Annual Report and Accounts 2017/18 This is the 2017/18 Annual Report and Accounts for NHS Nottingham City Clinical Commissioning Group. It includes information about the organisation and its activities during 2017/18. This document can be made available in large print and in other languages on request to: Corporate Development Directorate NHS Nottingham City Clinical Commissioning Group 1 Standard Court Park Row Nottingham NG1 6GN Telephone: 0115 9123384 Email: [email protected]Website: www.nottinghamcity.nhs.uk
Transcript
Annual Report and Accounts 2017/18
This is the 2017/18 Annual Report and Accounts for NHS Nottingham City Clinical Commissioning Group. It includes information about the organisation and its activities during 2017/18.
This document can be made available in large print and in other languages on request to:
Corporate Development Directorate NHS Nottingham City Clinical Commissioning Group 1 Standard Court Park Row Nottingham NG1 6GN
About us .................................................................................................................................................. 3
Our Vision and Values ............................................................................................................................. 5
Our Principal Risks ................................................................................................................................... 8
Members Report ................................................................................................................................... 34
Our Governing Body .............................................................................................................................. 35
The Audit Committee ............................................................................................................................ 36
Member Profiles .................................................................................................................................... 36
Transparency and Probity ..................................................................................................................... 36
Personal Data Related Incidents ........................................................................................................... 37
Statement of Disclosure to Auditors ..................................................................................................... 37
Modern Slavery Act ............................................................................................................................... 37
Statement of Accountable Officer’s Responsibilities ............................................................................ 37
Statement of comprehensive net expenditure for the year ended 31 March 2018 ............................ 81
Statement of financial position as at 31 March 2018 ........................................................................... 82
Statement of changes in taxpayers’ equity for the year ended 31 March 2018 .................................. 84
Statement of cash flows for the year ended 31 March 2018 ............................................................... 86
Notes to the accounts ........................................................................................................................... 88
Independent Auditor’s Report to the Members of NHS Nottingham City CCG ...................... 127
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Performance Report Performance Overview
Introduction
This section of the report describes who we are, how we are structured and governed, what we do, and how we do it. It outlines some of our key achievements over the past year and highlights some of the main challenges we are facing. It also describes how we are working closely with our health and social care partners to ensure continuous improvements in the quality of services provided for our patients and citizens.
Statement from the Chair
It has been a year of transition for us and this report reflects upon some of our key milestones and achievements in a period when there were significant changes in the local healthcare landscape.
We launched a new CCG strategy in the City for 2017-2020 with a focus on improving healthy life expectancy by addressing life limiting health issues such as cancer, musculoskeletal problems, long-term conditions and mental health.
These four themes represent some of the most significant health challenges for Nottingham City residents, and we have kept these priorities in sharp focus while managing exceptionally difficult financial pressures.
Despite these pressures, we have achieved all our statutory duties and delivered improvements against national priorities such as perinatal mental health and crisis services for children and adults.
At the same time we have continued to invest in primary care services – launching a new out-of-hours GP+ service for patients who struggle to attend appointments during normal hours. We’ve also had positive feedback from the primary care community about the new translation enhanced service we launched in June, which supports practices with large numbers of patients with English as a second language.
These are just are just a handful of the many examples of how we continue to support patients and staff in the here and now – yet alongside all this we have also been taking significant steps towards greater service integration and healthcare transformation with partners in the last 12 months.
This year saw closer alignment with the three south county CCGs really accelerate, and a result we established the Greater Nottingham Clinical Commissioning Partnership with a Joint Commissioning Committee to oversee decisions best taken collectively. Working in partnership with our neighbouring CCGs will help ensure commissioning arrangements and future health services are more joined up and coordinated for local patients. The changes saw Dawn Smith depart her role as Nottingham City CCG’s Chief Officer, and we are extremely grateful to both Dawn and our previous Chief Finance Officer, Louise Bainbridge, for the work they contributed both during this period and in previous years since the formation of the CCG.
In October 2017 we welcomed Samantha Walters to the role of Accountable Officer for the four aligned CCGs and later welcomed Jonathan Bemrose as Chief Finance Officer. Sam and Jonathan have made an invaluable contribution to the achievements in this report, and I’m very much looking forward to working with our newly-formed management structure to ensure that the people of Nottingham and Nottinghamshire continue to receive effective, safe and joined up health and care services.
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Statement from the Accountable Officer
I am delighted to present the Annual Report and Accounts 2017/18 for NHS Nottingham City Clinical Commissioning Group (CCG).
This is my first report for Nottingham City CCG following my appointment as Accountable Officer for the four Greater Nottingham CCGs: NHS Nottingham City CCG, NHS Nottingham North and East CCG, NHS Nottingham West CCG and NHS Rushcliffe CCG in October 2017. It is a tremendous privilege to serve in this capacity and I intend to build on the excellent collaborative working within Greater Nottingham, always with patients at the centre of everything we do.
The last 12 months have been characterised by intense preparation to ensure we are well placed to meet the significant challenges within the health and care system. The last year has been one of the most challenging for the NHS, in Nottinghamshire and nationally. The financial pressures we face are unprecedented, and are driven by continued growth and demand on hospital, and continuing healthcare services. Despite these challenges, the CCG met all of its financial duties and we will continue to work on achieving further efficiencies.
During 2017/18, the CCG continued to perform well, meeting or exceeding all the national targets for dementia diagnosis and the 18 weeks referral to treatment target. Our performance against cancer targets has improved. This includes targets being met for the number of patients with suspected cancer being seen by a consultant within 14 days and receiving their first treatment within 31 days following diagnosis. However, performance against ambulance response times and waits in A&E continued to be below target.
The journey towards an Integrated Care System (ICS) has been a key driver this year in making significant changes to our governance arrangements. The Governing Bodies of the four Greater Nottingham CCGs have agreed to establish a joint commissioning committee with delegated responsibilities for those work programmes and decisions which are best taken at Greater Nottingham level. The Greater Nottingham Joint Commissioning Committee will be operational from April 2018.
Nottingham and Nottinghamshire are already among the leading areas in the country in terms of working together to provide better quality of care by joining up GP, community, mental health, hospital and social care services. However, in order to deliver sustainable high-quality care to the populations we serve we need to look beyond our own organisational boundaries to ensure we get the best value from sharing resources. This year, we began the process with our staff to align the four CCGs in Greater Nottingham and form a single management structure.
I would like to thank our CCG staff during this transitional period for their professionalism and commitment. I would also like to thank our member practices and partners for their ongoing dedication and commitment; and our patients and communities who give their free time to help us develop our services.
Samantha Walters Accountable Officer
Dr Hugh Porter Chair
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About us
Clinical commissioning groups (CCGs) were created following the Health and Social Care Act in 2012, and replaced primary care trusts on 1 April 2013. Reporting to NHS England, we are a membership organisation, comprised of local GP practices, and accountable to local people. We maintain our authorisation by demonstrating to NHS England how we are meeting our responsibilities through a detailed assurance process.
We work from Standard Court on Park Row in Nottingham City centre. However, the provider organisations delivering the services we commission operate from numerous locations around the City, including GP practices, health centres, community venues, hospitals and in people’s own homes.
We commission (plan and buy) healthcare services that meet the needs of local people. To do this well, we have to understand what health problems affect people living in Nottingham City, and commission services that will deliver the most benefit to these people. We are also responsible for making certain that the healthcare provided is of a high standard, delivers quality improvements and offers value for money, and that systems are in place to make sure people are looked after in the best way possible.
The level of funding we receive from NHS England is set by the Government through a comprehensive spending review process. This takes into account all the funding available for allocation across the public sector. A formula is then applied to adjust funding accordingly with the age, gender and health needs of the local population.
Although our GP member practices provide patient care within their practices, as a commissioner we do not directly provide any healthcare or treatment ourselves.
Our GP practice members
As at 31 March 2018, NHS Nottingham City CCG has 54 member practices. Our practices are organised into four groups known as ‘GP Clusters’, which are based partly on geographical location and partly on pre-existing relationships between practices with similar interests and approaches. The Clusters provide a framework through which we engage member practices in developing and delivering the CCG’s commissioning strategy and priorities, and to channel the knowledge and experience of member practices into related service redesign and quality improvement.
The four GP Leads from each Cluster are members of the CCG’s Governing Body, and representatives from the CCG’s senior management team attend Cluster Board meetings as required.
Our Governing Body
The Chair of the CCG and Clinical Leader is Dr Hugh Porter and since 1 October 2017, our Accountable Officer is Samantha Walters. Samantha has a joint appointment as Accountable Officer for the four CCGs in Greater Nottingham: NHS Nottingham City CCG; NHS Nottingham North and East CCG; NHS Nottingham West CCG and NHS Rushcliffe CCG. Dawn Smith held the role of Accountable Officer from 1 April to 30 September 2017. Three further GPs – Dr Marcus Bicknell, Dr Margaret Abbott and Dr Arun Tangri – sit on our Governing Body to ensure clinical leadership and representation from each of the four GP Clusters. The Governing Body also includes the Chief Finance Officer, the Corporate Medical Lead, an independent secondary care doctor, an independent nurse, independent lay members, and expert advisory members.
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We also have four Associate Lay Members to provide increased independent membership to Committees of the Governing Body.
A full membership list and information on any registered interests are provided in the Members Report section of this report.
Our structure
We are a dynamic, clinically-led membership organisation with a proven governance structure to ensure the effective delivery of our vision and strategy. Through these arrangements we can ensure clear accountability against each of our strategic priorities, and against our overarching strategy.
At the end of 2017/18 we employed 151 staff within the CCG. The CCG staffing structure is divided into a number of directorates that have responsibilities in the areas of: commissioning, finance, quality and governance. Clinical expertise to commissioning activities is provided from eight GP Leads and a Practice Nurse Lead, who each have a defined remit in line with the CCG’s strategic priority areas.
During 2017/18, there has been a significant staffing reorganisation that has seen staff from across the four Greater Nottingham CCGs coming together to work as part of an aligned staffing structure.
In accordance with the size of the local population, our CCG is of sufficient scale to employ most key functions in-house. However, the CCG has a contractual arrangement with Arden and Greater East Midlands Commissioning Support Unit to provide a number of specialist services. During 2017/18, these services included:
• HR Recruitment (People and Change) services
• Technical procurement and supplies
• Contract management and support for some specific contracts
• Clinical procurement
• Service redesign
The CCG commissions IT provision and technical support through the Nottinghamshire Health Informatics Service, hosted by Sherwood Forest Hospitals NHS Foundation Trust. We also commission support for the continuing healthcare assessment process through Nottingham CityCare Partnership.
Our principal providers
We commission healthcare from a number of providers. Our main acute (secondary care) provider is Nottingham University Hospitals NHS Trust, which accounts for 80 per cent of all our hospital admissions.
For mental health and learning disabilities, our key provider is Nottinghamshire Healthcare NHS Foundation Trust. Nottingham CityCare Partnership provides a range of nursing and healthcare services, including community nursing and home-based rehabilitation services for older people, the NHS Urgent Care Centre, and specialist diabetes services.
We also commission services from NHS organisations outside of our area and from independent and voluntary organisations, for example Nottingham Woodthorpe Hospital, BMI The Park Hospital, Age UK and Self-Help Nottingham.
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Our partners
We know that making a difference to the health and wellbeing of local people cannot be done in isolation, and we recognise that working with other organisations can bring opportunities to do things better, on a larger scale, and more efficiently. We continue to build on our well-established networks and relationships with partners, in particular Nottingham City Council (including public health and social care) whose geographical boundaries match our own and we are active members of the Nottingham City Health and Wellbeing Board.
We are also members of a number of other key partnerships and you can read more about these in the Governance Statement within this report.
Our local population
We serve the 379,277 people who are registered with our member practices. We also ensure access to emergency care for anyone who lives in or visits the City, regardless of where they usually live or which GP practice (if any) they are registered with.
The population of Nottingham City continues to increase, owing largely to an increase in the number of students, the natural increase in the population (the excess of births over deaths), and people moving here from overseas, particularly from Eastern Europe. Nottingham is home to significantly more young people than the England average, due largely to the presence of the two universities. Full-time university students account for approximately one in eight of the population.
Although Nottingham City has a relatively young population, adults in the City are more likely to live in ill health than elsewhere. Levels of deprivation, smoking prevalence and hospital stays for alcohol related harm are significantly higher than the England average.
Our Vision and Values
Our CCG vision statement defines our purpose and what we aim to achieve for the benefit of local people and local healthcare services. It was developed in conjunction with GPs, staff, patients and partners and underpins everything that we do. It encapsulates our long-term vision and aspirations for future local healthcare.
“We will work together with compassion and caring to improve health outcomes and end health inequalities through the provision of high quality, inclusive and value-for-money services that are patient-centred.”
Our vision statement is supported by a set of values that describe the approach we take to all of our commissioning activities. We believe that harnessing a culture that embraces these values, both within our organisation and extending to partners and others who work with us, will stand us in the best possible stead to achieve our ambitions.
Our values also reflect what member GP practices, staff, partners and local people have told us are the aspects most important to them. They will therefore enable us to be an organisation that operates in a way that best meets the expectations of the population we serve. Our values are:
Involving others – We will actively involve patients and the public, carers, community groups, clinicians, and partners in everything that we do
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Being responsive – We will understand and respond fairly to the changing needs of our diverse population
Improving quality – We will continually improve the quality of services through collaborative, innovative and clinically-led commissioning
Promoting education and development – We will support and encourage the education, training and development of the local workforce
Securing value for money – We will secure high quality, cost-effective and integrated services within available resources
Our Strategic Priorities
Our strategic priorities are informed by engagement with patients, carers, partners and local people and by facts and figures about the current state of people’s health in Nottingham City. During the year we have refreshed our strategic priorities to focus on the areas that the CCG, as the local of commissioner of healthcare services, believe we can have the greatest impact on the health and wellbeing of Nottingham City residents. Our strategic priorities are as follows:
Priority Area Description
1a. Mental Health - Adults
‘Mental Health’ relates to a person’s emotional, psychological wellbeing. Our mental health affects how we think, feel and behave, and influences how we handle stress, relate to others and the choices that we make. Mental ill health is very common and affects people of all ages, with one in every four people experiencing related problems at some point during their lives. Diagnosing and treating mental illness at an early stage can reduce its impact dramatically.
1b. Mental Health - Children and Young People
It is estimated that around one in ten children and young people aged 5-16 years have a clinically diagnosable mental health problem. However, seven in ten of these do not receive appropriate interventions at a sufficiently early age. It is also known that around half of all lifelong mental health problems start before a child reaches their fourteenth birthday.
2. Cancer Cancer is a term for a number of related diseases. There are more than 100 types of cancer and it can start anywhere in the human body. In all cases, abnormal cells divide without control and can invade nearby tissues. Cancer cells can also spread to other parts of the body through the blood and lymph systems. Some cancers are preventable, as they are influenced by lifestyle choices such as smoking, poor diet or exposure to the sun without protection. Not surprisingly, people living with cancer can experience psychological stress, such as anxiety or depression.
3. Long Term Conditions A long-term condition cannot be cured, but can be managed by medication and other therapies. Examples are diabetes, heart disease and chronic obstructive pulmonary disease (COPD). Long-term conditions last a year or longer and can affect the quality of a person’s life. They may require ongoing care and support, and can lead to psychological problems. People with these conditions can be supported to lead a healthier and longer life by undertaking activities to manage their condition effectively. There are clear links between long-term conditions, deprivation and lifestyle factors. Many conditions are preventable through encouraging people to make informed lifestyle choices, such as eating healthily or not smoking.
4. Musculoskeletal Problems
Musculoskeletal (MSK) disorders affect your muscles, bones or joints and include conditions such as osteoarthritis, tendonitis or fibromyalgia. Problems cause various symptoms such as recurrent pain, swelling or joint stiffness, and can greatly affect the quality of someone’s life. MSK disorders are common with the risk of developing conditions increasing with age. Choices in lifestyle, occupation, activity levels and family history also influence the likelihood of developing a MSK condition.
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In order to maximise the impact we make within these four strategic priority areas, we have identified two further key enablers, where it is essential that we make progress:
Key Enabler Description
1. Primary Care Primary care is the first point of contact for most people when they need healthcare services. GPs (family doctors) are the main provider of primary care services, alongside community nurses, pharmacists, opticians and dentists. Primary care clinicians may refer a patient to a specialist for assessment or treatment. Our CCG is responsible for managing contracts with GPs and NHS England commissions all other primary care services.
2. Social value and cultural competence
When commissioning the services we are responsible for, we can also have a positive impact on wider social, economic and environmental aspects that benefit the local community. The extra benefit we create is known as ‘social value’. Before starting any procurement process, as commissioners we are encouraged to think about the services we need to buy, or the way we will buy them, to help secure benefits for the local area and the people we serve. There is also a recognised need to improve communications and engagement with local people so that we target and tailor information and education people to manage their own health better. We are also committed to improving the cultural competency of our staff, clinicians and services.
Delivering these priorities will enable us to make stepped improvements in the quality of local services, and will ensure that we are making ever-better use of limited resources across the local health and social care economy. You can read more about the progress we’ve made in relation to our strategic priorities in the Performance Analysis section of this report.
The full document ‘Our Strategic Priorities 2017-2020’ can be found at www.nottinghamcity.nhs.uk.
Our Performance
Through the mechanisms detailed in the Performance Analysis section of this report, we have maintained a robust and consistent focus on our performance during the year. We have continued to achieve many national and local performance targets, including referral to treatment waiting times, diagnostic test waiting times and dementia diagnosis rates. We have also seen improvements in critical areas such cancer waiting times and Early Intervention in Psychosis (EIP). Work will continue into 2018/19 to ensure that the improvements are embedded and sustained. However, 2017/18 has been a challenging year for us in terms of delivering against national urgent and emergency care targets (although improvements have been made) and we have not met the standards relating to Accident and Emergency waiting times and ambulance response times throughout the year. Key actions to improve Accident and Emergency waiting time performance are focussing on streaming at the front door of the Emergency Department, integration of urgent care systems, patient flow, and discharge to assess arrangements. A great deal of focus has been placed on this area, and improvements are starting to be seen as a result of the actions delivered in 2017/18, although this has been hindered by a very difficult winter. Key actions to improve ambulance response times are focussing on addressing increased demand, reducing ambulance handover delays and improving resource availability, along with improving the quality of services.
We are working closely with partners across the health and social care community to improve performance in these areas through implementation of robust recovery plans. Improving performance against these standards will continue to be a focus for the coming year.
The CCG has a responsibility to manage our finances carefully to make sure we are able to deliver our everyday commitments, as well as to invest in securing the delivery of continuous improvements in the
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quality of services provided for our patients and citizens. Many factors can influence how much we have to spend, for example, the national economy, a major incident, unexpected increased demand for local health services, or projects taking longer than planned. It is therefore important that we have contingency plans in place to ensure that we can flex our finances accordingly.
The CCG achieved all of its statutory financial duties for the 2017/18 year, delivering its agreed surplus whilst remaining within revenue and cash limits.
You can read more about our financial performance in the Performance Analysis section of this report. For full details of our accounts please see the Annual Accounts section of this report.
The Performance Analysis section of this report also provides further information on the CCG’s performance in relation to equality and diversity and sustainable development.
Our Principal Risks
We have a clear and integrated approach to risk management, combined with defined ownership of risk at all levels within the organisation. Identifying and assessing risks at both strategic and organisational levels is a well-embedded process within the CCG.
Our Integrated Risk Management Framework clearly sets out how the organisation will identify, manage and monitor its strategic and organisational risks in a consistent, systematic and co-ordinated manner. Organisational risks arising from our day-to-day activities are monitored through the Organisational Risk Register and strategic risks are monitored through our Governing Body Assurance Framework.
The main risks identified by the CCG and monitored through the Organisational Risk Register during 2017/18 related to local authority disinvestments that may have an impact on demand for health services, the pace of delivery against partnership transformation plans across the Greater Nottingham health and social care system, and the number of GP Practices in Nottingham City who received an inadequate rating from the Care Quality Commission.
For more information on how we manage risk within the CCG, see the Governance Statement contained within this report.
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Performance Analysis Introduction
This section of the report describes our performance measures in more detail, explains how our performance is monitored (both internally and externally) and shows the extent to which we have met our targets and delivered against our priorities during 2017/18.
Monitoring Performance
We are required to report on some key national health targets and performance standards, many of which are drawn from the NHS Constitution, or are derived from national priorities. We also monitor ourselves against local targets that we have established to improve the quality of services and health outcomes for our population. These are delivered through the service contracts we hold with local health organisations providing NHS services. We meet regularly with our providers to review the achievement of national and jointly agreed local measures to help ensure services perform well and meet the health needs of our patients and citizens. Since August 2016, an Accident and Emergency Local Delivery Board has been in place with responsibility for oversight of the urgent and emergency care pathway, with a clear aim of improving performance against the national Accident and Emergency waiting time standard. The Board has been established in line with national guidance and its membership includes senior leaders from across the health and social care community. The Board is chaired by the Chief Executive of Nottingham University Hospitals NHS Trust.
Responsibility for performance management across the CCG ultimately sits with our Governing Body, and as such, performance against key NHS Constitution Standards is reviewed on a monthly basis. Similarly, financial performance and delivery of the CCG’s QIPP Programme is also reviewed monthly. The Governing Body has delegated certain aspects of its performance management responsibilities to its Audit, Risk and Performance, and Quality Improvement Committees. Further information on the role of each of these committees and highlights of their work over the year can be found in the Governance Statement contained within this report.
NHS England has a statutory duty to conduct performance assessments of CCGs to assess their capability, ensure that they are complying with statutory responsibilities and are also performing in a way that is delivering improvements to patients. For 2017/18, this duty has been enacted through the CCG Improvement and Assessment Framework (available at www.england.nhs.uk) and involves a robust and continuous process, using information derived from a variety of sources. As part of this process, NHS England monitors us against a range of indicators across the following four domains:
Domain Summary description of indicators
Better Health Indicators within this domain look at how the CCG is contributing towards improving the health and wellbeing of its population, and bending the demand curve.
Better Care Indicators within this domain focus on care redesign, performance of constitutional standards, and outcomes, including in important clinical areas.
Sustainability Indicators within this domain look at in-year financial performance and being paper-free at the point of care Leadership Indicators within this domain assess the quality of the CCG’s leadership, the quality of its plans, how the CCG works
with its partners, and the governance arrangements that the CCG has in place to ensure it acts with probity, for example in managing conflicts of interest. In 2017/18, this domain also introduced an assessment of patient and community engagement.
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The latest ratings available for NHS Nottingham City CCG in relation to the Improvement and Assessment Framework can be found on the My NHS website (www.nhs.uk/mynhs). Performance against a number of these indicators is also reported later within this Performance Analysis section.
Based on historical performance, the most challenging performance targets for the CCG are the NHS Constitution targets for urgent and emergency care. The vast majority of Nottingham City residents use the Accident and Emergency Department at Nottingham University Hospitals NHS Trust (NUH) when they need to access urgent and emergency care. However, some of these services are also delivered at the Urgent Care Centre in the City. The national standard requires that 95% of attending patients are seen within four hours of their arrival at the Accident and Emergency Department. Performance against the standard is measured in relation to services provided by NUH and the Urgent Care Centre provided by Nottingham CityCare; however, the ability of the Trust to respond depends upon a number of factors across the health and social care community. These include a reliance on social workers and community health teams to assess and arrange placements or support in the home for people who the hospital discharge who have ongoing health and social care needs.
East Midlands Ambulance Services NHS Trust (EMAS) provides all ambulance services within Nottingham City. EMAS performance reporting changed to the Ambulance Response Programme (ARP) standards in July 2017, which has affected reporting. The changes focus on making sure the best, high quality, most appropriate response is provided for each patient first time. Call handlers are now given more time to assess 999 calls that are not immediately life-threatening, which enables them to identify patients’ needs better and send the most appropriate response. Category 1 calls are those for people with life-threatening illnesses or injuries; category 2 relates to emergency calls; category 3 relates to urgent calls; and category 4 relates to less urgent calls. The data included below is based on these new standards and is therefore only given from August 2017 onwards.
Below is a table summarising the CCG’s performance in these areas for 2017/18. More detail in terms of our approach to improve performance can be found in the Governance Statement contained within this report.
NHS Constitution Standard Target 2017/18 Commentary
A&E waiting time
Percentage of patients who spent four hours or less in A&E
95% 80.0%
This has remained a significant area of focus during 2017/18. Performance against this standard has been consistently below target throughout the year. The main reasons for the target being breached remain consistent and relate to clinical decision making, bed availability and the clinical needs of the patients. A system wide recovery action plan is in place, which is being continually reviewed and updated to improve performance. The figure reported is annualised for 2017/18 and reflects the combined performance of NUH and the Urgent Care Centre.
Ambulance clinical quality
Category 1 Average Response Time 00:07:00 00:07:10 This has been a significant area of focus during 2017/18. Performance at a Trust level against
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NHS Constitution Standard Target 2017/18 Commentary
Category 1 90th Centile Response Time 00:15:00 00:11:35 these standards has been consistently below target throughout the year. The new standards have also not been consistently delivered at a local level for the Nottingham City area. Reasons for non-performance relate to increased demand, resource availability, and reduced service capacity. Recovery action plans are in place, which are being continually reviewed and updated to improve performance. The reported figures are based on the period August 2017 (when the new standards took effect) to March 2018 for the Nottinghamshire EMAS division.
Category 2 Average Response Time 00:18:00 00:29:39
Category 2 90th Centile Response Time 00:40:00 01:04:31
Category 3 90th Centile Response Time 02:00:00 03:12:37
Category 4 90th Centile Response Time 03:00:00 03:25:05
Planned Care – Access to Treatment
Nottingham University Hospitals NHS Trust (NUH) is our main provider of acute services, although many Nottingham City residents also access these services at the Nottingham Treatment Centre. For certain referrals patients can also choose to be treated locally by independent providers such as The Park BMI and Ramsey Woodthorpe.
Below is a table summarising the CCG’s performance in 2017/18 for key NHS Constitution Standards relating to waiting times for diagnostic tests and planned treatment. Performance for the referral to treatment and diagnostic test waiting times are measured at CCG level.
NHS Constitution Standard Target 2017/18 Commentary
This target has been consistently achieved throughout 2017/18. This figure reflects the snapshot figure for March 2018. The performance level has been above the target for each month of the financial year.
Number of 52 week referral to treatment pathways 0 15
This is the cumulative number of breaches reported on a monthly basis in 2017/18. Some patients may have breached over a number of months so the figure is not a count of unique patients. Waits increased in the final quarter of the year as a result of the NHS England directive to cancel non-urgent elective operations during the winter period.
Diagnostic test waiting times No more than one per cent of patients waiting six weeks or more for a diagnostic test
1% 0.6% This target has been achieved overall for the year and. Figure is annualised for 2017/18.
Cancer Care – Access to Treatment
Cancer diagnostics and treatment is primarily provided by Nottingham University Hospitals NHS Trust (NUH). NUH is a regional cancer centre offering specialist cancer diagnostic and treatment services, and as such, it receives a relatively high number of tertiary referrals from surrounding areas, which can in some instances impact on the Trust’s performance. Some diagnostic and treatment services are also provided by the
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Nottingham NHS Treatment Centre. There are eight indicators to meet for access to cancer treatment, depending on the access route, stage of illness and the treatment needed. Sometimes very small numbers of patients go through these pathways and not every target will be met every month.
Below is a table summarising the CCG’s performance in these areas for 2017/18. Performance against all of these indicators is measured at CCG level.
NHS Constitution Standard Target 2017/18 Commentary
Cancer two week waits
All cancer two week wait 93% 95.2%
The all cancer two-week wait target has been achieved overall for 2017/18, as has the two-week wait target for breast symptoms. Performance in-year against both targets has been consistently on target in the second half of the year. The figures are annualised for 2017/18.
Two week wait for breast symptoms (where cancer was not initially suspected)
93% 96.2%
Cancer 31 day waits
Percentage of patients receiving first definitive treatment within one month of a cancer diagnosis
96% 97.1% The 31 day targets for 2017/18 have been met. Performance in-year against the targets has been variable, which is mainly due to the small numbers of patients involved, with breaches attributable to clinical reasons, patient initiated delays and some surgical capacity issues. The figures are annualised for 2017/18.
31-day standard for subsequent cancer treatments – surgery
94% 95.1%
31-day standard for subsequent cancer treatments - anti cancer drug regimens
98% 98.3%
31-day standard for subsequent cancer treatments – radiotherapy
94% 99.0%
Cancer 62 day waits
62-day wait for first treatment following an urgent GP referral
85% 83.5%
This target has not been met for 2017/18 and performance has been below target for much of the year. Breaches are attributable to clinical reasons, patient initiated delays and capacity issues in certain specialties. As a large tertiary cancer centre, the impact of late referrals on performance at NUH is also considerable. Recovery action plans are in place, which are being continually reviewed and updated to improve performance. The figure is annualised for 2017/18.
62-day wait for first treatment following referral from an NHS cancer screening service
90% 94.1%
This target has been met for 2017/18 however in-year performance has been variable, mainly due to the small numbers of patients involved. The figure is annualised for 2017/18.
Quality and Safety Standards
We review performance against quality schedules which comprise a range of indicators covering aspects of patient safety, patient experience and clinical effectiveness.
Performance in 2017/18 against some of these key quality indicators is shown in the table below. Performance against all of these indicators is measured at CCG level. For healthcare associated infections this will be the combined performance of Nottingham University Hospitals NHS Trust (NUH) and other
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community providers. For mixed sex accommodation breaches, this will be the combined performance of NUH and Nottinghamshire Healthcare NHS Foundation Trust.
Quality or Safety Indicator Target 2017/18 Commentary
Healthcare associated infection – MRSA Number of MRSA cases 0 0 The 2017/18 target has been achieved Healthcare associated infection – clostridium difficile
Number of c-diff cases 51 60 The number of reported cases has been above the monthly target in 10 of 12 the months in 2017/18.
Mixed sex accommodation breaches
Number of mixed sex accommodation breaches 0 1
For 2017/18, one breach was recorded at Nottingham University Hospitals NHS Trust in February 2018. Nottinghamshire Healthcare Foundation Trust reported no breaches.
Other National Priorities
Additional targets have been set nationally, including targets to improve mental health services and support people with dementia. To deliver these targets we work closely with Nottinghamshire Healthcare NHS Foundation Trust and GP practices within Nottingham City, along with a wide range of local providers of community mental health services.
Below is a table summarising the CCG’s performance in these areas for 2017/18. Performance against all of these indicators is measured at CCG level.
National Indicator Target 2017/18 Commentary
Estimated diagnosis rate for people with dementia
Dementia diagnosis rate 67% 84.2% This target has been consistently achieved throughout 2017/18. The figure shown relates to the March 2018 reporting.
Improved Access to Psychological Therapy (IAPT)
Percentage of population entering therapy 16.2% 16.4% This target has achieved based on activity to February 2018 (the most recent data available).
Percentage recovery rate 50% 53.0% This target has been met for 2017/18 based on figures to February 2018. Performance in-year has been variable.
Percentage of people that wait six weeks or less from referral to first treatment
75% 78.0% These targets have been achieved overall for 2017/18. In year performance was variable with the 6 week target being met in 7 of 12 months. The 18 week target was met in all months of the year.
Percentage of people that wait 18 weeks or less from referral to first treatment
95% 99.0%
First episode of psychosis – referral to treatment pathway Percentage of people experiencing a first episode of psychosis treated with a NICE approved care package within two weeks of referral
50% 70.3% This target has been achieved for the year. The figure shown is annualised for 2017/18.
Financial Performance
CCGs receive an allocation of funds for ‘programme costs’, which is money to be used directly for commissioning healthcare services. During 2017/18 Nottingham City CCG had recurrent (continuing) and
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non-recurrent (for one year only) programme resources of £486.7 million, which includes £47.2 million for primary care co-commissioning.
CCGs have a statutory financial duty not to spend more than their allocation, and in 2017/18 we were also required to deliver a surplus. We successfully delivered a £10.026 million surplus against a planned surplus of £9.601 million (and a revised control total of £10.002 million), which will be returned to the CCG in 2018/19 when the CCG has the potential to agree a level of ‘drawdown’. This is the use of surpluses achieved in the prior year to fund spending in the current year.
As set out in the 2017/18 NHS Planning Guidance, CCGs were required to hold a 0.5% 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. The national position across CCG prescribing costs pressures for Category M drugs and No Cheaper Stock Obtainable (NCSO) has been such that NHS England has agreed to allow CCGs to support the in-year cost pressure with the 0.5% reserve monies. Therefore, NHS Nottingham City CCG has released its 0.5% reserve to the bottom line, which has enabled the CCG to meet its control total, while supporting the additional prescribing pressures.
We also receive a separate allocation of money to be used for the running costs of the CCG, which in 2017/18 was £7.182 million. This equates to £21.91 per head of population. These costs are those associated with keeping our CCG running, and do not cover the delivery of healthcare. We are pleased to report that we remained within our running cost allocation in 2017/18.
The CCG had a significant savings requirement in 2017/18 of £17.306 million. A joint approach to Financial Recovery was initiated with the three neighbouring South Nottinghamshire CCGs (NHS Nottingham North and East CCG, NHS Nottingham West CCG and NHS Rushcliffe CCG). A programme of savings schemes was developed through the 2017/18 planning process, contracting round and in-year. In 2017/18, Nottingham City CCG delivered savings of £13.8 million.
2017/18 Summary of Financial Duties/Targets
Statutory Duties – remain within Revenue Resource Limit
For 2018/19, the CCG allocation will continue to be based on the CCG ‘fair shares’ formula. This aims to balance the three factors in healthcare needs: population growth, deprivation, and the impact of an ageing population. For our CCG, the allocation equates to £499 million in 2018/19.
Our future financial challenges are largely related to the NHS England five-year plan for the NHS and the implementation of our local transformation programmes. The NHS needs to be able to deal with challenges ahead, such as an ageing population, a rise in the number of people with long-term conditions, lifestyle risk
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factors for young people, and increasing public expectations of the service. Combined with rising costs and constrained financial resources, these trends threaten the long-term sustainability of the health service.
The five-year plan for the NHS published by NHS England in 2014 stated that a further £22 billion of efficiency savings were required by 2020. There are some particularly large efficiency opportunities that now require concerted action right across the NHS, with national implementation support. These are part, but not the whole, of the efficiencies the NHS will be delivering in 2018/19, alongside local programmes.
For full details of our financial performance during 2017/18 please see the Annual Accounts within this report. The accounts have been prepared under a Direction issued by the NHS Commissioning Board (NHS England) under the National Health Service Act 2006 (as amended). The CCG has adopted the Going Concern principle as described within the Annual Accounts (note 1.1).
Quality, Innovation, Productivity and Prevention (QIPP)
In 2017/18, NHS Nottingham City CCG had a Quality, Innovation, Productivity and Prevention (QIPP) Programme to deliver £17.3 million of in-year savings, all of which were required to be cash releasing, of which £15.3 million was required recurrently and £2 million non-recurrently. The overall target was met with £13.806 million delivered (of which £4 million was delivered non-recurrently) through programme savings and the under delivery of £3.5 million is offset by non-recurrent mitigations. The final delivery by programme is as follows:
Programme Area £000
Planned care (including primary care unwarranted variation) – Services for pre-arranged health care either in a community setting or in hospital, supported by effective clinical management of referrals by GPs
5,664
Prescribing – Services relating to the authorisation and usage of a medicine or treatment
1,463
Internal efficiencies – Internal review of organisation resources 2,940 Urgent Care – Improved management of non-elective admissions
3,739 Community Care – Services enabling people to remain living in their own homes and to retain as much independence as possible Total 13,806
Our Commissioning Priorities
In the Performance Summary section of this report, we set out our vision, values and strategic commissioning priorities. We monitor our progress against our commissioning priorities by regularly reporting on achievement against the specific priority objectives to our Governing Body. These reports can be found in the Governing Body Meetings and Papers section of our website at www.nottinghamcity.nhs.uk.
We are pleased to say that over the last year we have continued to make significant inroads into delivering against these areas, a number of which are shown below:
Faecal Immunochemical Test (FIT) pathway for colorectal cancer
A new test for screening out colorectal cancer has been piloted in Greater Nottingham. The 12-month trial of the new Faecal Immunochemical Test (FIT) pathway started in November 2017 and has reduced the number of unnecessary colonoscopies by almost 60 per cent.
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The FIT test is a screening process that detects hidden blood in the stool, which can be an early sign of cancer. When GPs suspect that a patient’s symptoms may be caused by colorectal cancer they can order a FIT test. A test kit is then sent to the patient’s home and the patient can return a stool sample to the lab using a pre-paid envelope.
The pilot has shown that about 60 per cent of patients that would have previously been referred to secondary care have a negative test result and no longer need to be referred for a colonoscopy. This means that many patients can avoid an unnecessary invasive procedure and cancer is ruled out quicker. The test also saves the NHS money as well as frees up consultant time by reducing unnecessary outpatient appointments. The pilot, which is a UK-first, is expected to save 1,200 colonoscopy procedures a year.
Direct access to diagnostic pathways
GPs in Nottingham are helping to cut down the amount of time patients with cancer symptoms wait for diagnosis by ordering and viewing diagnostic tests directly – without referral to secondary care.
The changes to a range of cancer pathways provide GPs with direct access to diagnostic tests such as x-rays and CT tests for diagnosing lung cancer.
Around 97 per cent of patients with symptoms that suggest cancer go on to receive a clear test result. The new process means that these patients can stay in primary care and receive a diagnosis from their GP without attending an outpatient appointment at the hospital or seeing a specialist.
Under conventional systems of care, outpatient clinics see patients referred by a GP for clinical assessment by a hospital specialist. Subsequent hospital visits are arranged to undertake any specialist diagnostic tests and treatment where necessary. This way the specialist in the outpatient clinic acts as a gatekeeper to other hospital resources. Allowing the GP to bypass this gatekeeper and gain direct access to tests can enable GPs to make more efficient use of hospital resources and reduce waiting times for patients.
Direct access diagnostic pathways allow patients to get a cancer diagnosis or, equally as important, the all clear quicker.
Extended GP Access services/GP +
GP+ was launched during 2018 to improve access to general practice services for people in Nottingham City. Nottingham City General Practice Alliance was commissioned to deliver the extended hours service, which provides appointments in evenings and at weekends.
GP+ enables patients registered at a Nottingham City GP practice to book appointments with GPs, advanced nurse practitioners, clinical pharmacists and physiotherapists between 4pm and 8pm on weekdays and between 9am and 1pm on Saturdays and Sundays. Appointments are booked through the patient’s GP practice and are held at a city centre hub on Upper Parliament Street in Nottingham.
During the first month of the service, more than 1,300 appointments were held, including 958 GP appointments and 183 advanced nurse practitioner appointments.
The service has been received positively by patients with good feedback on the availability and length of appointments, professionalism of clinicians and ability to book appointments at convenient times during evenings and weekends.
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Perinatal Mental Health
A team providing mental health services to pregnant women and new mothers has reduced waiting times by appointing more frontline staff with national funding secured by the CCG.
Nottinghamshire was selected as one of only 20 areas of the country to be awarded a share of £40 million of funding to support pregnant women and new mothers experiencing mental illness.
Perinatal mental illness affects up to 20 per cent of women, and covers a wide range of conditions. If left untreated, it can have significant and long lasting effects on the woman and her family. The specialist care offered by the service makes a huge difference to the way women experience pregnancy and motherhood.
The funding, which totals more than £337,000 per annum, pays for an additional perinatal consultant, specialist nurse, occupational therapy, psychology and nursery nurse time. The team provide specialist care for those with severe mental ill health such as severe post-natal depression or psychosis.
Since April 2017 the new team has seen an additional 120 women, which represents an increase of over 20 per cent of their previous caseload.
With the added investment the Nottinghamshire team is able to help identify and support more vulnerable women and improve their experience of what should be one of the happiest times of their lives.
Improving Access to Psychological Therapies
The CCG is improving the outcomes for patients with mental health conditions by increasing coordination with physical health treatment and delivering employment advice.
The Improving Access to Psychological Therapies (IAPT) programme began nationally in 2008 to transform the treatment of adult anxiety disorders and depression. Over 900,000 people access IAPT services every year across England and the NHS England Five Year Forward View for Mental Health is committed to expanding services and improving quality.
Around 40 per cent of people with depression and anxiety disorders also have a long-term physical health condition. These were often treated in separate services and not coordinated. This is inconvenient for patients and can lead to sub-optimal outcomes. ‘Integrated IAPT’ services work between psychological therapies providers and physical healthcare services for cancer, respiratory disease, dementia, diabetes and pain services to ensure that people with mental and physical health problems receive joined-up healthcare.
Employment advisors in IAPT services are offering a range of support options. They help people who may be struggling to maintain employment, those with long term sickness issues and those who are looking to change jobs or find employment. Employment is recognised as having many benefits including financial income, structure and social connections. People accessing IAPT services can self-refer to an employment advisor who will provide ongoing guidance to help them with the challenges they are experiencing.
Atrial Fibrillation
The CCG has been working in close partnership with the Academic Health Science Network (AHSN) to reduce the number of undiagnosed patients with atrial fibrillation.
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Atrial Fibrillation (AF) is a potential cause of stroke and sudden cardiac death but better detection of the condition and appropriate management could avoid 44 strokes and prevent 15 deaths a year in Nottingham.
The CCG arranged for AliveCor Kardia devices to be distributed to local GP practices in order to improve detection of AF. The devices can be used in consultations and suitable patient clinics to identify potential AF sufferers from appropriate patient groups.
The AliveCor Kardia Mobile device takes a 30 second medical-grade ECG reading which, in most cases, immediately indicates if a person suffers with AF.
The device works alongside a practice smart phone or and mobile app to capture the heart rhythm reading. Where AF is detected, the reading can be emailed to a GP for diagnosis and treatment.
Patients diagnosed with the condition can then be treated with anticoagulation management.
Diagnosing Well
The CCG participated in an initiative with the Alzheimer’s Society to support all GP practices to become Dementia-Friendly General Practices, by delivering a bespoke training programme for practice staff and GPs.
People who are affected with dementia often experience specific challenges in accessing GP services. These patients often struggle with remembering to attend appointments, navigating the physical environment of the practice, expressing their concerns in the short time available with the GP, and recalling details of discussions regarding their care. They also often find that they do not receive information on support available, and do not receive reviews of their care as needs change.
This can result in missed appointments, repeat appointments, and people not getting the support and care they need to live well and manage dementia and any co-morbidities. This impacts not only on quality of life and health for the person with dementia, but can also have an impact on usage of primary care, emergency admissions to hospitals, and transition to residential care.
The programme includes bespoke training to raise awareness of:
The person affected by dementia is respected, valued and understood The physical environment ensures the patient’s comfort, allows ease of access and enables
independence The health care needs of the patient are met in a manner, which reflects choice, control and the
possibility of living well with dementia throughout each part the dementia journey Systems and processes allow a safe, secure and positive patient experience in the Primary Care
setting
In order to achieve ‘Dementia-Friendly’ accreditation practices are required to produce and audit an action plan which they deliver in partnership with Alzheimer’s Society. A total of 46 practices have completed the self-audit process and achieved Dementia Friendly status to date.
Red Bag Scheme
In early 2018 the CCG secured funding to implement a number of quality interventions. These were developed in partnership with care home managers and also informed by the outcome of resident and staff interviews carried out as part of a project evaluation.
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The Red Bag Care Homes Initiative is making it easier for healthcare staff to plan treatment and speed up the discharge process for care home residents across Greater Nottingham when they are admitted to hospital.
Care home residents are issued with a red bag which contains standardised information about their general health, existing conditions and medication they are taking, and any current health concerns. Keeping this information readily available in one place makes it easily accessible to ambulance and hospital staff which helps them to more effectively determine the treatment the patient needs.
The bag accompanies the resident throughout their journey in and out of hospital and contains personal belongings, medications and essential transfer documentation. The standardised documentation from care homes to hospital will assist with communication and help to ensure the personal belongings remain with the resident throughout their stay. This scheme was initially introduced by Sutton CCG vanguard and they found a reduction in length of stay of four days.
When the patient is ready to go home, the red bag helps hospital staff to plan an effective discharge from hospital. The bag identifies the patient as a care home resident which can make it possible for the discharge to be organised sooner. It gives the patient a place to store personal belongings such as clothes, toiletries, glasses and hearing aids. When the patient returns to the care home, a copy of their discharge summary detailing the care they received in hospital is included in the red bag so staff at the care home have access to the information they need.
The red bag initiative was implemented across the Greater Nottingham CCGs and has been supported by a programme of training for care home staff.
Interpreter Assisted Appointments
Nottingham City CCG has developed an Interpreter Assisted Appointments (IAA) incentive scheme to help meet the needs of Nottingham’s diverse population when visiting GP practices.
Nottingham City has a diverse demographic, the number and complexity of consultations in primary care is increasing and many consultations require an interpreter to be present. The CCG recognises that to support this population and provide the care they need, additional pressure is placed on a workforce which is facing unprecedented challenges.
The IAA incentive scheme aims to financially reimburse practices in order to acknowledge the additional time and administration requirements required for some appointments. For example, where a longer appointment is needed.
Practices are required to demonstrate how the additional funding is being used to increase clinical appointments.
Currently 13 Nottingham City practices have signed up to the scheme which started in September 2017. The number of IAA appointments provided by the practices is influenced by list size and practice demographics but can be as high as 150 appointments per month per practice.
Training for care homes staff
The CCG has provided a programme of training for 650 local care home staff aimed at upskilling the care home workforce and improving the quality of care for residents.
An evaluation of care homes published in April 2017 highlighted knowledge and skill gaps in the local care home workforce. To address this gap the CCG commissioned a bespoke training package funded with £100,000 as part of the Enhanced Health in Care Homes Vanguard.
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The programme was developed in collaboration with care home managers, staff working in Nottingham care homes and local quality teams to cover the following elements:
end of life care nutrition and dietetics wound-care restraint and managing challenging behaviours activities for activity coordinators chair based exercises identifying deteriorating residents and sepsis care home management training
The training programme was delivered by staff from partnering organisations: Nottingham University Hospitals NHS Trust; CityCare; Nottinghamshire Healthcare NHS Foundation Trust and Primary Care Development Centre.
An external evaluation of the vanguard including training was carried out by Age UK and highlighted improvements in staff satisfaction including staff reporting feeling more part of the multi-disciplinary team and improved access to training.
Equality and Diversity
The CCG recognises and values the diverse needs of its population and is committed to reducing health inequalities and improving the equality of health outcomes within the City. We aim to ensure the provision of high quality and accessible healthcare and to develop a diverse and well-supported workforce which is representative of the population we serve. We are committed to embedding equality and diversity considerations into all aspects of our work. We recognise that equality is not about treating everyone the same; it is about ensuring that access to opportunities are available to all by taking account of people’s differing needs and capabilities. We believe that diversity is about recognising and valuing differences through inclusion, regardless of age, disability, gender re-assignment, marriage or civil partnership status, pregnancy and maternity, race, religion or belief, sex, or sexual orientation. Also, we believe that our employees are essential to the provision of high quality healthcare and we are committed to maintaining a working environment that promotes their health and wellbeing.
Equality Act requirements
The Public Sector Equality Duty of the Equality Act 2010 requires all public sector organisations to analyse and measure their equality performance and prepare associated information for publication each year. It also requires organisations to prepare and publish equality objectives and set out how progress towards achieving the objectives will be measured.
The following is a summary of a report on the work undertaken by the CCG during 2017/18 to ensure that we meet the requirements of the Public Sector Equality Duty. The Annual Equality Assurance Report –Meeting the Public Sector Equality Duty report was approved by the CCG’s Governing Body in January 2018 and the full version can be found on the CCG’s website www.nottinghamcity.nhs.uk.
The NHS Equality Delivery System
The NHS Equality Delivery System (EDS2) was introduced in 2011 to help NHS organisations deliver better outcomes for patients and communities, and better working environments for staff, which are personal, fair
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and diverse with equality of opportunity and treatment for all. The Equality Delivery System also helps NHS organisations to obtain, analyse and grade the evidence required to demonstrate compliance with the Public Sector Equality Duty. It includes a set of 18 outcomes grouped under four overarching goals.
It is against these outcomes and goals that organisational performance is analysed and graded and further action determined. The grading system encourages organisations to use EDS2 flexibly and selectively, to enable key local health inequalities to be embraced.
Inclusive leadership
The CCG’s Governing Body and senior leaders are committed to promoting equality and ensuring that equality-related impacts and risks are identified and managed. Staff are supported to work in culturally competent ways within a work environment that is free from discrimination.
To strengthen our equality performance, the CCG has developed an Equality, Diversity and Inclusion (EDI) vision for the CCG. The vision is supported by a set of pledges that have been informed by the need to ensure that we identify and address key local health inequalities to deliver better outcomes for patients and communities. They also reflect the need to ensure a working environment for CCG staff that is personal, fair and diverse, with equality of opportunity and treatment for all. The EDI vision and pledges are outlined in the CCG’s EDI Framework.
All members of the Governing Body and its committees are required to sign declarations of compliance with the Professional Standards Authority for Health & Social Care’s Standards for members of NHS Boards and Clinical Commissioning Group Governing Bodies in England. This commits them to promoting equality and human rights in the treatment of patients and service users, their families and carers, the community, colleagues and staff, and in the design and delivery of services for which they are responsible. CCG managers are expected to work to the Code of Conduct for NHS Managers, which requires managers to ensure that no one is unlawfully discriminated against because of their protected characteristics or economic status. All staff have responsibility for treating everyone with dignity and respect and must not discriminate or encourage others to discriminate.
The Governing Body provides strategic leadership to the equality and diversity agenda and its committees have specific delegated equality and diversity responsibilities. The roles, responsibilities and accountability of individual Governing Body members for ensuring compliance with the Public Sector Equality Duty and promoting equality are outlined in the CCG’s EDI Framework.
All CCG staff are responsible for treating everyone with dignity and respect and must not discriminate or encourage others to discriminate. Consequently, all new staff complete mandatory Equality and Diversity Awareness training as part of their induction to the organisation. To reinforce this basic equality training we also implement a rolling cultural competence development programme, which is responsive to the diversity of our local population. In 2016 and 2017, we focused our attention on barriers to communication. This took the form of a series of face to face Deaf Equality training sessions, which were positively received. The training was attended by 55 employees, including the CCG’s Chief Officer, Chair of the Governing Body, our GP leads and a number of our Directors. Participants’ feedback has confirmed our belief that understanding a specific barrier to communication provides an insight into other communication barriers and the negative impact they can have on patients’ access to health services.
Better health outcomes
We commission and procure services with the aim of meeting the health needs of our local community and work with providers of health services to ensure that individual people’s health needs are assessed in
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appropriate and effective ways. We also commission actions to improve transitions between services and to ensure that all health promotion services reach and benefit our local communities.
As it is essential for us to fully understand the health needs of our population if we are to be successful in addressing health inequalities, we produce a Joint Strategic Needs Assessment (JSNA) in conjunction with Nottingham City Council. This identifies where inequalities exist and describes the future health and wellbeing needs of Nottingham City’s population. The JSNA examines a variety of behavioural factors and the health needs for children, young people, families, and adults. Local Authority Public Health colleagues also complete targeted health needs assessments in areas where it is felt there is a lack of information. In recent years this has resulted in a number of new JSNA chapters dedicated to areas such as musculoskeletal conditions, physical disabilities and learning disabilities, along with chapters focusing on a number of inclusion health groups, including people who are homeless, asylum seekers and carers. Each JSNA chapter addresses some of the protected characteristics in terms of health needs and access to services. A BME Health Needs Assessment was launched in January 2018 and identifies a range of recommendations to tackle health inequalities and to improve health outcomes for Nottingham’s BME populations. A continued focus will be maintained on ensuring that the protected characteristic and Inclusion Health groups are appropriately addressed within each individual JSNA chapter, as and when they are updated. The JSNA and supporting health needs assessments form a key part of the evidence base on which commissioning decisions are made in order to improve health outcomes and reduce health inequalities.
The CCG also funds and commissions research and evaluation activities, which inform the evidence base to support the commissioning of health services to reduce health inequalities. An exploratory study commissioned to look at the Mental Health Needs of Nottingham’s Homeless population started in November 2016 and a draft of the final report has been received. The findings have already informed discussions with local partners on how we can work to better meet needs and promote and support timely mental health service uptake for people who are homeless. A further exploratory study to look at improving the mental health outcomes of Nottingham’s lesbian, gay, bisexual and trans (LGBT) population commenced at the end of 2017 and will end in June 2019. Evidence indicates that LGBT people are at higher risk of mental health problems, self-harm and suicide, and report lower well-being compared to the wider population due to discrimination, harassment, bullying, rejection and social isolation. Other factors such as age, religion or ethnicity can further complicate mental distress. The focus for the research is the prevention, early diagnosis and self-care of mental health issues. Findings will inform how primary and community health services can be best commissioned to better meet the mental health needs of LGBT people.
During 2017, the CCG became involved in a national Task and Finish Group to develop an Implementation Guide in support of an Information Standard on sexual orientation monitoring launched by NHS Digital. The Information Standard provides the mechanism for recording the sexual orientation of all patients/service users aged 16 years and over, across all health services and Local Authorities. While no-one is under any obligation to disclose their sexual orientation, there is a dearth of evidence within the public sector around the specific needs and experiences of lesbian, gay and bisexual (LGB) people. The Implementation Guide is designed to explain why the monitoring can improve outcomes. Although it is predominantly for front line staff, it contains useful information to support CCG colleagues responsible for completing equality impact assessments. The monitoring data obtained will support commissioning and planning services for specific groups and will help to identify health risks at a population level. The Information Standard and supporting Implementation Guide have also been discussed at the CCG’s GP Cluster Board meetings.
The CCG is committed to ensuring that it pays due regard to the three aims of the Public Sector Equality Duty. The systematic analysis of the impact of our actions and decisions on equality is one way that this can
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be achieved. During 2017 we introduced a process to support the Greater Nottingham CCGs’ Financial Recovery Plan that brings together equality and quality impact considerations into a single EQuality Impact Assessment (EQIA). This provides a consistent, pre-defined and streamlined process to ensure that we understand the individual and collective impact of proposed financial recovery schemes prior to any decision-making. It also prevents equality and quality risks from being considered in isolation. The EQIA is an assessment of whether proposed changes could have a positive, negative or neutral impact on people’s different protected characteristics, as defined by the Equality Act 2010. It also considers the impacts on people from relevant inclusion health groups (e.g. carers, homeless people, people experiencing economic or social deprivation). The EQIA also assesses impacts in line with the CCGs’ duty to maintain and improve the three elements of quality (patient safety, patient experience and clinical effectiveness) and considers access to services. EQIAs are treated as ‘live’ documents, and are revisited at key stages of scheme development and implementation, particularly following the conclusion of any patient and public engagement and consultation activities to inform decision-making. An EQIA Panel comprised of Directors from across the Greater Nottingham CCGs with equality, quality and engagement expertise and knowledge of the different CCG populations supports the development and quality assurance of EQIAs for all relevant schemes within the Financial Recovery Plan. The support provided to staff to complete EQIAs has provided an opportunity for them to develop a greater understanding of the potential impact of QIPP schemes on patients/carers; it has also increased colleague awareness of equality of access to the services we commission.
The CCG is committed to putting the voice of patients and the public at the heart of its commissioning activities. We have established an Engagement Framework and an Engagement Toolkit, which are aimed at ensuring that meaningful engagement activities are undertaken at all stages of the commissioning cycle. The CCG also produces an annual Engagement Report, which outlines the organisation’s approach to patient and public engagement and provides a summary of the key engagement activities completed during the preceding year. The CCG has established a People’s Council as an advisory group to the Governing Body. The People’s Council helps us to develop and implement meaningful patient and public engagement as an integral element of the commissioning cycle. All of these engagement actions aim to ensure that the diverse needs of the people living in Nottingham City inform the services we commission.
A key part of our approach to engagement is improving our understanding of the needs of people who are seldom heard. After consulting with a number of partner organisations we identified that there was a significant gap in understanding the health needs of Eastern European communities in the City, particularly Polish, Czech, Bulgarian and Romanian (including Roma communities). We have since worked with our People’s Council to develop an approach to engaging Eastern European communities, which identified that the best way to engage is through trusted organisations already working within those communities. This meant that we needed to identify who is already working with these communities and find a way to work with them. As a result, a steering group was established during 2017 to deliver this project and two Eastern European community organisations have been commissioned to be involved in the project.
Improved patient access and experience
We manage our contracts in order to support local people to access hospital, community and primary care services and to be informed and involved in decisions about their care. As many of our patients use the same services from the same providers as the patients of neighbouring CCGs, coordinating commissioners have been appointed to oversee the major shared contracts with key providers. We co-ordinate the contracts for Nottinghamshire Healthcare NHS Foundation Trust and Nottingham CityCare Partnership CIC. We use the national NHS Standard Contract, which requires that providers do not discriminate between or against service users or carers on the grounds of any of the nine protected characteristics. The contract specifically
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requires appropriate assistance and reasonable adjustments to be made for service users and carers who do not speak, read or write English or who have communication difficulties. Providers are required to have due regard to the Equality Act 2010 and to make information available to enable the equality of access to be monitored. The NHS Standard Contract also requires all providers to implement the NHS Equality Delivery System, which helps to provide us with a further source of assurance on patients’ access to, and experience of, the services we commission.
To embed equality and diversity considerations into the CCG’s contract monitoring processes we have devised a four-year cycle of assurances that we are seeking from our main providers (Nottinghamshire Healthcare Foundation Trust, Nottingham CityCare Partnership and Nottingham University Hospitals NHS Trust), starting from 2017/18. The cycle requires:
A general assurance at the beginning of the contract year to demonstrate providers’ compliance with EDS2, as mandated by the NHS Standard Contract
An assurance that the Accessible Information Standard is being implemented
Reports of the outcome of a cycle of ‘deep dives’ - focused exercises to provide in-depth and comprehensive reviews on the extent to which providers are addressing specific EDS2 outcomes.
For 2017/18 we have sought assurances on two specific areas: the first is that the services we commission are readily accessible to all of our population; the second is that the diversity of Nottingham City’s population is reflected in the cultural awareness and competency training received by our providers’ staff.
The CCG has developed a standardised service review process for all services commissioned from Nottinghamshire Healthcare NHS Foundation Trust and Nottingham CityCare Partnership CIC. The process requires the following equality performance considerations to be discussed:
Confirmations of arrangements for providing assistance and reasonable adjustments for service users and carers who do not speak, read or write English or who have communication difficulties
Review of the extent to which the service is being accessed on an equitable basis.
The service review mechanism for Nottinghamshire Healthcare NHS Foundation Trust now requires the Trust to develop an Equality Impact Assessment for each of its services and work has been undertaken to align this approach as much as possible with the Nottingham CityCare Partnership CIC contract.
The CCG has specifically commissioned a range of services to ensure that patients, their carers and wider communities can readily access appropriate services. We have also specifically commissioned services and communications campaigns to support patients and their carers with their information needs and to enable them to be involved in decisions about their care. Examples of these commissioning activities are described within our Annual Equality Assurance Reports.
A representative and supported workforce
The CCG operates fair, inclusive and transparent recruitment and selection processes and its Recruitment and Employment Checks Policy is in line with the requirements of the Equality Act. All vacancies are advertised via the NHS Jobs website and the CCG’s recruitment process includes a number of measures to minimise the opportunity for discrimination. We take action to ensure that all relevant information is obtained and recorded during the recruitment process in a form that can be analysed and reported by protected characteristics, to determine whether any equality issues need to be addressed. Several CCG leaders and recruiting managers have undertaken training on Inclusive Leadership and Unconscious Bias. The
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aim of the training has been for attendees to develop a greater awareness of unconscious bias and to understand how it affects different aspects of their working lives, including its potential impact on recruitment decisions.
The CCG is committed to ensuring that staff are treated fairly, equally and are free from discrimination. We are also committed to providing staff with personal development, access to appropriate education and training for their jobs, and line management support to enable them to fulfil their potential. We conduct an annual staff survey that is structured around the four pledges to staff in the NHS Constitution and addresses equality and diversity issues.
The CCG participates in the Apprenticeship Scheme run by New College Nottingham. It is currently supporting its third group of three Apprentice Administrators to work for 18 months in different parts of the organisation. We recognise the valuable contribution that apprenticeships make to the CCG by bringing young people into our workforce and developing their skills. Participation in the Apprenticeship Scheme also sends a positive message to our workforce and population about the values of the CCG and our commitment to engaging with our community. Two of our former apprentices subsequently secured permanent posts with us and a further five have gained employment in other local health organisations.
Equality, Diversity and Inclusion Framework
To demonstrate our accountability for promoting equality to our population, staff and other key stakeholders we have an Equality, Diversity and Inclusion (EDI) Framework. At the heart of this Framework is the need for discrimination to be eliminated, equality to be advanced and good relations to be fostered. It is the mechanism for ensuring that we address our statutory equality duties, which includes identifying a number of equality objectives, and for setting out our prioritised equality action plan.
The EDI Framework also lists the CCG’s five equality objectives, which are detailed in the table below. The first three are associated with the services we commission and the remaining two are workforce objectives. Progress towards achieving the objectives is measured via information in strategic priority updates and workforce reports to the Governing Body. At the beginning of 2016 it was agreed that action to deliver the equality objective focused on the workforce was ongoing, but that the objectives focusing on elements of the CCG’s strategic priorities had been delivered.
Equality objective
1 Increase the number of people from Black and Minority Ethnic (BME) groups entering psychological therapies – To achieve a year-on-year increase in numbers of people from BME groups entering psychological therapies. People from BME groups are often underserved in primary mental health services and are much less likely than other groups to be referred to psychological therapies.
2 Improve prevention and early detection of breast cancer in women and prostate cancer in men, to increase survival rates – To improve cancer prevention and early detection so that 95% of women will survive breast cancer within one year of diagnosis (an increase of 2.5% by April 2015) and 87% of men will survive prostate cancer within one year of diagnosis (an increase of 5% by April 2015).
3 Reduce unplanned and emergency admissions for children, young people and people over 85 – To achieve a 3% reduction in both unplanned admissions to acute care and attendance at the Emergency Department for people aged 85 years and over by March 2015, and to achieve a 5% reduction in emergency admissions for children and young people by March 2016.
4 Increase the diversity of the CCG’s workforce, focusing on disability, race and sexual orientation – To achieve a year-on-year increase in the diversity of the CCG’s workforce across all grades, with a specific focus on disability, race and sexual orientation.
5 Reduce the gender imbalance in the CCG’s clinical leadership team – To put in place a succession planning system for clinical leadership that incorporates robust diversity considerations, so that the current gender imbalance in the CCG’s
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Equality objective
clinical leadership team has reduced by April 2016.
Sustainability Report
What is meant by sustainability?
Sustainability in this context is about the smart and efficient use of natural resources, to reduce both immediate and long term social, environmental and economic risks. The cost of all natural resources is rising and there are increasing health and wellbeing impacts from the social, economic and environmental costs of natural resource extraction and use. The most widely accepted definition for sustainable development comes from the 1992 Rio Earth summit, which defines it as “development that meets the needs of the present without compromising the ability of future generations to meet their own needs”.
The mandate for sustainability reporting
For the NHS, sustainable development has been recognised at a national level as an integral part of efficiently delivering high quality healthcare. To this end, the Department of Health and Social Care Group Accounting Manual (DHSC GAM) states that all NHS bodies are required to produce a sustainability report for inclusion in their Annual Report. This sustainability report has been prepared in accordance with HM Treasury’s Public Sector Annual Reports: Sustainability Reporting Guidance and guidance from the Sustainable Development Unit (SDU).
Summary of performance
Nottingham City CCG is committed to reducing its impact on the environment and moving towards a more environmentally friendly way of working. The CCG is working closely with partner organisations to achieve the target of 28% reduction in NHS greenhouse gas emissions by 2020. The CCG has an environmental policy and a Sustainable Development Management Plan (SDMP), and has also produced an annual sustainability report for the past four years.
Lucy Branson (Director of Corporate Development) is the CCG's Sustainability Lead, supported by Nottingham City Council's Public Health Department. Together, they are involved in the CCG’s sustainability work at a regional and national level. We have also appointed the environmental consultancy Loreus Ltd to support in delivering our sustainability agenda.
A table summarising the main sustainability metrics for the 2017/18 financial year and the four preceding years can be found below. This shows that the CCG’s total greenhouse gas emissions for 2017/18 were 120.59 t CO2e, which is a 13.96% decrease from the previous year and a 23.37% decrease since the baseline year. Further commentary on this data and the observed changes can be found in the relevant sections below.
Kg / WTE 20.61 107.14 117.55 63.95 40.25 Number of staff (WTE) 114 91 102 119 122 t CO2e / WTE 1.38 1.55 1.34 1.18 0.99
The number of staff reported above is an average over the whole year.
Greenhouse gas emissions
The latest CO2e conversion factors published by the Department for Environment, Food and Rural Affairs (DEFRA) have been used to calculate the greenhouse gas emissions arising from the CCG’s operations. In line with guidance from the SDU, HM Treasury and DEFRA, this report allocates emissions between the three recognised ‘scopes’ and main emission sources. The CCG first published this information in its 2016/17 sustainability report and a comparison is included within the table below.
Scope Main emission sources
2016/17 (tCO2e)
2017/18 (tCO2e)
Scope 1 Direct emissions from sources owned or controlled by the CCG
Gas usage 46.00 48.00
Water usage 1.44 1.45 Scope 2 Indirect emissions from purchased energy Electricity usage 72.00 60.00 Scope 3 All other indirect emissions Grey fleet travel 10.75 9.92 Taxi and train travel 9.39 0.94 Waste disposal 0.78 0.28 Total emissions 140.16 120.59
Grey fleet refers to travel by CCG staff, using their own vehicles and for which they claim travel expenses.
The CCG is primarily based at Standard Court in Nottingham; however, this building is not solely occupied by us and at present, the energy and water consumption is not sufficiently sub-metered to directly monitor our usage. Therefore, an estimation using occupied floor area has been used to apportion consumption between ourselves and the other tenant. Using this methodology, it has been determined that the CCG occupies 61.28% of Standard Court (excluding shared areas e.g. meeting rooms), which remains unchanged from last year.
A small number of staff are also based at the Wollaton Vale Health Centre. Like Standard Court, the health centre is not solely occupied by CCG staff, however unlike Standard Court it is managed by NHS Property Services who have been able to apportion total energy, water and waste to the CCG. These figures have been combined for publication in this report as the total impact of the CCG across both sites.
Energy usage
The following table provides details of the CCG’s gas and electricity usage for 2017/18, along with comparative data for each year since the CCG was established.
Electricity usage has fallen compared to 2016/17, and is likely to be a result of the installation of LED lighting where possible. Gas consumption remains lower than the baseline year; however, it has increased compared to 2016/17. The reasons for this are unclear, although a particularly cold winter is likely to have resulted in an increased use of heating.
During early 2018, new hot water dispensers have been introduced to the kitchens at Standard Court, which can be switched off overnight to reduce gas usage. It is anticipated that this will be evident in next year’s report.
Staff are reminded and updated through weekly ‘green bulletins’ about the impact of wasting energy and how they can improve their own carbon footprint, both at work and at home. Feedback to the green bulletins has been largely positive and several members of staff have reported that they have made changes as a result of the improved knowledge.
Water usage
The following table provides details of the CCG’s water usage for 2017/18, along with comparative data for each year since the CCG was established.
Activity 2013/14 2014/15 2015/16 2016/17 2017/18
Water usage (m3) 1,622 1,389 1,268 1,585 1,595
Number of staff (WTE) 114 91 102 119 122 m3 / WTE 14.23 15.22 12.39 13.32 13.08
The number of staff reported above is an average over the whole year.
Total water consumed by the CCG in 2017/18 is fairly consistent with the 2016/17 financial year; however, a small water use efficiency saving per WTE member of staff has been achieved. As part of routine maintenance at Standard Court, numerous technologies have been deployed to reduce water consumption since 2013/14. These have included the use of push button taps and aerators on most taps. These and other technologies will continue to be rolled out in the future, further reducing the CCG’s water consumption.
Transport
The following table provides details of the CCG’s business travel for 2017/18, along with comparative data for each year since the CCG was established.
Grey fleet refers to travel by CCG staff, using their own vehicles and for which they claim travel expenses.
The total distance travelled by CCG staff decreased by 30.45% compared to last year and is the lowest level since the CCG began reporting this data in 2013/14. Travel attributable to grey fleet comprises most of the miles travelled by CCG staff. Grey fleet has seen a 12.36% reduction, rail travel a 55.13% reduction, and taxi travel has been reduced by 12.99% from 2016/17.
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The reduction in all forms of business travel and the associated financial savings are due to a programme of environmental awareness raising, behaviour change and financial efficiency savings within the CCG. The significant decrease in rail travel is mostly due to a change in policy regarding attendance at long-distance events, in an effort to reduce travel costs. Taxi usage is being analysed and challenged on an increased basis to understand need and support staff to make a more informed decision on their travel habits.
We will continue to deliver this agenda, with changes to the taxi booking process and more availability of information on public transport and active travel, with the aim of both reducing our emissions and making further financial savings. The CCG also works closely with partner organisations across Nottinghamshire to share information, learning and processes for improving air quality and reducing travel related emissions.
Waste
The following table provides details of the waste produced, recycled and sent to landfill by the CCG during 2017/18, along with comparative data for the previous two financial years.
Waste sent to landfill 0.51 2.13 2.60 1.66 0.53 Waste recycled 1.84 7.62 9.39 5.95 4.38 Total waste 2.35 9.75 11.99 7.61 4.91
There are designated recycle bins at both sites occupied by our staff, this on site-segregation is in addition to the post-collection segregation undertaken by the CCG’s waste contractor, who like many other waste contractors, seeks to divert as much waste as possible from landfill either through recycling or incineration.
Total waste produced by the CCG in 2017/18 has decreased by 35.48% compared with last year, down to 4.91 tonnes. This is likely in part to be as a result of the awareness raising undertaken by the CCG in regards to reducing paper waste. There are now various electronic systems for internal communication which, reduce the use of paper, in addition to our work in encouraging double-sided printing and discouraging the printing of emails. Waste sent to landfill is influenced by the CCG through on-site segregation, however where waste has not been segregated on-site, the waste contractor will seek to segregate and divert waste from landfill where possible. By further increasing on-site segregation, primarily through staff engagement and awareness raising, we will seek to directly reduce the waste sent to landfill.
Sustainable procurement
In addition to our direct greenhouse gas emissions, we have also set 2013/14 as the baseline for greenhouse gas emissions arising from commissioned healthcare services and the procurement of non-healthcare products and services. This total has been calculated at 99,158 tCO2e which is significantly larger than our direct emissions. In an effort to reduce this impact, we have encouraged our main provider organisations to regularly report their environmental performance or to have a Sustainable Development Management Plan (SDMP) in place.
At least five of our provider organisations regularly report their environmental performance or have an SDMP in place. Together, these five organisations account for approximately 80% of our total commissioned spend. These five organisations are Nottingham University Hospitals NHS Trust, Nottinghamshire Healthcare NHS Foundation Trust, East Midlands Ambulance Services NHS Trust, Nottingham CityCare Partnership CIC and Sherwood Forest Hospitals NHS Foundation Trust.
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Our Statutory Duties
The statutory duties and powers of CCGs are set out within NHS England’s ‘The functions of Clinical Commissioning Groups’ (March 2013). The responsibility for discharging our key statutory duties rests with the Governing Body and, as such, we have established an Annual Reporting Framework. This provides a cycle of assurance through a series of annual assurance reports presented at public Governing Body meetings. These demonstrate our compliance with each key duty. Further assurance is provided through our Governing Body Assurance Framework, which identifies high-level risks with the potential to impact on the delivery of strategic objectives and statutory duties. It also details the controls and actions in place to mitigate such risks.
The governance arrangements for the way in which we manage our key statutory duties are outlined within our Constitution, which is available on our website at www.nottinghamcity.nhs.uk. Further details are also provided within the Governance Statement contained within this report.
The following sections focus specifically on how we are meeting some of these duties.
Act with a view to securing continuous improvement to the quality of services
A Quality Improvement Framework has been published that clearly sets out how the CCG will be assured on the quality of commissioned services and how continuous improvements in quality outcomes and the quality of primary medical services will be secured. Continuous quality improvement is promoted and encouraged through the CCG’s Clinical Council and Quality Impact Assessments are required to be completed as an integral element of service planning and policy development. The CCG actively supports the education and training of the primary care workforce and has established an annual programme of member practice performance review and development visits. These are peer led multi-disciplinary visits where member practices are encouraged to share their ideas for future improvements or service changes that provide high quality cost effective care. Our Governing Body’s membership includes an Independent Nurse who has a lead oversight role in ensuring a consistent focus on quality in all aspects of the CCG’s activity and who chairs the Quality Improvement Committee, which has delegated responsibility for monitoring the safety and effectiveness of the treatment and care provided to patients and the experience patients have of the treatment and care they receive. During 2017/18, the CCG has published annual reports on the management of safeguarding (adults and children), complaints, serious incidents, and infection prevention and control, which are available on the CCG’s website at www.nottinghamcity.nhs.uk.
Have regard to the need to reduce inequalities
Our strategic commissioning priorities are developed in line with the needs of the local population in order to reduce health inequalities in access to services and outcomes achieved. We work in partnership with the Nottingham City Health and Wellbeing Board to deliver the Joint Health and Wellbeing Strategy and assist Nottingham City Council in maintaining Nottingham’s Joint Strategic Needs Assessment. The CCG has established a Commissioning Policy for Prioritisation and Resource Allocation, which ensures that the duty to reduce inequalities is taken into account when making investment and disinvestment decisions. We have also adopted the NHS Equality Delivery System as a tool towards delivering reduced health inequalities.
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Engaging People and Communities
The NHS belongs to all of us and we welcome the active participation of patients, carers, community representatives and groups and the public in planning, delivering and evaluating services that we commission. We have an established Engagement Framework, which acknowledges that the way in which we engage with the population of Nottingham City is critical to ensuring that we commission appropriate and effective services. Our arrangements aim to reflect both Nottingham’s diverse population and the health inequalities we need to address. They also highlight the need to engage and communicate with people who may be from disadvantaged or vulnerable groups, as well as those who struggle to access services. As a result, we are able to understand fully the impact that our decisions may have on different groups and individuals.
We ensure that we work to the following principles when implementing the arrangements outlined within our Engagement Framework:
Being clear about who is being engaged, the possible options, the engagement process, what is being proposed, the scope to influence and the expected costs and benefits of the proposal.
Ensuring that engagement takes place in a suitable timeframe to allow decisions to be genuinely influenced by feedback received.
Adapting engagement activities and methods to meet the specific needs of different patient groups and communities.
Keeping the burden of engagement to a minimum to retain continued patient and public buy-in to the process.
Ensuring that responses to engagement exercises are carefully analysed with clear feedback provided to participants, which explains the decision made and the influence the results of the engagement exercise had on the final decision.
We have established a People’s Council that is reflective of the City’s population and its health challenges. Its membership is comprised of patient leaders with lived experience of different health conditions along with representatives from voluntary sector organisations that work with different groups in the City. Our patient leaders are also undergoing a programme of development to enable them to work directly with the CCG in its day-to-day commissioning activity.
Our People’s Council is an advisory body that helps to shape our approach to engagement by advising on the most appropriate ways to reach the communities we need to work with. It sits alongside the Clinical Council (made up of clinicians) at the heart of the CCG and advises the Governing Body on patient experience and engagement processes in order to influence commissioning decisions.
The membership of our Governing Body includes a lay member role with lead oversight responsibility for our patient and public involvement arrangements. This role includes responsibility for chairing the People’s Council and for overseeing our work to ensure that diverse voices within the local population are fully represented, and that there are equal opportunities for patients and local people to become involved in all aspects of our commissioning activity.
We benefit from good links with Healthwatch Nottingham, the health and social care consumer champion, which helps us to further understand and respond to the concerns of our population. We have also continued to ensure compliance with Nottingham City Council’s health scrutiny requirements in relation to proposals on service change.
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You can read more about how we involve patients, carers, community groups and the public in all stages of our commissioning processes via the Get involved section of our website, which provides more information on how patients, carers, community groups and the public can get involved in shaping NHS services. We publish the results of all our engagement activity within this section of our website.
An Annual Patient Engagement Report is presented to the CCG’s Governing Body to provide assurance and further information on how the CCG is meeting its statutory duties in relation to patient and public engagement. This can be found in the Get involved and the Governing Body Meetings and Papers sections of our website at www.nottinghamcity.nhs.uk.
Working with the Health and Wellbeing Board
We are active members of the Nottingham City Health and Wellbeing Board; a statutory partnership established to lead and advise on work to improve the health and wellbeing of the population of Nottingham City and specifically to reduce health inequalities. This Board brings us together with Nottingham City Council to address City-wide issues where a collaborative approach between partners is essential. Other local organisations, including Nottinghamshire Police, Nottinghamshire Fire and Rescue Service, Nottingham University Hospitals NHS Trust, Nottingham CityCare Partnership, Nottinghamshire Healthcare NHS Trust, Healthwatch Nottingham and representatives from the voluntary sector also attend. Further information on the Health and Wellbeing Board can be found in the Governance Statement within this report.
Happier, Healthier Lives, the Nottingham City Joint Health and Wellbeing Strategy 2016-2020 was launched on 7 December 2016. The aim of the strategy is to increase healthy life expectancy in Nottingham and make it one of the healthiest big cities; and to reduce inequalities in health by targeting the neighbourhoods with the lowest levels of healthy life expectancy. The strategy sets out four key priorities, which focus on the adoption of healthy lifestyles, maintaining positive mental health, the empowerment of citizens to manage their own health, and achieving a sustainable environment. During the last year, we have continued to work closely with the Board to develop these priorities and their supporting action plans.
Promoting Research
The CCG has a Research Strategy Group to oversee delivery against our statutory duties to promote research and the use of research evidence. The Group meets three times a year and is chaired by Dr Alastair McLachlan, Corporate Medical Lead. The Group’s membership includes representatives from research active member GP practices, representatives from the CCG’s Commissioning and Quality Governance Teams and from the Local Authority Public Health Team, along with the Deputy Director of the NIHR Research Design Service East Midlands. The CCG has well established research partnerships with the University of Nottingham, Nottingham Trent University, NIHR Clinical Research Network East Midlands, NIHR Collaboration for Applied Leadership Health Research and Care East Midlands and the East Midlands Academic Health Science Network. Where we are lead commissioner, the CCG has also promoted research by including research indicators within its provider contract quality schedules.
As at the end of March 2018, 19 member GP practices had recruited into at least one NIHR Clinical Research Network portfolio study recruiting a total of 470 participants. An additional 12 practices recruited into at least one non-portfolio research study, recruiting a total of 75 participants. A total of 31 practices (67%) took part in research during the year.
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Accountability Report Corporate Governance Report
Members Report
At the start of 2016/17, NHS Nottingham City Clinical Commissioning Group had 55 member practices. Membership reduced to 54 practices during the year, due to a practice merger (as indicated below).
Our member practices are as follows:
1. Aspley Medical Centre 2. Bakersfield Medical Centre 3. Beechdale Surgery 4. Bilborough Medical Centre 5. Bilborough Surgery 6. Boulevard Medical Centre 7. Bridgeway Practice 8. Churchfields Medical Practice 9. Clifton Medical Practice 10. Dale Surgery 11. Deer Park Family Medical Practice 12. Derby Road Health Centre 13. Elmswood Surgery 14. Family Medical Centre 15. Grange Farm Medical Centre 16. Greenfields Medical Centre 17. Greenwood & Sneinton Family Medical Centre 18. Hucknall Road Medical Centre 19. John Ryle Medical Centre 20. Leen View Surgery 21. Lenton Medical Centre (merged with Derby Road Health Centre on 1 April 2017) 22. Limetree Surgery 23. Mapperley Park Medical Centre 24. Mayfield Medical Practice 25. Meadows Health Centre 26. Melbourne Park Medical Centre 27. NEMS Platform One Practice 28. Parkside Medical Practice 29. Queens Bower Surgery 30. Radford Health Centre 31. Radford Medical Practice 32. RHR Medical Centre 33. Rise Park Surgery 34. Rivergreen Medical Centre 35. Riverlyn Medical Centre
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36. Sherrington Park Medical Centre 37. Sherwood Rise Medical Centre 38. Springfield Medical Centre 39. Southglade Medical Centre 40. St Albans Medical Centre 41. St Luke’s Surgery 42. Strelley Health Centre 43. Sunrise Medical Practice 44. The Alice Medical Centre 45. The Fairfields Practice 46. The Forest Practice 47. The High Green Medical Practice 48. The Medical Centre 49. The University of Nottingham Health Service 50. Tudor House Medical Practice 51. Victoria and Mapperley Practice 52. Welbeck Surgery 53. Wellspring Surgery 54. Windmill Practice 55. Wollaton Park Medical Centre
Our Governing Body
The Governing Body has responsibility for ensuring that the CCG has appropriate arrangements in place to exercise its functions effectively, efficiently and economically and in accordance with the CCG’s principles of good governance (its main function).
The Governing Body is clinically led with Dr Hugh Porter taking the role of Chair and Clinical Leader. The Governing Body is composed of members from our constituent practices who have been selected and elected through a formal process, along with five independent members, three of whom are lay members, and two who provide independent clinical expertise in the form of a registered nurse and secondary care doctor. The Governing Body may also co-opt observers and attendees with speaking rights to attend meetings as required.
The Governing Body is supported by a committee structure which reports on a regular basis to the Governing Body. You can read more about the committee structure in the Governance Statement contained within this report.
The following shows people who were full members of the CCG Governing Body with speaking and voting rights from 1 April 2017 to 31 March 2018:
Dr Hugh Porter – Chair, Clinical Leader and GP Cluster Lead for UNICOM Samantha Walters – Accountable Officer (from 1 October 2017) Dawn Smith – Accountable Officer (to 30 September 2017) Jonathan Bemrose – Chief Finance Officer (from 1 November 2017) Louise Bainbridge – Chief Finance Officer (to 31 October 2017) Dr Alastair McLachlan – Corporate Medical Lead Dr Margaret Abbot – GP Cluster Lead for Robin Hood
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Dr Marcus Bicknell – GP Cluster Lead for Norcomm Dr Arun Tangri – GP Cluster Lead for City Central Tim Woods – Lay Member Sue Clague – Lay Member Steve Hale - Lay Member (to 31 May 2017) Dr Adedeji Okubadejo – Independent Secondary Care Doctor Sharon Robson – Independent Nurse (from 1 May 2017) Rosie Trainor – Independent Nurse (to 30 April 2017)
The Audit Committee
The following people attended as members of the Audit Committee throughout the year and up to the signing of our annual report and accounts:
Tim Woods – Lay Member Sue Clague – Lay Member Janet Champion – Associate Lay Member Suma Harding – Associate Lay Member
Please refer to the Governance Statement contained within this report for details about all the Governing Body’s committees, including their membership.
Member Profiles
Biographies of all Governing Body members and our Associate Lay Members can be found on our website at www.nottinghamcity.nhs.uk.
Transparency and Probity
We are committed to ensuring that our organisation inspires confidence and trust, avoiding any potential situations of undue bias or influence in decision-making and protecting the NHS, the CCG, and individuals involved from any appearance of impropriety.
The CCG has a publically available Register of Declared Interests that captures the declared interests of all members and attendees of the Governing Body and its committees, along with all other employees of the CCG. Further details on how we manage conflicts of interest are detailed in the Governance Statement within this report.
As part of our arrangements for ensuring a culture of openness and transparency in our business transactions, we also maintain a Register of Procurement Decisions and a Register of Gifts, Hospitality and Sponsorship.
These documents can be found on our website at www.nottinghamcity.nhs.uk.
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Personal Data Related Incidents
We are committed to reporting, managing and investigating all information governance incidents and near-misses. We actively encourage staff to report all incidents and near misses to ensure that learning can be collated and disseminated within the organisation. We did not report any serious incidents involving information, confidentiality or security between April 2017 and March 2018.
Three personal data related incidents were reported during 2017/18; however, these were not rated as being serious in nature. Two incidents related to pseudonomised data being inappropriately shared and one incident was due to the sending of patient data via an insecure email account (although the recipient was correct). Appropriate action was promptly taken to resolve these matters, lessons learnt were implemented and there have been no further re-occurrences. These incidents are shown in the following table:
Summary of personal data related incidents in 2017/18
Category Nature of incident Total
I Loss of inadequately protected electronic equipment, devices or paper documents from secured NHS premises
0
II Loss of inadequately protected electronic equipment, devices or paper documents from outside secured NHS premises
0
III Insecure disposal of inadequately protected electronic equipment, devices or paper documents
0
IV Unauthorised disclosure 2 V Other 1
Statement of Disclosure to Auditors
Each individual who is a member of the Governing Body at the time the Members’ Report is approved confirms:
So far as the member is aware, there is no relevant audit information of which the CCG’s auditor is unaware that would be relevant for the purposes of their audit report; and
The member has taken all the steps that they ought to have taken in order to make him or herself aware of any relevant audit information and to establish that the CCG’s auditor is aware of it.
Modern Slavery Act
NHS Nottingham City Clinical Commissioning Group fully supports the Government’s objectives to eradicate modern slavery and human trafficking, but does not meet the requirements for producing an annual Slavery and Human Trafficking Statement as set out in the Modern Slavery Act 2015.
Statement of Accountable Officer’s Responsibilities
The National Health Service Act 2006 (as amended) (the NHS Act 2006) states that each Clinical Commissioning Group (CCG) shall have an Accountable Officer and that Officer shall be appointed by
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the NHS Commissioning Board (NHS England). NHS England has appointed Samantha Walters to be the Accountable Officer of NHS Nottingham City CCG.
The responsibilities of an Accountable Officer are set out under the NHS Act 2006, Managing Public Money and in the Clinical Commissioning Group Accountable Officer Appointment Letter. They include responsibilities for:
The propriety and regularity of the public finances for which the Accountable Officer is answerable;
Keeping proper accounting records which disclose with reasonable accuracy at any time the financial position of the CCG and enable them to ensure that the accounts comply with the requirements of the Accounts Direction;
Such internal control as they determine is necessary to enable the preparation of financial statements that are free from material misstatement, whether due to fraud or error;
Safeguarding the CCGs assets (and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities);
The relevant responsibilities of accounting officers under Managing Public Money;
Ensuring the CCG exercises its functions effectively, efficiently and economically (in accordance with Section 14Q of the NHS Act 2006 and with a view to securing continuous improvement in the quality of services (in accordance with Section14R of the NHS Act 2006; and
Ensuring that the CCG complies with its financial duties under Sections 223H to 223J of the NHS Act 2006.
Under the NHS Act 2006, NHS England has directed each CCG to prepare for each financial year financial statements in the form and on the basis set out in the Accounts Direction. The financial statements are prepared on an accruals basis and must give a true and fair view of the state of affairs of the CCG and of its net expenditure, changes in taxpayers’ equity and cash flows for the financial year.
In preparing the financial statements, the Accountable Officer is required to comply with the requirements of the Group Accounting Manual issued by the Department of Health and in particular to:
Observe the Accounts Direction issued by NHS England, including the relevant accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis;
Make judgements and estimates on a reasonable basis;
State whether applicable accounting standards as set out in the Group Accounting Manual issued by the Department of Health have been followed, and disclose and explain any material departures in the financial statements; and,
Assess the CCG’s ability to continue as a going concern, disclosing, as applicable, matters related to going concern; and
Use the going concern basis of accounting unless they have been informed by the relevant national body of the intention to dissolve the CCG without the transfer of its services to another public sector entity.
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Governance Statement Introduction and context
NHS Nottingham City CCG is a body corporate established by NHS England on 1 April 2013 under the National Health Service Act 2006 (as amended).
The clinical commissioning group’s statutory functions are set out under the National Health Service Act 2006 (as amended). The CCG’s general function is arranging the provision of services for persons for the purposes of the health service in England. The CCG is, in particular, required to arrange for the provision of certain health services to such extent as it considers necessary to meet the reasonable requirements of its local population.
As at 31 March 2018, the clinical commissioning group is not subject to any directions from NHS England issued under Section 14Z21 of the National Health Service Act 2006.
The Clinical Commissioning Group is a clinically-led membership organisation comprised of the GP practices in Nottingham City. We have strong clinical leadership and involvement with our GPs and other clinicians, having worked together for many years innovating and commissioning new and re-designed services. The area we look after has the same boundary as Nottingham City Council, which combined with our membership model ensures that the organisation is well placed to understand the needs of our diverse population and to develop and redesign healthcare services to address these needs. We are committed to ensuring that patient engagement and involvement is at the centre of all our decision-making processes and work has continued to strengthen our arrangements for engagement with local people throughout 2017/18.
We are responsible for commissioning the majority of healthcare services for the people of Nottingham City, including elective hospital care and rehabilitation care, maternity services, urgent and emergency care, community services and mental health and learning disability services. We commission these health services in collaboration with neighbouring Clinical Commissioning Groups, Public Health colleagues and NHS England’s Specialised Commissioning Teams. Since 1 April 2015, we have also taken on full delegated responsibility for commissioning primary medical services for the people of Nottingham City.
We have productive and well-established relationships with a number of key partners within the City, including Nottingham City Council and the Nottingham Crime and Drugs Partnership, with whom we work to improve not only health and wellbeing, but also the overall quality of life for those living within Nottingham City.
We have always worked closely with the three Clinical Commissioning Groups in South Nottinghamshire to ensure a co-ordinated approach to health and wellbeing across Greater Nottingham. In 2017, Governing Bodies of the four CCGs formally agreed to create a joint commissioning committee with delegated responsibilities for work programmes and decisions which are best taken at Greater Nottingham Level. This new joint commissioning committee will be established in 2018/19.
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Scope of responsibility
As Accountable Officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of the clinical commissioning group’s policies, aims and objectives, whilst safeguarding the public funds and assets for which I am personally responsible, in accordance with the responsibilities assigned to me in Managing Public Money. I also acknowledge my responsibilities as set out under the National Health Service Act 2006 (as amended) and in my Clinical Commissioning Group Accountable Officer Appointment Letter.
I am responsible for ensuring that the clinical commissioning group is administered prudently and economically and that resources are applied efficiently and effectively, safeguarding financial propriety and regularity. I also have responsibility for reviewing the effectiveness of the system of internal control within the clinical commissioning group as set out in this governance statement.
As I am also the Accountable Officer for NHS Nottingham North and East CCG, NHS Nottingham West CCG and NHS Rushcliffe CCG, I have the same responsibilities across the four CCGs.
Governance arrangements and effectiveness
The main function of the governing body is to ensure that the group has made appropriate arrangements for ensuring that it exercises its functions effectively, efficiently and economically and complies with such generally accepted principles of good governance as are relevant to it.
The Clinical Commissioning Group’s membership is organised into groups of GP practices, known as GP Clusters, which are based partly on geographical location and partly on inter practice relationships and culture. The GP Clusters provide a forum for groups of member practices to work together in a shared framework to support the development of the organisation’s commissioning priorities and delivery of its commissioning strategy and operational plans. The GP Clusters also enable the knowledge and experience of member practices to be channelled into service redesign and quality improvement. The member practices working in each GP Cluster are responsible for electing a GP Cluster Lead who will also represent them, and act on their behalf, on the Governing Body.
The Clinical Commissioning Group has established a Constitution and Inter-Practice Agreement, which together set out how the organisation will ensure that it is well governed and accountable to both its member GP practices and its local population. The Constitution sets out the organisation’s statutory responsibilities and the structures and processes that have been developed to ensure that these are met in line with the principles of good governance. It also describes the relationship between the Governing Body and the Clinical Commissioning Group’s membership and the democratic processes to appoint the organisation’s clinical leadership team. The Inter-Practice Agreement details the local working arrangements between member GP practices working in GP Clusters.
The Clinical Commissioning Group has also established a Scheme of Reservation and Delegation, which sets out those decisions that are reserved for the membership as a whole. These relate to the approval of any material changes to the Clinical Commissioning Group’s Constitution, approval of any changes to the Clinical Commissioning Group’s Inter-Practice Agreement, and approval of arrangements for electing GP Cluster Leads.
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All remaining decisions are delegated by the Clinical Commissioning Group’s membership to its Governing Body, its committees, and individuals employed by the organisation. In line with this delegation, bi-annual members meetings are held in order for the Governing Body to formally report back to the Clinical Commissioning Group’s membership on delegated matters and for the membership as a whole to feed into the organisation’s strategic development. In addition to the bi-annual meetings, regular two-way communication is maintained between the Governing Body and the Clinical Commissioning Group’s membership. This is achieved in part through the provision of performance and financial progress reports to the monthly GP Cluster Management Boards and member practices’ ability to influence management actions being taken. These meetings also facilitate the ability for any quality concerns identified at GP practice level to be captured and fed into the work of the Clinical Commissioning Group.
In addition to the responsibilities delegated to it under the Scheme of Reservation and Delegation, the main function of the Governing Body is to ensure that appropriate arrangements have been made to ensure that the organisation complies with its obligations to act effectively, efficiently and economically and to ensure that the principles of good governance are embedded throughout the Clinical Commissioning Group.
As part of the Clinical Commissioning Group’s commitment to openness and accountability, meetings of the Governing Body are held in public and at various locations across the City, with members of the public invited to attend. Members of the public may ask questions in advance of each meeting, which will be orally responded to at the meeting. In line with good governance practice, the Governing Body is supported by an annual cycle of business that sets out a coherent overall programme for meetings. The Governing Body’s forward plan is a key mechanism by which appropriately timed governance oversight, scrutiny and transparency can be maintained in a way that doesn’t place an onerous burden on those in executive roles or create unnecessary or bureaucratic governance processes. For 2017/18, the forward plan has ensured that the Governing Body has received appropriate and timely updates and assurances in relation to key strategies and plans (including the CCG’s Commissioning Strategy and Operational Plan, the Nottingham City Joint Health and Wellbeing Strategy, and the Nottingham and Nottinghamshire Sustainability and Transformation Plan), quality improvement, financial stewardship, and corporate performance and assurance.
The Governing Body’s membership has a clinical majority and is led by an elected GP in the role of Chair of the Governing Body. Its membership also includes three further elected GPs from member practices and the organisation’s Accountable Officer, Chief Finance Officer and Corporate Medical Lead. Membership also includes five independent members, comprising three lay members and independent clinical expertise from a registered nurse and secondary care doctor. The Governing Body may also co-opt observers and attendees with speaking rights to attend meetings as required.
As part of their role as members of the Governing Body, the five independent members provide an external view of the work of the Clinical Commissioning Group that is removed from the day-to-day running of the organisation. This brings insight and impartiality to the Governing Body and provides constructive challenge to discussions at meetings of the Governing Body and its committees in order to support the robustness of decision making arrangements. The Clinical Commissioning Group has also appointed four additional Associate Lay Members to provide further independent scrutiny and challenge to the work of the Governing Body’s committees, decision-making panels and advisory councils.
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The Governing Body has appointed the following committees:
Audit Committee – This statutory committee provides the Governing Body with an independent and objective view of the Clinical Commissioning Group’s financial systems, financial information and compliance with laws, regulations and directions governing the organisation in so far as they relate to finance. The committee also has responsibility for reviewing the establishment and maintenance of an effective system of integrated governance, risk management and internal control, across the whole of the organisation’s activities. This includes reviewing the integrity of the Clinical Commissioning Group’s financial statements, the adequacy and effectiveness of all risk and control related disclosure statements, and ensuring that the organisation has effective whistle blowing and anti-fraud systems in place.
The committee scrutinises every instance of non-compliance with the Clinical Commissioning Group’s Standing Orders, Scheme of Reservation and Delegation and Prime Financial Policies and monitors compliance with the Clinical Commissioning Group’s policies relating to standards of business conduct. The Audit Committee meets no less than six times per year at appropriate times in the reporting and audit cycle and its membership is comprised solely of independent members; two Governing Body Lay Members and two Associate Lay Members. Audit Committee members are supported by the Clinical Commissioning Group’s internal auditors, external auditors and local counter fraud specialist.
Key highlights of the work of the committee during 2017/18:
Throughout the year, the committee has received regular reports from the CCG’s internal and external auditors, which will culminate in the receipt of their year-end opinions and conclusions in May 2018. To complement the programme of internal audit reviews over the year, the committee has received targeted ‘Risk and Assurance’ reports. These reports are derived from the Governing Body Assurance Framework and enable a focussed review of specific risks; allowing for robust discussions with senior managers on any gaps in controls and assurances.
The committee has discharged its duties in relation to financial reporting by maintaining a consistent focus on financial control matters throughout the year. This has included approval of the year-end accounts timetable and accounting policies for 2017/18, and will include a review of the CCG’s unaudited and final Annual Accounts at its May 2018 meetings. Meetings in March and May 2018 were held as “Committees in Common” with the Audit Committees of Nottingham North and East CCG, Nottingham West CCG and Rushcliffe CCG.
During 2017/18, the committee has continued its scrutiny of the organisation’s arrangements for ensuring high standards of business conduct and received detailed assurance reports on the management of conflicts of interest in line with the requirements of Managing Conflicts of Interest: Revised Statutory Guidance for CCGs (published in June 2017 by NHS England). As part of this review, the committee scrutinised the organisation’s Register of Declared Interests, Register of Gifts, Hospitality and Sponsorship and its Register of Procurement Decisions. It has also received regular updates from Counter Fraud on progress in achieving the NHS Counter Fraud Authority Standards (formerly NHS Protect) for Commissioners: Fraud, Bribery and Corruption.
Remuneration Committee – This statutory committee makes determinations about the remuneration, fees and other allowances for Governing Body members, Clinical Leads and other senior managers. The Remuneration Committee meets as and when necessary, with at least one
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meeting being held each year. Its membership is determined on the basis of the matters to be discussed at each meeting, ensuring that no member of the committee is involved in discussions and decisions about their own remuneration. Membership is drawn from the Governing Body’s independent and elected members.
Key highlights of the work of the committee during 2017/18:
The Remuneration Committee has met five times during 2017/18. Meetings in April and May were convened to review the remuneration packages for existing Lay Member, Associate Lay Member and senior management posts; alongside national guidance and benchmarking data from the ‘Core Cities’ CCGs.
Meetings held in June, November and December were conducted as ‘Committees in Common’ with the Remuneration Committees of Nottingham North and East CCG, Nottingham West CCG and Rushcliffe CCG. The purpose of these meetings was to discuss the recruitment process for senior management posts within the Greater Nottingham CCG structure and to agree the remuneration of several new senior management posts.
Quality Improvement Committee – This committee exists to scrutinise arrangements for ensuring the quality of services commissioned by the organisation and to oversee the quality of primary medical services within the geographical area covered by the Clinical Commissioning Group. The committee promotes a culture of continuous improvement and innovation with respect to safety of services, clinical effectiveness and patient experience. The committee also has responsibility for monitoring improvements in the Clinical Commissioning Group’s equality performance, with a specific focus on health outcomes and patient access and experience. The Quality Improvement Committee meets no less than nine times per year and has a balanced membership comprised of independent members, clinical leads and relevant management leads.
Key highlights of the work of the committee during 2017/18:
The Committee has received regular Quality Update Reports that provide the committee with assurance on the processes used by the CCG to manage the areas of: patient safety (including management of reported serious incidents), infection prevention and control, patient experience (including CCG managed complaints), clinical effectiveness and suicide prevention. It has also received Personalisation Reports, which provide assurance on the quality of personalised care in relation to NHS continuing healthcare, individual funding requests, integrated personal commissioning and personal health budgets and the Nottinghamshire Transforming Care Programme for people with learning disabilities and/or autism who are being treated in inpatient hospital facilities.
The Committee also received regular quality reports and quarterly dashboards for each of the organisation’s main providers, including care homes and domiciliary care agencies. These culminated in scrutiny of the Clinical Commissioning Group’s main providers’ Quality Accounts for 2017/18. The committee has also had oversight of the development and delivery of provider quality schedule requirements and Commissioning for Quality and Innovation (CQUIN) indicators. During the year, focussed reports were received in relation to:
- Unwarranted clinical variation in primary care. - The quality of maternity services in Nottingham City (including progress against
recommendations made in the national review of maternity care ‘Better Births, improving outcomes of maternity services in England, 2016’).
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- The CCG’s main providers’ workforce indicators.
Finally, the committee continued to have an ongoing focus on the robustness of patient and public engagement arrangements throughout the year, along with oversight of equality action plans relating to inequalities in health outcomes, patient access and patient experience.
Risk and Performance Committee – This committee exists to ensure that robust risk management and assurance processes are in place regarding the delivery of the Clinical Commissioning Group’s statutory and delegated responsibilities and to oversee the development, implementation and monitoring of the organisation’s performance management arrangements and local Quality, Innovation, Productivity and Prevention (QIPP) Programme. The committee also has responsibility for overseeing all aspects of information governance, monitoring plans associated with sustainability and corporate social responsibility, approving the organisation’s arrangements for business continuity and monitoring the uptake of statutory and mandatory training and delivery of staff appraisals. In addition, the committee has responsibility for monitoring improvements in the Clinical Commissioning Group’s equality performance, with a specific focus on workforce and leadership issues. The Risk and Performance Committee meets no less than nine times per year and has a balanced membership comprised of independent members, clinical leads and relevant management leads.
Key highlights of the work of the committee during 2017/18:
The Committee has scrutinised the Organisational Risk Register at every meeting, with a particular focus on new risks, major risks and risks that have increased in score, along with the effectiveness and progress of management actions in place to mitigate them. During the year, the committee has overseen an enhancement to the Organisational Risk Register reports to enable a more effective review of the timeliness of progressing mitigating actions and an ability to obtain assurance that risks are being routinely identified and captured across the CCG.
The committee has discharged its duty to oversee the CCG’s local QIPP programme through the receipt of monthly progress reports that detail QIPP scheme delivery against plan. In addition, the committee received a detailed report on the Greater Nottingham CCGs’ Financial Recovery Plan, which outlined how financial risks were being mitigated and provided assurances on the resources in place to focus on financial delivery.
The Committee has robustly monitored the organisation’s Performance Reports, focussing specifically on all areas of under-performance against NHS Constitution standards. In addition to the review of the organisation’s Performance Report at every meeting, the committee has also received a programme of targeted ‘deep dive’ performance reports. These reports focused on areas where trends in under-performance had been noted by the committee. During 2017/18, the committee reviewed reports relating to:
- The Accident and Emergency Department four hour waiting time standard - Performance against the 62 day referral to treatment target - Elective care - The Nottinghamshire Healthcare Foundation Trust - Transforming Care Programme for people with learning disabilities and/or autism
In addition, the committee received detailed performance reports in relation to the Better Care Fund and the organisation’s 2017/19 Operational Plan.
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The committee continued to monitor the robustness of information governance arrangements throughout the year, with a particular focus on the actions being implemented across the Greater Nottingham CCGs following the WannaCry ransomware cyber-attack in May 2017. It also had oversight of a range of workforce issues (including workforce equality considerations), and received assurances around the organisation’s health, safety and security arrangements.
Attendance at Governing Body meetings and those of its committees during 2017/18 is set out below.
Governing Body / Committee Average Attendance of Members
Governing Body 89% Audit Committee 83% Quality Improvement Committee 77% Risk and Performance Committee 77%
The Governing Body has also appointed the following decision-making panels and advisory councils:
Resource Allocation and Prioritisation Panel – This panel exists to make the organisation’s investment, disinvestment, and resource allocation decisions. The panel reviews the robustness and consistency of decisions, ensuring that appropriate public involvement and consultation has been completed with due regard to equality considerations. The Resource Allocation and Prioritisation Panel is scheduled to meet on a monthly basis, but meetings only go ahead as required, dependent on business need. The panel’s membership is comprised of independent members, clinical leads, senior management leads and a public health consultant.
During 2017/18, the panel met on ten occasions to consider a range of investment proposals in line with the organisation’s Prioritisation and Resource Allocation Policy and to evaluate previously approved investments to ascertain if they had delivered as expected. The panel also approved a number of applications for research excess treatment costs.
Primary Care Commissioning Panel – This panel was established following the issuance of the formal delegation agreement from NHS England to empower the organisation to commission primary medical services for the people of Nottingham City. The panel operates as the corporate decision-making body for the management of the delegated functions and the exercise of the delegated powers. The Primary Care Commissioning Panel is scheduled to meet on a monthly basis, but meetings only go ahead as required, dependent on business need. The panel’s membership consists of independent members and executive leads, which include a non-practising General Practitioner and a registered nurse. Representatives from Healthwatch and the Health and Wellbeing Board are also invited to attend all meetings. Meetings are held in public in line with statutory requirements, albeit where necessary, confidential sessions may also be held.
During 2017/18, the panel met on seven occasions and held one teleconference meeting in order to take an urgent decision. During the year, the panel considered a number of applications to either temporarily close GP practice patient lists or to alter GP practice geographic boundaries; received an update on ‘Transforming General Practice in Greater Nottingham’, which set out how the four Greater Nottingham CCGs plan to collectively
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transform and strengthen general practice in line with the requirements of the General Practice Forward View, published in 2016 by NHS England; and agreed the principles to be applied to the planning of larger redevelopments for General Practice across Greater Nottingham. Two proposals to commission services on a direct award basis where GP practices are providers were also approved by the panel.
Individual Funding Request Panel – This panel exists to make the organisation’s decisions on Individual Funding Requests. The Individual Funding Request Panel meets as and when necessary and its membership is comprised of independent members, clinical leads, a public health consultant and relevant management leads. The panel was not required to meet during 2017/18.
Clinical Council – The Clinical Council is not a formally appointed committee of the Governing Body, and as such, does not have any delegated decision making powers. Instead, it operates in a clinical leadership and advisory capacity to the Governing Body and its committees and decision-making panels, and provides a clear mechanism for individual member practice and GP Cluster views to be fed into the Clinical Commissioning Group’s decision making processes. The Clinical Council also takes a lead role in ensuring that appropriate mechanisms are in place within the organisation to secure the involvement and engagement of secondary care clinicians and nursing, midwifery and allied health professionals in all aspects of the Clinical Commissioning Group’s commissioning activity. The Clinical Council meets on a monthly basis and its membership is comprised of representatives from each of the GP Clusters, proportionate to their overall registered patient list sizes. The organisation’s senior management team also attend meetings, as required.
People’s Council – The People’s Council is not a formally appointed committee of the Governing Body, and as such, does not have any delegated decision making powers. Instead, it operates in an advisory capacity to the Governing Body and its committees and decision-making panels. The council supports the Clinical Commissioning Group in ensuring that the views and experiences of NHS service users are identified and taken into account when local health services are being commissioned and reviewed. The People’s Council is scheduled to meet on a bi-monthly basis and its membership is comprised of patient, carer and community group representatives that reflect the demographic of Nottingham City’s population. The organisation’s senior management team also attend meetings, as required.
The Governing Body has approved and keeps under review the Terms of Reference for all of its committees, decision-making panels and advisory councils. All committees, decision-making panels and advisory councils demonstrate how they have discharged their responsibilities (as set out within their terms of reference) by reporting to the full Governing Body. This is performed through the submission of formal minutes, specific assurance reports and other appropriate updates as necessary. These documents can be found in the Governing Body Meetings and Papers section of our website at www.nottinghamcity.nhs.uk.
All members of the Governing Body and its committees, decision-making panels and advisory councils are required to reaffirm their commitment to upholding the Standards for members of NHS Boards and Clinical Commissioning Group Governing Bodies in England on an annual basis. These declarations are published on the Clinical Commissioning Group’s website.
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A formal programme of development sessions is delivered on an annual basis in order to ensure that Governing Body Members and Associate Lay Members are suitably updated and able to refresh their skills and knowledge and to provide time to reflect on individual and group effectiveness. During 2017/18, these sessions have primarily focussed on the developing the joint commissioning committee arrangements for the Greater Nottingham CCGs and the associated retained duties of the Governing Body.
The Clinical Commissioning Group has established robust arrangements for managing conflicts of interests in such a way as to ensure that they do not affect the integrity of the organisation’s decision-making processes. These include the maintenance and publication of a Register of Declared Interests for all employees and appointees of the Clinical Commissioning Group. Governing Body members, and those of its committees, decision-making panels and advisory councils, are also asked to declare any conflict of interest with regard to agenda items at the start of each of their meetings.
The key health and social care partnership fora during 2017/18 have included:
The Health and Wellbeing Board – The Nottingham City Health and Wellbeing Board is a statutory partnership, set up to lead and advise on work to improve the health and wellbeing of the population of Nottingham City and specifically to reduce health inequalities. The Board’s membership is drawn from organisations including Nottingham City Council, local NHS organisations, the Police and voluntary sector organisations, and has both voting and non-voting members. Voting members include:
- Four Nottingham City Councillors, including the Portfolio Holders for Health and Children’s Services
- Three representatives from NHS Nottingham City CCG’s Governing Body - Corporate Director for Children and Adults - Director of Adult Social Care - Director of Public Health - Representative of Healthwatch Nottingham - Representative of NHS England
Non-voting members include representatives from:
- Nottingham University Hospitals NHS Trust - Nottinghamshire Healthcare NHS Foundation Trust - Nottingham CityCare Partnership CIC - Nottingham City Homes - Nottinghamshire Police (Nottingham City Division) - Department for Work and Pensions - Nottinghamshire Fire and Rescue Service - Nottingham’s Universities - Nottingham’s third sector
The Board leads on the development of the Joint Strategic Needs Assessment for Health and Social Care, which identifies the issues that need addressing across a broad range of health related behaviours, vulnerable groups and health and wellbeing outcomes. It oversees joint commissioning and joined up provision for citizens and patients, including social care, public health and NHS services. It also considers the impact on health and wellbeing of the wider local authority and partnership agenda, such as housing, education, employment, and crime and
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antisocial behaviour. The Board has responsibility for the delivery of the Healthy Nottingham targets in The Nottingham Plan to 2020 and the delivery of the Joint Health and Wellbeing Strategy.
Robust governance arrangements have been established between the Clinical Commissioning Group and Nottingham City Council in relation to the management of the Better Care Fund. The Better Care Fund, which came into effect on 1 April 2015, is intended to drive closer integration of health and social care services and improve outcomes for patients, service users and carers. For 2017/18, the fund equated to £34.6 million for Nottingham City and operated as a pooled budget arrangement under a Section 75 Agreement. A Commissioning Sub-committee of the Health and Wellbeing Board has been formally established to make decisions in relation to the Better Care Fund, with the Clinical Commissioning Group and Nottingham City Council having equal voting rights. The Clinical Commissioning Group’s Governing Body has delegated responsibility for overseeing and scrutinising performance against the Better Care Fund indicators to its Risk and Performance Committee, with risks and issues escalated as necessary.
Crime and Drugs Partnership Board – The Board consists of members of the key organisations which constitute the Partnership including Responsible Authorities and other partners from higher education, the voluntary sector and business communities. The Board sets the strategic priorities for the Partnership in accordance with the strategic direction established by One Nottingham and the Sustainable Community Strategy. The Board provides a governance function ensuring that Partnership monies and activities are directed towards the Board's priorities as well as serving as a forum for members.
Nottingham City Children’s Partnership Board – This Board is a statutory partnership which ensures that services, agencies, organisations and the community are protecting children from harm and safeguarding their wellbeing.
Nottingham City Safeguarding Adults Partnership Board – This Board is a statutory partnership. Its role is to assure itself that local safeguarding arrangements and partners act to help and protect adults in its area who meet the criteria set out within the Care Act that have been or who are at risk of being abused.
One Nottingham Board – This Board is the overarching body which provides strategic direction to One Nottingham, a local strategic partnership for the city of Nottingham. This partnership brings together the strengths and resources of the public, business, faith, voluntary and community sectors.
Nottingham and Nottinghamshire Sustainability and Transformation Leadership Board – This Board provides system leadership and oversight to ensure successful delivery of the objectives and outcomes agreed in the Nottingham and Nottinghamshire Sustainability and Transformation Plan.
Greater Nottingham Transformation Partnership Board – This Board is the overarching, strategic governing group for the Greater Nottingham Transformation Programme, a delivery unit of the Nottingham and Nottingham Sustainability and Transformation Plan. It brings together partners from all of the organisations responsible for health and care across Greater Nottingham to deliver a programme of large scale strategic change, aimed at fundamentally reshaping the health and social care system.
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Clinical Congress – The purpose of the Clinical Congress is to provide a platform for establishing and confirming the collaborative commissioning strategy of the six Nottinghamshire Clinical Commissioning Groups, and to facilitate the ongoing review of the effectiveness of the framework set out within the Collaborative Commissioning Memorandum of Understanding. It enables the Clinical Commissioning Groups to share their local commissioning strategies and identify commonalities in order to address strategic issues across the health community. It is also the vehicle for ensuring that collaborative commissioning arrangements for key contracts (e.g. Nottingham University Hospitals NHS Trust) are robust and make best use of commissioning resources across Clinical Commissioning Groups so that contracting responsibilities can be delegated to a coordinating Clinical Commissioning Group whilst retaining oversight and accountability for service planning, quality and outcomes.
UK Corporate Governance Code
NHS Bodies are not required to comply with the UK Code of Corporate Governance. However, compliance with relevant principles of the Code is considered to be good practice.
This Governance Statement is intended to demonstrate how the Clinical Commissioning Group had regard to the principles set out in the Code that are considered appropriate for Clinical Commissioning Groups during the financial year ending 31 March 2018, and up to the date of signing this statement.
Discharge of Statutory Functions
In light of the recommendations of the 1983 Harris Review, the Clinical Commissioning Group has reviewed all of the statutory duties and powers conferred on it by the National Health Service Act 2006 (as amended) and other associated legislation and regulations. As a result, I can confirm that the Clinical Commissioning Group is clear about the legislative requirements associated with each of the statutory functions for which it is responsible, including any restrictions on delegation of those functions.
Responsibility for each duty and power has been clearly allocated to lead directors, who have confirmed that their structures provide the necessary capability and capacity to undertake all of the Clinical Commissioning Group’s statutory duties.
Risk management arrangements and effectiveness
The identification and assessment of strategic and organisational risks is embedded within the culture of the Clinical Commissioning Group through a clear and integrated approach to risk management, combined with defined ownership of risk at all levels within the organisation.
The organisation’s ‘Integrated Risk Management Framework’ clearly sets out the organisation’s risk architecture and describes how the CCG will identify, manage and monitor its strategic and organisational risks in a consistent, systematic and co-ordinated manner. The Framework was refreshed and reapproved by the Governing Body this year and the organisation’s risk appetite and risk tolerance level were revisited as part of this review. The Framework was also updated to reflect increased strategic partnership working and to ensure that mechanisms are in place to identify and evaluate any strategic partnership risks internally.
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Principal risks to the Clinical Commissioning Group’s strategic objectives are monitored through the Governing Body Assurance Framework; thus providing the Governing Body with assurance that internal control systems are functioning effectively. The Governing Body Assurance Framework has also been aligned to the four domains of the Clinical Commissioning Group Improvement and Assessment Framework (Better Health, Better Care, Sustainability and Leadership); providing the Governing Body with an integrated mechanism for reviewing key controls, assurances and the progress of actions required in support of the ongoing assurance process with NHS England.
Organisational risks arising from the Clinical Commissioning Group’s day-to-day activities are monitored through the Organisational Risk Register; a live document, underpinned by a robust risk assessment and evaluation process. The Organisational Risk Register is recognised as being both reactive and proactive; reactive in ensuring that sufficient and timely management actions are being taken and that adequate resource to do so is in place, and proactive in anticipating further related risks and enabling the organisation to review where its internal controls may need to be strengthened.
The following key elements are explicitly identified within the Integrated Risk Management Framework as being essential for its successful implementation and in ensuring a risk aware culture:
Governing Body commitment to, and leadership of, the total risk management function – This is demonstrated by Governing Body approval and ownership of the Integrated Risk Management Framework and the ongoing review of strategic and major organisational risks through regular and consistent Governing Body reporting.
Having defined individual roles and responsibilities in relation to risk management – As the Accountable Officer, I am ultimately responsible for risk management within the Clinical Commissioning Group, however, all members of my Senior Management Team and the organisation’s Clinical Leadership Team have a specific duty to ensure that appropriate mechanisms are in place within their areas of responsibility for identifying and highlighting new and emerging risks.
Embedding risk identification within business decision making processes – Wide-spread employee participation in risk management processes is supported by ongoing support from in-house officers with specific risk management expertise. Risks are identified through an assortment of means, such as horizon scanning, external and self-assessments, complaints, formal risk assessments and during both committee and routine team meetings. How risks may impact on the public and the organisation’s stakeholders is considered at the initial risk identification stage and then in more depth by senior managers to ensure that the correct approach to any communication is taken.
Examples of how risk identification has been embedded within the Clinical Commissioning Group include:
- Routine consideration of risk within planning, procurement and contract management arrangements.
- Routine completion of equality, quality and privacy impact assessments as an integral part of service planning and policy development.
- By fostering an open, supportive and ‘fair blame’ culture within the Clinical Commissioning Group in relation to incident and near miss reporting.
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- All Governing Body papers being presented with identified risk implications and the actions being taken to mitigate these.
- The Governing Body and its committees having ‘risk identification’ as a standing item on their agendas to ensure any risks identified during the course of meetings are captured and transferred to the Organisational Risk Register where appropriate.
Having standardised mechanisms in place to systematically assess, control and minimise risk across the organisation – All risks are assessed by defining qualitative measures of impact and likelihood, and scored methodically using the organisational risk scoring matrix. Risks and risk scores are initially subject to challenge from senior managers to ensure that the full consequences of the risk have been considered in relation to its actual impact on the Clinical Commissioning Group and to ensure that adequate resources are in place to enable effective risk mitigation. Risks are then prioritised for management action dependent on the residual risk score.
Having effective reporting and scrutiny mechanisms for all risks, incidents and near misses – The Clinical Commissioning Group is committed to the development of a learning culture and in ensuring that lessons learnt are shared and measures to prevent reoccurrence are promptly applied and integrated into the organisation’s activities where necessary. This focus is applied to all scrutiny arrangements. The Risk and Performance Committee undertakes a robust review of the Organisational Risk Register on a monthly basis, with a particular focus on the sufficiency and timeliness of mitigating actions. The committee also monitors and scrutinises the actions in place to address gaps in controls and assurances identified through the Governing Body Assurance Framework. The Quality Improvement Committee ensures that risks to quality of care in services are properly considered and appropriately mitigated, including risks relating to safeguarding children and adults. All major risks are reported to the Governing Body on a monthly basis.
Ensuring the effectiveness of the Integrated Risk Management Framework – This is achieved through the work of the Governing Body’s committees. The Risk and Performance Committee has delegated responsibility for monitoring how the framework is being implemented and the Audit Committee is charged with providing assurance to the Governing Body on the effectiveness of the of the organisation’s risk management arrangements. The Audit Committee is supported by the Clinical Commissioning Group’s internal and external auditors in discharging this responsibility.
The organisation’s Integrated Risk Management Framework was developed in recognition that well-managed risk taking could contribute positively to the organisation’s performance, allowing for innovation and potentially driving improvements. A fundamental aspect of the framework is the organisation’s risk appetite, which is considered from the following two perspectives:
Risk taking – which acknowledges where the Clinical Commissioning Group has the resources, skills and control environment in place to be innovative in pursuit of its strategic objectives; and
Risk tolerance – which clearly sets out the boundaries of risk that the Governing Body is willing to accept.
In general, the Governing Body will accept risks where there is considered to be:
There is current evidence and a general consensus that the objective will lead to improved quality health outcomes.
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Any possible risk of harm to patients, the public or staff is minimised as a result of robust assessment.
There is minimal or no negative financial impact on the CCG.
There is no undue risk of adverse publicity, damage to the CCG’s reputation or to public and partnership confidence in the CCG.
There is no negative impact on the CCG’s ability to achieve its strategic objectives.
There is no potential for non-compliance with the law or in meeting the CCG’s statutory obligations.
Sufficient assurance has been received (through the Governing Body Assurance Framework) that the relevant organisational controls are in place and effective.
Whilst the organisation acknowledges that considered risk-taking is an important factor in supporting innovation and achieving better health outcomes, there are robust and integrated controls in place to ensure the prevention and detection of risk throughout the organisation; the principles of which are embedded through the organisation’s strategies, policies and procedures.
Capacity to Handle Risk
The Clinical Commissioning Group ensures its ongoing capacity to handle risk in a number of key ways. The Integrated Risk Management Framework is owned by the Governing Body and its members and named advisors provide leadership to the total risk management function. However, risk is considered to be the business of all staff, and managers are expected to lead by example by ensuring that risk management is acknowledged and embedded throughout the organisation as a fundamental part of our approach to good integrated governance.
All members of the organisation’s Executive Management Team are accountable for the effective management of risk within their areas of responsibility. This includes ensuring that appropriate controls are in place and that appropriate risk identification and mitigating actions are progressed and monitored.
Risk awareness is a key element of the organisation’s approach to risk management, ensuring that all staff understand and are able to discharge their roles and responsibilities in relation to risk. This approach is led by officers with in-house expertise in risk management and includes highlighting the need for risk assessments and explanation of, and subsequent support through, the risk management process.
We are committed to being a learning organisation and to support this, we ensure that there is regular analysis of incidents, complaints and claims to identify learning points and necessary actions. The organisation understands that good risk management opens up opportunities to create value and can have a positive impact on its long-term resilience.
Risk Assessment
The main risks identified by the Clinical Commissioning Group and monitored through the Organisational Risk Register during 2017/18 related to:
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Disinvestments made by the local authority due to its large scale reduction in funding which could lead to an increased demand for health services. The likelihood of this risk occurring has increased during the year following the Council’s announcement that it needed to save £27 million to balance its 2018/19 budget and a further £19 million in 2019/20. The organisation already works closely with the Council and together, we have recently increased oversight of system performance across health and social care and are assessing any known issues resulting from the disinvestments.
Commissioning decisions not being made and communicated in a timely manner which could potentially impact on Transformation. Whilst this was identified as a major risk at the start of the year, the risk has diminished during the year as work has progressed to integrate the Greater Nottingham CCGs’ governance arrangements and move towards a single staffing structure. It is anticipated that this risk will be mitigated to an acceptable level following inauguration of the new arrangements in April 2018.
A lack of assurance around the governance arrangements in place to support the Transformation Programme due to the absence of formal reporting arrangements. This risk was identified following a review performed by our Internal Auditors during 2017 and the organisation has since received regular assurances that the recommendations made in the report are being addressed.
The number of Nottingham City GP practices rated as ‘inadequate’ by the Care Quality Commission (CQC), which indicates a risk that patients may be receiving poor quality primary care and the potential for increased pressures on neighbouring practices. As at 31 March 2018, there are seven practices in the City with a rating of ‘inadequate’. This issue is being monitored closely by the organisation and we will continue to work closely with the CQC and NHS England to help address this.
The Clinical Commissioning Group monitors the performance of its main providers against key delivery priorities via a separate but parallel process to the organisation’s risk management arrangements, enhanced by the remit of the Risk and Performance Committee, which has a primary responsibility for scrutinising the robustness of both. The non-delivery of performance standards presents a potential risk of a detrimental impact on health outcomes, patient safety and patient experience. During 2017/18, the main performance concerns identified by the Clinical Commissioning Group related to:
Performance against the Accident and Emergency Department 4-hour waiting time standard – The national standard requires that 95% of attending patients are seen within four hours of their arrival at the Accident and Emergency Department. The vast majority of Nottingham City residents use the Accident and Emergency Department at Nottingham University Hospitals NHS Trust (NUH) when they need to access urgent and emergency care. Some of these services are also delivered at the Urgent Care Centre in the City, however, performance against the standard is principally measured in relation to services provided by NUH. The ability of the Trust to respond depends upon a number of factors across the health and social care community, including a reliance on social workers and community health teams to assess and arrange placements or support in the home for people who the hospital discharge who have ongoing health and social care needs. Despite the work that the Clinical Commissioning Group has been taking forward with partners to deliver improvements across the urgent care system, we have
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been unable to deliver the 4-hour waiting time standard throughout the year with an average performance of 80% (combined performance at NUH and the Urgent Care Centre). The main reasons for the target being breached remain consistent and relate to clinical decision making, bed availability and the clinical needs of the patients. A system wide recovery action plan is in place, which is being continually reviewed and updated to improve performance. The Accident and Emergency Local Delivery Board includes within its membership senior leaders from across the health and social care community. The Board is chaired by NUH's Chief Executive and has been meeting on a monthly basis since August 2016 with responsibility for monitoring the delivery of the Remedial Action Plan. In addition to this work, we monitor how patients feel about their experiences of care and undertake reviews to ensure that there has been no harm to patients as a result of the waiting time standard being missed. This work is overseen by a Quality and Scrutiny Panel.
Performance against this standard will continue to be a focus for 2018/19.
Performance against response time standards for East Midland Ambulance Service (EMAS) – From August 2017, performance for the service was monitored against the new ambulance response time standards, which were introduced following the largest clinical ambulance trials in the world, with a focus on ensuring the best, high quality, most appropriate response for each patient first time. Performance at a Trust level against these standards has been consistently below target throughout the year and the standards have not been delivered locally for the Nottingham City area. The main reasons for this are attributed to increased demand, resource availability, and reduced service capacity. Recovery action plans are in place, which are being continually reviewed and updated to improve performance. The quality of services for patients continues to be monitored closely.
Other sources of assurance
Internal Control Framework
A system of internal control is the set of processes and procedures in place in the clinical commissioning group to ensure it delivers its policies, aims and objectives. It is designed to identify and prioritise the risks, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically.
The system of internal control allows risk to be managed to a reasonable level rather than eliminating all risk; it can therefore only provide reasonable and not absolute assurance of effectiveness.
The Clinical Commissioning Group has established a wide range of monitoring procedures in order to ensure that the organisation’s system of internal control continues to operate effectively and that controls do not deteriorate over time. This includes the organisation’s contract monitoring arrangements and the work of a range of operational steering groups. It also includes the work of the Governing Body and its committees, particularly in relation to the scrutiny of the Governing Body Assurance Framework and progress against any gaps in controls and assurances that have been identified.
Annual audit of conflicts of interest management
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The revised statutory guidance on managing conflicts of interest for CCGs (published June 2017) requires CCGs to undertake an annual internal audit of conflicts of interest management. To support CCG’s complete this task, NHS England has published a template audit framework.
The organisation’s arrangements for managing conflicts of interest have been independently reviewed by our internal auditors and provided an opinion of significant assurance.
Data Quality
The Clinical Commissioning Group recognises that good quality data is essential for the effective commissioning of services and underpins the delivery of high quality patient care. Data quality is central to the organisation’s ongoing ability to meet its statutory, legal and financial responsibilities.
All of the organisation’s main providers are required under their contract to have good quality data that is compliant with national standards and we undertake validation processes to ensure data is complete, accurate, relevant and timely. We have responsibility for monitoring data quality of the services we commission and this is achieved through formal contract monitoring arrangements.
The CCG has a Data Quality Policy in place, which sets out the organisation’s requirements for maintaining and increasing high levels of data quality.
Information Governance
The NHS Information Governance Framework sets the processes and procedures by which the NHS handles information about patients and employees, in particular person-identifiable information. It is supported by the Information Governance Toolkit self-assessment tool which is completed and submitted annually providing assurances to the clinical commissioning group, other organisations and to individuals that personal information is dealt with legally, securely, efficiently and effectively.
We place high importance on ensuring there are robust information governance systems and processes in place to help protect personal and corporate information. The CCG has established an Information Governance Management Framework and a comprehensive suite of information governance policies, which outline the mechanisms in place to ensure that risks to confidentiality and data security are effectively managed and controlled. The roles of Caldicott Guardian and Senior Information Risk Owner (SIRO) have been assigned to appropriate members of the organisation’s Senior Management Team. The Risk and Performance Committee meets at least nine times per year and is responsible for overseeing the implementation of information governance policies, procedures, systems and processes, and for reviewing any breaches of confidentiality and other information security incidents should any occur.
We have ensured all staff have undertaken the latest annual information governance training and have provided staff with a series of briefings to ensure they are aware of their information governance roles and responsibilities in relation to confidentiality, data protection and information security.
There are processes in place for incident reporting and investigation of serious information incidents. We continue to develop information risk assessment and management procedures and an action plan has been established in order to fully embed an information risk culture throughout the organisation.
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We have submitted a satisfactory level of compliance with the Information Governance Toolkit assessment, achieving level 2 or above in all standards, resulting in an overall compliance rating of 69%. The organisation’s self-assessment has been independently reviewed and confirmed by our internal auditors. There have been no serious incidents relating to data security during the year.
The organisation has been preparing for the introduction of the EU General Data Protection Regulations (GDPR), which will replace the existing Data Protection Act 1998 on 25 May 2018. The new legislation is an enhancement on current data protection requirements and in particular, strengthens individuals’ rights over use of their personal data. Nottingham City CCG has a history of demonstrable assurance of compliance with data protection obligations. A programme of work has progressed to address any shortfalls in line with the GDPR preparedness guidance which has been released by the Information Commissioner’s Office and NHS Information Governance Alliance to ensure the organisation maintains lawful compliance.
We will continue to develop information governance processes and procedures in line with the requirements of the law, the Information Governance Toolkit and the national information governance agenda
Business Critical Models
In line with the best practice recommendations of the 2013 MacPherson review, I can confirm that the Clinical Commissioning Group has an appropriate framework and environment in place to provide quality assurance of business critical models.
Third party assurances
I also receive assurance through reports from audits performed on other organisations that provide services to the Clinical Commissioning Group. During 2017/18, the Clinical Commissioning Group has received reports relating to Arden and Greater East Midlands Commissioning Support Unit and NHS Shared Business Services Limited (employment services) regarding the employment and payroll services they provide across a number of NHS organisations. A number of exceptions have been noted from each of these reports.
The CCG also received reports relating to NHS Digital and its control system for GP payments to providers of General Practice services in England, for Capita Business Services Limited, in respect of the primary care support services provided to NHS England and delegated CCGs. In 2016/17, an Adverse Opinion was provided in respect of the operation of controls. As a result the CCG has implemented alternative assurance arrangements as discussed with external auditors. For 2017/18, an interim service auditor report has been published, covering the period 1 October 2017 to 31 December 2017. The opinion noted in this interim report is Qualified, so still not providing adequate assurance, albeit improved. As a result, the CCG arrangements for obtaining the additional assurance, as implemented last year, have continued.
The CCG has produced a statement for external audit about how it gains assurance from the local Primary Care Contracting and Finance team at NHS England, and also places reliance upon the ISA3402 service audit report on NHS Digital and the ISA 3402 service audit report on SBS ISFE, which have been issued nationally.
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In terms of detail, the CCG works closely with the NHSE Primary care Finance Team, and the following outlines the additional controls that the NHSE team have in place, in turn providing assurance to the CCG.
The NHSE Finance Team sets the initial budget at practice level, incorporating all negotiated uplifts and contract changes as well as making adjustments to budgets on a periodic basis for changes in list size, impact of rent reviews. GMS Contract payments are generated directly through systems such as Exeter and CQRS and interfaced directly into ISFE, assurance for these systems are provided by the NHS Digital Service Audit. Primary Medical Service Contracts, Premises, some enhanced services, out of hours deduction and LMC Levies are calculated by the NHS England Finance Team and entered on a payment schedule which is sent through to Capita (PCSE) for processing payment. The CCG approve final payment of GP Contract Runs before the BACS is submitted.
As part of the Management Accounts service provided by the local Primary Care Finance Team detailed working papers are maintained that reconcile payments made by Capita shown in the ledger to the budget set at the start of the year and updated on an on-going basis as required by changes in areas such as GP Practice List Sizes. Any variances in payments against budget that cannot be explained locally are investigated with Capita. The local Primary Care Finance Team also takes part in a National Primary Care Finance Leads meeting on a monthly basis to discuss updates on issues with PCSE. This information is then cascaded to CCG finance leads. Further to this a monthly financial report is produced outlining the CCG’s current and forecast financial position with explanation of any material variances from budget.
In overall terms, the CCG notes that this is a national issue and that any further assurance required by the external auditors is likely to be part of a national solution.
Control Issues
In addition to the above control issues regarding third party assurance, there has been one significant control issue with regard to elective outpatients and day case procurement at the Nottingham Treatment Centre.
The contract for services at the Nottingham Treatment Centre was retendered by the Greater Nottingham Clinical Commissioning Partnership in January / February 2018. The contract was for three years with the potential to extend to a total of five years, covering a range of services including outpatients, surgical theatres and dedicated diagnostic facilities such as scans and x-rays.
Service specifications were developed with local GPs and specialist clinicians, with advice from public health professionals and relevant professional bodies. The procurement value reflected changes in the local health system such as the expansion of alternative community services as well as tariff adjustments to accord to national policy.
The Invitation to Tender (ITT) was reissued shortly after publication, with changes in response to concerns raised by one of the bidders.
As part of the revised bidding process providers were required to submit transformation plans to demonstrate how they could reduce activity in line with wider transformation plans. These plans could include innovations in clinical practice, improving the quality and responsiveness of service user care and reducing unwarranted clinical variation.
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Circle Nottingham Ltd confirmed their intention to withdraw from the competitive process in March 2018, citing concerns around the sustainability of services. Bids from other providers were received and commissioners completed the evaluation and moderation process on these bids.
Circle Nottingham Ltd subsequently issued two sets of proceedings against NHS Rushcliffe Clinical Commissioning Group (as the lead commissioner) at the end of March on the basis of procurement law and by way of judicial review.
In May 2018 the Greater Nottingham CCGs and Circle Nottingham Ltd reached an agreement to protect patients’ interests and ensure no disruption to services by ending the legal challenge on negotiated terms. This agreement was to extend the contract for Circle to provide services at the Treatment Centre by one year.
The agreement removed the risk that legal issues would impact on service provision averting the threat of disruption to services for patients.
The CCGs have now initiated a new procurement project and aim to award a new contract to the successful bidder in 2019. The CCG have encouraged all interested providers and bidders from the first process to continue with their interest in the provision of services at the treatment centre to ensure this new procurement leads to the best service provision for the future
Review of economy, efficiency & effectiveness of the use of resources
The Clinical Commissioning Group’s Governing Body has oversight of the appropriateness of the organisation’s arrangements to exercise its functions effectively, efficiently and economically, and as Accountable Officer, I have overall executive responsibility for the use of resources.
The following key processes and review and assurance mechanisms have been established within the organisation in order to ensure that we meet our statutory duty to act effectively, efficiently and economically:
Clear Standing Orders, Scheme of Reservation and Delegation and Prime Financial Policies have been set out to ensure proper stewardship of public money and assets. Clear policies in relation to the required standards of business conduct are also in place.
A Procurement Policy is in place, which sets out the organisation’s approach for establishing contracts that provide value for money in line with the principles of good procurement practice. The policy clearly requires the Clinical Commissioning Group to ensure the delivery of improved efficiency and effectiveness in the provision of healthcare and non-healthcare services. The Audit Committee scrutinises all instances where requirements for formal competitive tendering or competitive quotations have been waived.
A Policy for Prioritisation and Resource Allocation is in place to ensure that a transparent and principle-based prioritisation process is applied to all investment and disinvestment decisions made by the organisation. The principles set out in the policy clearly require the Clinical Commissioning Group to demonstrate value for money and effectiveness when making resource allocation decisions so that the greatest health benefit can be achieved for our population from the available funding. The implementation of the policy is monitored by the Resource Allocation and Prioritisation Panel.
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Robust financial procedures and controls and effective financial management and financial planning arrangements have also been established, which are set out within the organisation’s Detailed Financial Policies. The Chief Finance Officer provides monthly reports to the Governing Body on financial performance, including performance against the organisation’s statutory financial duties.
Robust procedures have been implemented to control the development, implementation and monitoring of the Clinical Commissioning Group’s local Quality, Innovation, Productivity and Prevention (QIPP) Programme, ensuring that all QIPP schemes are embedded within the organisation’s operational commissioning plans. This work is overseen by the Risk and Performance Committee, which provides assurance to the Governing Body in terms of in-year progress, advising on any significant risks that may affect the organisation in delivery of its QIPP programme.
A Remuneration Committee is in place with delegated responsibility for setting the remuneration and terms of service for key senior leaders within the Clinical Commissioning Group. Suitable arrangements have been established to ensure that no member of the Committee is involved in discussions and decisions about their own remuneration.
The Clinical Commissioning Group has clear internal audit, external audit and counter fraud arrangements, which provide independent assurance to the organisation on a range of systems and processes that are designed to deliver economy, efficiency and effectiveness, including the organisation’s annual accounts and reporting process.
The Clinical Commissioning Group has a financial risk pooling arrangement with the five Clinical Commissioning Groups in Nottinghamshire County. This ensures that the financial risks associated with high cost patients are shared across the wider health economy.
Delegation of functions
The Clinical Commissioning Group’s Governing Body has approved the following external delegation of functions:
The CCG is currently party to three Section 75 Partnership Agreements with Nottingham City Council. These relate to the Better Care Fund, Domestic Violence and Tier 2 Child and Adolescent Mental Health Services. Section 75 partnership agreements are legally provided by the NHS Act 2006 and allow budgets to be pooled between NHS organisations and local authorities. These are partnerships of equal control, whereby one partner can act as a ‘host’ to manage the delegated functions and pooled budgets, however both partners remain equally responsible and accountable for those functions being carried out in a suitable manner. Nottingham City Council is acting as host in relation to the Partnership Agreements and overall strategic oversight responsibility sits with the Nottingham City Health and Wellbeing Board. However, a Commissioning Sub-Committee has been formally established to take strategic funding decisions relevant to the pooled budgets, which has equal voting rights between the two partners. Performance in relation to the Better Care Fund indicators is also monitored by the CCG’s Risk and Performance Committee and updates from the Nottingham City Health and Wellbeing Board are routinely presented to the CCG’s Governing Body.
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During early 2016/17, the 19 East Midlands CCGs established an East Midlands Affiliated Commissioning Committee (EMACC). This has been established to enable the CCGs to work collaboratively on the development and maintenance of policies for services that CCGs have responsibility for commissioning and have been identified as appropriate to implement on a regional scale. The EMACC is hosted by NHS Nottingham West CCG and is required to report to each CCG’s Governing Body following every meeting. Suitable arrangements have been established in relation to the work of the EMACC to ensure the effective management of risks and the declared interests of members. This is subject to regular monitoring by the host CCG’s Audit Committee. The EMACC met twice during 2017/18 and the minutes were received by the Governing Body.
On 1 April 2015, the Clinical Commissioning Group took on responsibility for a number of delegated functions relating to the commissioning of primary medical services under a formal Delegation Agreement with NHS England. In line with the Delegation Agreement, the CCG’s Primary Care Commissioning Panel acts as the corporate decision-making body for the management of the delegated functions. The Panel is accountable to the Governing Body, which is fulfilled through the regular submission of minutes from its meetings and an annual report at year-end. An exercise has also been completed for each individual delegated function to map out where responsibilities for operational delivery and governance oversight sit within the organisation. The purpose of this exercise was to ensure that appropriate arrangements have been established to enable the Clinical Commissioning Group to effectively discharge its delegated functions.
During May and June 2017, Governing Bodies of the Greater Nottingham CCGs (NHS Nottingham City CCG, NHS Nottingham North and East CCG, NHS Nottingham West CCG and NHS Rushcliffe CCG) formally agreed to the creation of a joint commissioning committee, supported by a shared management team and single Accountable Officer; as this was seen as the best solution to help address local challenges and an important first step toward developing an Integrated Care System. The Governing Body, along with the Governing Bodies of the Greater Nottingham CCGs, has overseen work to develop the Joint Commissioning Committee’s terms of reference and each formally agreed to approve changes to their Constitutions to reflect the establishment of the committee during their meetings in March 2018. The Constitutional changes were also approved by the CCG’s member practice in February 2018. The Joint Commissioning Committee’s inaugural public meeting was held in April 2018.
Counter fraud arrangements
The Clinical Commissioning Group has established arrangements to prevent fraud, bribery and corruption, and to deal with it should it occur. An accredited Counter Fraud Specialist (CFS) is contracted to undertake counter fraud work proportionate to the CCG’s identified risks. This work is delivered through the production and implementation of an organisational fraud, bribery and corruption risk assessment and work plan, developed in line with national standards.
The Chief Finance Officer has executive responsibility for the CCG’s counter fraud arrangements, with the Audit Committee taking an oversight and scrutiny role in this area. During 2017/18, the Audit Committee has received regular progress reports against the CCG’s counter fraud, bribery and corruption work plan and has monitored the organisation’s compliance with the requirements set
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out within NHS Protect’s Standards for Commissioners: Fraud, Bribery and Corruption. On 31 March 2018, a completed self-review tool was submitted to the NHS Counter Fraud Authority (formerly NHS Protect), which demonstrated an overall ‘Green’ score in relation to the CCG’s compliance with the standards.
Head of Internal Audit Opinion
Following completion of the planned audit work for the financial year for the clinical commissioning group, the Head of Internal Audit issued an independent and objective opinion on the adequacy and effectiveness of the clinical commissioning group’s system of risk management, governance and internal control. The summary Head of Internal Audit Opinion (issued in May 2018) concluded that:
“I am providing an opinion of Significant Assurance, that there is a generally sound framework of governance, risk management and control designed to meet the organisation’s objectives, and that controls are generally being applied consistently.
This Opinion is based on my review of your systems of internal control, primarily through the operation of your Governing Body Assurance Framework in the year to date, the outcome of individual assignments completed and your response to recommendations made.
I have reflected on the context in which the CCG operates, as well as the significant challenges currently facing many organisations operating in the NHS, and my opinion recognises that the system of internal control is designed to manage risk to a reasonable level, rather than eliminate all risk of failure to the achievement of strategic objectives”.
During the year, Internal Audit issued the following audit reports:
Audit Report Audit Objectives Level of Assurance
Commissioning Strategy Development
(1718/NCCCG/07)
The aim of this review was to determine whether a robust control framework was in place to support the development of the organisation’s commissioning strategy “Our Strategic Priorities 2017-2020”.
Significant
Review of Quality Governance
(1718/NCCCG/08)
The objective of this review was to determine the robustness of the organisation’s systems and processes for internal assurance of quality governance.
Significant
Key Financial Systems (1718/NCCCG/13)
The objective of the review was to determine whether robust systems and processes are in place in relation to the integrity of the CCG’s General Ledger, budgetary control systems, financial reporting and pay expenditure.
Significant
Contract Management Framework
(1718/NCCCG/15)
The aim of this review was to determine whether a robust control framework was in place within the CCG to ensure that healthcare contracts are being appropriately managed
Significant
Information Governance Toolkit
(1718/NCCCG/18)
The objective of this review was twofold: to assess whether there is sufficient appropriate evidence in support of the self-assessed IGT scores, and to evaluate the arrangements that the CCG has in place to ensure an effective and embedded Information Governance framework (as set out in standard 14-130).
Full
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Audit Report Audit Objectives Level of Assurance
Conflicts of Interest
The purpose of this audit was to evaluate the design and operating effectiveness of the arrangements that the CCG has in place to manage conflicts of interest and gifts and hospitality, including compliance with NHS England’s updated statutory guidance.
Significant
From the prior year’s Internal Audit Plan but not concluded for the final 2016/17 HOIA Opinion
Collaborative Commissioning (Associate Role) Review - Focus on the EMAS Contract
1718/NCCCG/02
This review was undertaken to ascertain whether a robust control framework exists within the organisation to assure itself (as an associate commissioner) to assure itself that contract management arrangements are in place and working effectively, in relation to the East Midlands Ambulance Service contract.
Significant
Managing Transformation: STP Governance
1718/NCCCG/03
This review was commissioned collectively by the Greater Nottingham CCGs; the objective being to provide each organisation with assurance that robust governance arrangements are in place to support the development and implementation of the Nottingham and Nottinghamshire STP. The review also included an overview of the Greater Nottingham Transformation Partnership’s governance arrangements.
Limited
The opinion of limited assurance issued for the Managing Transformation: STP Governance review was attributed to a lack of evidence to demonstrate effective oversight and management of risks; a lack of evidence to show how groups within the governance structure were being administered and the Governing Body being provided with insufficient information to provide adequate assurance that the governance arrangements were working effectively. The final report recognised the context in which the review was undertaken, stating:
“The review focussed on the governance structures in place during the planning (and early delivery) stages of the STP. This audit opinion does not detract from the volume of work which was undertaken, during this period, to produce and submit the STP in line with national timescales. Progress of the STP has also been recognised, nationally, as ‘advanced’ by NHS England (in July 2017)”.
Work has since been performed to ensure consistent information is provided to the Governing Body and the follow-up review on the recommendations is scheduled to take place early in 2018/19. The organisation has reflected the findings of the report on to its Organisational Risk Register; which has ensured an ongoing focus on the risk management actions by the Risk and Performance Committee.
In addition to the work performed in line with the CCG’s Internal Audit Plan 2017/18, the organisation has utilised the internal audit function to provide independent support for the development of integrated governance and risk management arrangements for the Greater Nottingham Clinical Commissioning Partnership.
Review of the effectiveness of governance, risk management and internal control
My review of the effectiveness of the system of internal control is informed by the work of the internal auditors and the executive managers and clinical leads within the Clinical Commissioning
makiphi
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Remuneration and Staff Report Remuneration Report
Remuneration Committee
The Remuneration Committee exists to make determinations about the remuneration, fees and other allowances for Governing Body members, and make recommendations to the Governing Body on determinations about the remuneration, fees and other allowances for employees and for people who provide services to the CCG and on determinations about allowances under any pension scheme that the CCG may establish as an alternative to the NHS pension scheme.
Membership of the Committee is drawn from the independent and GP members of the Governing Body and is determined on the basis of the matters to be discussed at each meeting, ensuring that no member of the Committee is involved in discussions and decisions about their own remuneration.
During 2017/18 the Remuneration Committee met on 19 April and 14 June 2017. The Committee also met as ‘committees in common’ with Remuneration Committees of NHS Nottingham North and East CCG, NHS Nottingham West CCG and NHS Rushcliffe CCG on 28 June, 22 November and 19 December 2017. These meetings in common were convened to discuss the recruitment process and remuneration packages for joint senior management posts across the four organisations. Further information on the work of the Committee over the year can be found in the Governance Statement contained within this report.
Policy on the remuneration of senior managers
For the purpose of this report, senior managers are defined as being ‘those persons in senior positions having authority or responsibility for directing or controlling the major activities of the Clinical Commissioning Group’. This means those who influence the decisions of the organisation as a whole, rather than the decisions of individual directorates or departments. Such persons will include advisory and Lay Members.
Our Remuneration Committee has responsibility to review and set senior manager remuneration packages. This is done on appointment in accordance with national guidance Clinical Commissioning Groups: Remuneration guidance for Chief Officers (where the senior manager also undertakes the accountable officer role) and Chief Finance Officers published by NHS England in 2012 and Clinical Commissioning Group Guidance on Senior Appointments including Accountable Officers published by NHS England in 2015. Benchmarking data is also used from neighbouring CCGs and those in national peer groups.
The Committee reviews senior managers’ pay on an annual basis, this includes consideration of both basic pay awards and cost of living increases. Our senior managers’ pay is not subject to any Performance Related Pay considerations.
Standard contracts have been established for all senior manager posts, which differ depending on whether the post is appointed for a term of office (as is the case for some Governing Body roles – i.e. Lay Members and elected GP Cluster Leads) or a permanent employment. Both contracts have standard terms and conditions, notice periods and termination payments, based on NHS Terms and Conditions of Service where relevant. Standard notice periods are currently three months.
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Senior manager remuneration (including salary and pension entitlements)
M Principe6 Director of Contracting and Transformation
85-90 25-27.5 110-115 65-70 0-2.5 65-70
L Branson Director of Corporate Development
75-80 42.5-45 120-125 75-80 17.5-20 95-100
N Bramhall7 Chief Nurse and Director of Quality
N/A N/A N/A 15-20 20-22.5 35-40
S Seeley Director of Quality and Personalisation
80-85 80-82.5 160-165 80-85 20-22.5 105-110
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2016/17 2017/18
Salary Expense payments (taxable)
Performance pay and bonuses
Long term performance
pay and bonuses
All pension-related benefits
TOTAL Salary Expense payments (taxable)
Performance pay and bonuses
Long term performance
pay and bonuses
All pension-related benefits
TOTAL
Name and Title (bands of £5,000)
(to nearest £100)
(bands of £5,000)
(bands of £5,000)
(bands of £2,500)
(bands of
£5,000) (bands of £5,000)
(to nearest £100)
(bands of £5,000)
(bands of £5,000)
(bands of £2,500)
(bands of
£5,000)
Dr M Abbott GP Cluster Lead
10-15 10-15 10-15 10-15
Dr Marcus Bicknell GP Cluster Lead
50-55 50-55 50-55 50-55
Dr Arun Tangri GP Cluster Lead
50-55 50-55 50-55 50-55
Dr Alastair McLachlan Corporate Medical Director
75-80 75-80 75-80 75-80
S Robson8
Independent Nurse N/A N/A 5-10 5-10
R Trainor9 Independent Nurse
10-15 10-15 0-5 0-5
Dr A Okudadej Independent Secondary Care Doctor
5-10 5-10 5-10 5-10
T Woods10 Lay Member and Deputy Chair
10-15 10-15 10-15 10-15
S Clague Lay Member
5-10 5-10 5-10 5-10
S Hale11 Lay Member
5-10 5-10 0-5 0-5
W Kendrick12 Lay Member
0-5 0-5 N/A N/A
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2016/17 2017/18
Salary Expense payments (taxable)
Performance pay and bonuses
Long term performance
pay and bonuses
All pension-related benefits
TOTAL Salary Expense payments (taxable)
Performance pay and bonuses
Long term performance
pay and bonuses
All pension-related benefits
TOTAL
Name and Title (bands of £5,000)
(to nearest £100)
(bands of £5,000)
(bands of £5,000)
(bands of £2,500)
(bands of
£5,000) (bands of £5,000)
(to nearest £100)
(bands of £5,000)
(bands of £5,000)
(bands of £2,500)
(bands of
£5,000)
J Howell Associate Lay Member
5-10 5-10 5-10 5-10
J Champion Associate Lay Member
5-10 5-10 5-10 5-10
S Harding Associate Lay Member
5-10 5-10 5-10 5-10
S Sunderland Associate Lay Member
5-10 5-10 5-10 5-10
Notes: The Accountable Officer has confirmed that the above table includes all those deemed to be 'senior managers', i.e. those persons in senior positions having authority or responsibility for directing or controlling the major activities of the Clinical Commissioning Group. All senior managers were in post for the whole accounting period, with the following exceptions: 1 S Walters took up her senior manager post on 1 October 2017. Remuneration shown is that which is in respect of the period the senior manager held office. 2 D Smith left her senior manager post on 7 January 2018. Remuneration shown is that which is in respect of the period the senior manager held office. 3 J Bemrose took up his senior manager post on 1 November 2017. Remuneration shown is that which is in respect of the period the senior manager held office. 4 L Bainbridge left her senior manager post on 31 October 2017. Remuneration shown is that which is in respect of the period the senior manager held office. 5 G Thompson took up his senior manager post on 1 January 2018. Remuneration shown is that which is in respect of the period the senior manager held office. 6 M Principe left her senior manager post on 31 December 2017. Remuneration shown is that which is in respect of the period the senior manager held office. 7 N Bramhall took up her senior manager post on 1 December 2017. Remuneration shown is that which is in respect of the period the senior manager held office. 8 S Robson took up her senior manager post on 1 May 2017. Remuneration shown is that which is in respect of the period the senior manager held office. 9 R Trainor left her senior manager post on 30 April 2017. Remuneration shown is that which is in respect of the period the senior manager held office. 10 T Woods took up his senior manager post on 25 April 2016. Remuneration shown is that which is in respect of the period the senior manager held office. 11 S Hale took up his senior manager post on 3 May 2016 and left his senior manager post on 31 May 2017. Remuneration shown is that which is in respect of the period the senior manager held
office. 12 W Kendrick left his senior manager post on 25 May 2016. Remuneration shown is that which is in respect of the period the senior manager held office.
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The salaries of the members below were allocated over a number of CCGs. The allocation to NHS Nottingham City CCG is shown above. Their total remuneration is shown below:
Name & Title Salary Expenses payments (taxable)
Performance pay & bonuses
Long term performance pay &
bonuses
All pension related benefits
Total
At 31 March 2018 (bands of £5,000) to nearest £100 (bands of £5,000) (bands of £5,000) (bands of £2,500) (bands of £5,000)
S Walters 120-125 97.5-100 220-225 Accountable Officer, Greater Nottingham CCGs
N Bramhall 105-110 142.5-145 245-250 Chief Nurse and Director of Quality, Greater Nottingham CCGs
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Pension benefits as at 31 March 2018
Name & Title Real increase in pension at
pension age
Real increase in lump sum at
pension age
Total accrued pension at
pension age at 31 March 2018
Lump sum at pension age
related to accrued pension
at 31 March 2018
Cash Equivalent
Transfer value at 1 April 2017
Real increase in Cash
Equivalent Transfer value
Cash Equivalent
Transfer value at
31 March 2018
Employers contribution
to stakeholder
pension
(bands of £2,500) (bands of £2,500)
(bands of £5,000)
(bands of £5,000)
£000 £000 £000 £000 £000 £000 £000 £000
Dr J Porter 2.5-5 0-2.5 30-35 35-40 252 3 267 N/A Chair, Clinical Leader and GP Cluster Lead
D Smith 0 0-2.5 45-50 145-150 1011 0 0 N/A Chief Officer (Nottingham City CCG)
L Bainbridge 0-2.5 0-2.5 20-25 40-45 229 29 281 N/A Chief Finance Officer (Nottingham City CCG)
M Principe 0-2.5 0 15-20 40-45 244 24 278 N/A Director of Contracts & Transformation
L Branson 0-2.5 0 20-25 45-50 260 32 294 N/A Director of Corporate Development
S Seeley 0-2.5 0-2.5 25-30 60-65 351 40 394 N/A Director of Quality and Personalisation
Notes: This disclosure is only for senior managers disclosed in the Salaries and Allowances table, where the Clinical Commissioning group makes contributions direct to a pension scheme (i.e. as an employer) or a sharing arrangement is in place which is being disclosed as if the person were employed. Other persons paid via an invoice to their employer and those where no pension contributions are being made will not be included in the table. Where NHS Pensions has provided the pension values relating to GP's membership of the Practitioner Pension scheme this is not relevant to the CCG role of that GP - only pension entitlements built up as part of contributions paid on the income from the CCG would be relevant.
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Compensation on early retirement of loss of office
There were no payments for loss of office made in 2017/18.
Payments to past members
There were no payments to past senior managers made in 2017/18.
Pay multiples
Reporting bodies are required to disclose the relationship between the remuneration of the highest paid member in their organisation and the median remuneration of the organisation’s workforce.
2017/18 2016/17
Band of highest paid director’s total remuneration1 (£000) - 0 130 – 135 Median total remuneration1 of the workforce £37,777 £36,250 Ratio 3.72
During 2017/18 there were no employees paid greater than the highest paid director.
Total remuneration includes salary, non-consolidated performance-related pay, benefits-in-kind as well as severance payments. It does not include employer’s pension contributions and the cash equivalent transfer value of pensions.
Staff Report
Analysis of staff numbers
At the start of the financial year, the CCG employed 151 members of staff (including appointees to the Governing Body and its committees). Despite some staff leaving the CCG’s employment or starting their employment with the CCG during the year, the CCG employed 151 members of staff as at 31 March 2018.
Breakdown of staff by gender at 31 March 2018:
Male Female Total
Governing Body members 6 4 10 Senior Managers (not included above)
0 7 7
Other members of staff 31 103 134 Total 37 109 151
Bi-annual Workforce Reports are presented to the Governing Body, which provide further analysis of the CCG’s workforce profile, including for example, an analysis of staff by pay band. These can be found in the Governing Body Meetings and Papers section of our website at www.nottinghamcity.nhs.uk.
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Sickness absence
Sickness absence can be problematic for small organisations as it is more difficult to cover the absence of key individuals or to disseminate the work between teams. This can in turn, have a significant impact on the organisation’s ability to deliver its key objectives and can lead to a decrease in staff morale and performance. The chart below details our monthly and cumulative absence rates for the period April 2017 to March 2018. This shows a fluctuating picture of absence across the year, which is primarily due to a number of long-term absences from the organisation.
Employee consultation and engagement
The CCG places a high importance on the delivery of effective communications, involvement and engagement with all of its employees. It discharges these duties through a variety of means including:
Staff communications framework: we have established a range of mechanisms for ensuring timely and transparent communications with our employees. These include a weekly e-newsletter and bi-monthly staff meetings.
Staff Reference Group: we have established a Staff Reference Group to engender an empowered, engaged and well-supported workforce. The Group advises on staff engagement and communication mechanisms and on the CCG’s approach to staff training, personal development and performance appraisals. It inputs to the production of organisational policies and procedures and the analysis and action planning resulting from the annual staff survey. The Group also supports the healthy workforce agenda and seeks to harness different perspectives and encourage innovative ideas and feedback from employees on the organisation’s working practices and the working environment.
0.00%
0.50%
1.00%
1.50%
2.00%
2.50%
3.00%
3.50%
4.00%
Abse
nce
Rate
(%)
Sickness Absence Rates
Monthly(Actual)
Monthly(Average)
AgreedTolerance(Average)
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Health and safety
As with all employers, we are required to comply with health, safety and fire legislation. We are committed to a culture of health and safety awareness in our organisation and in providing a secure and healthy environment for our employees and any other individual who may come into contact with the organisation’s activities. We ensure this by having robust arrangements in place for the delivery of all statutory and mandatory requirements in relation to health, safety and fire and by ensuring that all staff are sufficiently trained and instructed in these areas.
To support the wellbeing of staff, we have an occupational health service in place. Our Occupational Health Service is provided by COPE, an organisation that has extensive experience of successfully delivering flexible, bespoke, business-appropriate occupational health solutions to a wide range of clients in all sectors. COPE provide a comprehensive service to our staff that includes, flu vaccinations, ergonomic assessments, physiotherapy and staff wellbeing support.
Staff policies
The CCG has policies in place to provide guidance to all employees. We are committed to being a fair and inclusive employer, as well as maintaining a working environment that promotes the health and wellbeing of our employees. We have therefore taken positive steps to ensure that our policies deal with equality implications relating to recruitment and selection, pay and benefits, flexible working hours, training and development, and that we have policies around managing employees and protecting employees from harassment, victimisation and discrimination.
We operate a Guaranteed Interview Scheme, which ensures an interview for any candidate with a disclosed disability whose application meets all of the essential criteria for the post. We were previously accredited as a Disability Two Ticks Symbol Holder and we are currently in the process of becoming a Disability Confident employer. We also have Mindful Employer status, which demonstrates our commitment to supporting mental wellbeing at work. These accreditations support the recruitment of a workforce that reflects the diversity of our population and help to ensure that specific needs of employees are identified and addressed, whilst promoting positive attitudes towards people with physical, sensory and mental impairments.
Our Management of Absence Policy supports disabled employees and states that in cases where the employee is disabled within the meaning of the Equality Act 2010, or where employees become disabled and wish to remain in employment, every effort will be made to make reasonable adjustments or find an alternative post. We are not aware of any of our employees becoming disabled during 2017/18.
Apprenticeship Scheme
We participate in the apprenticeship scheme run by ProStart and are supporting three Apprentice Administrators to work for 18 months in different parts of the organisation. We recognise the valuable contribution made by apprenticeships to the organisation by bringing young people into our workforce and developing the skills of local people. Participation in the scheme also sends a positive message to our workforce and population about the values of the CCG and our commitment to engaging with our community.
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Expenditure on consultancy
During the year the CCG incurred expenditure totalling £109,000 (2016/17: £317,000).
Off-payroll engagements
Following the Review of Tax Arrangements of Public Sector Appointees published by the Chief Secretary to the Treasury on 23 May 2012, Clinical Commissioning Groups must publish information on their highly paid and/or senior off-payroll engagements.
Between 1 April 2017 and 31 March 2018, the CCG had no off-payroll engagements for more than £245 per day which lasted more than six months.
Off-payroll engagements longer than six months
Off-payroll engagement as at 31 March 2018, for more than £245 per day and that last longer than six months are shown in the table below.
Number
Number of existing engagements as of 31 March 2018 0 Of which, the number that have existed:
For less than one year at the time of reporting For between one and two years at the time of reporting For between 2 and 3 years at the time of reporting For between 3 and 4 years at the time of reporting For 4 or more years at the time of reporting
New Off-Payroll engagements
New off-payroll engagements between 1 April 2017 and 31 March 2018, for more than £245 per day and that last longer than six months are shown below:
Number
Number of new engagements, or those that reached six months in duration, between 1st April 2017 and 31st March 2018
0
Of which: Number assessed as caught by IR35 Number assessed as not caught by IR35 Number engaged directly (via person with significant control contacted to department) and are on the departmental payroll Number of engagements reassessed for consistency / assurance purposes during the year Number of engagements that saw a change to IR35 status following the consistency review
Off-Payroll Governing Body members/senior official engagements
Off-payroll engagements of Governing Body members and / or senior officials with significant financial responsibility between 1 April 2017 and 31 March 2018 are shown in the table below:
Number
Number of off-payroll engagements of Membership Body and / or Governing Body members, and / or senior officials with significant financial responsibility, during the financial year
0
Total number of individuals on-payroll and off-payroll that have been deemed 'board members, 11*
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and/or, senior officials with significant financial responsibility' during the financial year. This figure includes both on-payroll and off-payroll engagements.
* All existing voting Governing Body members
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Exit Packages
In 2017/18 there was one exit package for early retirement of the Chief Officer in the efficiency of the service, following the recruitment of a Greater Nottingham CCGs’ Accountable Officer. The total amount paid was £140,000. Only contractual costs were paid.
Exit Package cost band (including any special payment element)
Number of Compulsory
Redundancies
Cost of Compulsory
redundancies
Number of Other
agreed departures
Cost of other departures
agreed
Total number of exit
packages
Total cost of exit
packages
Number of departures where special payments have been made
Cost of special payment element included in exit
packages
Whole Numbers
only £s
Whole Numbers
only £s
Whole Numbers
only £s Whole Numbers
only £s
Less than £10,000
£10,000 - £25,000
£25,001 - £50,000
£50,001 - £100,000
£100,001 - £150,000 1 £140,000 1 £140,000
£150,001 - £200,000 >£200,000 Totals
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Analysis of Other Departures
Agreements Number
Total Value of Agreements £000
Voluntary redundancies including early retirement contractual costs Mutually agreed resignations (MARS) contractual costs
Early retirements in the efficiency of the service contractual costs
1 £140
Contractual payments in lieu of notice Exit payments following Employment Tribunals or court orders Non-contractual payments requiring HMT approval
Total 1 £140
Other Employee Matters
Trade Union Relationships
The CCG has a Recognition Agreement which provides a framework for successful
partnership arrangements between the Trade Unions and the CCG in order to develop professional practice and foster good employment relations. It provides methods whereby the CCG will recognise the recognised Trade Unions to support, represent and bargain for its members. We are a member of the Nottinghamshire/Derbyshire Joint Staff Partnership Forum, where the CCGs meet with regional Trade Union representatives.
Time off for Trade Union duties and activities is detailed in the CCG’s Special Leave Policy. For members of a recognised Trade Union, Trade Union activities are unpaid. For Trade Union duties, training or acting as a Learning Representative payment is made in line with ACAS Code of Practice.
To date, none of the Trade Unions has approached the CCG to ask for any employees to be considered as a Trade Union representative.
Relevant union officials
Total number of employees who were relevant union officials during the relevant period:
Number of employees who were relevant union officials during the relevant period
Full-time equivalent employee number
0 0
makiphi
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Parliamentary Accountability and Audit Report NHS Nottingham City CCG is not required to produce a Parliamentary Accountability and Audit Report. Disclosures on remote contingent liabilities, losses and special payments, gifts, and fees and charges are included as notes in the Annual Accounts section of this report. An audit certificate and report is also included in Annual Accounts section of this report.
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Annual Accounts Statement of comprehensive net expenditure for the year ended 31 March 2018
2017-18 2016-17 Note £'000 £'000
Income from sale of goods and services 2 (3,963) (15,799) Other operating income 2 (2,969) (800) Total operating income (6,932) (16,599)
Staff costs 4 7,872 6,907 Purchase of goods and services 5 491,784 486,101 Depreciation and impairment charges 5 0 0 Provision expense 5 51 425 Other Operating Expenditure 5 631 1,179 Total operating expenditure 500,338 494,612
Net Operating Expenditure 493,406 478,013
Finance income Finance expense 10 0 0 Net expenditure for the year 493,406 478,013 Net Gain/(Loss) on Transfer by Absorption 0 0 Total Net Expenditure for the year 493,406 478,013 Other Comprehensive Expenditure Items which will not be reclassified to net operating costs Net (gain)/loss on revaluation of PPE 0 0 Net (gain)/loss on revaluation of Intangibles 0 0 Net (gain)/loss on revaluation of Financial Assets 0 0 Actuarial (gain)/loss in pension schemes 0 0 Impairments and reversals taken to Revaluation Reserve 0 0 Items that may be reclassified to Net Operating Costs 0 0 Net gain/loss on revaluation of available for sale financial assets 0 0 Reclassification adjustment on disposal of available for sale financial assets
0 0
Sub total 0 0
Comprehensive Expenditure for the year ended 31 March 2018 493,406 478,013
Statement of financial position as at 31 March 2018
Non-current assets: Property, plant and equipment Intangible assets Investment property Trade and other receivables Other financial assets Total non-current assets
Current assets: Inventories Trade and other receivables Other financial assets Other current assets Cash and cash equivalents Total current assets
Non-current assets held for sale
Total current assets
Total assets
Current liabilities Trade and other payables Other financial liabilities Other liabilities Borrowings Provisions Total current liabilities
Non-Current Assets plus/less Net Current Assets/Liabilities
Non-current liabilities Trade and other payables Other financial liabilities Other liabilities Borrowings Provisions Total non-current liabilities
Assets less Liabilities
Financed by Taxpayers’ Equity General fund Revaluation reserve Other reserves Charitable Reserves Total taxpayers' equity: The notes on pages 88 to 126 form part of this statement
The financial statements on pages 81 to 126 were approved by the Audit Committee (as delegated by
the Governing Body) on 24 May 2018 and signed on its behalf by:
�w� Samantha Walters
Accountable Officer
24 May 2018
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Rectangle
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Statement of changes in taxpayers’ equity for the year ended 31 March 2018
General fund
Revaluation reserve
Other reserves
Total reserves
£'000 £'000 £'000 £'000 Changes in taxpayers’ equity for 2017-18
Balance at 01 April 2017 (24,415) 0 0 (24,415)
Transfer between reserves in respect of assets transferred from closed NHS bodies 0 0 0 0 Adjusted NHS Clinical Commissioning Group balance at 31 March 2018 (24,415) 0 0 (24,415)
Changes in NHS Clinical Commissioning Group taxpayers’ equity for 2017-18 Net operating expenditure for the financial year (493,406) (493,406)
Net gain/(loss) on revaluation of property, plant and equipment 0 0 Net gain/(loss) on revaluation of intangible assets 0 0 Net gain/(loss) on revaluation of financial assets 0 0 Total revaluations against revaluation reserve 0 0 0 0
Net gain (loss) on available for sale financial assets 0 0 0 0 Net gain (loss) on revaluation of assets held for sale 0 0 0 0 Impairments and reversals 0 0 0 0 Net actuarial gain (loss) on pensions 0 0 0 0 Movements in other reserves 0 0 0 0 Transfers between reserves 0 0 0 0 Release of reserves to the Statement of Comprehensive Net Expenditure 0 0 0 0 Reclassification adjustment on disposal of available for sale financial assets 0 0 0 0 Transfers by absorption to (from) other bodies 0 0 0 0 Reserves eliminated on dissolution 0 0 0 0 Net Recognised NHS Clinical Commissioning Group Expenditure for the Financial Year (493,406) 0 0 (493,406)
Balance at 01 April 2016 Transfer of assets and liabilities from closed NHS bodies as a result of the 1 April 2013 transition Adjusted NHS Clinical Commissioning Group balance at 31 March 2017
Changes in NHS Clinical Commissioning Group taxpayers’ equity for 2016-17 Net operating costs for the financial year
Net gain/(loss) on revaluation of property, plant and equipment Net gain/(loss) on revaluation of intangible assets Net gain/(loss) on revaluation of financial assets Total revaluations against revaluation reserve
Net gain (loss) on available for sale financial assets Net gain (loss) on revaluation of assets held for sale Impairments and reversals Net actuarial gain (loss) on pensions Movements in other reserves Transfers between reserves Release of reserves to the Statement of Comprehensive Net Expenditure Reclassification adjustment on disposal of available for sale financial assets Transfers by absorption to (from) other bodies Reserves eliminated on dissolution Net Recognised NHS Clinical Commissioning Group Expenditure for the Financial Year
Net funding
Balance at 31 March 2017
The notes on pages 88 to 126 form part of this statement
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Statement of cash flows for the year ended 31 March 2018
2017-18 2016-17
Note £'000 £'000
Cash Flows from Operating Activities
Net operating expenditure for the financial year (493,406) (478,013) Depreciation and amortisation 5 0 0 Impairments and reversals 5 0 0 Movement due to transfer by Modified Absorption 0 0 Other gains (losses) on foreign exchange 0 0 Donated assets received credited to revenue but non-cash 0 0 Government granted assets received credited to revenue but non-cash 0 0 Interest paid 0 0 Release of PFI deferred credit 0 0 Other Gains & Losses 0 0 Finance Costs 0 0 Unwinding of Discounts 0 0 (Increase)/decrease in inventories 0 0 (Increase)/decrease in trade & other receivables 17 (4,539) 7 (Increase)/decrease in other current assets 0 0 Increase/(decrease) in trade & other payables 23 11,041 (206) Increase/(decrease) in other current liabilities 0 0 Provisions utilised 30 0 0 Increase/(decrease) in provisions 30 51 425
Net Cash Inflow (Outflow) from Operating Activities (486,853) (477,787)
Cash Flows from Investing Activities
Interest received 0 0 (Payments) for property, plant and equipment 0 0 (Payments) for intangible assets 0 0 (Payments) for investments with the Department of Health 0 0 (Payments) for other financial assets 0 0 (Payments) for financial assets (LIFT) 0 0 Proceeds from disposal of assets held for sale: property, plant and equipment 0 Proceeds from disposal of assets held for sale: intangible assets 0 0 Proceeds from disposal of investments with the Department of Health 0 0 Proceeds from disposal of other financial assets 0 0 Proceeds from disposal of financial assets (LIFT) 0 0 Loans made in respect of LIFT 0 0 Loans repaid in respect of LIFT 0 0 Rental revenue 0 0
Net Cash Inflow (Outflow) from Investing Activities 0 0
Net Cash Inflow (Outflow) before Financing (486,853) (477,787)
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486,720 477,914 0 0 0 0
0 0 0 0 0 0
486,720 477,914
20 (133) 126
166 39
0 0
33 166
Cash Flows from Financing Activities
Grant in Aid Funding Received Other loans received Other loans repaid Capital element of payments in respect of finance leases and on Statement of Financial Position PFI and LIFT Capital grants and other capital receipts Capital receipts surrendered
Net Cash Inflow (Outflow) from Financing Activities
Net Increase (Decrease) in Cash & Cash Equivalents
Cash & Cash Equivalents at the Beginning of the Financial Year
Effect of exchange rate changes on the balance of cash and cash equivalents held in foreign currencies
Cash & Cash Equivalents (including bank overdrafts) at the End of the Financial Year
The notes on pages 88 to 126 form part of this statement
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Notes to the accounts
1 Accounting Policies
NHS England has directed that the financial statements of clinical commissioning groups shall meet the accounting requirements of the Group Accounting Manual issued by the Department of Health and Social Care. Consequently, the following financial statements have been prepared in accordance with the Group Accounting Manual 2017-18 issued by the Department of Health and Social Care. The accounting policies contained in the Group Accounting Manual follow International Financial Reporting Standards to the extent that they are meaningful and appropriate to clinical commissioning groups, as determined by HM Treasury, which is advised by the Financial Reporting Advisory Board. Where the Group Accounting Manual permits a choice of accounting policy, the accounting policy which is judged to be most appropriate to the particular circumstances of the clinical commissioning group for the purpose of giving a true and fair view has been selected. The particular policies adopted by the clinical commissioning group are described below. They have been applied consistently in dealing with items considered material in relation to the accounts.
1.1 Going Concern
These accounts have been prepared on the going concern basis.
Public sector bodies are assumed to be going concerns where the continuation of the provision of a service in the future is anticipated, as evidenced by inclusion of financial provision for that service in published documents.
Where a clinical commissioning group ceases to exist, it considers whether or not its services will continue to be provided (using the same assets, by another public sector entity) in determining whether to use the concept of going concern for the final set of Financial Statements. If services will continue to be provided the financial statements are prepared on the going concern basis.
1.2 Accounting Convention
These accounts have been prepared under the historical cost convention modified to account for the revaluation of property, plant and equipment, intangible assets, inventories and certain financial assets and financial liabilities.
1.3 Acquisitions & Discontinued Operations
Activities are considered to be ‘acquired’ only if they are taken on from outside the public sector. Activities are considered to be ‘discontinued’ only if they cease entirely. They are not considered to be ‘discontinued’ if they transfer from one public sector body to another.
1.4 Movement of Assets within the Department of Health and Social Care Group
Transfers as part of reorganisation fall to be accounted for by use of absorption accounting in line with the Government Financial Reporting Manual, issued by HM Treasury. The Government Financial Reporting Manual does not require retrospective adoption, so prior year transactions (which have been accounted for under merger accounting) have not been restated. Absorption accounting requires that entities account for their transactions in the period in which they took place, with no restatement of performance required when functions transfer within the public sector. Where assets and liabilities transfer, the gain or loss resulting is recognised in the Statement of Comprehensive Net Expenditure, and is
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disclosed separately from operating costs.
Other transfers of assets and liabilities within the Department of Health and Social Care Group are accounted for in line with IAS 20 and similarly give rise to income and expenditure entries.
1.5 Charitable Funds
Under the provisions of IAS 27: Consolidated & Separate Financial Statements, those Charitable Funds that fall under common control with NHS bodies are consolidated within the entities’ accounts. NHS Nottingham City CCG holds no charitable funds, and so there is no consolidation of charitable funds within these accounts.
1.6 Pooled Budgets
Where the clinical commissioning group has entered into a pooled budget arrangement under Section 75 of the National Health Service Act 2006 the clinical commissioning group accounts for its share of the assets, liabilities, income and expenditure arising from the activities of the pooled budget, identified in accordance with the pooled budget agreement.
NHS Nottingham City CCG has entered into two pooled budget arrangements under Section 75 of the NHS Act 2006.
The first pooled budget arrangement is between Nottingham City Council, Nottinghamshire County Council, NHS Rushcliffe CCG, NHS Nottingham North and East CCG, NHS Nottingham West CCG, NHS Bassetlaw CCG, NHS Newark and Sherwood CCG and NHS Mansfield and Ashfield CCG.
This pooled budget is hosted by Nottinghamshire County Council and provides an Integrated Community Equipment Service, which delivers the provision, delivery and collection of equipment provided by the British Red Cross. Integrated Community Equipment and Loan Services (ICELS) provides a range of equipment to adults and children across Nottinghamshire.
The second pooled budget is the 'Better Care Fund (BCF)' and is hosted by Nottingham City Council. It utilises pooled funds, aligns budgets and jointly commissions services to achieve national and local objectives to integrate health and social care services in Nottingham City. It is between NHS Nottingham City CCG and Nottingham City Council, and its aims are to improve the quality and efficiency of services.
A memorandum note to the accounts provides details of the joint Income and Expenditure in respect of the two pooled budgets (refer to Note 35).
1.7 Critical Accounting Judgements & Key Sources of Estimation Uncertainty
In the application of the clinical commissioning group’s accounting policies, management is required to make judgements, estimates and assumptions about the carrying amounts of assets and liabilities that are not readily apparent from other sources. The estimates and associated assumptions are based on historical experience and other factors that are considered to be relevant. Actual results may differ from those estimates and the estimates and underlying assumptions are continually reviewed. Revisions to accounting estimates
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are recognised in the period in which the estimate is revised if the revision affects only that period or in the period of the revision and future periods if the revision affects both current and future periods.
1.7.1 Critical Judgements in Applying Accounting Policies
The following are the critical judgements, apart from those involving estimations (see below) that management has made in the process of applying the Clinical Commissioning Group’s accounting policies that have the most significant effect on the amounts recognised in the financial statements:
Maternity Pathway Costs
The Clinical Commissioning Group prepays out Maternity Pathway Costs which span the end of the financial year.
1.7.2 Key Sources of Estimation Uncertainty
The following are the key estimations that management has made in the process of applying the Clinical Commissioning Group’s accounting policies that have the most significant effect on the amounts recognised in the financial statements:
Partially Completed Spells
The Clinical Commissioning Group includes estimations for partially completed spells which span the end of the Financial Year. The Provider produces activity information to the Clinical Commissioning Group on which to base the estimation.
1.8 Revenue
Revenue in respect of services provided is recognised when, and to the extent that, performance occurs, and is measured at the fair value of the consideration receivable.
Where income is received for a specific activity that is to be delivered in the following year, that income is deferred.
1.9 Employee Benefits
1.9.1 Short-term Employee Benefits
Salaries, wages and employment-related payments are recognised in the period in which the service is received from employees, including bonuses earned but not yet taken.
The cost of leave earned but not taken by employees at the end of the period is recognised in the financial statements to the extent that employees are permitted to carry forward leave into the following period.
1.9.2 Retirement Benefit Costs
Past and present employees are covered by the provisions of the NHS Pensions Scheme. The scheme is an unfunded, defined benefit scheme that covers NHS employers, General Practices and other bodies, allowed under the direction of the Secretary of State, in England and Wales. The scheme is not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities. Therefore, the scheme is accounted for as if it were a defined contribution scheme: the cost to the clinical
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commissioning group of participating in the scheme is taken as equal to the contributions payable to the scheme for the accounting period.
For early retirements other than those due to ill health the additional pension liabilities are not funded by the scheme. The full amount of the liability for the additional costs is charged to expenditure at the time the clinical commissioning group commits itself to the retirement, regardless of the method of payment.
1.10 Other Expenses
Other operating expenses are recognised when, and to the extent that, the goods or services have been received. They are measured at the fair value of the consideration payable.
Expenses and liabilities in respect of grants are recognised when the clinical commissioning group has a present legal or constructive obligation, which occurs when all of the conditions attached to the payment have been met.
1.11 Leases
Leases are classified as finance leases when substantially all the risks and rewards of ownership are transferred to the lessee. All other leases are classified as operating leases.
1.11.1 The Clinical Commissioning Group as Lessee
Operating lease payments are recognised as an expense on a straight-line basis over the lease term. Lease incentives are recognised initially as a liability and subsequently as a reduction of rentals on a straight-line basis over the lease term.
1.12 Cash & Cash Equivalents
Cash is cash in hand and deposits with any financial institution repayable without penalty on notice of not more than 24 hours. Cash equivalents are investments that mature in 3 months or less from the date of acquisition and that are readily convertible to known amounts of cash with insignificant risk of change in value.
In the Statement of Cash Flows, cash and cash equivalents are shown net of bank overdrafts that are repayable on demand and that form an integral part of the clinical commissioning group’s cash management.
1.13 Provisions
Provisions are recognised when the clinical commissioning group has a present legal or constructive obligation as a result of a past event, it is probable that the clinical commissioning group will be required to settle the obligation, and a reliable estimate can be made of the amount of the obligation. The amount recognised as a provision is the best estimate of the expenditure required to settle the obligation at the end of the reporting period, taking into account the risks and uncertainties. Where a provision is measured using the cash flows estimated to settle the obligation, its carrying amount is the present value of those cash flows using HM Treasury’s discount rate as follows:
Timing of cash flows (0 to 5 years inclusive): Minus 2.420% (previously: minus 2.70%)
Timing of cash flows (6 to 10 years inclusive): Minus 1.85% (previously: minus 1.95%)
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Timing of cash flows (over 10 years): Minus 1.56% (previously: minus 0.80%)
When some or all of the economic benefits required to settle a provision are expected to be recovered from a third party, the receivable is recognised as an asset if it is virtually certain that reimbursements will be received and the amount of the receivable can be measured reliably.
1.14 Clinical Negligence Costs
The NHS Resolution operates a risk pooling scheme under which the clinical commissioning group pays an annual contribution to the NHS Resolution which in return settles all clinical negligence claims. The contribution is charged to expenditure. Although the NHS Resolution is administratively responsible for all clinical negligence cases the legal liability remains with the clinical commissioning group.
1.15 Non-clinical Risk Pooling
The clinical commissioning group participates in the Property Expenses Scheme and the Liabilities to Third Parties Scheme. Both are risk pooling schemes under which the clinical commissioning group pays an annual contribution to the NHS Resolution and, in return, receives assistance with the costs of claims arising. The annual membership contributions, and any excesses payable in respect of particular claims are charged to operating expenses as and when they become due.
1.16 Continuing healthcare risk pooling
In 2014-15 a risk pool scheme was been introduced by NHS England for continuing healthcare claims, for claim periods prior to 31 March 2013. Under the scheme NHS Nottingham City CCG contributes annually to a pooled fund, which is used to settle the claims.
1.17 Contingencies
A contingent liability is a possible obligation that arises from past events and whose existence will be confirmed only by the occurrence or non-occurrence of one or more uncertain future events not wholly within the control of the clinical commissioning group, or a present obligation that is not recognised because it is not probable that a payment will be required to settle the obligation or the amount of the obligation cannot be measured sufficiently reliably. A contingent liability is disclosed unless the possibility of a payment is remote.
A contingent asset is a possible asset that arises from past events and whose existence will be confirmed by the occurrence or non-occurrence of one or more uncertain future events not wholly within the control of the clinical commissioning group. A contingent asset is disclosed where an inflow of economic benefits is probable.
Where the time value of money is material, contingencies are disclosed at their present value.
1.18 Financial Assets
Financial assets are recognised when the clinical commissioning group becomes party to the financial instrument contract or, in the case of trade receivables, when the goods or
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services have been delivered. Financial assets are derecognised when the contractual rights have expired or the asset has been transferred.
Financial assets are classified into the following categories:
Financial assets at fair value through profit and loss;
Held to maturity investments;
Available for sale financial assets; and,
Loans and receivables.
The classification depends on the nature and purpose of the financial assets and is determined at the time of initial recognition.
1.18.1 Financial Assets at Fair Value Through Profit and Loss
Embedded derivatives that have different risks and characteristics to their host contracts, and contracts with embedded derivatives whose separate value cannot be ascertained, are treated as financial assets at fair value through profit and loss. They are held at fair value, with any resultant gain or loss recognised in calculating the clinical commissioning group’s surplus or deficit for the year. The net gain or loss incorporates any interest earned on the financial asset.
1.18.2 Held to Maturity Assets
Held to maturity investments are non-derivative financial assets with fixed or determinable payments and fixed maturity, and there is a positive intention and ability to hold to maturity. After initial recognition, they are held at amortised cost using the effective interest method, less any impairment. Interest is recognised using the effective interest method.
1.18.3 Available For Sale Financial Assets
Available for sale financial assets are non-derivative financial assets that are designated as available for sale or that do not fall within any of the other three financial asset classifications. They are measured at fair value with changes in value taken to the revaluation reserve, with the exception of impairment losses. Accumulated gains or losses are recycled to surplus/deficit on de-recognition.
1.18.4 Loans & Receivables
Loans and receivables are non-derivative financial assets with fixed or determinable payments which are not quoted in an active market. After initial recognition, they are measured at amortised cost using the effective interest method, less any impairment. Interest is recognised using the effective interest method.
Fair value is determined by reference to quoted market prices where possible, otherwise by valuation techniques.
The effective interest rate is the rate that exactly discounts estimated future cash receipts through the expected life of the financial asset, to the initial fair value of the financial asset.
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At the end of the reporting period, the clinical commissioning group assesses whether any financial assets, other than those held at ‘fair value through profit and loss’ are impaired. Financial assets are impaired and impairment losses recognised if there is objective evidence of impairment as a result of one or more events which occurred after the initial recognition of the asset and which has an impact on the estimated future cash flows of the asset.
For financial assets carried at amortised cost, the amount of the impairment loss is measured as the difference between the asset’s carrying amount and the present value of the revised future cash flows discounted at the asset’s original effective interest rate. The loss is recognised in expenditure and the carrying amount of the asset is reduced through a provision for impairment of receivables.
If, in a subsequent period, the amount of the impairment loss decreases and the decrease can be related objectively to an event occurring after the impairment was recognised, the previously recognised impairment loss is reversed through expenditure to the extent that the carrying amount of the receivable at the date of the impairment is reversed does not exceed what the amortised cost would have been had the impairment not been recognised.
1.19 Financial Liabilities
Financial liabilities are recognised on the statement of financial position when the clinical commissioning group becomes party to the contractual provisions of the financial instrument or, in the case of trade payables, when the goods or services have been received. Financial liabilities are de-recognised when the liability has been discharged, that is, the liability has been paid or has expired.
1.19.1 Financial Guarantee Contract Liabilities
Financial guarantee contract liabilities are subsequently measured at the higher of:
The premium received (or imputed) for entering into the guarantee less cumulative amortisation; and,
The amount of the obligation under the contract, as determined in accordance with IAS 37: Provisions, Contingent Liabilities and Contingent Assets.
1.19.2 Financial Liabilities at Fair Value Through Profit and Loss
Embedded derivatives that have different risks and characteristics to their host contracts, and contracts with embedded derivatives whose separate value cannot be ascertained, are treated as financial liabilities at fair value through profit and loss. They are held at fair value, with any resultant gain or loss recognised in the clinical commissioning group’s surplus/deficit. The net gain or loss incorporates any interest payable on the financial liability.
1.19.3 Other Financial Liabilities
After initial recognition, all other financial liabilities are measured at amortised cost using the effective interest method, except for loans from Department of Health and Social Care, which are carried at historic cost. The effective interest rate is the rate that exactly discounts estimated future cash payments through the life of the asset, to the net carrying
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amount of the financial liability. Interest is recognised using the effective interest method.
1.20 Value Added Tax
Most of the activities of the clinical commissioning group are outside the scope of VAT and, in general, output tax does not apply and input tax on purchases is not recoverable. Irrecoverable VAT is charged to the relevant expenditure category or included in the capitalised purchase cost of fixed assets. Where output tax is charged or input VAT is recoverable, the amounts are stated net of VAT.
1.21 Foreign Currencies
The clinical commissioning group’s functional currency and presentational currency is sterling. Transactions denominated in a foreign currency are translated into sterling at the exchange rate ruling on the dates of the transactions. At the end of the reporting period, monetary items denominated in foreign currencies are retranslated at the spot exchange rate on 31 March. Resulting exchange gains and losses for either of these are recognised in the clinical commissioning group’s surplus/deficit in the period in which they arise.
1.22 Third Party Assets
Assets belonging to third parties (such as money held on behalf of patients) are not recognised in the accounts since the clinical commissioning group has no beneficial interest in them.
1.23 Losses & Special Payments
Losses and special payments are items that Parliament would not have contemplated when it agreed funds for the health service or passed legislation. By their nature they are items that ideally should not arise. They are therefore subject to special control procedures compared with the generality of payments. They are divided into different categories, which govern the way that individual cases are handled.
Losses and special payments are charged to the relevant functional headings in expenditure on an accruals basis, including losses which would have been made good through insurance cover had the clinical commissioning group not been bearing its own risks (with insurance premiums then being included as normal revenue expenditure).
1.24 Joint Ventures
Material entities over which the clinical commissioning group has joint control with one or more other parties so as to obtain economic or other benefits are classified as joint ventures. Joint ventures are accounted for using the equity method.
Joint ventures that are classified as ‘held for sale’ are measured at the lower of their carrying amount or ‘fair value less costs to sell’.
1.25 Joint Operations
Joint operations are activities undertaken by the clinical commissioning group in conjunction with one or more other parties but which are not performed through a separate entity. The clinical commissioning group records its share of the income and expenditure; gains and losses; assets and liabilities; and cash flows.
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1.26 Research & Development
Research and development expenditure is charged in the year in which it is incurred, except insofar as development expenditure relates to a clearly defined project and the benefits of it can reasonably be regarded as assured. Expenditure so deferred is limited to the value of future benefits expected and is amortised through the Statement of Comprehensive Net Expenditure on a systematic basis over the period expected to benefit from the project. It should be re-valued on the basis of current cost. The amortisation is calculated on the same basis as depreciation.
1.27 Accounting Standards That Have Been Issued But Have Not Yet Been Adopted
The DHSC Group accounting manual does not require the following Standards and Interpretations to be applied in 2017-18. These standards are still subject to FREM adoption and early adoption is not therefore permitted.
IFRS 9: Financial Instruments ( application from 1 January 2018)
IFRS 14: Regulatory Deferral Accounts ( not applicable to DH groups bodies)
IFRS 15: Revenue for Contract with Customers (application from 1 January 2018)
IFRS 16: Leases (application from 1 January 2019)
IFRS 17: Insurance Contracts (application from 1 January 2021)
IFRIC 22: Foreign Currency Transactions and Advance Consideration (application from 1 January 2018)
IFRIC 23: Uncertainty over Income Tax Treatments (application from 1 January 2019)
The application of the Standards as revised would not have a material impact on the accounts for 2017-18, were they applied in that year.
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2. Other Operating Revenue2017-18 2017-18 2017-18 2016-17
Total Admin Programme Total
£'000 £'000 £'000 £'000
Recoveries in respect of employee benefits 0 0 0 0 Patient transport services 0 0 0 0 Prescription fees and charges 2 0 2 2 Dental fees and charges 0 0 0 0 Education, training and research 0 0 0 2 Charitable and other contributions to revenue expenditure: NHS 0 0 0 0 Charitable and other contributions to revenue expenditure: non-NHS 0 0 0 0 Receipt of donations for capital acquisitions: NHS Charity 0 0 0 0 Receipt of Government grants for capital acquisitions 0 0 0 0 Non-patient care services to other bodies 3,963 907 3,056 15,797 Continuing Health Care risk pool contributions 0 0 0 0 Income generation 0 0 0 0 Rental revenue from finance leases 0 0 0 0 Rental revenue from operating leases 0 0 0 0 Non cash apprenticeship training grants revenue 0 0 0 0 Other revenue 2,967 176 2,791 798 Total other operating revenue 6,932 1,083 5,849 16,599
Admin revenue is revenue received that is not directly attributable to the provision of health care services.
3. Revenue2017-18 2017-18 2017-18 2016-17
Total Admin Programme Total £'000 £'000 £'000 £'000
From rendering of services 6,932 1,083 5,849 16,599 From sale of goods 0 0 0 0 Total 6,932 1,083 5,849 16,599
Less recoveries in respect of employee benefits (note 4.1.2) 0
0
0
0
0
0
0
0
0 Total - Net admin employee benefits including capitalised costs 6,907
5,580
1,327
5,153
4,479
674
1,754
1,101
653 Less: Employee costs capitalised 0
0
0
0
0
0
0
0
0
Net employee benefits excluding capitalised costs 6,907
5,580
1,327
5,153
4,479
674
1,754
1,101
653
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4.1.2 Recoveries in respect of employee benefits
2017-18 2016-17
Total Permanent Employees Other Total
£'000 £'000 £'000 £'000
Employee Benefits – Revenue
Salaries and wages 0 0 0 0 Social security costs 0 0 0 0 Employer contributions to the NHS Pension Scheme 0 0 0 0 Other pension costs 0 0 0 0 Other post-employment benefits 0 0 0 0 Other employment benefits 0 0 0 0 Termination benefits 0 0 0 0
Total recoveries in respect of employee benefits 0 0 0 0
4.2 Average number of people employed
2017-18 2016-17 Total Permanently employed Other Total
Number Number Number Number Total 128 115 13 140 Of the above: Number of whole time equivalent people engaged on capital projects 0 0 0 0
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4.3 Staff sickness absence and ill health retirements
Details of Staff Sickness Absence in the year 2017-18: 2017-2018 2016-2017 Number Number Total Days Lost 564 629 Total Staff Years 126 119 Average working days lost 4.5 5.2 Ill Health Retirements 2017-18: 2017-2018 2016-2017 Number Number Number of persons retired early on ill health grounds 0 0
4.4 Exit packages agreed in the financial year
2017-18 2017-18 2017-18 Compulsory redundancies Other agreed departures Total
Number £ Number £ Number £ Less than £10,000 0 0 0 0 0 0 £10,001 to £25,000 0 0 0 0 0 0 £25,001 to £50,000 0 0 0 0 0 0 £50,001 to £100,000 0 0 0 0 0 0 £100,001 to £150,000 0 0 1 140,000 1 140,000 £150,001 to £200,000 0 0 0 0 0 0 Over £200,001 0 0 0 0 0 0 Total 0 0 1 140,000 1 140,000
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2016-17 2016-17 2016-17 Compulsory redundancies Other agreed departures Total
Number £ Number £ Number £ Less than £10,000 0 0 0 0 0 0 £10,001 to £25,000 0 0 0 0 0 0 £25,001 to £50,000 0 0 0 0 0 0 £50,001 to £100,000 0 0 0 0 0 0 £100,001 to £150,000 0 0 0 0 0 0 £150,001 to £200,000 0 0 0 0 0 0 Over £200,001 0 0 0 0 0 0 Total 0 0 0 0 0 0
2017-18 2016-17 Departures where special payments
have been made Departures where special
payments have been made Number £ Number £
Less than £10,000 0 0 0 0 £10,001 to £25,000 0 0 0 0 £25,001 to £50,000 0 0 0 0 £50,001 to £100,000 0 0 0 0 £100,001 to £150,000 0 0 0 0 £150,001 to £200,000 0 0 0 0 Over £200,001 0 0 0 0 Total 0 0 0 0
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Analysis of Other Agreed Departures
2017-18 2016-17 Other agreed departures Other agreed departures Number £ Number £
Voluntary redundancies including early retirement contractual costs 0 0 0 0 Mutually agreed resignations (MARS) contractual costs 0 0 0 0 Early retirements in the efficiency of the service contractual costs 1 140,000 0 0 Contractual payments in lieu of notice 0 0 0 0 Exit payments following Employment Tribunals or court orders 0 0 0 0 Non-contractual payments requiring HMT approval* 0 0 0 0 Total 1 140,000 0 0
These tables report the number and value of exit packages agreed in the financial year. The expense associated with these departures may have been recognised in part or in full in a previous period.
Where the Clinical Commissioning Group has agreed early retirements, the additional costs are met by the Clinical Commissioning Group and not by the NHS Pension Scheme, and are included in the tables. Ill-health retirement costs are met by the NHS Pension Scheme and are not included in the tables.
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4.5 Pension costs
Past and present employees are covered by the provisions of the two NHS Pension Schemes. Details of the benefits payable and rules of the Schemes can be found on the NHS Pensions website at www.nhsbsa.nhs.uk/pensions.
Both are unfunded defined benefit schemes that cover NHS employers, GP practices and other bodies, allowed under the direction of the Secretary of State in England and Wales. They are not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities.
Therefore, each scheme is accounted for as if it were a defined contribution scheme: the cost to the NHS body of participating in each scheme is taken as equal to the contributions payable to that scheme for the accounting period.
In order that the defined benefit obligations recognised in the financial statements do not differ materially from those that would be determined at the reporting date by a formal actuarial valuation, the FReM requires that “the period between formal valuations shall be four years, with approximate assessments in intervening years”. An outline of these follows:
4.5.1 Accounting valuation
A valuation of scheme liability is carried out annually by the scheme actuary (currently the Government Actuary’s Department) as at the end of the reporting period. This utilises an actuarial assessment for the previous accounting period in conjunction with updated membership and financial data for the current reporting period, and is accepted as providing suitably robust figures for financial reporting purposes. The valuation of the scheme liability as at 31 March 2018, is based on valuation data as 31 March 2017, updated to 31 March 2018 with summary global member and accounting data. In undertaking this actuarial assessment, the methodology prescribed in IAS 19, relevant FReM interpretations, and the discount rate prescribed by HM Treasury have also been used.
The latest assessment of the liabilities of the scheme is contained in the report of the scheme actuary, which forms part of the annual NHS Pension Scheme Accounts. These accounts can be viewed on the NHS Pensions website and are published annually. Copies can also be obtained from The Stationery Office.
4.5.2 Full actuarial (funding) valuation
The purpose of this valuation is to assess the level of liability in respect of the benefits due under the schemes (taking into account recent demographic experience), and to recommend contribution rates payable by employees and employers.
The last published actuarial valuation undertaken for the NHS Pension Scheme was completed for the year ending 31 March 2012. The Scheme Regulations allow for the level of contribution rates to be changed by the Secretary of State for Health, with the consent of HM Treasury, and consideration of the advice of the Scheme Actuary and employee and employer representatives as deemed appropriate.
The next actuarial valuation is to be carried out as at 31 March 2016 and is currently being prepared. The direction assumptions are published by HM Treasury which are used to complete the valuation calculations, from which the final valuation report can be signed off by the scheme actuary. This will set the employer contribution rate payable from April 2019 and will consider the cost of the Scheme relative to the employer cost cap. There are provisions in the Public Service Pension Act 2013 to adjust member benefits or contribution rates if the cost of the Scheme changes by more than 2% of pay. Subject to this ‘employer cost cap’ assessment, any required revisions to member benefits or contribution rates will be determined by the Secretary of State for Health after consultation with the relevant stakeholders.
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For 2017-18, employers’ contributions of £651,604 were payable to the NHS Pensions Scheme (2016-17: £616,253) were payable to the NHS Pension Scheme at the rate of 14.38% of pensionable pay. The scheme’s actuary reviews employer contributions, usually every four years and now based on HMT Valuation Directions, following a full scheme valuation. The latest review used data from 31 March 2012 and was published on the Government website on 6 June 2014.
5. Operating Expenses
2017-18 2017-18 2017-18 2016-17 Total Admin Programme Total £000 £000 £000 £000
Gross employee benefits 7,391 5,403 1,988 6,408 Employee benefits excluding governing body members 481 481 0 499 Executive governing body members 7,872 5,884 1,988 6,907 Total gross employee benefits Other costs Services from other CCGs and NHS England 930 389 541 853 Services from foundation trusts 59,571 222 59,349 58,735 Services from other NHS trusts 189,417 151 189,266 185,385 Sustainability Transformation Fund 0 0 0 0 Services from other WGA bodies 0 0 0 0 Purchase of healthcare from non-NHS bodies 144,684 0 144,684 144,752 Purchase of social care 0 0 0 0 Chair and Non Executive Members 163 163 0 178 Supplies and services – clinical 0 0 0 0 Supplies and services – general 797 42 755 663 Consultancy services 109 12 97 317 Establishment 648 199 449 377 Transport 18 9 9 32 Premises 4,868 956 3,912 4,905 Impairments and reversals of receivables 0 0 0 0 Inventories written down and consumed 0 0 0 0 Depreciation 0 0 0 0 Amortisation 0 0 0 0 Impairments and reversals of property, plant and equipment 0 0 0 0 Impairments and reversals of intangible assets 0 0 0 0 Impairments and reversals of financial assets · Assets carried at amortised cost 0 0 0 0 · Assets carried at cost 0 0 0 0 · Available for sale financial assets 0 0 0 0 Impairments and reversals of non-current assets held for sale 0 0 0 0 Impairments and reversals of investment properties 0 0 0 0 Audit fees 36 36 0 75 Other non statutory audit expenditure · Internal audit services 0 0 0 0 · Other services 0 0 0 0
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2017-18 2017-18 2017-18 2016-17 Total Admin Programme Total £000 £000 £000 £000
General dental services and personal dental services 0 0 0 0 Prescribing costs 43,224 0 43,224 43,347 Pharmaceutical services 0 0 0 0 General ophthalmic services 0 0 0 0 GPMS/APMS and PCTMS 47,158 0 47,158 45,578 Other professional fees excl. audit 39 39 0 243 Legal fees 154 154 0 0 Grants to Other bodies 0 0 0 0 Clinical negligence 0 0 0 0 Research and development (excluding staff costs) 460 0 460 1,000 Education and training 129 5 124 434 Change in discount rate 0 0 0 0 Provisions 52 2 50 425 Funding to group bodies 0 0 0 0 CHC Risk Pool contributions 0 0 0 406 Non cash apprenticeship training grants 0 0 0 0 Other expenditure 7 0 7 1 Total other costs 492,466 2,379 490,087 487,705
Total operating expenses 500,338 8,263 492,075 494,612
Admin expenditure incurred that is not a direct payment for the provision of healthcare services.
*Audit Fees - KPMG LLP fee for 2017-18 was £36,109 plus VAT. An additional fee of £2,364 plusVAT was received by KPMG LLP for 2016-17 additional work required in respect of delegated co-commissioning.
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6.1 Better payment practice code
The Better Payment Practice Code requires NHS Nottingham City CCG to aim to pay all valid invoices by the due date or within 30 days of receipt of a valid invoice, whichever is later. The target for NHS is 95%.
Measure of compliance 2017-18 2017-18 2016-17 2016-17 Number £'000 Number £'000 Non-NHS Payables Total Non-NHS Trade invoices paid in the Year 10,350 196,986 11,293 189,837 Total Non-NHS Trade Invoices paid within target 10,243 196,329 11,146 187,844 Percentage of Non-NHS Trade invoices paid within target 98.97%
99.67%
98.70%
98.95%
NHS Payables Total NHS Trade Invoices Paid in the Year 3,626 250,450 3,875 246,808 Total NHS Trade Invoices Paid within target 3,592 250,290 3,858 246,569 Percentage of NHS Trade Invoices paid within target 99.06%
99.94%
99.56%
99.90%
6.2 The Late Payment of Commercial Debts (Interest) Act 1998
2017-18 2016-17 £000 £000
Amounts included in finance costs from claims made under this legislation 0 0 Compensation paid to cover debt recovery costs under this legislation 0 0 Total 0 0
7. Income Generation Activities
NHS Nottingham City CCG did not undertake any income generation activities during the financial year 2017-18(2016-17: £NIL)
8. Investment revenue
NHS Nottingham City CCG received no investment revenue during the financial year 2017-18 (2016-17: £NIL).
9. Other gains and losses
NHS Nottingham City CCG made no other gains or losses during the financial year 2017-18 (2016-17: £NIL).
10. Finance costs
NHS Nottingham City CCG incurred no financial costs during the financial year 2017-18 (2016-17: £NIL).
11. Net gain/(loss) on transfer by absorption
No functions were transferred to NHS Nottingham City CCG during the financial year 2017-18 (2016-17: £NIL).
NHS Nottingham City CCG made no gains or losses on transfer by absorption during the financial year 2017-18 (2016-17: £NIL).
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12. Operating Leases
Operating lease payments are recognised as an expense on a straight line basis over the lease term. Lease incentives are recognised initially as a liability and subsequently as a reduction of rentals on a straight line basis over the term.
Contingent rentals are recognised as an expense in the period in which they are incurred.
12.1 As lessee
Operating lease payments are recognised as an expense on a straight line basis over the lease term. Lease incentives are recognised initially as a liability and subsequently as a reduction of rentals on a straight line basis over the term.
12.1.1 Payments recognised as an expense
NHS Nottingham City CCG occupies property owned and managed by Community Health Partnership Ltd, NHS Property Services Ltd, and Aviva.
For 2017-18, a transitional occupancy rent based on annual property cost allocations was agreed. This is reflected in Note 12.1.1.
2017-18 2016-17 Land Buildings Other Total Land Buildings Other Total £000 £000 £000 £000 £000 £000 £000 £000
Whilst our arrangements with Community Health Partnership's Limited and NHS Property Services Limited fall within the definition of operating leases, rental charge for future years have not yet been agreed. The amounts shown below relate to signed lease with Aviva for the occupancy of Standard Court.
2017-18 2016-17 Land Buildings Other Total Land Buildings Other Total £000 £000 £000 £000 £000 £000 £000 £000
Payable:
No later than one year 0 384 0 384 0 384 0 384 Between one and five years 0 1,536 0 1,536 0 1,536 0 1,536 After five years 0 1,152 0 1,152 0 1,536 0 1,536 Total 0 3,072 0 3,072 0 3,456 0 3,456
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12.2 As lessor
12.2.1 Rental revenue
2017-18 2016-17 £000 £000
Recognised as income Rent 0 0 Contingent rents 0 0 Total 0 0
12.2.2 Future minimum rental value
2017-18 2016-17 £000 £000
Receivable: No later than one year 0 0 Between one and five years 0 0 After five years 0 0 Total 0 0
13 Property, plant and equipment
NHS Nottingham City CCG owned no property, plant or equipment in the financial year 2017-18 (2016-17: £NIL).
13.1 Additions to assets under construction
NHS Nottingham City CCG had no assets under construction in the Financial Year 2017-18 (2016-17: £NIL).
13.2 Donated assets
NHS Nottingham City CCG received no donated assets during the Financial Year 2017-18 (2016-17: £NIL).
13.3 Government granted assets
NHS Nottingham City CCG received no government granted assets during the Financial Year 2017-18 (2016-17: £NIL).
13.4 Property revaluation
NHS Nottingham City CCG does not hold property, plant or equipment. No property revaluations were undertaken during the Financial Year 2017-18 (2016-17: £NIL).
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13.5 Compensation from third parties
NHS Nottingham City CCG received no compensation from third parties for assets impaired, lost or given up during the Financial Year 2017-18 (2016-17: £NIL).
13.6 Write downs to recoverable amount No assets were written down during the Financial Year 2017-18 (2016-17: £NIL). 13.7 Temporarily idle assets NHS Nottingham City CCG had no temporarily idle assets as at 31st March 2018 (31st March 2017: £NIL).
13.8 Cost or valuation of fully depreciated assets NHS Nottingham City CCG had no fully depreciated assets as at 31st March 2018 (31st March 2017: £NIL).
13.9 Economic lives No economic lives apply as NHS Nottingham City CCG holds no property, plant or equipment (31st March 2017: £NIL). 14 Intangible non-current assets NHS Nottingham City CCG owned no intangible assets as at 31st March 2018 (31st March 2017: £NIL). 14.1 Donated assets NHS Nottingham City CCG owned no donated assets as at 31st March 2018 (31st March 2017: £NIL). 14.2 Government granted assets
NHS Nottingham City CCG had no government granted assets as at 31st March 2018 (31st March 2017: £NIL).
14.3 Revaluation
NHS Nottingham City CCG had no intangible assets in the Financial Year 2017-18 and no revaluations have been undertaken (2016-17: £NIL). 14.4 Compensation from third parties
NHS Nottingham City CCG received no compensation for impairment of intangible assets as at 31st March 2018 (31st March 2017: £NIL).
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14.5 Write downs to recoverable amount NHS Nottingham City CCG received no intangible non current assets and therefore no write downs to recoverable amounts applied as at 31st March 2018 (31st March 2017: £NIL). 14.6 Non-capitalised assets NHS Nottingham City CCG had no non-capitalised assets as at 31st March 2018 (31st March 2017: £NIL). 14.7 Temporarily idle assets NHS Nottingham City CCG had no temporarily idle assets as at 31st March 2018 (31st March 2017: £NIL). 14.8 Cost or valuation of fully amortised assets NHS Nottingham City CCG had no fully amortised assets still in use as at 31st March 2018 (31st March 2017: £NIL).
14.9 Economic lives No economic lives apply as NHS Nottingham City CCG holds no intangible non current assets (31st March 2017: £NIL). 15 Investment property NHS Nottingham City CCG had no investment property as at 31st March 2018 (31st March 2017: £NIL). 16 Inventories NHS Nottingham City CCG held no inventories as at 31st March 2018 (31st March 2017: £NIL).
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17. Trade and other receivables
Current Non-
current Current Non-
current
2017-18 2017-18 2016-17 2016-17
£000 £000 £000 £000 NHS receivables: Revenue 632 0 498 0 NHS receivables: Capital 0 0 0 0 NHS prepayments 2,322 0 2,289 0 NHS accrued income 17 0 120 0 Non-NHS and Other WGA receivables: Revenue 633 0 1,162 0 Non-NHS and Other WGA receivables: Capital 0 0 0 0 Non-NHS and Other WGA prepayments 5,510 0 308 0 Non-NHS and Other WGA accrued income 5 0 116 0 Provision for the impairment of receivables 0 0 (1) 0 VAT 78 0 135 0 Private finance initiative and other public private partnership arrangement prepayments and accrued income 0 0 0 0 Interest receivables 0 0 0 0 Finance lease receivables 0 0 0 0 Operating lease receivables 0 0 0 0 Other receivables and accruals 0 0 31 0 Total trade and other receivables 9,197 0 4,658 0
Total current and non-current 9,197 4,658
Included above: Prepaid pensions contributions 0 0
The great majority of trade is with NHS England. As NHS England is funded by Government to provide funding to clinical commissioning groups to commission services, no credit scoring of them is considered necessary.
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17.1 Receivables past their due date but not impaired
2017-18 2017-18 2016-17
£'000 £'000 £'000
DH Group Bodies
Non DH Group Bodies
All receivables prior years
By up to three months 36 16 389 By three to six months 0 80 554 By more than six months 0 57 345 Total 36 153 1,288
£1k of the amount above has subsequently been recovered post the statement of financial position date.
NHS Nottingham City CCG held no collateral against receivables outstanding at 31 March 2018 (31 March 2017 £NIL).
17.2 Provision for impairment of receivables
2017-18 2017-18 2016-17
£'000 £'000 £'000
DH Group Bodies
Non DH Group Bodies
All receivables prior years
Balance at 1 April 2018 (1) 0 0
Amounts written off during the year 0 1 0
Amounts recovered during the year 0 0 0 (Increase) decrease in receivables impaired 0 0 0 Transfer (to) from other public sector body 0 0 0 Balance at 31 March 2018 (1) 1 (1)
NHS Nottingham City CCG has no provisions for the impairment of receivables as none of the receivables are considered to be at risk.
18. Other financial assets
NHS Nottingham City CCG had no other financial assets as at 31 March 2018 (31 March 2017: £NIL).
Non current: capital analysis
NHS Nottingham City CCG had no capital revenue or expenditure in the financial year 2017-18 (2016-17: £NIL).
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19. Other current assets
NHS Nottingham City CCG had no other current assets as at 31 March 2018 (31 March 2017: £NIL).
20. Cash and cash equivalents
2017-18 2016-17
£'000 £'000
Balance at 01 April 2017 166 39
Net change in year (133) 127
Balance at 31 March 2018 33 166
Made up of: Cash with the Government Banking Service 33 166 Cash with Commercial banks 0 0 Cash in hand 0 0 Current investments 0 0
Cash and cash equivalents as in statement of financial position 33 166
Bank overdraft: Government Banking Service 0 0 Bank overdraft: Commercial banks 0 0
Total bank overdrafts 0 0
Balance at 31 March 2018 33 166
Patients’ money held by the clinical commissioning group, not included above 0 0
21. Non-current assets held for sale
NHS Nottingham City CCG had no non-current assets held for sale as at 31 March 2018 (31 March 2017: £NIL).
22. Analysis of impairments and reversals
NHS Nottingham City CCG had no impairments or reversals of impairments recognised in expenditure during the financial year 2017-18 (2016-17: £NIL).
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23. Trade and other payables
24. Other financial liabilities
NHS Nottingham City CCG had no other financial liabilities as at 31 March 2018 (31 March 2017: £NIL).
25. Other liabilities
NHS Nottingham City CCG had no other liabilities as at 31 March 2018 (31 March 2017: £NIL).
26. Borrowings
NHS Nottingham City CCG had no borrowings as at 31 March 2018 (31 March 2017: £NIL).
27. Private finance initiative, LIFT and other service concession arrangements
NHS Nottingham City CCG had no Private Finance Initiatives, LIFT or other service concession arrangements that were excluded from the Statement of Financial Position as at 31st March 2018 (31 March 2017: £NIL).
28. Finance lease obligations
NHS Nottingham City CCG had no finance lease obligations as at 31 March 2018 (31 March 2017: £NIL).
28.1 Finance leases as lessee
NHS Nottingham City CCG had no future sublease payments expected to be received as at 31 March 2018 (31 March 2017: £NIL).
NHS Nottingham City CCG had no contingent rents recognised in expenditure during the financial year 2017-18 (2016-17: £NIL).
Current Non-current Current Non-current 2017-18 2017-18 2016-17 2016-17
£000 £000 £000 £000 Interest payable 0 0 0 0 NHS payables: revenue 2,449 0 672 0 NHS payables: capital 0 0 0 0 NHS accruals 3,264 0 3,129 0 NHS deferred income 0 0 0 0 Non-NHS and other WGA payables: revenue 6,502 0 3,613 0 Non-NHS and other WGA payables: capital 0 0 0 0 Non-NHS and other WGA accruals 25,647 0 17,491 0 Non-NHS and other WGA deferred income 0 0 0 0 Social security costs 75 0 75 0 VAT 0 0 0 0 Tax 46 0 61 0 Payments received on account 0 0 0 0 Other payables and accruals 1,782 0 3,683 0 Total trade and other payables 39,765 0 28,724 0
Total current and non-current 39,765 28,724
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29 Finance lease receivables
NHS Nottingham City CCG had no finance lease receivables during the financial year 2017-18 (2016-17: £NIL).
29.1 Finance leases as lessor
NHS Nottingham City CCG had no unguaranteed residual value accruing as at 31st March 2018 (31 March 2018: £NIL).
NHS Nottingham City CCG had no accumulated allowance for uncollectable lease receivables as at 31 March 2018 (31 March 2017: £NIL).
29.2 Rental revenue
NHS Nottingham City CCG had no finance lease revenue rental received during the financial year 2017-18 (2016-17: £NIL).
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30 Provisions
2017-18 2017-18 2016-17 2016-17 Current Non-current Current Non-current
£000 £000 £000 £000 Pensions relating to former directors 0 0 0 0 Pensions relating to other staff 0 0 0 0 Restructuring 0 0 0 0 Redundancy 0 0 0 0 Agenda for change 0 0 0 0 Equal pay 0 0 0 0 Legal claims 58 0 0 0 Continuing care 0 0 0 0 Other 0 508 0 515 Total 58 508 0 515
Total current and non-current 566 515
Pensions Relating
to Former Directors
Pensions Relating to
Other Staff Restructuring Redundancy
Agenda for
Change Equal
Pay Legal
Claims Continuing
Care Other Total £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s
Balance at 1 April 2017 0 0 0 0 0 0 0 0 515 515
Arising during the year 0 0 0 0 0 0 58 0 (7) 51 Utilised during the year 0 0 0 0 0 0 0 0 0 0 Reversed unused 0 0 0 0 0 0 0 0 0 0 Unwinding of discount 0 0 0 0 0 0 0 0 0 0 Change in discount rate 0 0 0 0 0 0 0 0 0 0
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Pensions Relating
to Former Directors
Pensions Relating to
Other Staff Restructuring Redundancy
Agenda for
Change Equal
Pay Legal
Claims Continuing
Care Other Total £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s
Transfer (to) from other public sector body 0 0 0 0 0 0 0 0 0 0 Transfer (to) from other public sector body under absorption 0 0 0 0 0 0 0 0 0 0 Balance at 31 March 2018 0 0 0 0 0 0 58 0 508 566
Expected timing of cash flows: Within one year 0 0 0 0 0 0 0 0 0 58 Between one and five years 0 0 0 0 0 0 0 0 508 508 After five years 0 0 0 0 0 0 0 0 0 0 Balance at 31 March 2018 0 0 0 0 0 0 58 0 508 566
Provisions in relation to NHS Resolution as at 31st March 2018 in respect of Clinical Negligence liabilities is £1.5k (31st March 2017: £NIL)
There is a £58k provision in place in relation to Legal costs that may occur in relation to Contract renegotiations.
Other Provisions include £206k which is equal to NHS Nottingham City CCG's exposure in the underwriting of 50% of Nottingham University Hospital Trust's (NUH) overseas patients debts, which are considered by NUH to be at risk. Timings of repayments or write offs are governed by the ability of NUH to pursue and recover monies owed in part or in full.
The balance of (£214k) is the reversal of the £378k provision input previously for NHS Nottingham City CCG's share of a risk share agreement across Nottinghamshire CCG's for high cost patients, then a revised provision made of £164k.
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31 Contingencies
2017-18 2016-17 £'000 £'000
Contingent liabilities LTPS 2 0 Net value of contingent liabilities 2 0
NHS Nottingham City CCG has a Contingent Liability of £1,500 as notified by the NHS Resolution in relation to Liabilities to Third Party Scheme.
32 Commitments
32.1 Capital commitments
NHS Nottingham City CCG had no contracted capital commitments not otherwise included in these financial statements as at 31 March 2018 (31 March 2017: £NIL).
32.2 Other financial commitments
NHS Nottingham City CCG has entered into non-cancellable contracts (which are not leases, private finance initiative contracts or other service concession arrangements) for The Urgent Care Centre, Arriva Transport Services, Nottingham Emergency Medical Services and Derbyshire Health United (111). These expire as follows:
2017-18 2016-17 £000 £000 In not more than one year 7,006 6,726 In more than one year but not more than five years 4,160 9,963 In more than five years 0 0 Total 11,166 16,689
33 Financial instruments
33.1 Financial risk management
Financial reporting standard IFRS 7 requires disclosure of the role that financial instruments have had during the period in creating or changing the risks a body faces in undertaking its activities.
As NHS Nottingham City CCG is financed through parliamentary funding, it is not exposed to the degree of financial risk faced by business entities. Also, financial instruments play a much more limited role in creating or changing risk than would be typical of listed companies, to which the financial reporting standards mainly apply. The clinical commissioning group has limited powers to borrow or invest surplus funds and financial assets and liabilities are generated by day-to-day operational activities rather than being held to change the risks facing the clinical commissioning group in undertaking its activities.
Treasury management operations are carried out by the finance department, within parameters defined formally within NHS Nottingham City CCG’s Detailed Financial Policies agreed by the Governing Body. Treasury activity is subject to review by the clinical commissioning group and its internal auditors.
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33.1.1 Currency risk
NHS Nottingham City CCG is principally a domestic organisation with the great majority of transactions, assets and liabilities being in the UK and sterling based. NHS Nottingham City CCG has no overseas operations and therefore has low exposure to currency rate fluctuations.
33.1.2 Interest rate risk
NHS Nottingham City CCG borrows from Government for capital expenditure, subject to affordability as confirmed by NHS England. The borrowings are for 1 to 25 years, in line with the life of the associated assets, and interest is charged at the National Loans Fund rate, fixed for the life of the loan. NHS Nottingham City CCG therefore has low exposure to interest rate fluctuations.
33.1.3 Credit risk
As the majority of NHS Nottingham City CCG revenue comes from parliamentary funding, it has low exposure to credit risk. The maximum exposures as at the end of the financial year are in receivables from customers, as disclosed in the trade and other receivables note.
33.1.4 Liquidity risk
NHS Nottingham City CCG is required to operate within revenue and capital resource limits, which are financed from resources voted annually by Parliament. NHS Nottingham City CCG draws down cash to cover expenditure, as the need arises. NHS Nottingham City CCG is not, therefore, exposed to significant liquidity risks.
Embedded derivatives 0 0 0 0 Receivables: • NHS 0 649 0 649 • Non-NHS 0 638 0 638 Cash at bank and in hand 0 33 0 33 Total at 31 March 2018 0 1,320 0 1,320
Embedded derivatives 0 0 0 0 Receivables: • NHS 0 618 0 618 • Non-NHS 0 1,278 0 1,278 Cash at bank and in hand 0 166 0 166 Other financial assets 0 31 0 31 Total at 31 March 2017 0 2,093 0 2,093
33.3 Financial liabilities
At ‘fair value through profit and
loss’ Other Total 2017-18 2017-18 2017-18
£000 £000 £000 Payables: • NHS 0 5,714 5,714 • Non-NHS 0 33,930 33,930 Total at 31 March 2018 0 39,644 39,644
Other Total 2016-17 2016-17
At ‘fair value through profit and
loss’ 2016-17
£000 £000 £000 Payables: • NHS 0 3,800 3,800 • Non-NHS 0 24,788 24,788 Total at 31 March 2017 0 28,588 28,588
34 Operating segments
The CCG and consolidated group consider they have only one segment: Commissioning of Healthcare Services.
35 Pooled budgets
NHS Nottingham City CCG has entered into two pooled budget arrangements under section 75 of the NHS Act 2006.
The first pooled budget agreement is between Nottingham City Council, Nottinghamshire County Council, NHS Rushcliffe CCG,NHS Nottingham North and East CCG, NHS Nottingham West CCG, NHS Bassetlaw CCG, NHS Newark and Sherwood CCG and NHS Mansfield and Ashfield CCG.
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This pooled budget is hosted by Nottingham City Council and provides an Integrated Community Equipment Service, which delivers the provision, delivery and collection of equipment provided by British Red Cross.
The Integrated Community Equipment and Loan Services (ICELS) provides range of equipment to adults and children across Nottinghamshire.
The equipment provided supports the independence of people who mainly live in their own homes, through maximising mobility and self-care. It assists both family and paid carers to support people with complex physical disability in their own homes.
The draft memorandum of account for this pooled budget is:
Nottingham City Council 985 1,111 Nottinghamshire County Council 1,757 1,776 NHS Bassetlaw CCG 449 477 NHS Nottingham City CCG 1,097 1,154 NHS Nottinghamshire County CCGs 2,630 2,937 Continuing care contributions 185 210 Miscellaneous 19 82 Total funding 7,651 7,857
Expenditure Employees 643 615 Supplies and services 6,706 6,461 Continuing care 114 252 Total expenditure 7,463 7,328
Balance carried forward for all partners 188 529
NHS Nottingham City CCG's shares of the income and expenditure handled by the pooled budget in the financial year were:
2017-18 2016-17 £000 £000
Income 1,097 1,154 Expenditure (1,148) (1,097) Net expenditure (51) 57
The second pooled budget is 'The Better Care Fund (BCF)' and is hosted by Nottingham City Council, which jointly commission services to achieve national and local objectives to integrate health and social care services in Nottingham City.
It is between NHS Nottingham City CCG and Nottingham City Council, and its aims are to improve the quality and efficiency of services.
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Memorandum Account for Nottingham City Better Care Fund 2017-18 2016-17
Funding £000's £000's NHS Nottingham City CCG 23,253 23,253 Nottingham City Council (capital) 2,075 1,889 Nottingham City Council 716 716
Nottingham City Council (Improved Better Care Fund) 8,570 - Total Funding 34,614 25,858
Expenditure Access & Navigation - Support integration of front door access to social care & health services & navigation through to appropriate service delivery 2,291 1,602
Assistive technology - Create joined up equipment solutions to improve Health & Social Care outcomes 1,061 1,204
Carers - Improve experience & access of Health & Social Care through a range of integrated & comprehensive carers services
1,350 1,380
Co-ordinated care - Provide new model of care with emphasis on joined up care & proactive support 15,957 8,184
Capital grants - Support vision to improve experience of access to Health & Social Care services by enabling citizens to receive care in their home of community
2,075 1,889
Independence pathway - Ensure citizens able to access most appropriate short term enablement, reablement and crisis support at the right time
11,636 11,259
Programme costs 244 340 Total Expenditure 34,614 25,858
Balance carried forward for all partners 0 0
NHS Nottingham City CCG's shares of the income and expenditure handled by the pooled budget in the financial year were:
2017-18 2016-17 £'000 £'000
Income 9,649 11,402 Expenditure (9,649) (11,402)
0 0
36 NHS Lift investments
Nottingham City CCG had no LIFT investments as at 31 March 2018 (31 March 2017: £NIL).
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37 Related party transactions
Details of related party transactions with individuals are as follows:
Payments to related
party
Receipts from
related party
Amounts owed to
related party
Amounts due from
related party
2016-17 Payments to related Party
£000 £000 £000 £000 £'000
Dr Hugh Porter (Cripps Health Centre) 2,524 0 29 0 2,528 Dr Hugh Porter (Family Medical Centre) 1,187 0 27 0 1,474 Dr Marcus Bicknell (Beechdale Surgery) 624 0 35 0 657 Dr Marcus Bicknell (Boulevard Medical Centre) 2 0 12 0 0 Dr Marcus Bicknell (RHR Medical Centre) 411 0 7 0 0 Dr Marcus Bicknell (Strelley Health Centre) 484 0 1 0 0 Dr Marcus Bicknell (Derby Road Health Centre) 1,541 0 13 0 1,342 Dr Safiy Karim (Lime Tree Surgery) 462 0 8 0 453 Dr Arun Tangri (Riverlyn Medical Centre) 481 0 7 0 423 Dr Om Sharma (Greenfields Med Cent) 339 0 0 0 316 Dr Margaret Abbott (The Windmill Practice) 1,014 0 0 0 1,035 Dr Manik Arora (Rivergreen Medical Centre) 1,024 0 15 0 1,091
10,364 0 154 0 9,319
The amounts reported above are the practice payments for Local Enhanced Services claims and also include Co Commissioning payments and does not reflect payments made to the individual.
The Department of Health is regarded as a related party. During the year NHS Nottingham City CCG has had a significant number of material transactions with entities for which the Department is regarded as the parent Department. For example:
£'000 £'000 £'000 £'000 NHS England 452 648 1,165 1,859 NHS Foundation Trusts 1,329 62 59,763 221 NHS Trusts 3,924 2,260 189,784 90 Health Education England 0 0 0 0 Special Health Authorities 1 0 8 5 Other Group Bodies 3,328 0 3,518 0
9,034 2,970 254,238 2,175
In addition, NHS Nottingham City CCG has had a number of material transactions with other government departments and other central and local government bodies. Most of these transactions have been with Nottingham City Council and Nottinghamshire County Council.
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38 Events after the end of the reporting period
There are currently no known events occurring after the reporting date that will have a significant impact on NHS Nottingham City CCG.
39 Losses and special payments
39.1 Losses
The total number of Nottingham City CCG losses and special payments cases, and their total value, was as follows:
Expenditure not to exceed income 500,763 500,338 504,812 494,612 Capital resource use does not exceed the amount specified in Directions 0 0 0 0 Revenue resource use does not exceed the amount specified in Directions 493,831 493,406 488,213 478,013 Capital resource use on specified matter(s) does not exceed the amount specified in Directions 0 0 0 0 Revenue resource use on specified matter(s) does not exceed the amount specified in Directions 0 0 0 0 Revenue administration resource use does not exceed the amount specified in Directions 7,394 7,182 7,388 7,214
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42 Impact of IFRS
Accounting under IFRS had no impact on the results of NHS Nottingham City CCG during the 2017-18 financial year.
43 Analysis of charitable reserves
NHS Nottingham City CCG held no charitable reserves during the financial year 2017-18 (2016-17: £NIL).
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Independent Auditor’s Report to the Members of NHS Nottingham
City CCG
Opinion
We have audited the financial statements of NHS Nottingham City Clinical Commissioning Group (“the CCG”) for the year ended 31 March 2018 which comprise the Statement of Comprehensive Net Expenditure, Statement of Financial Position, Statement of Changes in Taxpayers Equity and Statement of Cash Flows, and the related notes, including the accounting policies in note 1.
In our opinion the financial statements:
give a true and fair view of the state of the CCG’s affairs as at 31 March 2018 and of its income and expenditure for the year then ended; and
have been properly prepared in accordance with the accounting policies directed by the NHS Commissioning Board with the consent of the Secretary of State as being relevant to CCGs in England and included in the Department of Health Group Accounting Manual 2017/18.
Basis for opinion
We conducted our audit in accordance with International Standards on Auditing (UK) (“ISAs (UK)”) and applicable law. Our responsibilities are described below. We have fulfilled our ethical responsibilities under, and are independent of the CCG in accordance with, UK ethical requirements including the FRC Ethical Standard. We believe that the audit evidence we have obtained is a sufficient and appropriate basis for our opinion.
Going concern
We are required to report to you if we have concluded that the use of the going concern basis of accounting is inappropriate or there is an undisclosed material uncertainty that may cast significant doubt over the use of that basis for a period of at least twelve months from the date of approval of the financial statements. We have nothing to report in these respects.
Other information in the Annual Report
The Accountable Officer is responsible for the other information presented in the Annual Report together with the financial statements. Our opinion on the financial statements does not cover the other information and, accordingly, we do not express an audit opinion or, except as explicitly stated below, any form of assurance conclusion thereon.
Our responsibility is to read the other information and, in doing so, consider whether, based on our financial statements audit work, the information therein is materially misstated or inconsistent with the financial statements or our audit knowledge. Based solely on that work we have not identified material misstatements in the other information. In our opinion the other information included in the Annual Report for the financial year is consistent with the financial statements.
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Annual Governance Statement
We are required to report to you if the Annual Governance Statement does not comply with guidance issued by the NHS Commissioning Board. We have nothing to report in this respect.
Remuneration and Staff Report
In our opinion the parts of the Remuneration and Staff Report subject to audit have been properly prepared in accordance with the Department of Health Group Accounting Manual 2017/18.
Accountable Officer’s responsibilities
As explained more fully in the statement set out on page 37, the Accountable Officer is responsible for: the preparation of financial statements that give a true and fair view; such internal control as they determine is necessary to enable the preparation of financial statements that are free from material misstatement, whether due to fraud or error; assessing the CCGs ability to continue as a going concern, disclosing, as applicable, matters related to going concern; and using the going concern basis of accounting unless they have been informed by the relevant national body of the intention to dissolve the CCG without the transfer of its services to another public sector entity.
Auditor’s responsibilities
Our objectives are to obtain reasonable assurance about whether the financial statements as a whole are free from material misstatement, whether due to fraud or error, and to issue our opinion in an auditor’s report. Reasonable assurance is a high level of assurance, but does not guarantee that an audit conducted in accordance with ISAs (UK) will always detect a material misstatement when it exists. Misstatements can arise from fraud or error and are considered material if, individually or in aggregate, they could reasonably be expected to influence the economic decisions of users taken on the basis of the financial statements.
A fuller description of our responsibilities is provided on the FRC’s website at www.frc.org.uk/auditorsresponsibilities
REPORT ON OTHER LEGAL AND REGULATORY MATTERS
Opinion on regularity
We are required to report on the following matters under Section 25(1) of the Local Audit and Accountability Act 2014.
In our opinion, in all material respects, the expenditure and income recorded in the financial statements have been applied to the purposes intended by Parliament and the financial transactions conform to the authorities which govern them.
Report on the CCG’s arrangements for securing economy, efficiency and effectiveness in its use of resources
Under the Code of Audit Practice we are required to report to you if the CCG has not made proper arrangements for securing economy, efficiency and effectiveness in its use of resources.
We have nothing to report in this respect.
Respective responsibilities in respect of our review of arrangements for securing economy, efficiency and effectiveness in the use of resources
As explained more fully in the statement set out on page , the Accountable Officer is responsible for ensuring that the CCG exercises its functions effectively, efficiently and economically. We are required under section 21(1)(c) of the Local Audit and Accountability Act 2014 to be satisfied that
