singh Dr Andrew Cameron Dr Andrew Roxburgh Dr Garry Singh Dr Bob Bowes Dr Mark Whistler Caroline Becher Dr Meriel Wynter Reg Middleton Chair, Chief GP Commissioner & Governing Body Member GP Governing Body Member GP Governing Body Member GP Governing Body Member Chair of the Governing Body Clinical Lead, Urgent Care Independent Nurse, Governing Body Member GP Governing Body Member Chief Finance Officer In attendance: Richard Segall Jones Adam Wickings Kofo Abayomi Paula Wilkings Company Secretary Chief Operating Officer Deputy Company Secretary (Minutes) Chief Nurse Apologies: Dr Stefano Santini Gail Arnold Dr Tim Palmer Nic Goodger Dr Katie Collier GP Governing Body Member Chief Operating Officer (Transformation) GP Governing Body Member Governing Body Member GP Governing Body Member 69/17 Welcomes and introductions The Chair formally welcomed all present to the meeting. 70/17 Apologies for absence Page 139 of 176

Apologies for absence were noted. 71/17 Quorum The Chair noted the meeting was quorate. 72/17 Declaration of Members Interests No additional declarations were received. 73/17 Minutes from the previous meeting held on Tuesday 11 th April 2017 The Minutes of the previous meeting held on Tuesday 11 th April 2017 were APPROVED as an accurate record of the meeting. 74/17 Actions arising from the previous meeting held on Tuesday 11th April 2017 Progress and outcomes of actions arising from the previous meeting held on Tuesday 11 th April 2017 were noted. 75/17 Matters Arising from the meeting held on Tuesday 11 th April 2017 There were no matters arising from the meeting held on Tuesday 11 th April 2017. 76/17 Chair s Report The Chair reported that the core cluster specification was launched in two of the CCG Clusters (Tonbridge and Mallings). It was noted that the launch was successful with positive feedback from the practices, with general acceptance of the MDT process. A trial was carried out prior to the launch to ensure efficiency. Specification and workforce of the new MDT process has been created and work is in progress to determine how to work together as a team around practices and patients. An implementation Group of the CCG and providers/federations was established with the task of standardizing the MDT process. An evidence based standard process has been devised which minimizes GP time spent on MDT. The Chair informed the CSG of outcomes of the Dementia pilot undertaken simultaneously with the core cluster specification, in Mallings Cluster and it was noted that there was a 50% reduction of referrals to secondary care in cases considered during the pilot. The CSG noted that as part of the frailty core service specifications, community nurses would take the lead in the MDT teams whilst GPs will remain the clinical leads. By September 2017 community nurses would be fully trained in detecting and assessing frailty cases and a training programme is being rolled out. Page 140 of 176

The CSG noted the Chair s report. 77/17 Urgent Care Redesign Clinical Model The Chair informed CSG members that this item was withdrawn from the CSG agenda. 78/17 Integrated Diabetes Service Options Appraisal Introducing the agenda item, the Chair informed the CSG that the paper had been withdrawn from the agenda as it had not received final sign off, however an update was requested to be presented by Mr Wickings on progress of the service to date. Whilst a start date for the service could not be confirmed at this meeting, the CSG was assured that there were ongoing discussions and brokering of investments with MTW. The CSG noted that due to the Federation capacity challenges, Mr Wickings had not been able to meet with the federation leadership to discuss and resolve all matters pertaining to the service. A meeting was already scheduled between Mr Wickings and the Federation diabetes lead, but this was not the appropriate forum to raise the said issues. The following issues were raised and discussed by the CSG: Ms Becher enquired whether there was a definite timescale around meeting with senior leadership of the Federation. Mr Wickings responded that he was not in a position to confirm any matter relating to timescales until brokered discussions had commenced. Dr Whistler advised that the capacity challenge faced by the Federation could potentially be a systemic risk and enquired whether there was a need for it to be included on the relevant operational and corporate risk register. In response to this, Mr Wickings highlighted the CCG s continued support to the Federation and assured the CSG that there were plans underway to mitigate the capacity challenge. This matter was being approached from the following perspectives i.e. how can the CCG sufficiently resource the Federation and clarity around what the CCG required from the Federation. Dr Chesover also expressed concern on the issue of capacity and stated that this issue was frequently raised during discussions and it appeared that there was an increasing gap between reality and aspiration of the Federation. Could this impact their ability to deliver? Dr Chesover advised that there was a need to assess the situation analytically. Mr Wickings responded that since this was a resource issue, there was a need to identify priorities as a way forward in order to deliver the national requirement and the STP aspect. RM supported this view, whilst agreeing that the CCG would incur double running cost, however it could be done in a more efficient and smarter way. Page 141 of 176

From a Federation perspective, Dr Roxburgh explained that there were a number of background work and projects in development stages that would start to reflect in due course. Dr Wynter recommended that the Federation leads undergo leadership training similar to the training taken by all Governing Body members. She advised that this training would equip the leads to progress the work of the federation. The Chair concluded that a stricter approach to prioritisation was required and informed the CSG that this was raised at the last Senior Team Meeting (SET). 79/17 Integrated West Kent MSK Service Outline Business Case The paper was presented by Dr Sanjay Singh and Laura Tilley. Ms Tilley tabled a document highlighting proposed change in current secondary care activity and proposed shift of activity in the community (services to be commissioned). Introducing the paper, Dr S Singh provided a background to the MSK service and informed the CSG that this was preceded by the service specification previously presented to the CSG and embedded in the report for reference. It was noted that the current stage was defining the specification within the business case and feedback from stakeholder engagement carried out. It was noted that there had also been clinical support prior to the engagement. Dr S Singh explained that as part of the design, community based service for the CDMU would triage all MSK referrals and carry out some clinical activities in the community. The ambition was to redesign the MSK service for a more qualitative and efficient way outside secondary care. It was noted that the business case defined the CDMU, which would commence with specialist nurse, GYwSI and consultants (details in the service specification). Dr S Singh informed the CSG that the financial details in the paper required further adjustments and members were to bear this in mind during the discussion. The assumptions were based on the shift from secondary care. It was noted that the paper highlighted the ambition to redesign MSK, i.e. significant amount of activities going into secondary care could be done in a qualitative and cost effective way in the community. There had been at least 12 month multi- stakeholder input i.e. CCG, MTW and the federation to develop the service specifications. Furthermore, clinical support had been provided from the specialities. Ms Tilley added that through the MSK pilot, elements of this service were being tested and details of the pilots were highlighted. The following issues were raised and discussed by the CSG: Ms Becher enquired about skilled staff within the community, particularly GPs with Specialist Interests (GPwSI) and enquired what educational training would be provided and how these would be updated. Secondly Ms Becher expressed concern that the CDMU may Page 142 of 176

lack major clinical input and could potentially affect patients when decisions are delayed. Lastly, Ms Becher sought clarity on the issue of education i.e. the educational aspect for primary care on page 87of the report. Dr S Singh addressed the question regarding GPwSI s by stating that there was a formal process for GPwSI accreditation with clinical supervision and appraisal system in place. In regards to the second issue, Dr Singh commented that there was a terms of reference for decision making and there was a two tiered triage system to escalate issues to consultants. Complex cases are referred directly to secondary care. Furthermore complex cases were reviewed periodically. Lastly in the case of educational aspect for primary care, a more formal process is to be set out in a formal contract. Dr Roxburgh referred to QIPP 17/18 (page 92 of the paper) total investment for CDMU 690k, this appeared substantial and sought justification for the amount. Dr Roxburgh also pointed out the disinvestments listed in this section, the range of reductions and a total QIPP highlighted and he sought clarity on the final QIPP. Ms Tilley clarified the position and concluded that the QIPP figure was work in progress and awaiting finalising with the finance team. Dr Roxburgh further enquired whether the back and neck AQP contract would be merged into this service when it came to an end in March 2018. Ms Tilley stated that it was envisaged that primary care physiotherapy assess would not be removed, as it supported the management of MSK in primary care. The CDMU would have access to specialist physiotherapy and utilise the services available. In terms of primary care AQP, there was a need to review the contract with KCHT in terms of access and waiting times. It was concluded that a conscious decision was made to take primary care physiotherapy out of CDMU. Dr Roxburgh highlighted that although savings for 2017/18 had been identified, it appeared there would be costs in other areas. Mr Middleton contributed to this discussion by stating that significant amount of work had been put into the redesign of the service, which was supported by the CCG, Trusts and clinicians and it was believed that this new approach would improve things clinically for patients. In addition there were system financial benefits to be secured through the redesign. Mr Middleton stated that the old proposal was framed under the PbR terms and what was required if supported by CSG, was to use this as a basis for a different proposition i.e. 1) moving away from tariff based to a cost approach the assumptions would have to be tested 2) work was needed on how the switch would be engineered and resourced from an acute to primary care setting (the aligned incentive contract supports this but further negotiations need to take place) 3) once benefits are realised, how would it be assigned to the parties. It was noted that the above required further work, which would be simplified once CCG SET and clinical/trust sign off was obtained. Following from the above discussion, Mr Wickings advised that the business case should be developed using PbR as the starting point and highlight benefits of the alternative approach. Further reflections were highlighted by Mr Middleton as follows: the need to progress this piece of work on a tripartite basis; secondly the risk of clinicians potentially bypassing the system despite mitigations, Mr Middleton s main concern was that of private sector providers, i.e. he was not certain that the CCG could get the same level of engagement and commitment with them. There was a need to address this risk. Dr S Singh commented that it Page 143 of 176

was evident form the service specification that a multipartite arrangement would be put in place in future. The second issue was slightly complicated because choice did not apply to community referrals, however from a CDMU basis, choice would be offered where further interventions are required. Therefore significant engagement was needed with primary care to market this issue successfully. Whilst engagement was needed, referring to CDMU choice did not apply. Legally there was no infringement of patient choice in on this matter. Miss Tilley assured Mr Middleton that a team was dedicated to reviewing the service and rerouting referrals to the single point of access where GPs had bypassed the system, these arose from lessons learnt from the hip and knee pilot. The CSG agreed that the next steps as highlighted in the discussions above would be progressed by the Working Group to be set up by Mr Wickings. The CSG supported the paper and recommended that the Governing Body approve the service subject to further financial adjustments requested by the CSG. 80/17 Medicines Optimisation Group (MOG) The CSG noted the Summary Report & Approved Minutes from the Medicines Optimisation Group. 81/17 Summary Reports from POG Meetings The CSG noted the March summary reports from the POG meetings (Mental Health, Urgent Care, Frailty & Medical Commissioning and Surgical Elective) 82/17 Approved Minutes from POG Meetings The CSG noted the approved Minutes from the POG meetings (Urgent Care, Frailty & Medical Commissioning, Surgical Electives and Children s Service). 83/17 Forward Planner The forward planner is to be confirmed. 84/17 Any Other Business There was no other business. The Chair thanked everyone for their attendance and closed the meeting at 4.00pm. Date of next meeting The next CSG meeting is scheduled for Tuesday 13 th June 2017 at 2.30pm in the Medway Rooms at Wharf House. Page 144 of 176

Finance & Performance Committee (F&P) report: June 2017 Dr Kulvinder (Gary) Singh Chairman F&P Committee Page 145 of 176 Patient focused, providing quality, improving outcomes

Dr Kulvinder (Gary) Singh Chairman of Finance & Performance Committee The Finance & Performance Committee (F&PC) met on Wednesday 21st June 2017 and the following items were discussed. Integrated Performance Report The F&PC received the integrated performance report (IPR) for May 2017 where overall performance of meeting constitutional targets remain challenging; however the committee is encouraged by the progress of the aligned incentive contract with MTW in working together to address the shortfall in performance. The F&PC discussed the following notable developments which are likely to have a direct impact on constitutional targets: 645,000 capital investment in A&E impacting on the A&E access target The Government has made available 26.4 million of additional funding paid directly to Kent County Council (KCC) adult social care (IBCF) over the next three years. This social care grant funding is intended to enable local authorities to quickly provide stability and extra capacity in local care systems. IBCF funding has been discussed locally by all stakeholders at the A&E Local Delivery Board and we currently await formal confirmation of investment to be made in West Kent in 2017/18. In line with the grant conditions KCC have worked with West Kent Clinical Commissioning Group and providers to meet National Condition 4 (Managing Transfers of Care) in the Integration and Better Care Fund Policy Framework and Planning Requirements for 2017-19, with agreement on a local action plan to reduce delayed transfers of care to 3.75% (set by NHS-E) by September 2017. The A&E LDB feel this will be a challenge and West Kent CCG have suggested too NHS-E that a realistic trajectory is 4.9% by September 2017 The committee recognised that diagnostics waiting times was performing significantly ahead of National targets and National average performance. NHS West Kent Clinical Commissioning Group Page 146 of 176 Page 2 of 4

The F&PC were made aware and discussed the technical financial of issue of why the CCG now has a higher total allocation than plan in 2017/18. An extra allocation of 11.7m has been allocated to the CCG which represents the surplus that was achieved in 2016/17. The F&PC recognised that this required careful messaging and handling in the context that at the present time the CCG could not access or utilise this extra allocation. The requirement of the CCG is to achieve in-year operational balance. The F&PC has received the technical note on this subject issued from NHSE to CCGs for information. The IPR remains a key document to provide assurances to the F&PC that the CCG continues to focus on target performance, QIPP delivery and robust financial management for 2017/18. Support Services Procurement (Lead Provider Framework) The F&PC reviewed the key documents supporting recommendations to be made to the June Governing Body (part 2). The approach outlined was supported but the F&PC proposed some additional material could be made available to the Governing Body in the final report. The F&PC recognised that the format of the procurement differed from previous procurement reports to the Governing Body. This was in par a reflection that the process was led by NSHE from a procurement perspective. Quality Innovation Productivity and Prevention update 2017/18 focusing on the Local System Envelope approach The F&PC received an update on the Local System Envelope (LSE) approach building upon the capped expenditure process that had previously been discussed by the Governing Body in May 2017. This is viewed nationally as one of the ways in which the NHS will secure financial sustainability. The F&PC received a presentation and an update with regards to the operational implementation of the process within the CCG. A key critical success factor recognised by the committee in discussions was the need for CCG clinical leadership and endorsement of specific LSE approaches. The F&PC recognised that the LSE approach was one that needs to become business as usual for the CCG and that additional resources were being made available to support this process, which may indicate further opportunities for cost reduction. Whilst this was welcomed, the F&PC continues to urge the management team to maintain focus on the delivery of existing cost reduction schemes. NHS West Kent Clinical Commissioning Group Page 147 of 176 Page 3 of 4

Update on Diagnostic Services current performance and future options to change providers of the service The F&P received a presentation on the current activity, variation in practice activity for diagnostic services. In addition, analysis of benchmarked performance of diagnostic activity was provided against peer CCGs and against the National Average and Right Care benchmarks. It was evident that WKCCG patients were consuming a higher than national average level for diagnostic services and patients were receiving these significantly quicker than the national average waiting time for such services. It was recognised that WKCCG patients accessing the AQP network even with issued guidelines for appropriate referrals was potentially growing unchallenged. The F&PC endorsed the requirement of a firm challenge to those practices that were high referrers for diagnostic services as well as recommending the CCG consider clinical audits and triangulate the detail as to whether increased diagnostics were justified. E.g. referral for subsequent elective activity was successful on the bases of having diagnostic services. The F&PC received a briefing paper on the procurement options open to the CCG as it approaches the end of current AQP diagnostic contract agreements. NHS West Kent Clinical Commissioning Group Page 148 of 176 Page 4 of 4

` MINUTES Of FINANCE and PERFORMANCE COMMITTEE Meeting held on 17 th May 2017 The Medical Centre, 10a Northumberland Court, Shepway, Maidstone, ME15 7LN Date of Approval: 21 st June 2017 Present Job Title Organisation Dr Garry Singh GP Governing Body Member (Chair) WK CCG David Horne Lay Member Finance and Performance WK CCG James Hedges Lay Member Observer WK CCG Dr Steve Johnson GP Member WK CCG Adam Wickings Chief Operating Officer WK CCG Reg Middleton Chief Finance Officer WK CCG In Attendance Job Title Organisation James Gibbons Head of Performance & PMO WK CCG Yin Yau Deputy Chief Finance Officer WK CCG Sally Allen Head of System-wide Commissioning WK CCG Apologies Job Title Organisation Nic Goodger Governing Body Member WK CCG Rebecca Gibson Senior Finance Manager WK CCG 17 th May 2017 NHS West Kent CCG Page 149 of 176 Page 1 of 7

` ITEM NO. DISCUSSION ACTION OWNER 11/17 Welcome, Introductions and apologies The Chair welcomed everyone to the meeting. Apologies were received from Nick Goodger and Rebecca Gibson. 11/i/17 Conflicts of Interest There were no new conflicts of interest. 12/17 Minutes of Previous Meeting The minutes from the meeting of 19 th April 2017 were amended for 2 typographical errors and approved and adopted by the Committee as a formal record. Actions from Last Meeting Updates were received on the status of the following actions taken at the previous meeting. (Ongoing actions show the action owner.) 17.08.1 To send laminated A5 sheet to Practices with short price list of items including MRI and high end blood tests by 21 st June 2017. 21.12.5 Cancer prevalence and practice performance to be presented to F&P Committee in May 2017. 04.17.1 QIPP Review QIPP review actions and updates will be embedded within PMO process. An up to date paper on QIPP review actions will come to the next F&P in June. This will form the QIPP action plan detailing performance and progress since comments received from NHS England, Diagnostics 08.17.1 Clinical Strategy that addresses variation to be developed AW Closed James Gibbons Andrew Roxbourgh 08.17.2 To update the F&P committee regarding activity & referrals and provide progress report for AQP diagnostics direction of travel for 2018/19 agreed for August 2017. It was noted that the June PLT to focus on practice variation in respect of diagnostics (Dr Tony Jones). 17 th May 2017 NHS West Kent CCG Page 150 of 176 Page 2 of 7

` ITEM NO. DISCUSSION ACTION The Committee requested that the action to undertake the referral rate analysis at practice level be completed in time to present at the PLT and back to F&P in June. AW indicated there were discussions with MTW (AG) regarding cancer diagnostics. The Chair indicated that Primary Care can support more direct access for cancer diagnostics and that and redesign should integrate the role that primary care GPs can be involved. The Chair suggested that a key development could be the GPs in primary care being interfaced and integrated with hospital consultants. AW recognised the Chairs point and indicated that MTW has set up internal Trust groups to work together. AW will be reviewing the success of this and only if required will more specific groups be set up to facilitate the appropriate direction of travel which integrates primary care GPs with secondary care consultants. OWNER Matthew Freeman 08.17.3 08.17.4 Produce a plan to determine requirement for a 6 month contract extension. Pathology usage report by practice including variation to be presented to F&P. Matthew Freeman Matthew Freeman 13/17 Matters Arising There were no new matters arising from the previous minutes. 14/17 Integrated Performance Report JG guided the committee through the integrated performance report which detailed performance to the end of March 2017. Generally, WKCCG performance is in line with the trend witnessed in recent months which demonstrated an under performance against the CCG Improvement areas albeit largely in line with national performance. The exception being achievement of the 6 week 17 th May 2017 NHS West Kent CCG Page 151 of 176 Page 3 of 7

` ITEM NO. DISCUSSION ACTION diagnostic target where the CCG outturn performance was significantly ahead of the required threshold. Delivery against key constitutional targets continued to perform below plan but new system wide actions are in place to try an address embedded issues. OWNER 14.7.1 There was a discussion concerning dementia diagnosis where AW commented that although performance did not meet the target plan, the local system had pioneered pilots which was delivering increased dementia diagnosis. In light of this AW is engaging with NHS England to review the dementia diagnosis targets for WKCCG for 2017/18 and to change the trajectory that will reflect the impact of the pilots. The Chair commented why GPs cannot be involved in diagnosing dementia among their own patients that would contribute to the target of increased dementia diagnosis. AW indicated that the approach of the multi-disciplinary team was leading to an increased diagnosis for dementia. AW agreed that the GP Lead (Katie Collier) would liaise with the Chair to provide assurance that increasing dementia diagnosis would be achieved. DH asked the committee to note that within the IPR report that the net increase of 8 patients for dementia diagnosis is one that was needed to be placed in context. AW The Committee discussed the impact of South East Coast Ambulance Foundation Trust activity on the constitutional targets for 2017/18 and RM reported that there were anecdotes that indicated potential improved performance for 2017/18. JH raised the issue of whether the concept of sharing QP for 2017/18 achievement has been discussed with MTW. RM indicated that this had been shared with MTW and that this had not been discounted as an approach from the organisations working together. 15/17 Achieving Financial Resilience RM presented a process paper for discussion on delivering the review of over 200 service lines with a budget value in excess of 200m. RM indicated that the Capped Expenditure Process (CEP) is still work in progress and that the title did not adequately describe the project and would be changed in the near future. 17 th May 2017 NHS West Kent CCG Page 152 of 176 Page 4 of 7

` ITEM NO. DISCUSSION ACTION RM highlighted the rationale and drivers that contribute to the key messages in slides 4 and 5. Value based prioritisation as a concept was discussed by the committee where the Chair and DH shared views in terms of the concept. AW indicated that value based prioritisation also relied on judgement and experience and thereby gave the best opportunity for the CCG to succeed. There is already senior management engagement in the process and RM indicated that the next stage was to gain clinical buy in and support for the CEP. The CEP allows WKCCG to rebalance the health investment portfolio for WKCCG, in a framework that engages appropriate input from Member Practices, Regulators, Clinical Experts, Health Watch, PPG, Health and Well Being Board.etc as described in the slides. RM welcomed further engagement to refine or add to the inputs utilised in the CEP. SJ asked RM to demonstrate where the CEP process can be applied. RM indicated that there was a multitude of health service line investments which includes grants to social care, community services, mental health services that would be subject to the CEP process. JH questioned the resources that would be specifically deployed for the CEP. RM indicated that the CCG needed to prioritise and ensure that day to day operations incorporated the CEP within current workflows. The committee agreed that a key component to the success of the CEP was to maintain pace and transparency. OWNER 15.17.1 15.17.2 RM requested the Chair to consider how the GP membership could be involved in the CEP process. SJ indicated that the CEP process should be shared in a transparent fashion with the membership. The chair was reassured about this process and commended RM for developing the process to date and suggested that this should be taken forward to the May Governing Body (part 2) for discussion. RM agreed to circulate the current working papers for the CEP in respect of the 250 health investment lines that could potentially be reviewed. GS RM 17 th May 2017 NHS West Kent CCG Page 153 of 176 Page 5 of 7

` ITEM NO. DISCUSSION ACTION 16/17 Update On Cancer Services (deferred from April Meeting) OWNER Direct Access SA outlined that NICE guidance 2015, NG 12 indicated that certain direct access tests are to be required to be delivered within 2 weeks. The outcome of the tests would then determine if the patient followed an early cancer care pathway. The issue remained that MTW could only provide direct access tests on a current timeframe of 6 weeks. This means that GPs could not gate keep the early cancer pathway choice made at 2 weeks following the results of direct access diagnostic tests but need to make that decision without the knowledge of diagnostic test results. MTW are deploying colorectal triage in the absence of being able to deliver direct access to colonoscopy. Stage 1 and Stage 2 diagnosis recording of diagnosis. The Chair enquired about clarity for stage 1 and stage 2 with SA. SA indicated that the recording of stage 1 and 2 data is undertaken at consultant level within the acute trusts. For WKCCG there is growth of around 3% to 4% in diagnosis rate and that the Quality Premium linked payment is likely to be achieved by WKCCG in 17/18 based on trend in improvement. However, the data has a long time lag and the latest data available is June 2015 which indicates stage 1 and 2 is at 55% (initial baseline assessment was 53%). Clinical Network for cancer for the South East GP cancer training CPN is to be funded by the SE Clinical Network for a session in September. SA outlined other support packages including Macmillan training for practices nurses. The CRUK also has a local facilitator in place to offer support with training/audit targeted at 5 practices with the highest 2 WW breaches. 17/17 Quality Premium Action Plans JG provided an overview of the action plans. There still remains an issue with baseline data due to the time lag of having up to date data to measure the change in rate which will confirm whether the QP has been met. The chair asked questions around the continuing care QP and received clarification from the RM, JG and YY with regards to the component parts of 17 th May 2017 NHS West Kent CCG Page 154 of 176 Page 6 of 7

` ITEM NO. DISCUSSION ACTION the continuing care QP. OWNER 17.17.1 18/17 The committee reflected upon the constitutional gateway impact that negates the potential QP payments and agreed to receive future risk reports that informs QP achievement and constitutional gateway negation. Update on Support Services Procurement (LPF) JG 18.17.1 RM gave a brief update on progress and indicated that a formal paper will come to the next F&P committee which will subsequently go to the June governing body. RM 19/17 Any Other business There was no other business and the chair thanked committee members for their time. Date of next meeting: 3pm, 21 st June 2017, The Medical Centre, 10a Northumberland Court, Shepway, Maidstone, ME15 7LN 17 th May 2017 NHS West Kent CCG Page 155 of 176 Page 7 of 7