city and hackney us/2018-19 annua… · bhr barking and dagenham, havering and redbridge ......

City and Hackney Clinical Commissioning Group

Annual Report and Accounts 2018/19


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Abbreviations used in this report

AC Audit Committee

ACE Adverse Childhood Experiences

A&E Accident and Emergency

AFC Agenda for Change

AGM Annual General Meeting

BAF Board Assurance Framework

BAMER Black, Asian, Minority, Ethnic and Refugee

BCF Better Care Fund

BHR Barking and Dagenham, Havering and Redbridge

BHRUT Barking Havering and Redbridge University Hospitals NHS Trust

BME Black and Minority Ethnic

BTS British Thoracic Society

CAN Community African Network

CAMHS Child and Adolescent Mental Health Services

CCG Clinical Commissioning Group

CETV Cash Equivalent Transfer Value

CFO Chief Finance Officer

CHC Continuing Health Care

CHUHSE City & Hackney Urgent Health Care Social Enterprise

CHYPS City and Hackney Young People’s Service

CMS Coordinate My Care

COLC City of London Corporation

COPD Chronic Obstructive Pulmonary Disease

CQC Care Quality Commission

CQUIN Commissioning for Quality and Innovation

CYPMF Children, Young People, Maternity and Families

DA Dementia Alliance

DNA Did Not Attend

DSPT Data Security and Protection Toolkit

EIA Equality Impact Assessments

EIP Early Intervention in Psychosis

Annual report and accounts: 2018/19

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ELFT East London Foundation Trust

ELHCP East London Health and Care Partnership

EPPR Emergency Preparedness, Resilience and Response

ERIC Education Resources Information Centre

ERS E-Referral System

FIT Faecal Immunochemical Test

FFT Friends and Family Test

FPC Finance and Performance Committee

GB Governing Body

GP General Practitioner

GPC General Practitioner Confederation

HPV Human Papilloma Virus

HSCF Health and Social Care Forum

HSJ Health Services Journal

HUH Homerton University Hospital

HUHFT Homerton University Hospital NHS Foundation Trust

HWB Health and Wellbeing Board

IAF Improvement and Assessment Framework

IAPT Improving Access to Psychological Therapies

IC Integrated Commissioning

ICB Integrated Commissioning Board

ICO Information Commissioner’s Office

ICP Integrated Care Partnership

ICS Integrated Care System

IG Information Governance

IG Information Governance Group

INEL Inner North East London

JCC Joint Commissioning Committee

JSNA Joint Strategic Needs Assessment

LAS London Ambulance Service

LBH London Borough of Hackney

LD Learning Disabilities

LED Light-Emitting Diode

LGBTQ Lesbian, Gay, Bisexual, Trans, Queer/Questioning


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LGGPPCC Local GP Provider Contracts Committee

LPC Local Pharmaceutical Committee

MECS Minor Eye Conditions Services

MF Member’s Forum

MMR Measles, Mumps and Rubella

MRSA Methicillin-resistant Staphylococcus Aureus (a type of bacteria that is widely resistant to antibiotics)

MSA Mixed-Sex Accommodation

MSK Musculoskeletal

NEL North East London

NELCA North East London Commissioning Alliance

NELCSU North East London Commissioning Support Unit

NELFT NELFT NHS Foundation Trust

NHS National Health Service

NHSE NHS England

NHSI NHS Improvement

NICE National Institute for Health and Care Excellence

NRAD National Review of Asthma Deaths

NRLS National Reporting and Learning System

OCT Optical Coherence Tomography

OSP Obesity Strategic Partnership

PCCC Primary Care Commissioning Committee

PIC Prioritisation and Investment Committee

PLACE Patient-Led Assessments of Care

PPG Public Participation Group

PPI Patient and Public Involvement

PPIC Patient and Public Involvement Committee

PRB Pensions Related Benefits

PTL Patient Tracking Lists

QI Quality Improvement

QIPP Quality, innovation, productivity and prevention (a large-scale transformation programme which aims to deliver a better quality service for less money)

QOF Quality and Outcomes Framework

RC Remuneration Committee

RTT Referral to treatment time


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RRL Revenue Resource Limit

RSM Internal Auditors

SAO Single Accountable Officer

SCRs Serious Case Reviews

SDMP Sustainable Development Management Plan

SEND Special educational needs and disability

SIs Serious Incidents

SIRO Senior Information Risk Officer

STP Sustainable Transformation Plan

SUN Service User Network

TB Tuberculosis

UCLH University College London Hospital NHS Foundation Trust

VSO Voluntary Services Organisation

VCSE Voluntary Community and Social Enterprise

VTE Venous Thromboembolism


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Contents Section A. PERFORMANCE REPORT 10

A1. Performance overview 11

A1(1) Chair, Accountable Officer and Managing Director Introduction 11

A1(2) Accountable Officer’s perspective on performance 12

A1(3) The purpose, activities and objectives of the CCG 14

Our history, background and structure 14

Our population 14

Our commissioning activity 15

Our corporate objectives and how we measure success 16

Our Structure 17

Actions, Achievements and Successes - our four workstreams 18

A1(4) The key issues and risks of the CCG 23

A1(5) Going concern opinion 23

A1(6) Performance summary 23

Financial performance 24

CCG Improvement and Assessment Framework 24

Primary care performance 25

KPI performance 25

A2. Performance analysis 25

A2(1) Financial performance 25

Funding 26

How we spent the money 26

How we did 26

Financial pressures 27

Future years 27

A2(2) How the CCG measures and checks performance 27

The performance management framework 27

CCG Improvement and Assessment Framework 28

Local Rating 28

Future development of the framework 31

Primary care performance 32

CCG performance against the KPIs 32

Referral to Treatment (RTT) 32

Diagnostic waiting times 33


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A&E total waiting times 34

Cancer waiting times 35

Mixed-sex accommodation 37

Friends and family test 37

Incidents of MRSA 38

Incidents of C. difficile 39

Incidents of venous thromboembolism (VTE) 39

Mental health - Improving Access to Psychological Therapies (IAPT) 39

Mental health - Early Intervention Psychosis 40

The London Ambulance Service 40

A2(3) Other performance matters 41

Sustainable development 41

Emergency preparedness, resilience and response 45

Improving quality 45

Quality improvement in primary care 47

Engaging people and communities 48

Reducing inequalities and the health and wellbeing strategy 54

How we were involved in developing the HWB strategy 58

Equality disclosures 58

Section B. ACCOUNTABILITY REPORT 60

B1. Corporate governance report 61

B1(1) Members’ report 61

Member profiles 61

Member practices 61

Composition of Governing Body 62

Committees, including Audit Committee 63

Register of Interests 63

Personal data related incidents 63

Statement of disclosure to auditors 64

Modern Slavery Act 64

B1(2) Statement of Accountable Officer’s Responsibilities 64

B1(3) Governance Statement 65

Introduction and context 65

Scope of responsibility 65

Governance arrangements and effectiveness 66

UK Corporate Governance Code 71


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Discharge of statutory functions 72

Risk management arrangements and effectiveness 72

Capacity to handle risk 73

Risk assessment 74

Other sources of assurance 75

Internal control framework 75

Annual audit of conflicts of interest management 77

Data quality 77

Information governance 77

Business critical models 78

Third party assurances 78

Control issues 78

Review of economy, efficiency and effectiveness of the use of resources 78

Delegation of functions 79

Counter fraud arrangements 79

B1(4) Head of Internal Audit Opinion 79

The opinion 80

Internal audit reports 80

B1(5) Review of the effectiveness of governance, risk management and internal control 80

B2. Remuneration and Staff Report 81

B2(1) Remuneration report 81

Remuneration Committee 81

Policy on the remuneration of senior managers 81

Remuneration of Very Senior Managers 81

Contractual arrangements 82

Senior manager remuneration (including salary and pension entitlements) (subject to audit) 82

Pension benefits at 31 March 2018 (subject to audit) 83

Cash equivalent transfer values 83

Real increase in CETV 84

Compensation on early retirement of for loss of office 84

Payments to past members 84

Termination agreements or exit packages (subject to audit) 84

Pay multiples (subject to audit) 84

B2(2) Staff report 85

Staff numbers, costs and composition (subject to audit) 85

Sickness absence data 87


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Staff policies 87

Trade union facility time 87

Other staff matters 88

Expenditure on consultancy 89

Off-payroll engagements 89

Exit packages, including special (non-contractual) payments 90

B3. Parliamentary Accountability and Audit Report 90

B3(1) Audit certificate and report 90

Section C. ANNUAL ACCOUNTS 95


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Section A. PERFORMANCE REPORT

Jane Milligan

Accountable Officer

24 May 2019


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A1. Performance overview

A1(1) Chair, Accountable Officer and Managing Director Introduction We are proud to present our annual report for 2018/19. It details achievements and on-going challenges, describing the context in which work is undertaken and the outcomes experienced by the patients and public we serve.

We have a vision for creating truly integrated services, delivered in partnership with our providers and designed around our residents and their needs. This integration is developing at a Neighbourhood level, across City and Hackney and wider afield across North East London. It focuses on addressing what is best done at what scale. Some services are best organised once across a wide geography (eg some highly technical cancer or cardiac services), but most are best addressed as close as possible to where people live. The report describes how work is progressing with our partner organisations, how it is influenced by input from the public and is supported by our Integrated Commissioning Programme.

The report contains many highlights. Homerton Hospital’s A&E 4-hour waits performance was amongst the best in the country. Whilst it needs to be congratulated on this achievement, it is also the result of developing greater integration of services across City and Hackney. Patient’s urgent needs are becoming more effectively addressed in the community. For example all GP practices provide an enhanced duty doctor service where patients can either access a telephone, email or, where necessary, a face to face consultation. Thus reducing the need to attend A&E. Discharge planning at the other end of hospital in-patient care is also improving. Such work all adds up to enhancing people’s experience of their pathway of care as they move through the system.

Other highlights include:

93% of patients referred urgently for suspected cancer were seen in hospital clinics within 2 weeks;

Over the course of the year, the Homerton Hospital has improved its performance in meeting the national target of 85% of people being urgently referred by a GP for suspected cancer receiving their first treatment within 62 days. It is now is consistently meeting this standard;

Access to talking therapies for people with mental health issues and helping more of them towards recovery has improved. City and Hackney have the highest access and recovery rates in North East London;

The national standard is for 50% of people experiencing a first episode of psychotic mental illness to be treated with an approved care package within two weeks of referral. City and Hackney achieved 90.6%;

Our GP practices perform well on quality measures such as the national quality and outcomes framework. The CCG is currently ranked 1st or 2nd out of 194 CCGs in England across 42% of these clinical attainment measures, such as control of blood pressure, cholesterol, lung disease and asthma. Practices also perform well, compared with London, on measures of patient satisfaction;

The CCG is also ranked first in England for the percentage of people with serious mental illness receiving a physical health check in primary care in 2018-19;

The measles outbreak in the autumn of 2018 across North East Hackney was met with a fast and highly effective response. More than 1,000 immunisation appointments were delivered over two months.


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The financial statements contained with the report provide a summary of the CCG’s financial position and performance for 2018/19. We are accountable for how we spend public money and achieve good value for money for our patients. Once again, the CCG has met all its statutory requirements.

Jane Milligan Dr Mark Rickets David Maher Accountable Officer Chair Managing Director 24 May 2019

A1(2) Accountable Officer’s perspective on performance 2018/19 has been another successful year for NHS City and Hackney Clinical Commissioning Group (CCG) and there is much to be proud of. As Accountable Officer for all seven CCGs in the North East London Commissioning Alliance (NELCA) and the executive lead for the North East London (NEL) STP – the East London Health and Care Partnership (ELHCP), I am delighted with the progress we have made by working closely together with our neighbouring CCGs and partners.

At a NEL level, the Joint Commissioning Committee (JCC), which brings together representatives from all our CCGs and local authorities, has now met several times in public. Key areas discussed in detail include: outpatients, maternity, cancer diagnostics and urgent and emergency care. The Committee has also looked at things like performance and finance activity across the seven CCGs. The purpose of the JCC is to discuss common issues and, in a limited number of areas, take decisions on services that are commissioned once across NEL. The JCC meetings have been held in public with people given the opportunity to ask questions about the issues discussed.

Engaging and involving our local population is a key priority for us and working together as seven CCGs has enabled us to bring together our CCG Lay Members with a focus on developing a co-production charter – aimed at working in equal partnership with the people who use our services in order to create better outcomes.

Working together has been beneficial in a number of other areas such as the joint development of a north east London commissioning strategy which brought together our commissioning work across the whole system for the first time. We also successfully launched our integrated clinical


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assessment service (NHS 111) across all of north east London in the summer of 2018 and through working collaboratively we have also aligned approaches on areas such as acute mental health beds and health based places of safety.

Over the past year we have made great strides in developing our integrated care partnerships (ICP) – working collaboratively with our partners. These ICPs bring together our local authority and provider colleagues at a system level to focus on a range of priorities and outcomes.

We continue to work closely with our providers who are working hard to deliver quality services for our local population. In terms of CQC ratings we are delighted that East London Foundation Trust (ELFT) remains outstanding and Homerton remain as good, while Barts Health NHS Trust has been taken out of quality special measures. This is testament to the hard work and dedication of all the staff.

Looking ahead to 2019/20 we will continue to build on local successes and focus on implementing the requirements of the NHS Long Term Plan, using these as a basis for a refresh of our North East London plan. The direction of travel is to keep on developing our approach to integrated care partnerships and ensuring we are working with our partners to deliver the best care possible for our patients.

The following report provides an overview of City and Hackney’s performance in 2018/19 as well as the annual accounts.


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A1(3) The purpose, activities and objectives of the CCG

Our history, background and structure

NHS City and Hackney Clinical Commissioning Group (CCG) is responsible for the commissioning (planning and purchasing) of healthcare services to improve outcomes for all local people in Hackney and the City of London.

We made good progress during 2018-19 towards our vision for an integrated health and care system where local residents and patients can have the healthiest, happiest lives possible.

This involves residents, patients, providers and our staff as equal partners at every step along this journey. We want to create people-focused services by listening more to residents’ and patients’ voices.

Since 2016, we have moved towards achieving this vision of becoming an Integrated Care System, through the Integrated Commissioning (IC) Programme. The Programme is based on partnership - closer joint-working and integration between local health and care organisations, to improve health and wellbeing outcomes for residents in Hackney and City of London.

We have continued to work together with local partners and residents in four workstreams, making integrated decisions about how best to improve outcomes for local people:

● Planned Care; ● Unplanned Care (emergency, crisis); ● Children, Young People, Maternity and Families; ● Prevention.

The workstreams include staff from the CCG and local authorities - London Borough of Hackney (LBH), the City of London Corporation (COLC), alongside primary care and local hospital staff, mental health trust, community groups and other providers. City and Hackney’s GPs work with the workstreams to provide a wide breadth of practitioner views that help the CCG make clinically-led commissioning decisions. More detail on each of the workstreams and their achievements in 2018/19 is included later in this report.

Our population

We cover an area of North East London made up of the City of London and the London Borough of Hackney. Our total population is 283,600. Hackney has 275,900 residents, City has 7,700 (Office of National Statistics mid-year estimates 2017). We have 322,616 people currently registered with a local GP practice. Our population has been growing faster here in recent years, than in other parts of England. While the City has a low permanent-resident population compared to other areas, more than 400,000 people travel to work here every weekday. Our areas is one of the most diverse in the country, with nearly 90 languages spoken as a main language here. (Census 2011).

City and Hackney faces significant health and wellbeing challenges. For more detail, see the City and Hackney Health and Wellbeing profile, our local Joint Strategic Needs Assessment. Despite economic growth and regeneration in recent years, Hackney still has some deeply deprived areas and high levels of child poverty, which varies widely between wards. The City has low rates of child poverty except for some pockets, such as Portsoken Ward in the east of the City.

Hackney has high mortality rates from preventable diseases. The factors behind these are common here - such as smoking, obesity, poor diet, inactivity and high levels of deprivation. Deaths from cardiovascular disease are higher than elsewhere in the country. Hackney has more smokers than in most parts of London. Many adults and children are obese - including more than 40% of school pupils

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in Year 6. Our residents are more likely to be living with a long-term condition, such as diabetes, lung conditions, heart problems or diabetes and more likely to find it difficult to manage these. We also have a high number of local people with mental health conditions including severe and or enduring mental illness.

Our commissioning activity

We are tackling the major problems faced in our area by working to improve services to local people via our four workstreams. We commission activities and programmes to transform health and social care services in City and Hackney to provide what people need most, such as:

● Mental health care, urgent care, prevention and primary care; ● Reducing A&E waiting times; ● Improving access to a doctor; ● Improving outpatients services; ● Strengthening our workforce.

Working as part of the East London Health and Care Partnership

The ELHCP is made up of the eight councils, seven CCGS, three hospital trusts, two community and mental health trusts, London Ambulance Service, Community Voluntary Services, Partnership of East London Cooperatives and seven primary care Federations that serve over 1.9 million people in north east London, and this will rise to around 2.25 million people in the next 15 years putting exceptional pressure on our health and care services. To address this, we must transform the way we work together to improve the health and wellbeing of local people and create services that are sustainable and affordable. Our partnership will make sure we can do this.

Since 2016, our partnership has delivered our Sustainability and Transformation Plan (STP) and its programmes and projects to transform the care and health services our communities rely upon. This has included work on workforce, mental health, urgent care, prevention and primary care.

We have:

● Introduced new schemes to recruit and keep GPs in our boroughs and provide new training and development opportunities for midwives, physician associates and GP practice managers;

● Ensured that every pregnant woman now has a choice of three places to give birth and over 80% of pregnant women have consistency of care;

● Secured over £5 million to develop a new Cancer early diagnosis centre and improved delivery on the cancer 62 day standard;

● Re-commissioned our NHS 111 service, in line with national guidance, so that patients can make appointments at some of our urgent care services;

● Secured over £7m to improve our digital infrastructure, ‘switched-off’ paper referrals for hospital outpatient appointments and doubled the number of views of the electronic patient record making it easier for clinicians to provide better advice and treatment – no matter where they are working;

● Improved support on stopping smoking and diabetes.

All of this complements and enables the local planning and delivery in each CCG. But we want to do much more and the NHS Long Term Plan published in January 2019 gives us the


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opportunity to refresh our Sustainability and Transformation Plan with much greater involvement of local people and stakeholders than before.

For more information visit http://www.eastlondonhcp.nhs.uk/.

Our corporate objectives and how we measure success

City and Hackney’s objectives directly support our work in Planned Care, Unplanned Care (emergency and crisis care), Children, Young People, Maternity and Families and Prevention.

Our vision for creating an Integrated Care System that delivers a high-quality service in each of these four areas is supported by our Integrated Commissioning Programme. Our programme focuses on:

● More support for patients and their families to get healthy, stay well and be as independent as possible;

● Neighbourhoods, where people and communities are actively supported to help themselves and each other;

● Joined-up support that meets the physical, mental and other needs of patients and their families;

● High-quality GP practices, pharmacies and community services that offer patients more support closer to home;

● Thriving local hospitals for patients when they need them.

To achieve this, we have developed five strategic objectives:

● Shift resource and focus onto prevention and address health inequalities; ● Deliver proactive, community-based care close-to-home, rather than institutional settings,

where appropriate; ● Ensure we maintain financial balance as a system and achieve our financial plans; ● Deliver integrated care which meets the physical, mental health and social needs of our

diverse communities; ● Empower patients and residents.

We talked extensively to our residents and patients about what they want integrated care to deliver. Residents identified priority areas which were refined into 10 key themes:

1. Making sure all children and young people have a good start in life; 2. Reducing the present inequity in health and wellbeing, while contributing towards

reducing inequity in other areas outside the remit of the Integrated Commissioning Programme. This includes closing the health and wellbeing gap for people with long-term conditions and co-morbidities;

3. Increasing the length of a healthy life, so that local people have both longer lives and more years spent free of ill-health and disability;

4. Tackling the causes of poor health and wellbeing at an earlier stage, and putting better prevention measures in place;

5. Creating ‘services that work for me’, or services that are more joined-up and person-centred;

6. Improving the mental health and wellbeing of the local population, including ensuring better access to mental health care;

7. Helping local people to become resilient and empowered, increasing people’s sense of control, autonomy and self-efficacy. This includes encouraging people to become involved in their own care and to understand and manage their own health better;

8. Reducing social isolation;

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9. Increasing employment; 10. Creating a safe environment for everyone to live in, for example by linking in with housing

services.

An outcomes framework has been developed, based on these themes. We will use this to measure our success as a programme.

The programme brings together the three local commissioning organisations with a wide range of local health and social care providers, patients and residents’ groups:

● London Borough of Hackney; ● City of London Corporation; ● Hackney Clinical Commissioning Group; ● City and Hackney GP Confederation (GPC); ● City and Hackney Health and Social Care Forum (HSCF); ● City and Hackney Local Pharmaceutical Committee (LPC); ● City and Hackney Urgent Health Care Social Enterprise (CHUHSE); ● East London NHS Foundation Trust (ELFT); ● Healthwatch City of London; ● Healthwatch Hackney; ● Homerton University Hospital NHS Foundation Trust (HUHFT); ● Patient and resident panels.

Our Structure

Our four workstream areas include members from all these organisations, working together to improve services. Two Integrated Commissioning Boards (one for Hackney, one for City of London) meet in common to lead the commissioning agenda of the locality, ensure financial sustainability and drive local transformation programmes and initiatives.

The Accountable Officers Group (AOG) is attended by the system leaders across the City and Hackney health and social care system who are involved in the IC programme. This includes East London Foundation Trust (ELFT), the CCG, both local authorities - Corporation of the City of London (CoL) and the London Borough of Hackney (LBH) - the GP Confederation and the HUHFT.

The AOG is also attended by the IC Programme Director and IC Convenor. The AOG has overall accountability for the IC Programme and supports the delivery of the ICB’s strategic vision for the programme, working from the IC Programme’s Single Operating Plan for 2019/20.

The AOGs role is to assure the ICB about progress with the programme, unblock any system issues and ensure the ICB’s decisions are implemented effectively.

Our new Transformation Board is a place where new thinking is developed, new issues that impact across the system are explored and the work underway is tested, to ensure it achieves the integrated commissioning and care vision and objectives.


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Actions, Achievements and Successes - our four workstreams

Planned Care

We began a major programme to improve all aspects of our outpatients service in September 2018. The Outpatients Transformation programme with Homerton Hospital aims to find new ways to support primary care, develop smoother pathways, reduce unnecessary activity by providing more care in the community, and introduce technology where it will make patient care better.

The 18-month programme covers 12 specialties to improve and integrate services. So far it has:

● Introduced 6 additional consultant advice and guidance services to GPs, leading to improved care in the community;

● Identified a new Virtual Fracture Clinics service to be provided from July 2019, which will reduce unnecessary waiting for patients and provide faster and safer care pathways;

● Identified a new community acne service pathway, to be commissioned later in 2019, which will treat more patients in the community;

● Identified new patient care applications that can be used by patients to manage diabetes and these will be introduced later in 2019;

● Plans to introduce electronic check-in terminals across outpatients at the Homerton in 2019.

Cancer

In the 2017/18 Improvement and Assessment Framework (IAF) the CCG did not meet any of the standards within the clinical priority areas, returning an inadequate rating.

For cancers diagnosed at early stage (IAF Indicator 122a) - the assessment is based on data from 2016. The most recent local data we have is from year to Quarter 3 2017/18 which show that we have improve from 49% to 57%, which means we are surpassing the current target of 53.52%.

For one-year survival from all cancer indicator (IAF Indicator 122c) – the assessment includes data from 2016. We know from local data that the cancer early diagnosis rate has improved from 71.3% to 71.9%. Actions in place:

Work with partners across the ELHCP to deliver an early diagnosis hub; Continue to work with community groups to increase uptake to bowel cancer screening; To have a specific awareness programme to reach out to men at higher risk of prostate

cancer- Black African and Afro-Caribbean; To roll out a film competition to schools and colleges to promote uptake of the HPV

vaccination in girls and the new roll out to boys; To deliver the upcoming faster diagnosis standard; working with the HUH and other NEL

providers; To support the HUH and other NEL providers to implement the 4 national rapid diagnosis

pathways: Lung, Colorectal, Prostate and Oesphogastric; To work with screening commissioners on the changes to the bowel screening

programme due in 2019; The cancer waiting time standard – people with urgent GP referral having first definitive

treatment for cancer within 62 days of referral (IAF Indicator 122b) is being met in Q4; Cancer patient experience (IAF indicator 122d) poses a particular challenge as the

sample of people for City and Hackney is small. The local work currently being under taken to understanding the situation to identify opportunities for improvement.


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Learning Disability

In the 2017/18 assessment the CCG did not meet 1 out of 2 of the standards within the clinical priority areas generating a ‘requires improvement’ rating.

Reliance on specialist inpatient care for people with a learning disability and/or autism (IAF Indicator 124a), Proportion of people with a learning disability on the GP register receiving an annual health check (IAF Indicator 124b) is above the national benchmark.

The Indicator - proportion of the population on a GP learning disability register (IAF Indicator 124c) has not been met. Form local data reports the IAF performance does not reflect the actual position. We have found that the data from a GP manual submission is used to for this indicator by NHS England rather than the data that has been extracted from the GP system. We are requesting a resubmission of the 2018/19 quarterly submissions to ensure our performance is reflected correctly.

Actions in place:

Work in progress to align patients registered with the specialist integrated learning disabilities service with GP practice registers;

Communication work with practices to encourage them to follow the guidance in relation to manual upload of health checks completed;

An application has been made to the Darzi Fellowship programme for a fellow to work in Learning Disabilities with a remit to improve knowledge and quality of care for people with LD in primary care, including a focus on building registers and reasonable adjustments for health checks;

A five year learning disabilities strategy for City and Hackney is being co-produced with people with LD and carers. The vision for the strategy is “Learning disabled people are active and valued in a community which is accessible and enabling, with the same opportunities as anyone else in the community. They lead full, healthy and happy lives, achieving their potential”.

Wider achievements and improvements supported by our commissioning work include:

● Pathology quality and efficiency – Reducing unnecessary pathology testing, saving time for GP Practice and Pathology teams, while saving money needed to improve other services. We are expanding this work in 2019;

● Wound Care access – A 40% reduction in patients needing routine treatment having to attend Homerton Primary Urgent Care Centre. Achieved by working with Homerton and improving access to GP appointments for routine wound care;

● Women’s Health – Women seeking terminations have more choice, since we commissioned British Pregnancy Advisory Service (BPAS) as an alternative provider. This change improves access by making more locations outside of City and Hackney available to patients - 25% of patients are choosing this alternative;

● Fertility – Our fertility services are more culturally sensitive and flexible in how they link treatment with wider cultural belief systems, following our work with local providers;

● Eye health – Improved access to minor eye conditions services (MECS) by commissioning a new location in the City, and introducing GP referral support services that redirect appropriate referrals to MECS, where patients can often be seen and treated in a few days rather than wait several weeks;

● Eye health – Patients needing checks for diabetic retinopathy can now have an additional service - Optical Coherence Tomography (OCT) - at the same time, reducing ophthalmology referrals by 80%, which is more convenient for patients and saves money;


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● Colorectal cancer – GPs will get help to identify patients who may have colorectal cancer with a new Faecal Immunochemical Test (FIT) being introduced across North East London. Diagnosis will be more accurate and fewer people will need to go on to have unnecessary invasive diagnostics;

● Cervical cancer – Our work with the Barts Health will support a smooth transition to Primary HPV cervical screening across City and Hackney from April 2019;

● Prostate cancer – Improvements and changes to the way prostate cancer is followed-up from April 2019, through our work with HUH and our GP Confederation;

● Rare cancers – working with LBH to raise awareness and improve access to diagnosis; ● Cancer awareness – We delivered a series of “talk cancer” training sessions for our

voluntary sector. We are planning activities to increase cancer awareness and education across our area throughout 2019. After looking at how we currently encourage people to take up the offer of bowel cancer screening, we have developed a new specification and will deliver it in 2019-20;

● Administration – All GP referrals to our local hospitals are all now made via the ‘e’ referral system (e-RS), implemented in October 2018, in line with a national target. It means fewer administrative systems and more efficiency for our secondary care services;

● NHS Continuing Healthcare – ○ We have made Personal Health Budgets the way we deliver NHS Continuing

Healthcare packages to eligible patients who need care at home after a hospital stay. Patients will have a personalised assessment and care planning process, knowing how much money is available for their care, with the option to manage this money through a direct payment if they choose;

○ We reduced delays in hospital discharges by allowing more Continuing Health Care (CHC) assessments to be completed in a community setting, and making them quicker to complete. More staff resources were provided to help the CHC service reduce delays in the 12-month follow-up review that ensures packages of care or placements are still right for each client;

○ Personal Wheelchair Budgets – Eligible wheelchair users will have more choice and options from 2019/20 after our successful pilot for Personal Wheelchair Budgets with the Homerton Wheelchair Service. All eligible clients who get new equipment at a clinic appointment will have the option of using a Personal Wheelchair Budget to upgrade or improve their NHS chair. Clients can also use these funds to purchase a chair independently and outside of the NHS if they wish.

● Personal Health Budgets – People with severe and enduring mental health conditions will have access to a Personal Health Budget from May 2019, to help achieve their recovery goals. We developed and commissioned a pilot with experienced clinician experts from East London Mental Health Foundation Trust (ELMHF) and local Voluntary, Community and Social Enterprise (VCSE) provider, The Advocacy Project. It will provide a personal health budget advisory and support service to clinicians and up to 180 local people with mental health conditions, who are being treated in secondary mental health services;

● Diabetes – We improved our care of people with diabetes - based on the number achieving good control of their blood pressure, blood glucose levels and cholesterol - from ‘Needs Improvement’ to ‘Good’.


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Unplanned Care

Total waiting times for Accident and Emergency (A&E) at Homerton University Hospital NHS Foundation Trust (HUHFT) were on target and still improving. Homerton Hospital is consistently in the top three London Trusts for achieving national standards.

In 2018/19, 94.32% of people attending Homerton’s A&E were seen and treated or discharged within four hours. The national standard is that 95% of people should be seen and treated or discharged within four hours. This result was supported by improvement programmes across the local health system, good patient flow and operational management to avoid blockages in A&E.

Extra funding for the A&E service meant extra emergency-department staff could help meet increasing patient demand, particularly in the evening, and more staff could be there to help discharge patients, particularly at weekends.

Keeping people from having to make unnecessary trips to A&E by providing alternative help and treatment closer to home, via primary care, has also been a key focus:

● City and Hackney GP practices are proactive in supporting the most frail and vulnerable patients in our area, to avoid the need for A&E attendance and potential emergency admissions;

● Patients in crisis needing urgent care can have a rapid response service such as ParaDoc visit and treat them at home;

● All GP practices in City and Hackney provide a Duty Doctor Service. Patients with urgent issues can have same-day access to a doctor, by an initial telephone consultation, or urgent appointments where needed, to provide the right treatment or care and service for each patient, reducing the need to attend A&E;

● City and Hackney achieved a dementia diagnostic rate of 69.9% against prevalence by January 2019 - above the national target of 66.7%. We are currently working with NHS England to improve our dementia diagnostic rates further. In 2019-20 we aim to improve inconsistencies in coding and work more closely with care homes;

● City and Hackney has begun a pilot to provide mental health interventions to reduce frequent attendance in A&E, working with the London Ambulance Service.

Children, Young People, Maternity and Families (CYPMF)

We strive to provide high quality services for children, young people and their parents. We work with partners in health, social care, education, community and voluntary groups, alongside children and families themselves, to strengthen these services, through integrated commissioning and care.

During 2018/19, we also focussed on three key transformation priority areas:

1. Improving emotional wellbeing of our children and young people; 2. Improving our health offer for ‘vulnerable’ groups of children and young people; 3. Improving the offer of maternity and early years (0-5 years).

Improving Emotional wellbeing – Our Child and Adolescent Mental Health Service (CAMHS) continues to perform well. We

have placed CAMHS Clinicians and education wellbeing specialists in schools now covering 50% of City and Hackney state maintained schools with a plan for universal roll-out in 2020;

We have launched an extended hours CYP MH crisis resolution service in Homerton A&E. We also worked closely with our North East London neighbours, to increase our


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offer to support perinatal mental health. We have begun work on building resilience across our vulnerable groups, including commissioning a specifically tailored transition service for under-25 year olds, and work on our offer for LGBTQ+ groups;

Our CAMHS achieved a cumulative access rate target of 39.6% in March 2019 (preliminary self-reported data at time of writing), above the national target of 32% and a significant increase from the 2017/18 rate of 29%;

We have a comprehensive CAMHS Transformation Programme in place, with significant increases in investment through CAMHS Transformation equating to around £1.6M from a 2014/15 baseline.

Improving Our Health offer for vulnerable groups of children and young people –

● For our children with special educational needs and disability (SEND), we have strengthened the joint commissioning and funding arrangements we have with education, to give additional support to children whose complex health needs impact their engagement and achievement at school;

● All children eligible for Continuing Healthcare are now making use of Personal Health Budgets;

● A new ‘child-centred’ service, to improve the health and wellbeing of City and Hackney’s Looked After Children, has been re-designed to go live in September 2019, supporting around 400 of our vulnerable children;

● We are developing a joint approach to reducing the impact of adverse childhood experiences (ACEs) across City and Hackney, building on the strong offer around trauma-informed practice in Hackney and the City of London.

Improving our offer of maternity and services for early years (0-5) –

● Our maternity service was inspected by the Care Quality Commission (CQC) and upgraded from ‘Requires Improvement’ to ‘Good’ in August 2018;

● The maternity service implemented a number of initiatives to deliver the national agenda of providing Continuity of Carer for women birthing at Homerton Hospital and continues to focus on reducing neo-natal mortality and stillbirths;

● We responded robustly to the measles outbreak in North East Hackney, with funding to support primary care in meeting surges in demand for immunisations. More than 1,000 immunisation appointments were delivered over two months, with children being offered full schedule catch-up, as well as Measles, Mumps and Rubella (MMR);

● Through our GP Confederation, we continued to support improving pregnancy outcomes for women with long-term conditions. We helped 1,149 women receive targeted pre-conception advice, to support them in planning their pregnancies. More than 4,000 women received post-natal support following delivery;

● The Maternity Voices Partnership was refreshed and, through increased service user and provider engagement, has made changes that have already improved service user satisfaction.

Prevention

During 2018/19, our prevention workstream worked with partners across the health and care system to:

● Reduce exposure to the main preventable risk factors for poor health - such as smoking, obesity, inactivity, alcohol and drugs;

● Make early diagnoses and actions to prevent future ill-health and improve quality of life; ● Support people to take control of their own health and wellbeing and live healthy lives.


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Some key achievements include:

● High/increasing referrals to preventative services – ○ More than 1,500 referrals to Social Prescribing; ○ 3,500 annual referrals to weight management/exercise on referral; ○ 3,000 smokers setting a quit date each year; ○ Almost 1,000 people with pre-diabetes referred to the National Diabetes

Prevention Programme – a behaviour-change course to help them avoid developing diabetes.

● City and Hackney was top performing CCG in England, for 12 measures of care for people with a range of long-term conditions, including management of blood pressure and offering support to stop smoking. This achievement is thanks to our Long Term Conditions Contract with City and Hackney GP Confederation, which continues to help us deliver high-quality care to people at risk of, or who already have a long term condition;

● City and Hackney achieved the national target - and came second in London - for carrying out physical checks in primary care for those with serious mental illness. The target achieved was to check 50% of people with serious mental illnesses in 2018-19.

A1(4) The key issues and risks of the CCG During the financial year, we managed and contained material financial risk across our commissioning portfolio. The key financial risks that developed were with the Homerton and Barts Health contracts, which ended the financial year with a reported position of £4.7m and £1.8m respectively, adverse to full-year plan. Additionally, the CCG supported the wider NEL system as part of the Risk Share Framework with £1.0m support to Waltham Forest CCG. Through our the Planned Care Workstream, we undertook a Learning Disabilities (LD) Pilot programme with the London Borough of Hackney as part of a joint funding collaboration totalling £1.9m. The Planned Care Workstream is in the process of further developing the LD Programme to improve outcomes for these residents.

A1(5) Going concern opinion The ability of the CCG to continue as a going concern is dependent upon its ability to secure future funding from NHSE. The budget for 2019/20 has already been agreed with NHSE. On this basis, there is no reason to believe that sufficient funding will not be made available to the CCG in the 12 months from the date of approval of these Financial Statements.

As such the Financial Statements in Section C have been prepared on a going concern basis.

A1(6) Performance summary CCGs are accountable for how they spend public money and achieve good value for money for their patients. We have a wide range of statutory duties they are required to meet.

NHS England (NHSE) assesses CCGs against the national CCG Improvement and Assessment Framework.

CCGs measure and monitor performance against a range of national and local key performance indicators (KPIs), that measure the quality of services offered to local people.


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This section summarises key performance issues, with more detailed information later in this report, particularly in the performance analysis section (A2).

Financial performance

We are accountable for how we spend public money and achieve good value for money for people in City and Hackney. This is the sixth year of the CCG’s existence and good financial control and management continues to be vital.

We aim to improve the health and wellbeing of the people in the borough by ensuring that patients and their carers experience the highest possible standards of health and social care. We have a commissioning budget of around £459 million to do this work, which is allocated in the finance sections in this report.

CCG Improvement and Assessment Framework

Through a number of measures, NHS England assessed City and Hackney’s CCG’s performance released in 2018-19 as ‘Good’, based on an assessment of the CCG achievement and in comparison to all other CCGs in England of the indicators in four domains: better health, better care, sustainability and leadership.

We remained focused on improving our performance. At the end of Quarter 3 2018/19, the CCG has seen consistent improvement in the one-year survival from all cancers and in the Utilisation of the NHS e-referrals service to enable choice at the first routine elective referral.

We continue to be in the top 10 of the highest performing quartile, when compared to all the CCGs in England, for the following indicators:

● Injuries from falls in people ages 65 and over; ● Inequality in unplanned hospitalisation for ‘chronic ambulatory care-sensitive’ and ‘urgent

care-sensitive’ conditions; ● Antimicrobial resistance - appropriate prescribing of antibiotics in primary care; ● Reliance on specialist inpatient care for people with a Learning disability and/or autism; ● Dementia Care planning and post-diagnostic support; ● Emergency admissions for urgent care sensitive conditions; ● Primary Care access – proportion of population benefiting from extended access services; ● Patients waiting 18 weeks or less from referral to hospital treatment; ● The staff engagement index; ● Effectiveness of working relationships in the local system.

Our biggest challenges, where we are in the bottom 10 of all CCGs and in the lowest performing quartile nationally are:

● Percentage of children aged 10-11 classified as overweight or obese – 42% of children in City and Hackney CCG are classified as overweight or obese. Through the Integrated Commissioning programme, we have an established programme of work that is seeking to reduce the number of obese children;

● Cancer Patient Experience - We are seeing some improvement in this indicator, but it poses a particular challenge as the sample of people that underpins this indicator is very small. The local work currently being undertaken will supplement our understanding of the results to be able to identify the improvement opportunities;

● Percentage of NHS Continuing Healthcare assessments that take place in an acute hospital - the Continuing Healthcare Service offered to our population is currently under


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review, in collaboration with other North East London CCGs, to ensure that the service model supports high-quality service delivery and ensures maximum efficiency.

Primary care performance

There are 42 GP practices in Hackney and one practice in the City of London. All practices are members of the City and Hackney GP Confederation. The average list is 7,681 patients. The average number of full-time equivalent GPs per practice is 4.5. Around 1.6 million consultations are held each year; the ratio of face to face to phone consultations is 4:1, with a shift towards more phone consultations over time; 70% of consultations are with a GP.

Our practices perform well on quality measures such as the local quality dashboard and the national quality and outcomes framework (QOF). The CCG is currently ranked 1st or 2nd out of 194 CCGs in England across 42% of various QOF clinical attainment measures, such as control of blood pressure, cholesterol, lung disease and asthma; C&H practices also perform well, compared with London, on measures of patient satisfaction. The CCG is also ranked first in England for the percentage of people with Serious Mental Illness, who received a physical health check in primary care in 2018-19, covering all six of NHSE’s recommended measures.

KPI performance

We met or exceeded many of our KPI standard targets in 2018-19, with a number of exceptions. Wherever we need to make improvements, we are making plans and taking action to make the changes that will give local people the best services possible and equal to others elsewhere in London and the rest of England.

We commission a range of services from a number of providers. Our main acute hospital and community services provider is Homerton University Hospital Foundation Trust, although we also commission some acute services from Barts Health NHS Trust and University College London Hospitals. Our mental health services provider is East London NHS Foundation Trust, Homerton University Hospital Foundation Trust, and the City and Hackney GP Confederation.

The performance analysis section below contains information on the CCG’s and the local trusts’ performance against the KPIs.

A2. Performance analysis A2(1) Financial performance The financial statements contained with the report provide a summary of the CCG’s financial position and performance for 2018/19. This section of the report talks about how we manage our money and how our financial performance is measured.

We are accountable for how we spend public money and achieve good value for money for our patients. This is the sixth year of the CCG, and good financial control and management is vital for the development of the organisation.


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Funding

In 2018/19 City and Hackney CCG was given funding of £458,899,000 from NHS England. Within this funding the CCG is allowed to spend £6,295,000 on the running costs of the organisation.

How we spent the money

The majority of the CCG’s spend is used to purchase services from NHS Trusts and NHS Foundation Trusts. The following chart gives a breakdown by service of the CCG’s total net revenue expenditure of £458,896,000.

How we did

CCG’s have a number of financial duties under the National Health Service Act 2006 (as amended). The CCG’s performance against those duties was as follows.

NHS Act Section

Duty Target Performance Duty Achieved

£'000 £'000

223H (1) Expenditure not to exceed income 459,824 459,821 Yes

223I (2) Capital resource use does not exceed the amount specified in Directions

83 68 Yes


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223I (3) Revenue resource use does not exceed the amount specified in Directions

458,899 458,896 Yes

223J(1) Capital resource use on specified matter(s) does not exceed the amount specified in Directions

- - N/A

223J(2) Revenue resource use on specified matter(s) does not exceed the amount specified in Directions

- - N/A

223J(3) Revenue administration resource use does not exceed the amount specified in Directions

6,295 4,995 Yes

Note: For the purposes of 223H (1); expenditure is defined as the aggregate of gross expenditure on revenue and capital in the financial year; and, income is defined as the aggregate of the notified maximum revenue resource, notified capital resource and all other amounts accounted as receivable in the financial year (whether under provisions of the Act or from other sources, and included here on a gross basis).

Financial pressures

A number of key financial risks developed over the 2018/19 financial year, these include:

● The Homerton Hospital full-year reported position was £4.7m adverse to full year plan; ● The CCG reached a close-down agreement with Barts Health NHS Trust, with an over-

performance of £1.8million; ● Out of area acute over-performance of £2.0m, with the majority of the increased activity

being at Guy's Hospital and London Ambulance Service; ● The CCG transferred £1.0m to Waltham Forest CCG, under the 2018/19 NEL Risk Share

Framework, in support of the neighbouring health geography.

Future years

The City & Hackney CCG’s Financial Plan for 2019/20 reflects the required breakeven control total net of efficiency of £5m. In 2019/20, the CCG will receive the following funding streams:

● Core Services allocation of £421m, an increase of 6.6%; ● Delegated Primary Care allocation of £48m, an increase of 3.7%; ● Running Costs allocation of £6.3m, which remained unchanged from 2018/19. In 2020/21,

the Running Costs allocation reduces to £5.5m.

A2(2) How the CCG measures and checks performance

The performance management framework

The performance management framework looks at improving the performance of a range indicators that are part the CCG Improvement and Assurance Framework (IAF), Better Care Fund (BCF), Quality Premium, the NHS operating plan (inclusive of the NHS Constitution) and any other indicators that are part of NHS England-led National Programmes. Performance


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Dashboards are produced for each of the four Integrated Commissioning Programme Workstreams, to assess need and monitor impact on outcomes. These form part of the Performance Report presented to the Governing Body each quarter. The Finance and Performance Committee also carries out additional scrutiny of recovery plans, to improve outcomes in areas where there is some risk to performance or financial outlook.

CCG Improvement and Assessment Framework

The CCG Improvement and Assessment Framework (IAF) was updated in 2017/18 and builds on the IAF introduced in April 2016, which replaced both the historic CCG assurance framework and CCG performance dashboard. It was designed to provide a greater focus on assisting improvement, alongside NHS England’s statutory assessment function. The IAF aligns with NHS England’s Mandate and planning guidance, with the aim of unlocking change and improvement in a number of key areas. This approach aims to reach beyond CCGs, enabling local health systems and communities to assess their own progress from ratings published online. The framework is intended as a focal point for joint work and support between NHS England and CCGs. It draws together the NHS Constitution, performance and finance metrics and transformational challenges and plays an important part in the delivery of the Five Year Forward View.

This framework covers a total of 58 indicators, located in the four domains and 6 clinical priority areas (Mental Health, Dementia, Learning Disabilities, Cancer, Maternity and Diabetes). The domains we are assessed against are:

● Better health: How the CCG is contributing towards improving the health and wellbeing of its population, and bending the demand curve;

● Better care: Focuses on care-redesign, performance of constitutional standards, and outcomes, including in important clinical areas;

● Sustainability: How the CCG is remaining in financial balance, and is securing good value for patients and the public from the money it spends;

● Leadership across the ICS: 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.

This year a small number of indicators have been added and a number of updates made to existing indicators.

Local Rating

The rating given to City and Hackney CCG in 2018/19 from NHS England is based on our performance in 2017/18. We were given a rating of ‘Good’ with continued delivery against key national indicators and received particular commendation for the Musculoskeletal (MSK) triage high-impact process. The areas noted for improvement have been part of the CCG’s commissioning plans in 2018/19, with improvement seen within safeguarding partnerships and arrangements and within Learning Difficulties (LD) services which will impact on the indicators in the LD clinical priority area.

The annual assessment results of the clinical priority areas are outlined below:


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Better Health and Better Care

● RTT performance has reduced but has remained compliant with the standard. GP Referrals have remained below plan, the challenge is to maintain this position to help maintain Patient Tracking Lists (PTL) volumes;

● The CCG is to be commended on implementing a musculoskeletal (MSK) triage High-Impact Intervention which was a requirement of the 2017/18 Elective Care Demand Management programme. City & Hackney CCG remained compliant with the diagnostic standard through 2017/18;

● Mental Health – ○ In 2017/18, City & Hackney CCG delivered the Improving Access to Psychological

Therapies (IAPT) access over 9 out of 12 months and delivered the IAPT recovery standard in 7 out of 12 months. At Q4 2017/18 City & Hackney delivered an IAPT access rate of 5.04% (against the standard of 4.2%);

○ City & Hackney CCG did not meet the 6 and 18 weeks waiting time standards for IAPT in October 2017 and did not meet the 18 week waiting time standard in September 2017;

○ The CCG consistently delivered the Dementia Diagnosis Rate standard (66.7%) and the Early Intervention in Psychosis (EIP) standard of treating 50% within 2 weeks of referral;

○ At Q4 2017/18, the CCG delivered a Children and Young People’s Mental Health access rate of 39%, against the standard of 30%. At Q4 2017/18, 87.5% of Children and Young People entered treatment within one week for urgent eating disorders referrals and 81.08% for routine referrals.

● Quality – ○ In relation to Safeguarding, the CCG should continue to develop its leadership and

capacity to implement the requirements of Chapter 3 of the statutory guidance (Working Together to Safeguard Children, HM Government, 2018), which requires CCGs to work, as equal partners, with police and the Local Authority, to put together a safeguarding partnership and to set the safeguarding arrangements. The three safeguarding partners should agree on ways to co-ordinate their safeguarding services, act as a strategic leadership group in supporting and engaging others, and implement local and national learning including from serious child safeguarding incidents.

● Patient and Public Voice - ○ The CCG was rated green overall, following intensive national review. The CCG

should provide more information on how the CCG has fed back to the public about public involvement and make clear the difference it has made, with clear instructions for the public about how to access information in different formats (e.g. Easy Read, Braille, community languages).

Sustainability

The CCG received a Green rating as a result of meeting all of its financial targets.

Leadership across the Integrated Care System

The CCG retained a Green rating for the Quality of CCG Leadership rating in Q4 2017/18. The Governance review has been completed and recommendations are being implemented by the CCG.


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Governance – The CCG self-assessment provided sufficient detail to assure that it has appropriate governance policies and processes in place. NHS England (London) will be working with CCGs to develop a more effective governance assurance process over the coming quarter, which will take into account the structure of CCGs across North East London.

CCG 360 Stakeholder Survey (2018 vs 2017) – City & Hackney CCG saw the biggest improvement with stakeholders to the questions: ‘I have confidence that the CCG effectively monitors the quality of the services it commissions’; and, 'If I had concerns about the quality of local services I would feel able to raise my concerns with the CCG'. There was a change of 9.2% - both up from 86.0% to 95.2%. The biggest decrease was seen against the question 'When I have commented on the CCG's plans and priorities I feel that my comments have been taken on board' with a change of -7.9% (down from 69.8% to 61.9%).

Clinical priority area ratings

The CCG is given a rating for each clinical priority area on a 4 point scales (mirroring CQC ratings); how the rating is applied with the performance against each indicators varies for each domain.

The current ratings, based on 2017/18 data and published in 2018/19 for the 6 clinical priority areas for City and Hackney are:

IAF Clinical Priority Area

Current rating

Year rating applies to

Measures within the clinical priority area with commentary

Dementia Outstanding 2017/18 - Diagnosis of dementia

- Patients having their dementia care plan reviewed regularly

Mental Health Good 2017/18 - Improving IAPT access rates

- Improving IAPT recovery rates

- Reducing early intervention in psychosis waiting times

- Reducing inappropriate out of area placement bed days

- Improving crisis resolution and home treatment services provision

Diabetes Good

A marked improvement from 2016/17 where the rating was “requires improvement”

2017/18 - Diabetic patients who achieve treatment targets for blood sugar, cholesterol and blood pressure

- Newly diagnosed diabetics who have attended a structured education course


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Learning Disabilities

Requires improvement

2017/18 - Care for people with learning disabilities in a hospital (aim is more community care)

- People with learning disabilities who received annual health check

- Proportion of population on a GP learning disability register

Maternity Good

A marked improvement from 2016/17 where the rating was “requires improvement”

2017/18 - Women’s experience of maternity services

- Women’s experience of choice in maternity services

- Number of stillbirths and deaths of babies within 28 days

- Women who smoke at the time of delivery

Cancer Inadequate 2017/18 - Cancer patients who have their cancer diagnosed early

- One-year survival from cancer - Patient experience of care for their

cancer - Patients waiting longer than 62 days for

their 1st treatment

Our workstreams approach to addressing these clinical priority areas is set out on page 18.

Future development of the framework

The framework needs to be flexible to maintain its relevance and alignment to the highest local priorities for CCGs and their partners in STPs/ICSs.

NHS England (NHSE) and NHS Improvement (NHSI) are developing with STPs/ICSs a set of principles that will underpin oversight:

● NHSE and NHSI speaking with one voice, setting consistent expectations for local health systems;

● Greater focus on the performance of the local healthcare system as a whole, alongside the performance of individual providers and commissioners;

● Working with and through the STP/ICS leadership, wherever possible, to tackle problems in individual organisations or localities, rather than making uncoordinated national interventions. This will thereby stimulate the further growth of self-governing systems.

This will be informed by a new integrated oversight framework that will form a key part of the regular performance discussions between NHSE, NHSI and STPs/ICSs. Alongside this, NHSE, NHSI and STPs/ICSs will continue to review trust-level data – and CCG-level data – to help agree when individual organisations need support or intervention and who should provide that support or intervention.

Regulators envisage that this new framework will evolve to reflect a population-based approach to improving health outcomes and reducing health inequalities. Development of this framework


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will be informed by the long-term plan for the NHS, issued in January 2019, to ensure that the ambition described for the NHS is captured in the metrics that they use to assess and oversee CCGs and healthcare systems in the future.

Primary care performance

Our 42 GP practices perform well on quality measures such as the local quality dashboard and the national quality and outcomes framework (QOF). The CCG is currently ranked 1st or 2nd out of 194 CCGs in England across 42% of various QOF clinical attainment measures, such as control of blood pressure, cholesterol, lung disease and asthma. C&H practices also perform well, compared with London, on measures of patient satisfaction. City and Hackney GP practices are:

● Well-staffed – there is 1.0 GP or nurse per 1000 weighted patients, compared to 0.9 for NEL and London, and 1.0 for England;

● Efficient – City and Hackney has the lowest referral rate for a first outpatient appointment in London. It means that local practices are safely managing patients when other practices might refer. This helps keeps the local health economy in financial balance;

● Value for money – at about £35 for a face to face appointment with a GP; ● Accessible –

○ Half (51%) of local appointments take place on the same day of booking - the highest proportion in London where the average is 43%;

○ Eighty per cent of all City and Hackney appointments take place within a week of being booked, compared to 75% for the STP and 74% for London;

○ All practices have a Duty Doctor service for managing urgent activity; ○ Routine appointments outside core contract hours of 8-6.30 Mon-Fri (mostly

evening appointments from 6.30-8.00) are offered at 37 of our 42 practices; ○ All practices can refer their patients to weekday evening and all-day (8-8)

weekend primary care hubs; ○ Evening and weekend primary care access has been re-specified for 2019/20, to

allow for delivery on a neighbourhood footing.

CCG performance against the KPIs

We met or exceeded many of our KPI standard targets in 2018-19, with a number of exceptions. Wherever we need to make improvements, we are making plans and taking action to make the changes that will give local people the best services possible and equal to others elsewhere in London and the rest of England.

Referral to Treatment (RTT)

Patients have a right to start their non-emergency NHS consultant-led treatment within a maximum of 18 weeks from referral, unless they choose to wait longer or it is clinically appropriate that they wait longer.

The national standard is that 92% of patients should start their treatment within this time.

In City and Hackney, we monitor the percentage of patients waiting less than 18 weeks from the point of referral to treatment (RTT).


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During 2018/19, the CCG consistently met the target for the RTT standard. On average, 94% of City and Hackney patients waited less than 18 weeks during the year, achieving the national target of 92%.

During 2018/19, between 0 and 5 people waited more than 52 weeks for their treatment at the end of each month over the year.

Barts Health resumed reporting into the national return in April 2018 after suspending reports from October 2014 due to data quality concerns.

Indicator Standard Q1 2018/19

(April – June 2018)

Q2 2018/19 (July – Sept)

Q3 2018/19 (Oct – Dec)

Q4 2018/19 (Jan – March)

2018/19

Referral to treatment waiting times for non-urgent consultant led treatment

Patients on incomplete non-emergency pathways should have been waiting no more than 18 weeks from referral

92% 94% 94% 94% 94% 94%

Number of patients waiting more than 52 weeks (incomplete pathways)

n/a 4 2 3 0 3

Diagnostic waiting times

The national standard is for less than 1% of patients waiting over 6 weeks for a diagnostic test.

City and Hackney achieved this target with less than 0.6% of our patients waiting over 6 weeks for a diagnostic test during 2018/19.


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Q2 2018/19 (July – Sept)

Q3 2018/19 (Oct – Dec)

Q4 2018/19 (Jan – March)

2018/19

% of patients waiting less than 6 weeks for a diagnostic test

99% 99% 99% 99% 99% 99%

A&E total waiting times

The national standard for Accident and Emergency (A&E) is that 95% of people should be seen and treated or discharged within four hours. A&E performance is calculated as the percentage of patients attending A&E who spent 4 hours or less in A&E (from arrival to transfer, admission or discharge).

During 2018/19, 94% of patients waited for less than 4 hours to be admitted, transferred or discharged from their arrival at Homerton University Hospital Foundation Trust (HUHFT) Accident and Emergency (A&E).

The target of 95% was met for 5 months of the year with the other months being between 92% and 94.5%. The Homerton’s A&E 4-hour waits performance was amongst the best in the country in 2017/18. We are working to improve this with a number of measures including extra funding for staff to help with patient discharges, especially in the evenings and at weekends.



Q2 2018/19 (July – Sept)

Q3 2018/19 (Oct – Dec)

Q4 2018/19 (Jan – March)

2018/19

Accident and Emergency waiting times (Homerton University Hospital NHS Foundation Trust)

Patients should be admitted, transferred or discharged within 4 hours of their arrival at an A&E department

95% 94.7% 94.7% 94.9% 92.7% 94.1%


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Cancer waiting times

Cancer performance is one of the eight national priorities for delivery. There are eight national cancer waiting times standards against which performance is monitored.

● Two weeks from urgent GP referral for suspected cancer to first appointment (93%); ● Two weeks from referral for breast symptoms (whether cancer is suspected or not) to first

appointment (93%); ● 62 days from urgent GP referral for suspected cancer to first treatment (85%); ● 62 days from urgent referral from NHS Cancer Screening Programmes to first treatment

(90%); ● 62 days from a consultant's decision to upgrade the urgency of a patient to first treatment

(no operational standard set); ● 31 days from diagnosis (decision to treat) to first treatment for all cancers (96%); ● 31 days from decision to treat/earliest clinically appropriate date to second/subsequent

treatment (surgery or radiotherapy) (94%); ● 31 days from decision to treat/earliest clinically appropriate date to second/subsequent

treatment (drug therapy) (96%).

During 2018/19, City and Hackney achieved success in achieving and, at times, exceeding national targets. The volatility in the 31 day and 62 days targets is primarily due to the very small numbers that make up the denominator and numerator as outlined below. The national target of 93% of patients waiting a maximum of 2 weeks for their first outpatient appointment, who were referred urgently by the GP for suspected cancer was consistently achieved. On average, 95% of local patients were seen within 2 weeks:

● The national target of 93% of patients waiting a maximum of 2 weeks for their first outpatient appointment, who were referred urgently by the GP for suspected cancer was consistently achieved. On average, 95% of local patients were seen within 2 weeks;

● 95% of our patients waited a maximum of 2 weeks for their first outpatient appointment after being referred urgently with breast symptoms (where cancer was not initially suspected) against a target of 93%. The target was met consistently throughout the year;

● 98% of our patients waited a maximum of 31 days from diagnostics to the first definitive treatment for all cancers (against a target of 96%). This target was consistently achieved throughout the year;

● 95% of local patients waited a maximum of 31 days for subsequent surgical treatment for cancer (against a target of 94%);

● 99% of our patients waited a maximum of 31 days for subsequent anti-cancer drug regime treatment (against a target of 98%);

● 99% of local patients waited a maximum of 31 days for subsequent radiotherapy treatment for cancer (against a national target of 94%). This target has been consistently met throughout the year;

● 83% of our patients waited a maximum of 62 days from urgent referral to first definitive treatment for cancer (less than the national target of 85%). The target was only met in 4 months out of 12 with performance ranging from 77% to 85%. The number of people affected range from 0 to 10;

● There were only 2 patients throughout the year that waiting waited a maximum of 62 days from referral from an NHS screening service to first definitive treatment for all cancers against a target of 90%), causing the average performance (84%) for the year to be below target;

● 91% of local patients on average waited a maximum of 62 days for definitive treatment following a consultant decision to upgrade the priority of the patient. There is no target for this measure.


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Q2 2018/19 (July – Sept)

Q3 2018/19 (Oct – Dec)

Q4 2018/19 (Jan – March)

2018/19

Cancer patients – 2 week wait

Maximum 2 week wait for first outpatient appointment for patients referred urgently with suspected cancer by a GP

93% 94.68% 94.91% 95.46% 95.16% 95.06%

Maximum 2 week wait for first outpatient appointment for patients referred urgently with breast symptoms (where cancer was not initially suspected)

93% 92.78% 96.33% 95.56% 95.15% 94.97%

Cancer waits – 31 days

Maximum 31 day wait from diagnostics to first definitive treatment for all cancers

96% 99.08% 97.18% 99.01% 99.49% 98.68%

Maximum 31 day wait for subsequent treatment where the treatment is surgery

94% 100% 91.67% 95% 97.30% 95.95%

Maximum 31 day wait for subsequent treatment where the treatment is an anti-cancer drug regime

98% 99.08% 100% 100% 100% 99.71%

Maximum 31 day wait for subsequent treatment where the treatment is a course of radiotherapy

94% 100% 100% 100% 97.89% 99.37%


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Cancer waits – 62 days

Maximum 62 day wait from urgent referral to first definitive treatment for cancer

85% 84.87% 78.07% 85.85% 90.48% 84.40%

Maximum 62 day wait from referral from an NHS screening service to first definitive treatment for all cancers

90% 100% 75% 66.67% 90.91% 85.00%

Maximum 62 day wait for definitive treatment following a consultants decision to upgrade the priority of the patient

N/A 88.71% 92.75% 92.31% 88.31% 90.38%

Mixed-sex accommodation

During 2018-19, Mixed Sex Accommodation (MSA) breaches, occurring during treatment commissioned by City and Hackney, have continued to decline:

34 breaches in 2015/16; 27 breaches in 2016/17; 23 breaches in 2017/18; 22 breaches in 2018/19.

There have been no breaches at Homerton Hospital or ELFT for the last few years. The rate of MSA breaches by finished consultant episodes is low at Barts Health NHS Trust and UCLH compared to other London trusts. MSA breaches due to lack of bed capacity in critical care at Whipps Cross Hospital were highlighted by the CQC during the June 2017 inspection. Service leads had not flagged this as a risk. During the most recent inspection in September 2018, MSA breaches remained a challenge for the unit, but had been documented on the unit’s risk register. The CQC asked Barts to address issues of timely admission and transfer arrangements to reduce delayed discharges and MSA breaches.

Friends and family test

The Friends and Family Test (FFT) measures how likely a patient would be to recommend the ward or department to their friends and family, if they needed similar care or treatment.

Homerton Hospital’s ‘recommended’ rates for A&E and Maternity (Birth) are better than local trusts and the London average. Since April 2016, Homerton FFT response and recommended rates have remained stable or slightly improved, apart from A&E and Maternity (Birth) FFT response rates, which have declined. The Homerton have been focusing on a number of areas to improve patient experience at the Trust including teaching sessions for nurses on wards to improve their knowledge of better pain management, reducing noise at night on the wards and more dementia awareness training for a range of staff.


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Barts showed some lower patient recommendations and room for improvement in A&E and Outpatient FFT scores. The Trust has a quality improvement programme in place supported by East London Foundation Trust, which is a national leader in quality improvement systems. Barts Health has also invested in initiatives to improve patient experience including ‘We Can Talk’ training, that equipped hospital staff to be more comfortable in caring for young people with mental health problems and, regular Patient-Led Assessments of Care (PLACE) audits which look at the quality of food and the ward environment.

Recommended Rate 2018/19

London average

Homerton BHR Barts UCLH

A&E 85.8% 92.7% 90.6% 73.2% 84.7%

Inpatients 94.3% 94.4% 94.4% 89.5% 94.1%

Birth 96.2% 98.7% 98.0% 93.6% 97.0%

Community services

96.5% 93.9% 97.6% 100% n/a

Outpatient services

92.4% 92.9% 94.6% 88.0% 92.1%

Key Performance above 90%

Performance 85-95%

Performance below 85%

Provider does not deliver this service

Incidents of MRSA

The target set by NHSE for all trusts is zero tolerance of cases of MRSA.

There have been three community-onset cases in City and Hackney CCG so far this year (April – December 2018).

The number of hospital onset cases of MRSA at the Homerton has remained broadly the same over the last three years. There were two hospital onset cases in 2016/17, one in 2017/18 and two in 2018/19. The CCG discusses infection control issues with the Homerton regularly and there are a number of measures in place to improve performance such as regular hand washing audits, teaching on the wards by the infection control team and close monitoring of the cleaning contract. In addition the Trust has a focussed piece of work to reduce surgical site infections which can occur following a hip or knee replacement or other orthopaedic procedure. A review of the patient’s care is undertaken for any patient that develops MRSA and if it was possibly preventable, then an action plan is developed to prevent this happening again.


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Incidents of C. difficile

There have been 25 cases of C.Diff in City and Hackney CCG so far this year (April – December 2018). The threshold for 2018/19 is 30 cases.

The number of C.Diff cases at the Homerton has remained stable since April 2016. While this is a relatively low number of cases, the CCG supports the Homerton to improve by reviewing all cases of C.Difficile and once more if any areas of poor care are identified an action plan is developed.

Incidents of venous thromboembolism (VTE)

The number of patients with new VTEs at the Homerton has decreased overall since April 2014 and is below the national average. The CCG introduced a VTE CQUIN in 2016/17 based on NICE standards which strengthened identification and prevention. This data will continue to be monitored and are also reported as serious incidents. There is a thrombosis group in place at the Trust.

Mental health - Improving Access to Psychological Therapies (IAPT)

We are improving access to talking therapies for people with mental health issues and helping more of them towards recovery.

● The national target is that 4.75% of people with a reported prevalence for anxiety and/or depression should have access to talking therapies by Q4 2018-19. The CCG had exceeded the target achieving 5.27% for this group by Quarter 3 2018-19. We also had highest access rate in North East London;

● Our self-reported access rate for Q4 2018-19 is even higher at 7.2%. City and Hackney therefore appears to be well on the way to comfortably achieving the new 2019-20 Q4 access rate target of 5.5% by April 2019;

● Our recovery rate by January 2019 was 60.2%, the highest in North East London and above the national target of 50%. The recovery rate measures the number of people who are above the normal range for anxiety or depression at the start of therapy and move into the normal range afterwards;

● Our four IAPT providers (Talk Changes, Bikur Cholim, Mind and Derman) continue to achieve high recovery rates for black and minority ethnic (BME) groups and City and Hackney achieved its BME quality premium KPI, which was to achieve BME recovery rates equivalent to White British recovery rates;

● City and Hackney fell just short of achieving its targets for older adult (over 65) access rates (all ethnicities). As a result, we have developed support interventions for carers and strengthened referral pathways and communications focused on older adults;

● Our IAPT service saw 93.9% of people within 6 weeks of being referred as at January 2019 - above the national target of 75%. We saw 98.5% of people within 18 weeks of being referred, as at January 2019, which is above the 95% target;

● The Talk Changes IAPT service will be expanding in 2019/20. This expansion includes a new therapist to work with people with long term conditions such as diabetes and Chronic Obstructive Pulmonary Disease (COPD), who also experience anxiety and/or depression. This will improve our ability to integrate care across mental health and physical health conditions. There will also be two new therapists to work with young people (18-25) as we recognise this a growing area of need;


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● We are working to improve access to IAPT for under-represented groups, including young black men and older adults. This work involves strengthening referral pathways, removing barriers to access, creating leaders and champions and ensuring we have the right therapeutic offer.

Mental health - Early Intervention Psychosis

● The standard is for 50% of people experiencing a first episode of psychosis to be treated with a NICE-approved care package within two weeks of referral;

● City and Hackney exceeded the national target with 90.6% of people receiving a National Institute for Health and Care Excellence (NICE) approved care package within two weeks of referral;

● This places the CCG in the top performing quartile nationally, while the national average is 75.3%;

● In 2019/20 our provider (ELFT) is committed to achieving a higher audit rating for the service: audit level 3, in order to comply with the new national target.

The London Ambulance Service

Over the year, the London Ambulance Service (LAS) has met the Category One (responded to in an average time of seven minutes) standard. In quarter one 2018/19, the standard was just met, and quarter two the standard was marginally failed. Quarters three and four saw significant improvement and this contributed to the overall performance for 2018/19 of an average response time of 06:25 minutes for Category One calls.

The overall Category Two performance fell short of the required standard (responded to in an average time of 18 minutes). Every quarter in 2018/19 failed the standard, with performance worsening as the year progressed. Quarter four was particularly poor with performance averaging at a responded to time of 21:57 minutes. The overall performance for 2018/19 was an average response time of 20:43 minutes for Category Two calls.

The Category Three (responded to at least nine out of ten times within 120 minutes) and Category Four (less urgent calls requiring advice over the telephone or referral to another service such as a GP or pharmacist responded to at least nine out of ten times with 180 minutes) standards were met in very quarter for both standards. The overall performance for 2018/19 was an average response time of 57:08 minutes for Category Three calls and 01:12:17 hours for Category Four calls.

Across the NEL STP, a demand management Steering Group has been established to address the performance issues relating to LAS. This group is chaired by the Urgent & Emergency Care Programme Director and all seven CGGs are represented. A number of schemes have already been identified that will reduce calls to the ambulance service and reduce conveyances by ambulance to hospital. To date the following schemes have been identified:

Reduction in overall conveyances due to an increasing number of incidents being referred onto 111;

Reduction in overall conveyances due to an increasing number of incidents being referred onto ACPs;

Reduction in Care Home conveyances due to enhanced GP support; Reduction in High Intensity User (HIU) conveyances due to an improvement in HIU review

and management;


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Reduction in overall incidents due to an increasing number of calls being closed via Hear & Treat.

LAS have identified a significant growth in the number of Category 1 patients being conveyed where the chief complaint is breathing problems. Although the performance of Category One has not been significantly impacted, the pressure in the system that the additional conveyances creates could be one of the contributors to the worsening Category 2 position. Although this trend is affecting all age groups, there is most growth in the 1-4 years and <1 year patient age groups.

The overall performance of LAS continues to be monitored and challenged at the monthly LAS Contract and Performance Management Meetings.

A2(3) Other performance matters

Sustainable development

As an NHS organisation and spender of public funds, we have an obligation to work in a way that has a positive effect on the communities we serve. Sustainability means spending public money well, smart and efficient use of natural resources and building healthy, resilient communities. By making the most of social, environmental and economic assets, we can improve health both in the immediate and long term, even in the context of the rising cost of natural resources. Demonstrating that we consider the social and environmental impacts of what we do ensures that we meet the legal requirements of the Public Services (Social Value) Act (2012).

To fulfil our responsibilities for the role we play, NHS City and Hackney CCG has created a sustainable development management plan (SDMP), which has been reviewed by our Board within the last 12 months.

As a part of the NHS, public health and social care system, it is our duty to contribute towards the level of ambition for emissions set by Government in 2014. This was to reduce the carbon footprint of the NHS, public health and social care system by 34% from a 1990 baseline by 2020. The equivalent reduction for CCG’s from the year of their inception in 2013 is 27% by 2020 and we are on track to achieve this.

In 2018/19, we focused mainly on reviewing and analysing sustainable development activity across our internal operations and those of our commissioning partners. This work helped us revise and update our Sustainable Development Management Plan (SDMP). This focused partially on evaluating our last plan, written in 2015/16; but also aimed to review holistically the way we work across our City & Hackney Partnership – formed by the CCG, our two local authorities, and three NHS Trusts - so that we can incorporate sustainable development principles and maximum social value into every decision we make going forward.

We have begun to define how we measure the impact of our approach to commissioning, and how many of our recent structural decisions have been complementary to sustainable development - particularly in relation to our Prevention work-stream.

Some of the key challenges that have been identified through the review include:

● Long-term exposure to particulate matter in Hackney being attributable to 6.3% of mortalities;

● In 2017/18, HUH, ELFT and Bart’s (Royal London) combined estate footprint (energy and water) being 40,000 tonnes CO2 - equivalent to driving almost 100,000,000 miles or planting nearly 50,000 acres of forest to offset the carbon;


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● 3,500 residents using metered dose inhalers - which each carry a footprint of 500g of carbon, compared to 20g for dry powdered inhalers.

Mitigating these impacts through a partnership approach is at the forefront of our new SDMP.

Key opportunities have also been identified within the review:

● Taking a more collaborative approach to increasing social value from our operations, to target some of our most pressing health challenges, such as:

○ +40% of children in Hackney being overweight or obese in year 6; ○ Hackney being the 11th most deprived borough in the UK;

● The potential for us to actively and positively influence the behaviour of 300,000 plus commuters travelling into the City of London every day to improve local health and wellbeing.

Policies

One of the ways in which an organisation can embed sustainability is through the use of an SDMP, which, as already mentioned, forms the foundation of our efforts.

Details of supplier environment and social value policy and activity are currently requested in the procurement process, however during a review of sustainable activity last year, we identified a number of practices that can improve the output, which we aim to put into place 2019-20.

Climate change brings new challenges to our activities, both in direct effects on healthcare estates, but also to patient health. Examples of recent years include the effect of heat waves, extreme temperatures and prolonged periods of cold, floods, and droughts. Our board has approved plans to address the potential need to adapt the delivery of our activities and infrastructure to climate change and adverse weather events.

As an organisation that acknowledges its responsibility towards creating a sustainable future, we help achieve that goal by running awareness campaigns that promote the benefits of sustainability to our staff.

Our statement on Modern Slavery is “Compliance of the Modern Slavery Act is a requirement in procurement tenders”.

Partnerships

As a commissioning and contracting organisation, we need effective contract mechanisms to deliver our ambitions for sustainable healthcare delivery. The NHS policy framework already sets the scene for commissioners and providers to operate in a sustainable manner, but crucially for us as a CCG, we aim to ensure that evidence of this commitment is provided by partners through contracting mechanisms.

Strategic partnerships are already established with the following organisations: Hackney Council, City Of London Local Authority, Homerton University Hospital, East London NHS Foundation Trust, and Barts Health NHS Trust.

For commissioned services, here is the sustainability comparator for our providers (please note this is published a year in arrears):


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Performance

As stated earlier, it is our duty to contribute towards the level of ambition set in 2014 of reducing the carbon footprint of the NHS, public health and social care system by 34% from a 1990 baseline (equivalent to a 27% reduction for CCG’s from a 2013 baseline) by 2020. Comprehensive details of how well we are doing in relation to this aspiration can be found in the full report published at http://www.cityandhackneyccg.nhs.uk/about-us/sustainability-report-201819.htm.

But our headline performance is as follows:

Energy

Our Headquarters are located in a building managed by NHS Property Services, which though quite old and inefficient when it comes to heat retention, is equipped with LED lighting and motion sensors to switch off lights when rooms are not in use.

NHS City and Hackney CCG spent £8,512 on energy in 2018-19, which is a 2% decrease on energy spend from last year. Our energy consumption has reduced by 2.5% in the same period and the resulting carbon emissions were 40t, which is a change of -2% on last year.

This is significant considering that during the last year the size of our team has increased by 19%.

Paper

We actively encourage a reduction in paper consumption. Our printing has reduced by more than half (in terms of pages printed per member of staff) in the last four years and we are incrementally rolling out iPads to reduce reliance on printed copies in meetings. The movement towards a paperless NHS reduces the environmental impact and cost of paper consumption and improves information security.

Our spending on paper was £2067 in 2018-19, and consumption was 1.3 tonnes, which is a change of +9% and -13%% respectively on last year. A respectable achievement considering our increase of staff over the same period.

Travel

We recognise that a Healthy Transport Plan is a fundamental part of our Travel Policy. We know that we can improve local air quality and improve the health of our community by promoting active travel to our staff and to the patients and public that use our services. Our staff and visitors use public transport when commuting and for business travel. As a reflection, no business mileage was claimed in 2018-19.

http://www.cityandhackneyccg.nhs.uk/about-us/sustainability-report-201819.htm

http://www.cityandhackneyccg.nhs.uk/about-us/sustainability-report-201819.htm


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Waste

We recycle our waste into dry mixed recycling and general waste, which have clearly marked bins in recycling stations.

Due to our small occupation of office space within a large hospital site, and the different functions of the site, we have been unable to acquire an accurate understanding of waste production.

Water

Last year our water consumption last year was 838 m3, which is change of +20% on last year.

Our waste water volume was 670 m3.

Our total water related carbon emissions were 0.76t. This increase is not in line with our reduction targets, but it does correlate to our increase in staff members over the last year and additional increased meeting traffic to the building.

Social Value

Collectively as an organisation we recognise the contribution that commissioning, procurement and commercial activity can have in delivering sustainability and social value and our duty under the Public Services Value Act.

Our statement on Public Services (Social Value) Act is:

“Ensuring social and environmental value from our commissioning activities is vital to help prevent ill health and improve wellbeing from across our population, and beyond.”

Social and environmental value is part of our procurement tenders at present, but we believe we can achieve much more through a coordinated approach.

A significant part of our 2019/20 SDMP is dedicated to helping our staff and our commissioning partners to define what social value looks like for City and Hackney, and to put guidelines in place to help us to achieve and measure this effectively.

We have yet to use the Social Value Calculator Tool but are exploring its use to assist in the coming year.

More information on these measures is available here: http://www.sduhealth.org.uk/policy-strategy/reporting/sdmp-annual-reporting.aspx.

Conclusion

Ensuring social and environmental value from our commissioning activities is vital to help prevent ill health and improve wellbeing from across our population, and beyond.

Social and environmental value is part of our procurement tenders at present, but we believe we can achieve much more through a coordinated approach.

A significant part of our 2019/20 SDMP is dedicated to helping our staff and our commissioning partners to define what social value looks like for City and Hackney, and to put guidelines in place to help us to achieve and measure this effectively.

http://www.sduhealth.org.uk/policy-strategy/reporting/sdmp-annual-reporting.aspx

http://www.sduhealth.org.uk/policy-strategy/reporting/sdmp-annual-reporting.aspx


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Emergency preparedness, resilience and response

Under the Civil Contingencies Act (2004) NHS organisations must show that they can deal with such incidents while maintaining services to patients. This work is referred to as ‘emergency preparedness, resilience and response’ (EPRR).

Clinical Commissioning Groups have to meet a number of EPRR core standards and NHSE is responsible for ensuring that the Clinical Commissioning Group meets these via an annual assurance process, where a rating of compliance is issued. Following the 2018/19 process the Clinical Commissioning Group has been issued with a compliance rating of ‘substantial’.

Improving quality

Improving the quality of local NHS services is central to everything we do. We continuously review and evaluate GP, hospital and community services so they are as safe and effective as possible so that everyone, whatever their individual needs, has a good experience and easy access to local services. We believe that by working together as a health system, challenging each other to do better, we can all deliver “outstanding” services.

All our local GPs, mental health, community services, East London NHS Foundation Trust (ELFT) and the Homerton Hospital are now rated either ‘Good’ or ‘Outstanding’ by the Care Quality Commission (CQC).

In 2018/19, Homerton University Foundation Trust improved its CQC rating and now emergency care and medical care is rated ‘Outstanding’, with an overall rating of ‘Good’.

East London Foundation Trust, our mental health provider - was also rated by the CQC this year and again, it was judged to be ‘Outstanding’ overall, for the care it provides.

The CCG has a number of ways in which we monitor the quality of care and we support local Trusts and other services to improve. We hold monthly or quarterly quality review meetings with City and Hackney Urgent Care Social Enterprise (the GP out-of-hours service), Homerton University Foundation Trust, East London Foundation Trust and the Tavistock and Portman Primary Care Psychology service, to discuss and review quality of services. These meetings are led and chaired by the CCG, and we discuss and review a wide range of quality information, such as:

● Patient and staff experience and feedback and actions taken; ● Complaints; ● Staff training; ● Serious incidents; ● Safeguarding processes; ● Mortality reviews; ● Safe-staffing levels, including feedback from junior doctors about their workload; ● Infection control; ● National and local audits; ● Work to prevent avoidable harms such as pressure-ulcers or medication errors; ● Medicine management; ● Compliance with national guidance from NICE and CQC reports.

Where we feel there are improvements to be made, for example to improve complaints performance, we can use a range of levers which include additional support from the CCG, financial incentives and ultimately contract performance notices with required actions and set timeframes. We also use financial incentives to focus on particular areas and over the last two years, we incentivised both the Homerton and ELFT to support patients to quit smoking, to make


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sure all staff get a flu jab so they don’t infect patients and to support staff-wellbeing, to reduce sickness and staff turnover.

The CCG also visits services to assess the quality of care. In 2018/19, we undertook a visit to our enhanced primary care mental health service delivered by East London Foundation Trust. We were impressed with the care and commitment displayed by the staff and agreed to look at some gaps in the service and review how referrals are made to other mental health services, so these can be made easier for patients.

To improve the way we monitor continuing healthcare, care homes and care that is delivered in people’s homes, we set up a new information-sharing group in 2017/18. This has been developing well in 2018/19 and now includes the CCG, CQC, the City of London and London Borough of Hackney. We share any concerns about providers, in Hackney and elsewhere in London, so that partners can work together to intervene early and support the improvement of care homes and other providers.

Our improvement highlights include:

● Design of new services to support children with mental health needs, working closely with local schools;

● Local mental health services working with young people to identify their goals when they transition to adult services or if they are moving over to GP care. Young people are asked about their experience and given a key worker to help them feel more in control;

● Improving mental health services - we are currently in the top 25% of CCGs in England for people being able to access psychological therapies or talking treatments, and for people reporting a positive outcome from their talking therapy;

● Improving diagnosis and support for people who develop dementia has again put us in the top 25% nationally for dementia care planning and post-diagnostic support;

● Our new GP visiting service for people in care homes or sheltered housing helps avoid ambulance journeys provides immediate care close to home and keeps people out of hospital;

● GP to Consultant telephone advice lines help GPs get fast access to specialist advice to avoid patients needing hospital visits and waits for treatment;

● Action to reduce our waiting times puts us in the top 25% of CCGs in England for patients waiting no longer than 18 weeks to get a Consultant appointment;

● Our local urgent care services are some of the best in London and we work closely with local GPs and Homerton Hospital to give people fast access to the right care;

● Homerton Hospital A&E waiting times and ambulance turnaround times are among the best in London;

● Our skilled mental health team at Homerton A&E helps those people attending with a mental health crisis, providing a range of support including signposting to successful community services which earn highly positive patient feedback;

● Expanding our range of day case or same-day treatment and types; ● Our local GP services are rated very highly by patients and carers and the clinical care

they provide continue to be some of the best in London and England. The latest GP patient survey shows that we are top in east London for patients saying they can get a convenient appointment, feel listened to and are treated with care and concern and have a positive experience;

● Working with our local services to make sure they support their staff to deliver the best care possible, reduce staff turnover, sickness and vacancy rates and keep our highly trained staff in City and Hackney;

● Investing in and promoting NHS staff wellbeing initiatives at Homerton Hospital and East London Foundation Trust, including better food and drinks access for night staff;


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● Working hard to address the big Brexit challenge to our local workforce, many of whom are EU citizens, make sure all our EU staff feel wanted and cherished by the NHS, whatever the future brings.

For information on CCGs’ performance against a number of indicators, please visit the My NHS website which publishes data on NHS performance. All CCGs are assessed against a number of metrics in the following groups: better care, better health, sustainability and well-led, and each is then given an overall score. The overall score for City and Hackney CCG is ‘Good’.

Quality improvement in primary care

We work closely with our local partners across primary care, including the City and Hackney GP Confederation, to continuously improve our performance and services to people, involving residents and patients at all stages. Progress during 2018-19 included a number of highlights:

● Tackling inequalities - We offer financial support to GP practices so they can meet the needs of patients whose first language is not English. The increased workload this generates is not recognised in the way that practices are funded;

● Patient involvement - We plan to fund eight practices to become PPG neighbourhood leaders, to increase patient involvement in shaping our services. This follows our intensive review on how Public Participation Groups (PPG) are working in City and Hackney. We have commissioned the GP Confederation to test other ways that patients could give feedback to practices;

● New models of care - We have been testing online consultations and appointment-booking via phone keypads;

● Quality improvement skills - We have commissioned the GP Confederation to train Quality Improvement (QI) champions who can share their skills with other practices to make quality improvements (see below - 10 High Impact Actions);

● Medicines Management - ○ We have identified key improvement areas in treating patients with asthma, to

make sure they are receiving care in line with British Thoracic Society (BTS), National Review of Asthma Deaths (NRAD) and the National Institute for Health and Care Excellence (NICE) recommendations. These areas include consistent self-management plans, patient recording and identification on the prescribing system, and opportunities for prescribing inhalers by brand. This was the outcome of a respiratory audit carried out in practices, as part of our annual Prescribing Incentive Scheme, to encourage and reward action to improve quality, safety and cost-effective prescribing;

○ The primary care anticoagulation service has been expanded to cover all patients registered with a GP within NHS City & Hackney. The GP Confederation is now delivering the Primary Care Anticoagulation service and work is underway with Homerton hospital to transfer all stable patients from secondary to primary care;

○ Practices took part in patient-safety incident reporting to a national database known as the ‘National Reporting and Learning System (NRLS)’. Forty one practices each shared at least one incident with the CCG. In total, 86 out of 105 incidents were shared, anonymously, with the CCG via NRLS (1st April 2018 to 28 Mar 2019). By thoroughly reporting and analysing safety-related incidents, practices have been able to learn from these incidents and reduce their occurrence. In addition, the use of NRLS to report errors allows for patient safety incidents and the learning from these to be shared across the country thus raising awareness and improving patient safety on a wider scale;

https://www.nhs.uk/service-search/performance/search

https://www.nhs.uk/service-search/performance/search


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○ The CCG’s Prescribing Newsletter has been used to share learning from errors. This newsletter is circulated to all City and Hackney GPs, Practice Managers, Practice Nurses, Community Pharmacies and relevant stakeholders from local hospitals.

High Impact Actions

Our outcomes complement and reflect the 10 High Impact Actions, introduced by NHS England as part of the General Practice Forward View. These are a collection of ways to improve workload and improve care in general practice through smarter, more efficient ways of working.

1. Active signposting – we invested in training for practice reception staff to help them better deal with patient enquiries.

2. New consultation types – several local practices have received funding and support to offer online consultations via their practice websites.

3. Reduce ‘Did Not Attend’ (DNAs) – we continue to meet the network costs of appointment reminder messages to patients.

4. Develop the team – funding was provided for a nurse development programme, to widen the skill set of local primary care nurses.

5. Productive work flows – training and software have been provided to practice clerical staff, to help them screen routine clinical correspondence, saving GP time for seeing patients.

6. Personal productivity – practice staff are supported to get efficiencies out of IT systems, through training and regular tip sheets from our GP IT support service.

7. Partnership working – Practices have been encouraged to work in ‘Neighbourhood’ groupings to offer consistent, joined-up services to patients in their locality.

8. Social prescribing – GPs can refer to our social prescribing service, which helps patients find the most the most appropriate community activity, organisation or service to help them.

9. Support self-care – local practice websites offer self-care advice on treating minor illness which will be expanded with the launch of the NHS App and symptom checker in May 2019.

10. Develop Quality Improvement (QI) expertise – 15 staff working in primary care locally have been trained to be QI coaches in the last year. A strategy is being developed to use what they have learnt to help all of our practices.

Engaging people and communities

Working with our local communities, patient groups, carers, clinicians, and key partners, including our provider services, is vital to us in planning and providing high quality services that improve health and wellbeing for local people.

NHS England has regularly rated our public engagement work as ‘Good’ and ‘Outstanding’ since 2013/14. The latest review took place in 2017/18 and we were commended for how we involve residents and patients in our day-to-day processes and for commissioning and embedding public engagement in our governance arrangements.

When people tell us what they think about our services, share their views and ideas, we want to let them know what have done about it and how their contribution has helped shape things.

In 2018-19 we worked on improving how we do this. We focused on three areas: feedback and evaluation; making information accessible; and, equalities and involvement structures.


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Collective Duty

During 2018/2019, we provided a range of opportunities for local patients and residents to take part in and influence our commissioning decisions. We put co-production at the centre of our commissioning work, across our Integrated Care environment.

● All our partners have endorsed the first-ever Co-production Charter for Health and Social Care in City and Hackney. Each of the integrated commissioning workstreams involves at least one local resident, recruited as a community spokesperson. Workstreams are developing co-production plans for specific service redesign or transformation projects, including ensuring young people’s involvement in service redesign. We have run Advanced Co-production training for a group of programme staff, front-line staff, managers and residents, to help shape how we improve our approach to Co-production in future.

● We held our Annual General Meeting (AGM) in September 2017 at the Tomlinson Centre, and used this as an opportunity to further demonstrate our commitment to co-production in redesigning community services. Ninety stakeholders attended, including local clinicians, patients and residents, from both City and Hackney. After the AGM presentations, attendees were asked to discuss how community services can best meet people’s needs, what works well and what needs to change. Discussion also included looking at how the Neighbourhoods Model could be used as the basis for delivering community services. A neighbourhood Resident Involvement Group has now been established, with public representatives who sit on the Neighbourhoods board, collaborating and feeding back to each group, effecting change, and shaping service development.

● We commissioned the City and Hackney GP Confederation (GPC) to carry out a review to find out what was working or not working in practice-based Patient Participation Groups (PPGs). The findings have been shared between the GP Confederation, Primary Care workstream and the CCG's Patient and Public Involvement Committee (PPIC), all working together to implement the recommendations of the report. This includes offering intensive support for eight GP practices across City and Hackney to revitalise their PPGs.

● We ran a series of ‘Let’s Talk’ events in the community, to discuss with residents our plans and draft commissioning intentions for 2019-20 and beyond. People were also able to share their health and well-being priorities. More than 200 City and Hackney residents joined us at six events and most feedback was positive. Events were co-produced between workstream leads and their public/service user representatives. Discussions focused on key topic areas, with a more general feedback session on the broader plans. People were able vote on what they felt should be the local top health and care priorities. Here are some examples of those priorities - and what we are doing to address them:


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New, more integrated Out of Hours service, including a safe and effective 111 service

Health Advisors answering calls to 111 have completed a training programme specified by NHS Pathways. This helps them to better identify patients who need immediate care. The system is designed by senior doctors and consultants and it is reviewed and updated regularly, with a robust training programme for staff in place.

Meeting the needs of people with long term conditions, including Chronic Obstructive Pulmonary Disease and asthma, providing accessible information.

Provision of information on COPD in other languages is recognised as a gap. We are exploring options for translating COPD (and asthma) action plans into Turkish.

Action against air pollution is led by local authorities. This includes initiatives such as commitment to implementing a number of electronic streets (e.g. streets dedicated to electronic vehicles) and exploring implementation of zero emission zones in the City.

Positive outcomes for people with learning disabilities

There is a dedicated Learning Disabilities liaison nurse at Homerton Hospital. Our Outpatients Transformation plans include improving access to services for patients with learning disabilities. Widespread use is made of health passports by people in the borough.


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Smooth transition for patients leaving the hospital to go home

The Homerton Discharge Planning team has worked with hospitals outside City and Hackney to ensure they are aware of our local discharge pathways. Discharge planning includes discussion on the type of care required. Our ‘Discharge to Assess’ model, means that assessments can take place at home or in the community where a patient’s needs can be more accurately assessed. This also allows more time to consider choices and options for long-term arrangements.

The London Borough of Hackney has a social worker assigned to our main out-of-borough hospitals. The City of London has a Care Navigator at UCLH and the Royal London hospitals, to help with discharges for City patients.

Making mental health services available and accessible for all, including children and young people, working-age population, new mothers and those in crisis

All City and Hackney residents can self-refer to the Talking Therapies service and have access to Service User Network (SUN) Group, which offers a supportive and therapeutic group for individuals to develop self-help management strategies to prevent a future crisis.

We have a range of services and initiatives in place in City and Hackney for children with mild to moderate mental health needs. Children and Young People have access to Wellbeing and Mental Health services and the Five to Thrive (five ways to wellbeing) initiative in schools. Our CAMHS Transformation Plan includes targeted support for children and young people from LGBTQ+ communities and those self-harming.

Pregnant women, their partners and parents with children under 2 can be fast-tracked to Talking Therapies. All health visitors ask about mood and support women who are depressed. Support is also available from GPs at 6-week check-up and beyond. We have developed a 10 Top Tips leaflet to support mothers.


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● At ‘Outpatients’ and ‘Staying Healthy’ events, 80% of attendees said they felt more informed about health and care services, while more than 70% said attending the events gave them a better understanding of how to help shape services. A report of the feedback received and how each workstream responded to the feedback can be found here. People said the best things about the events were:

○ ‘sharing with other people’; ○ ‘getting our points across’; ○ ‘it was good to meet local people within the borough and seeing their involvement

within the community’; ○ ‘feeling that we were being listened to’; ○ ‘lots of information that relates to local amenities and causes’;

● We fund a patient-led involvement forum called NHS Community Voice. It is facilitated and coordinated by Healthwatch Hackney and City and holds monthly open meetings on issues identified by local patients, residents, and service commissioners. Issues discussed during 2018/19 include Mental Health and Housing, Staying Healthy, Advocacy Services and NHS Long Term Plan in City and Hackney. Feedback is shared with the relevant bodies, and their responses are reported back via the CCG website You Said We Did page;

● Community and voluntary sector organisations in City and Hackney are important partners to us, widening our reach to, and participation from some people who may be vulnerable or ‘seldom heard’, or people from Black, Asian, Minority, Ethnic and Refugee (BAMER) groups, children and young people, people with disabilities, and many more;

● We work closely with community and voluntary sector groups and not-for profit organisations, including City and Hackney Older People’s Reference Group, Health and Social Care Forum, Hackney Refugee Forum, The Huddleston Trust and Family Action;

● During 2018/19, the City and Hackney Involvement Alliance has brought together the user voice forums commissioned by the CCG, to coordinate activity, strengthen local user voice, widen the scope of the engagement, and raise awareness of local services. All the member organisations of the Alliance are required to help plan further inclusive engagement. The remit of the Alliance will be expanded to cover the whole of Integrated Commissioning, acting as a mechanism for engagement for the CCG and our local authority partners.

Meeting the individual duty to engage in 2018/19

We play a key role in helping people get involved in their own healthcare. We support patients and the general public to improve their knowledge, skills and confidence when making health and social care related decisions. For example:

● Let’s talk about staying healthy event - National Self-Care Week in November 2018 was marked in a joint event with local health and social care organisations. People of all backgrounds from across City and Hackney took part, with taster sessions and information on self-care, including exercise, healthy eating, health checks, massage, smoking cessation, NHS 111, and pharmacy. Feedback was gathered from local people on local self-care priorities;

● We commission number of services aimed at helping people stay healthy and take an active role in their care. These include Social Prescribing which links patients with local non-clinical support in the community and Five to Thrive, an initiative promoting five ways to mental wellbeing;

● Let’s talk about stroke - In February 2019 we hosted an event for people affected by stroke, and their family members or carers. Feedback was collected on what people think

http://www.cityandhackneyccg.nhs.uk/about-us/you-said-we-did.htm




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about the support services in place following a hospital stay around: 1) Staying Healthy; 2) Meaningful activity; and 3) Feeling good. The event was attended by more than 70 City and Hackney residents, who spoke about their experiences of stroke services received at home or in the community, with a series of discussion workshops to help shape the service they use;

● Improving uptake of bowel cancer screening services within Black, Asian, Minority, Ethnic and Refugee communities - We commissioned the Hackney Refugee and Migrant Forum to carry out focus groups with local people in these communities, to find out if there are barriers to their taking up cancer screening. Community African Network (CAN) was commissioned to do outreach work and awareness raising events aimed at increasing uptake of bowel screening among black African people in City and Hackney. CAN has volunteers based in GP surgeries with high-proportion of black African patients, who call other patients to advise on bowel cancer screening programme eligibility and encourage them to complete and return the test. Patient literature in local languages will be provided to help to address a key barrier to screening uptake for some people – raising awareness of cancer symptoms for most common cancers and cancer screening programme eligibility.

Strengthening our involvement activity

NHS England identified two areas in 2017-18 where we need to improve our involvement with local people and communities:

1. The CCG reviews its involvement activity, including how effective it has been, and takes action in response to what has been learnt.

2. The CCG tells patients and public who have been involved, about the difference their involvement has made.

The following actions are underway, or will be taken by March 2019:

● A ‘You Said – We Did’ section was added to our website, holding summaries of feedback from events and some of the responses from relevant organisation(s);

● We work closely with the Integrated Commissioning workstreams to ensure regular responses are provided on the public’s recommendations and feedback;

● The PPI committee requested that we write a bi-annual summary of involvement activity and its impact;

● We are re-launching our quarterly Patient and Public Involvement Newsletter, which will include a summary of ‘You Said – We Did’;

● Discussions were held with PPI providers about how improved reporting can tighten the feedback loop and share recommendations with commissioners;

● A patient-led review of our PPI committee was conducted to review the role of the committee and its relationship with the Governing Body. The recommendations have been discussed and endorsed by the Governing Body;

● The CCG has commissioned a piece of work to review local Practice-based Patient Participation Groups (PPGs);

We will provide regular updates at our PPI committee about the progress of this work.


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Reducing inequalities and the health and wellbeing strategy

In our work with local partners, all our commissioning processes require potential providers to indicate how their service will reduce health inequalities and improve access to address the four priority areas agreed in the local Health and Wellbeing Strategy.

1: Improving the health of children and young people, in particular tackling childhood obesity and working with pregnant women and children aged under five years old:

● Since February 2016, we have been working with the London Borough of Hackney (LBH), which has been developing a new ‘whole-systems’ approach to promoting healthy weight and reducing obesity through the Obesity Strategic Partnership (OSP). Chaired by the LBH Chief Executive, the OSP brings together senior partners from transport, parks, business and regeneration, education, housing, Young Hackney, regulatory services and environmental health, planning, the CCG and public health, to coordinate a whole-systems response to this complex issue;

● Hackney’s current Healthy Weight strategy ends in 2018. A new strategy has been planned to be complete in 2019, to reflect the new approach. A number of engagement events with key stakeholders were held in late 2018 to support this work;

● To date the OSP has overseen a number of actions across five broad, thematic areas: ○ Working with businesses to improve the food environment - such as implementing

the Healthier Catering Commitment in a number of hot food takeaways; ○ Getting people active as part of their everyday lives - such as connecting

Hackney’s parks and green spaces; ○ School based activities - such as implementing the Hackney Daily Mile in almost

half of the boroughs primary schools; ○ Behavioural Insight and Influence - such as research with communities most

affected by obesity, to inform future communications campaigns and consultation; ○ Staff health and wellbeing - such as providing healthier catering guidelines for staff

events and training.

In addition -

● The Health Visiting service works with all partners to tackle obesity through a ‘joined up’ approach, ensuring that healthy-lifestyles work is a priority. For example, Health and Education teams have embedded joint reviews within the 0-5s Early Years Health Visiting Service. One of the five ‘High Impact’ areas for the City & Hackney Health Visiting service is ‘Healthy Weight’, with an assigned Health Visitor lead;

● A new, integrated School Based Health Service launched in September 2018, working with children and young people aged between 5 and 19 attending schools in Hackney and the City of London, with safeguarding responsibilities for all children living in City and Hackney. The service includes the healthy child programme, statutory functions and key public health priorities to promote the health and development of children in City and Hackney, at every transitionary milestone.


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2: Controlling the use of tobacco, with a renewed emphasis on stopping people from starting smoking as well as helping them to quit:

● The CCG joined Homerton Hospital, the East London Foundation Trust, and the City and Hackney GP Confederation in signing the NHS Smokefree Pledge in September 2018;

● Hackney council’s Public Health team, worked with Homerton Hospital and the East London Foundation Trust, to implement smoke-free policies and motivate staff, patients and visitors who smoke to quit;

● Homerton Hospital rolled out its smoke-free policy in January 2018 banning patients, visitors and staff from smoking on hospital grounds;

● The new Stop Smoking Service (SSS) was awarded to Whittington Health as the lead provider in February 2018. This fully integrated service, which was launched in July 2018, works in a strategic alliance with the City and Hackney GP Confederation and in partnership with two voluntary sector organisations, Social Action for Health and Outward;

● A range of support to help people stop smoking is available from various accessible venues such as GP practices, pharmacies, and community settings, all tailored to the needs and preferences of the individual. It targets high risk groups and high prevalence communities whilst also providing a service that is accessible to people who need it who either work, study or live in the borough. The service also delivers smoking cessation training to relevant staff including Level 1 (otherwise known as ‘Very Brief Advice’), Level 2 (to become a specialist Stop Smoking Advisor), and Level 2 Refresher;

● Children and young people who need support to stop smoking can go to clinics run by CHYPS Plus, as part of the 5-19 Health and Wellbeing Service. For more information about the service, see www.smokefreehackney.org;

● The CCG works with Public Health, Homerton Midwifery, Health Visiting, and the Family Nurse Partnership to give pregnant women and those who have recently given birth the support they need to quit smoking. Pregnant women are given a carbon monoxide (CO) test at booking and during the third trimester at Homerton Hospital by midwives. Health visitors are also required to screen for carbon monoxide at the new birth visit. Links are in place with maternity staff from surrounding Trusts, to share ideas and connect maternity discharge notes on smoking;

● A mixed-methods research project is planned, to gain a better understanding of midwife and pregnant women’s perceptions of CO testing. The project looks at women’s reasons for declining testing or referral, the characteristics of pregnant or new mothers who do - versus who do not - quit successfully. The findings will help us tackle the barriers to smoking cessation in pregnant and post-partum women more effectively;

● The Stop Smoking Service aims to reach black and minority ethnic groups with high rates of smoking, and monitors this through KPI targets for the number of individuals from specific ethnic groups who successfully quit smoking. Some examples of ways in which these groups are engaged include:

○ Smoking cessation advisors who can provide support in a wide range of languages;

○ A GP Hub in Stamford Hill providing smoking cessation support to the Orthodox Jewish community;

○ Work with the Irish Traveller community to understand how they can be supported in smoking cessation efforts;

○ Two social marketing campaigns to be conducted each year as part of the Service, to target hard-to-reach groups with high rates of smoking more effectively. The first campaign in January 2018 planned to focus on Hackney’s Turkish-speaking communities.

http://www.smokefreehackney.org/


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3: Promoting mental health, focusing on relieving depression and anxiety for working age adults:

● Floating Housing Support - the current floating support services contracts are coming to an end; the London Borough of Hackney (LBH) has undertaken a review and consultation of these services, and a new model has been agreed, subject to Council sign off. The new model creates more opportunity for people with enduring mental illness to have longer term housing support, and those who have a housing crisis will be able to get quicker, more responsive support;

● Partners including the CCG, LBH and ELFT have been reviewing the supporting housing pathway, including those services that are spot-purchased. The partners are agreeing a commissioning strategy, to provide more suitable, longer-term and move-on services for people with mental illnesses;

● Our primary care psychological therapy service (IAPT) achieved its target waiting times with over 90% of people being seen within 6 weeks of referral. Our recovery rate has improved to make us the second-highest in London (out of 32 CCGs); our access rate improved to place us at third-highest;

● Joint working through the Psychological Therapies and Wellbeing Alliance has: ○ Expanded the number of IAPT providers to include three voluntary sector

organisations (VSOs): Bikur Cholim, Derman and Mind. This has improved access both overall (1.5% increase) and specifically to less-represented sectors of the community: Orthodox Jewish, Turkish, Kurdish. It has also improved recovery rates for these groups e.g., recovery rates for people from Turkish and Kurdish backgrounds has increased by more than 20%;

○ Improved the flow of referrals between organisations and reduced waiting times for IAPT providers and Tavistock and Portman’s Primary Care Psychotherapy Consultation Service (PCPCS). In addition, the Volunteer Centre Hackney is currently working with ELFT psychotherapy to provide a step-down service. We are aiming to clear psychotherapy waiting lists within 12 months;

● The Alliance has increased joint-working between organisations, for example, between ELFT and Bikur Cholim, Tavistock and Volunteer Centre Hackney, ELFT and Derman, which has allowed us to combine specialist expertise with reach into communities. Joint-working between Tavistock, ELFT and Volunteer Centre Hackney in the frequent-attenders pilot enables us to provide coverage of the whole care pathway from A&E into primary care;

● In August 2018, it was agreed to merge LBH’s Public Mental Health (PMH) and the City and Hackney CCG’s Five to Thrive Steering Groups. This new group will be co-chaired by Cllr Tom Rahilly, the Council’s Mental Health Champion, and Dr Rhiannon England, GP Clinical Lead for Mental Health, City and Hackney CCG. This group will oversee the PMH actions over 2018/19;

● A report was taken to the Health and Wellbeing Board in June 2018 that included an update on actions complete over 2017/18, and agreed the PMH priorities for 2018/19:

○ Action 1: Work to prevent suicide and self-harm, establishing a cross-sector partnership to produce a borough-wide suicide prevention strategy and action plan;

○ Action 2: Work to ensure that the built local environment promotes positive mental wellbeing and creates mentally healthy places;

○ Action 3: Make Hackney the most welcoming, healthy, and accessible place in London for residents with severe and enduring mental health conditions by March 2019;


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○ Action 4: A series of ‘Life Events’ support packs, that provide ideas, advice, phone numbers, video clips etc. of how to be mentally-resilient in times of change or stress;

○ Action 5: Deliver a child-centred, prevention-focused health and wellbeing education service, that builds the resilience of all children and young people in Hackney aged 5-19 years, and up to 25 years for those with additional needs;

● There will be a focus to embed the Five to Thrive campaign within this work and throughout the Borough to promote positive mental wellbeing and reduce stigma around mental health;

● A migrant health needs assessment and Charedi needs assessment were carried out, both with mental health components;

● The mental health Joint Strategic Needs Assessment (JSNA) was updated; ● We contributed to the mental health subgroup of the Young Black Men’s workstream; ● The Mental Health Coordinating Committee had oversight of the mental health element of

the four Integrated Commissioning workstreams.

4: Caring for people with dementia, ensuring our services are meeting the needs of the older population:

● The Dementia Alliance (DA) carried out a study to track the journey of a number of service users through the health and social care system. This fed into the thinking about navigation as part of the neighbourhood model and an integrated memory service model, developed by the DA and partners to provide a one-stop-shop, consultant-led assessment, which holds patients from diagnosis through to end of life. The model saw each service user having a named dementia navigator, with a clear pathway of interface with other crisis/admissions prevention services such ParaDoc, Integrated Independence Team (IIT), GP Out of Hours, Adult Social Care (ASC) out-of-hours and Crisis line, to prevent crisis, facilitate care navigation, reduce unnecessary hospital admissions and improve dementia diagnostic rates;

● Coordinate My Care (CMC) has been adopted by the DA as a common platform for sharing and accessing care plans for people with dementia, for rollout in 2019. This allows a wide variety of practitioners including 111, the London Ambulance Service, social workers, GPs, community health staff, Urgent Care Staff, Memory Clinic and Community Mental Health Teams to access relevant information and provide appropriate intervention, especially during crisis or an emergency, with a dedicated resource and in line with the governance protocol agreed with GPs and the CCG. The DA is also working with and influencing the CMC stakeholders’ group and Royal Marsden Hospital (CMC owners) in improving the application of CMC to dementia care;

● A comprehensive programme across health and social care was planned to improve the way information about local provision is publicised to residents and agencies. A review of the directory of services began, coordinated by LBH’s Digital service and funded by the Integrated Commissioning programme's IT enabler group. The review looked at overhauling the way information is stored and published through tools such as iCare and the Local Offer website, including updated information about services supporting residents with dementia.

Healthier City and Hackney Fund

This is a £500k co-funded community grant scheme, which is one of the most significant cross-organisational initiatives of its type in the country. It is designed to tackle health inequalities by


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supporting the most disadvantaged and vulnerable people in specific communities or groups. This is an exciting example of how we have worked in partnership with our two local authorities in this area of concern. More information on the list of projects and how they will contribute to reducing inequalities in our communities, can be found at https://www.hackney.gov.uk/healthier-city-and-hackney-fund.

How we were involved in developing the HWB strategy

We work closely with the two local Health and Wellbeing Boards – one for the City and one for Hackney. They both bring together senior leaders from the NHS, local authorities, Healthwatch and the voluntary and community sector, to agree joint priorities, under an overarching strategy to improve the health and wellbeing of people in City and Hackney and reduce health inequalities.

Our Chair sits on both Boards and we have played an active part in the development of the joint City and Hackney Health and Wellbeing Strategy. The strategy looks at the area’s key health priorities and issues (using the City and Hackney Health and Wellbeing Profile and other evidence) and sets out how we will work together to address them. From this, a joint work plan has been developed and we are committed to cooperating with partners to deliver on key activities.

The expertise, knowledge and scrutiny of Health and Wellbeing Board members is critical in the development of all our plans and we actively consult with them on key projects or pieces of commissioning. The above section sets out examples of some of the joint working successes we’ve produced together in the last year.

Equality disclosures

Equality impact assessments

We integrate equality impact assessments (EIA) into our commissioning cycle. When potential negative impacts are identified, we take action to deal with the issues raised. Progress is monitored against specific challenges and embedded throughout the everyday business of the CCG. From 2018/2019, we have taken a more systematic approach to completing EIAs, with 23 so far carried out on Quality, Innovation, Productivity and Prevention (QIPP) programmes. We will build on this in 2019/2020, so that all business cases and proposals have gone through an EIA, supported by training for staff.

Accessibility

We ensure our events take place at venues that are accessible by public transport, have wheelchair access, and are equipped with a hearing loop. We routinely ask participants about communication and mobility support needs. We provide interpretation and translation on request. During engagement meetings/events, guests and presenters are required to provide information that is easy to understand and tailored to a lay audience. Feedback from local people on this is positive. A patient/public friendly template is being developed for presenters and we encourage people to use the NHS Acronym Buster and Care and Support services jargon buster.

Many health services are now online and using the internet is becoming increasingly important. People can book medical appointments, renew prescriptions, find services, and look for health information. Using www.nhs.uk and Hackney i-Care helps patients and residents understand their health and take control of their well-being. GP Online can be used by residents to access a range of services, via their computer or mobile.

https://www.hackney.gov.uk/healthier-city-and-hackney-fund

https://www.hackney.gov.uk/healthier-city-and-hackney-fund


http://www.cityandhackneyccg.nhs.uk/about-us/useful-resources.htm





http://www.nhs.uk/pages/home.aspx

http://www.nhs.uk/pages/home.aspx

http://www.hackneyicare.org.uk/kb5/hackney/asch/home.page




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We hold our providers to account regarding the implementation of the Accessible Information Standard. We expect all organisations that provide NHS or publicly-funded adult social care to comply with this standard, so that people with learning disabilities/sensory impairments can access the information. We monitor this through regular Clinical Quality Review Meetings. For more information on the Accessible Information Standard, please click here. For an easy read leaflet on Accessible Information Standard, please click here.

Equality and Diversity

City and Hackney CCG is committed to promoting equality, diversity and human rights for staff and residents. Everyone is different and it is important to ensure our services and employment practices respect, promote, and celebrate these differences. We will not tolerate unlawful discrimination, victimisation, bullying or harassment based on age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, or sexual orientation.

Our Equality and Diversity structures include a Lay Chair, GP Lead, designated manager and a newly-reconvened, multi-agency working group which reports to our Governing Body. It also influences and holds providers to account. It makes sure that our equality and diversity principles underpin the way that our four workstreams operate. We are currently recruiting two public representatives to take forward the following priorities:

● Review and confirm governance arrangements and leadership commitment; ● Update and identify a local equality and diversity stakeholder list, ensuring representation

from groups with protected characteristics; ● Completing the review of the CCG’s 2013–2017 Equality Objectives; ● Working with local authority partners to, as far as possible, align priorities into a single

equality scheme for City and Hackney; ● Developing and agreeing a set of new objectives with workstreams that reflect the priority

areas covered by the workstreams.

https://www.england.nhs.uk/ourwork/accessibleinfo/

https://www.england.nhs.uk/wp-content/uploads/2016/07/access-info-stndrd-er-upd-jul16.pdf

https://www.england.nhs.uk/wp-content/uploads/2016/07/access-info-stndrd-er-upd-jul16.pdf

https://www.england.nhs.uk/wp-content/uploads/2017/10/easy-read-accessible-info-standard-overview-2017-18.pdf

http://www.cityandhackneyccg.nhs.uk/Downloads/About%20Us/Equality%20and%20diversity/1-7359392-CDM_n7051228_v2A_Equality_and_Diversity_Policy_Statement_2.pdf

http://www.cityandhackneyccg.nhs.uk/Downloads/About%20Us/Equality%20and%20diversity/1-7359392-CDM_n7051228_v2A_Equality_and_Diversity_Policy_Statement_2.pdf


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Section B. ACCOUNTABILITY REPORT

Jane Milligan

Accountable Officer

24 May 2019


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B1. Corporate governance report The purpose of the corporate governance report is to explain the composition and organisation of the CCG’s governance structures and how they support the achievement of our objectives.

B1(1) Members’ report

Member profiles

Our website gives more details about our GB, including profiles of members, with these available at http://www.cityandhackneyccg.nhs.uk/about-us/governing-body/governing-body-and-committees.htm.

Member practices

Our Member Practices have organised themselves into six consortia. Each Consortium elects its own Consortium Lead GP, to represent each group at CCG meetings. The Consortium and Member Practices making up the CCG are:

Klear Consortium North West Hackney Consortium

North East Hackney Consortium

Abney House Medical Centre Allerton Road Medical Centre Cranwich Road Spitzer and Partners

Brooke Road Surgery Barretts Grove Surgery Elm Practice

Dalston Practice Barton House Group Practice Nightingale Practice

Healy Medical Centre Cedar Practice Spring Hill Practice

Kingsmead Healthcare Heron Practice Stamford Hill Group Practice

Latimer Health Centre Somerford Grove Practice, The Health Centre

Lea Surgery Statham Grove Surgery

Richmond Road Practice

Riverside Practice

http://www.cityandhackneyccg.nhs.uk/about-us/governing-body/governing-body-and-committees.htm



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Sandringham Practice

South West Consortium Rainbow and Sunshine Consortium

Well Consortium

De Beauvoir Practice Athena Medical Centre Elsdale Street Surgery

Hoxton Surgery Beechwood Medical Centre Greenhouse Health Centre

Lawson Practice Clapton Surgery London Fields Medical Centre

Neaman Practice Gadhvi Practice Lower Clapton Group Practice

Queensbridge Group Practice Rosewood Practice Sorsby Health Centre

Shoreditch Park Surgery Southgate Road Medical Centre

Whiston Road Surgery

Trowbridge Surgery

Well Street Surgery

The Wick Health Centre

Composition of Governing Body

The NHS City and Hackney Clinical Commissioning Group Governing Body is made up of three local GPs, (Dr Mark Rickets, Dr Gary Marlowe and Dr Nikhil Katiyar); three Lay Members (Sue Evans, Catherine Macadam and Honor Rhodes); a Secondary Care Consultant (Chris Gallagher); one Nurse (Siobhan Clarke); our Accountable Officer (Jane Milligan); and, Chief Finance Officer (Henry Black). In addition, we have an Associate Lay Member (Jaime Bishop) who co-chairs one of the Governing Bodies Sub Committees, but does not hold a voting role on the Governing Body itself.

Our Managing Director (David Maher) and Director of Finance (Sunil Thakker) are standing attendees at the Governing Body, with the Managing Director able to exercise the Accountable Officer’s vote in their absence.

Our website gives more details about our Governing Body, including profiles of members at http://www.cityandhackneyccg.nhs.uk/about-us/governing-body/governing-body-and-committees.htm.




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Committees, including Audit Committee

Committee members are detailed below and more information about the committee and its work is contained in the Governance Statement (section B1 (3) of this report).

The Clinical Commissioning Group’s Audit Committee is chaired by our Lay Member for Governance (Sue Evans) and our other two Lay Members are also members of the Audit Committee (Catherine Macadam and Honor Rhodes). Our Accountable Officer (Jane Milligan), Chief Finance Officer (Henry Black), Managing Director (David Maher) and Director of Finance (Sunil Thakker) are standing attendees of the Audit Committee, along with representatives of our internal auditors, RSM and external auditors, KPMG.

Details of membership of other committees is contained in the Governance Statement (see page 71).

Register of Interests

We publish a register of members’ and senior managers’ interests on the Clinical Commissioning Group’s website. This is updated as and when changes are notified to the Clinical Commissioning Group.

The register gives details of company directorships or other significant interests held by members and senior managers where those companies are likely to do business, or are possibly seeking to do business with the NHS, where this may conflict with their managerial responsibilities.

Personal data related incidents

The NHS Information Governance (IG) Framework sets the processes and procedures by which the NHS handles information about patients and employees, in particular personal identifiable information. The framework is supported by an IG toolkit and the annual submission process provides assurances to the CCG, other organisations and to individuals that personal information is dealt with legally, securely, efficiently and effectively.

We are aware of the importance of maintaining high standards of information governance, including protecting the confidentiality of patients, staff and commercial information. Our Director of Finance is the senior information risk officer (SIRO) and one of our Clinical Lead GPs is our Caldicott Guardian.

The CCG also has a Data Protection Officer, an information governance manager and a range of policies, procedures and training to ensure that all staff are aware of information governance requirements.

The information governance group (IGG) oversees the completion of the Data Security and Protection toolkit (DSPT) on an annual basis, as well as reviewing any information governance incidents.

During 2018/19 no incidents have been reported to the Information Commissioner‘s Office (ICO) and the CCG published the NHS Digital Data Security and Protection with all standards being met.

http://www.cityandhackneyccg.nhs.uk/about-us/governing-body/register-of-interests.htm

http://www.cityandhackneyccg.nhs.uk/about-us/governing-body/register-of-interests.htm


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Statement of disclosure to auditors

Each individual who is a member of the GB 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 Clinical Commissioning Group’s auditor is unaware, that would be relevant for the purposes of their audit report;

● 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 Clinical Commissioning Group’s auditor is aware of it.

Modern Slavery Act

NHS City and Hackney 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.

B1(2) Statement of Accountable Officer’s Responsibilities The National Health Service Act 2006 (as amended) states that each Clinical Commissioning Group shall have an Accountable Officer and that Officer shall be appointed by the NHS Commissioning Board (NHS England). NHS England has appointed Jane Milligan to be the Accountable Officer of NHS City and Hackney Clinical Commissioning Group.

The responsibilities of an Accountable Officer are set out under the National Health Service Act 2006 (as amended), Managing Public Money and in the Clinical Commissioning Group Accountable Officer Appointment Letter. They include responsibilities for:

● The propriety and regularity of the public finances for which the Accountable Officer is answerable;

● For keeping proper accounting records (which disclose with reasonable accuracy at any time the financial position of the Clinical Commissioning Group and enable them to ensure that the accounts comply with the requirements of the Accounts Direction);

● Safeguarding the Clinical Commissioning Group’s assets (and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities);

● The relevant responsibilities of accounting officers under Managing Public Money; ● Ensuring the Clinical Commissioning Group exercises its functions effectively, efficiently and

economically (in accordance with Section 14Q of the National Health Service Act 2006 (as amended)) and with a view to securing continuous improvement in the quality of services (in accordance with Section14R of the National Health Service Act 2006 (as amended)) and with a view to securing continuous improvement in the quality of services (in accordance with Section14R of the National Health Service Act 2006 (as amended));

● Ensuring that the Clinical Commissioning Group complies with its financial duties under Sections 223H to 223J of the National Health Service Act 2006 (as amended).

Under the National Health Service Act 2006 (as amended), NHS England has directed each Clinical Commissioning Group to prepare for each financial year a statement of accounts in the form and on the basis set out in the Accounts Direction. The accounts are prepared on an accruals basis and must give a true and fair view of the state of affairs of the Clinical Commissioning Group and of its income and expenditure, Statement of Financial position and cash flows for the financial year.


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In preparing the financial statements, the Accountable Officer is required to comply with the requirements of the Government Financial Reporting Manual 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 Government Financial Reporting

Manual have been followed, and disclose and explain any material departures in the financial statements;

● Prepare the accounts on a going concern basis; ● Confirm that the Annual Report and Accounts as a whole is fair, balanced and understandable

and take personal responsibility for the Annual Report and Accounts and the judgements required for determining that it is fair, balanced and understandable.

As the Accountable Officer, I have taken all the steps that I ought to have taken to make myself aware of any relevant audit information and to establish that NHS City and Hackney Clinical Commissioning Group’s auditors are aware of that information. So far as I am aware, there is no relevant audit information of which the auditors are unaware.

To the best of my knowledge and belief, I have properly discharged the responsibilities set out under the National Health Service Act 2006 (as amended), Managing Public Money and in my Clinical Commissioning Group Accountable Officer Appointment Letter.

I also confirm that as far as I am aware, there is no relevant audit information of which the CCG’s auditors are unaware, and that as Accountable Officer, I have taken all the steps that I ought to have taken to make myself aware of any relevant audit information and to establish that the CCG’s auditors are aware of that information.

B1(3) Governance Statement

Introduction and context

NHS City and Hackney 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 Clinical Commissioning Group’s general function is arranging the provision of services for persons for the purposes of the health service in England. The Clinical Commissioning Group is, in particular, required to arrange for the provision of certain health services to such extent as it considers necessary to meet the reasonable requirements of its local population.

As at 1 April 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.

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.


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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.

Governance arrangements and effectiveness

The main function of the Governing Body is to ensure that the Clinical Commissioning 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.

NHS City and Hackney Clinical Commissioning Group is a membership organisation, with 42 GP practices across the City of London and London Borough of Hackney. Our practices are organised into Consortia of six groupings, each with five to six practices and led by a Consortium Lead GP.

Members Forum

The GP practice membership as a whole meets together within our Members Forum (MF), which has authority for agreeing Governing Body (GB) appointments, changes to our Constitution and governance framework and for holding the Governing Body to account. The CCG membership has delegated decision-making functions to the Governing Body and its sub-committees, to enable them to run the CCG on the membership’s behalf.

Clinical Executive Committee

The six Consortium Lead GPs are members of our Clinical Executive Committee, which is the ‘clinical engine room’ of the CCG, where local health services’ performance, changes and issues are debated and recommendations made to the Governing Body for agreement.

Governing Body

Two of the six Consortium Lead GPs sitting on the Clinical Executive Committee, step up to membership of our Governing Body, with one of these GPs taking on the Clinical Vice Chair role, which also chairs the Clinical Executive Committee and deputises for the CCG Chair in their absence. The other GP stepping up from the Clinical Executive Committee will become the Governing Body GP.

The CCG Chair is the third GP on our Governing Body, who chairs the meeting and this role is now recruited for through an open election process across our GP Practice membership.

Our Governing Body also has Consultant and Nurse Members, to provide independent clinical expertise to the Governing Body and four Lay Members to provide independent expertise and experience. Lastly, the CCG’s Accountable Officer and Chief Finance Officer (CFO) are members of our Governing Body.

Our Governing Body makes most decisions for the CCG and operates under the principles of accountability, transparency, probity, focussing on the sustainable success of the CCG over the longer term. These values are enshrined in our Constitution. The Governing Body places a high emphasis on conducting its business in a transparent manner in public, and accepts questions and challenges from public attendees during meetings. All Governing Body papers are published


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on our website for public scrutiny, as well as shared with the local Health and Wellbeing Boards, HealthWatches and Health Scrutiny Committees.

The Governing Body conducts an annual self-assessment process, involving members questioning and challenging each other on our effectiveness and ways of working to highlight possible improvements, and runs training sessions for the Governing Body to support their development. An annual 360 stakeholder survey looks at the practices and work of the CCG, run by an independent third party on behalf of NHS England. The results are published and discussed in public Governing Body papers. These processes feed into the annual development of leadership objectives across the CCG’s structure, which flow from the Governing Body across the whole of the CCG.

The Governing Body has a selection of Committees that report into it, mostly to examine items of work and service proposals in depth, before making a recommendation to the Governing Body.

Integrated Commissioning Committee

We have an established Integrated Commissioning Board (ICB) which meets in public and is formed as a Committee in Common with decision making powers between the CCG, London Borough of Hackney and the City of London Corporation. The CCG has an Integrated Commissioning Committee that joins with partner Committees in these arrangements. The ICB controls pooled budgets across the partners to agree together on matters to improve the local health and social care system. The ICBs are also able to make recommendations on matters that fall outside the pooled budgets to the relevant organisations, to enable further partnership working.

The Members of the CCG Committee that joins the Committee in Common are the CCG Chair, one Lay Member and the Accountable Officer. The Members of the partner Committees are three Council Members from each Local Authority and the Integrated Commissioning Board is supported by the Local Authorities’ Directors of Finance, Chief Executive, the CCG Chief Finance Officer and local HealthWatches, along with a voluntary sector representative and meets in public. Chairing of the ICB rotates amongst the CCG Chair and leaders from our partner organisations.

Our integrated commissioning arrangements are underpinned by a financial framework outlining how the partner statutory bodies set and manage the pooled budgets each year. The relevant statutory bodies retain responsibility for decisions taken within the ICB on the use of the pooled budgets.

Work in the Integrated Commissioning arrangements is developed and delivered within four care Workstreams (focused on integrated health and social care planning) and a series of Enabler Groups. A team is in place, working across the partner organisations to support these Integrated Commissioning structures, with the CCGs clinical service development driven and developed within the Workstream and Enabler Group structure.

Joint Commissioning Committee

NHS Barking & Dagenham CCG, City & Hackney CCG, Havering CCG, Newham CCG, Redbridge CCG, Tower Hamlets CCG and Waltham Forest CCG all meet together in public when required as a Committee in Common in the North East London (NEL) Joint Commissioning Committee (JCC). The role of the JCC is to deliver a set of delegated functions and powers transferred to it by the seven NEL CCG Governing Bodies. These functions are where the Governing Bodies consider there is additional value in working collaboratively with other CCGs.


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City and Hackney’s Committee is made up of the CCG Chair, Lay Member for Governance and the Accountable Officer, who works across all seven CCGs. The CCG Chairs collectively select a ‘Chair of Chairs’ who chairs the JCC.

At least once each year, the CCG Governing Body will receive a recommendation from the JCC of opportunities for collaborative work. The Governing Body decides those functions that will be transferred to the JCC. These delegated decision making powers are currently around the following work areas and decisions taken by the JCC must be done so through an unanimous vote:

● London Ambulance Service; ● Integrated Urgent Care; ● Maternity Planning; ● Mental health (acute beds only); ● NHSE assurance (except through exception done elsewhere e.g. A&E); ● Approval of any Integrated Care Systems framework.

Local GP Provider Contracts Committee

The Local GP Provider Contracts Committee (LGPPCC), which meets in public has been charged by the Governing Body to ensure the delivery of our clinical strategy, through robust contractual arrangements where the providers could include local GP providers. This includes both primary care services, which have been delegated to the Committee by NHS England and also CCG Contracts. The CCG Lay Member chairs part one of the LGPPCC, which deals with the delegated primary care commissioning business, while part two of the meeting, which considers other CCG contracts with primary care providers is chaired by our Associate Lay Member.

The Committee ensures CCG commissioning decisions around primary care are transacted in a way that effectively manages any potential conflicts of interest. The Committee has delegated powers from the Governing Body to agree payments to GP providers where a contract is in place and delegated powers from NHS England to make decisions on primary care services. The Committee also functions as our Primary Care Commissioning Committee (PCCC), making decisions on core primary care service matters delegated to the CCG from NHS England.

The Committee makes recommendations to the Governing Body on other CCG contracts with primary care providers for a decision to be made, often under a quorum without GP involvement, to avoid any conflicts of interest.

The Committee continues to review, appraise and scrutinise service specifications and proposals from across the CCG, utilising the expertise of the Independent GP Advisor, the Secondary Care Consultant and the Governing Body Nurse.

The Local GP Provider Contracts Committee receives feedback from the GP Confederation Oversight Group, a Lay Member chaired, non-conflicted sub-committee, that reviews the contracting arrangements and contract performance of the local GP Confederation on a bi-monthly basis.


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Finance and Performance Committee

Our Finance and Performance Committee is responsible for ensuring that financial and performance risks to our strategic objectives are identified and managed through a framework which enables the CCG to proactively manage its financial, performance, quality, innovation and productivity plans. The Committee provides assurance to the Governing Body about delivery and sustained performance in these areas, by reviewing and approving performance reports and action plans in detail. It holds the management team of the CCG to account for delivery in their respective areas of responsibility. The Committee is chaired by the CCG Lay Member for Governance.

Public and Patient Involvement Committee (PPI)

The primary role of the Public and Patient Involvement Committee is to ensure that the participation of patients and the public, their views and voices, influence every stage of the clinical commissioning cycle. The Committee is chaired by the CCG Lay Member for Public and Patient Involvement.

The Committee also has an important role in promoting co-production between patients and clinicians, holding our Governing Body to account in the PPI area and challenging the Governing Body, Clinical Executive Committee and the CCG as a whole. In particular, the Committee is responsible for reviewing draft and final commissioning intentions and provides feedback as to whether they reflect the needs and priorities of patients and local communities. The role of the Committee is also fundamental in ensuring that there is meaningful public consultation on proposals to change the services provided, or the ways in which they are provided.

The Committee promotes good practice in patient and public engagement and involvement, in the commissioning cycle and in encouraging and supporting patients in their own care. As patients of City and Hackney GP Practices, the Committee members also play a crucial role in ensuring that patients’ voices are heard and listened-to, in relation to the co-production of primary care services at individual practice level and in the delivery of services at scale, in the form of the Neighbourhood Model.

Safeguarding Group

The Safeguarding Group brings together the clinical commissioners for City and Hackney residents. It oversees monitoring of the quality of services with respect to adult and children’s safeguarding. It provides assurance to the Governing Body that all our commissioned organisations are working together and tackling any issues arising effectively. It’s chaired by the CCG Lay Member.

The Committee scrutinises assurance received from the North East London Commissioning Support Unit (NELCSU) and other partner organisations in respect of the safeguarding arrangements in place. In addition, the Group receives reports on progress with action plans where improvements are required, including reports from the local Safeguarding Boards for Adults and Children.

The Group also reviews the outcome of serious case reviews (SCRs), serious incidents (SIs) and where appropriate, complaints and any reports from the local HealthWatches.


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Prioritisation and Investment Committee

The Prioritisation and Investment Committee meets on an ‘as needed’ basis, to review bids for new, recurrent or non-recurrent investment. The Committee is responsible for reviewing the clinical evidence, performance and outcomes of investments, and ensuring they are providing high-quality services and good value for money. The Committee will then make recommendations to the Governing Body regarding investment of uncommitted CCG funds. The Committee did not meet in 2018/19.

Remuneration Committee

The Remuneration Committee meets as required and at least once every financial year. The Committee’s main business is to review the historic and forecast payments made to Clinical Lead GPs and Governing Body members. The Committee also receives assurance that individuals’ annual appraisals defined clear objectives and reviewed the outcomes for their sessional payments. More information about CCG remuneration can be found in the Remuneration and Staff Report on page 81 of this report.

The Audit Committee

The Audit Committee’s role is to seek assurance that financial reporting and internal control principles are applied and, to maintain an appropriate relationship with our organisation’s auditors, both internal and external. The Audit Committee offers scrutiny and advice to the Governing Body by critically-reviewing key governance and assurances processes. The Committee is chaired by the CCG Lay Member for Governance.


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Memberships of Committees

Governing Body and Committee attendance records

UK Corporate Governance Code

Whilst the detailed provisions of the UK Corporate Governance Code are not mandatory for public sector bodies, compliance is considered to be good practice. This Governance Statement is intended to demonstrate the CCG’s compliance with the principles set out in the Code (insofar as this applies to CCGs).

For the financial year ended 31 March 2019, and up to the date of signing this statement, we complied with the provisions set out in the Code, and applied the principles of the Code.


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Discharge of statutory functions

During the establishment of the Clinical Commissioning Group in 2013, the arrangements put in place and explained within this Governance Statement were developed with extensive expert external legal input, to ensure compliance with all relevant legislation. That legal advice also informed the matters reserved for our Membership Body, Governing Body decisions and the scheme of delegation.

In light of recommendations of the 2013 Harris Review, the CCG has reviewed all of the statutory duties and powers conferred on it by the National Health Service Act 2006 (as amended) and other associated legislative and regulations. As a result, I can confirm that the CCG 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 within our governance structure, ensuring the necessary capability and capacity to undertake all of the CCG’s statutory duties.

Risk management arrangements and effectiveness

Our Governing Body is collectively responsible for the management of risk for the CCG and for monitoring actions taken to reduce risk to its strategic objectives. It is important to note that our Officers have the prime responsibility for our risk management system, as outlined in the CCG’s Risk Management Policy, which is approved by the Governing Body. This policy outlines:

● How our colleagues are responsible for maintaining a register of risks relevant to their activity. Using the CCG’s risk matrix, colleagues are responsible for ascertaining how much a risk threatens the successful delivery of CCG business. Our teams are responsible for engaging with risk registers, and for scoring risks. It is the responsibility of these officers to identify issues which pose a significant threat to CCG business. A risk score can increase or decrease, based on changes in situation and the Risk Management Policy provides guidance on when risks should be escalated through our governance structure;

● Our Risk Management Policy stipulates that residual risk scores over 15 are to be escalated to the Governing Body for consideration and discussion, this is done through recording the risk on the CCG’s Board Assurance Framework (BAF) document. We find that this methodology, of identifying and escalating risks to the Governing Body in the first instance, is key for preventing risks developing, and impacting CCG business;

● All staff within the CCG are aware of the importance of managing risk, and the necessity of documenting it accurately and in a timely fashion;

● Colleagues are required to document actions planned to mitigate risks in their risk registers and the CCG’s BAF. This ensures our Governing Body is aware of how each risk is being managed and mitigated. Our BAF is reported at Governing Body at each monthly meeting and discussed in depth on a quarterly basis. Our Audit Committee discuss the document in depth at each meeting. Working with the CCG’s Internal Auditors (RSM), the Audit Committee are able to undertake ‘deep dives’ of risks on the BAF where they feel appropriate;

● Day to day management of risk, including updating and maintaining the BAF with actions taken to manage principle risks, fall to the CCG’s Officers, or other colleagues. A Member of the CCG’s Governance and Assurance Team is responsible for co-ordinating BAF activity across the CCG.


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We recognise that risk can never be eliminated in its entirety. Our objective in risk management is to progressively manage risk within what the organisation agrees are ‘acceptable’ levels.

With the CCG working in partnership with the London Borough of Hackney and City of London in a workstream structure, most risk related to our clinical services is now managed through workstreams and escalated through the Integrated Commissioning Board (ICB). The ICB then escalates risk to the CCG Governing Body and/or relevant Local Authority Committees as needed. The team supporting the Integrated Commissioning Board have developed, documented and agreed risk processes to support this process.

Risks to clinical quality in the CCG’s commissioned services are managed through comprehensive quarterly performance and quality reports, which are presented to our Governing Body. These documents highlight key clinical, performance or provider related risks and steps being taken to mitigate them. Each of our contracted providers are contractually-required to participate in a monthly Clinical Quality Review Meeting (CQRM) where clinical risks are also discussed and addressed. Similarly, non-clinical quality issues will be managed through the Service and Performance Review (SPR) meetings with our providers.

We involve our public stakeholders in risk management through the Governing Body (a public meeting), and publishing papers on the CCG website. Workstreams discuss risks impacting their work areas regularly, in meetings which often involve public representatives. Our Committees are also comprised of, or attended by partner organisations, providers and key local stakeholders, providing partners with an opportunity to engage with CCG risks and how risks may impact them.

Capacity to handle risk

Our Governing Body has determined the amount and type of risk the CCG is willing to tolerate, and ensures that our staff have a clear understanding of which risks are, or are not acceptable, through setting and agreeing risk tolerances against each risk in our BAF. This is influenced by a number of key factors such as the external environment, operational, regulatory, political and economic situation. Risk appetite has been defined as ‘the amount of risk that an organisation is prepared to accept, tolerate or to be exposed to at any point in time’ (HMT Orange Book definition 2005). We review our risk appetite continually throughout the year and it may be subject to change depending on our business environment.

Our risk appetite statement in our Risk Management Policy, as agreed by our Governing Body defines how we view and treat risk:

“We are comfortable in the acceptance of some risk in the pursuit of our vision for innovative clinical outcome improvements for patients. The likelihood of financial loss although recognised is reduced through managing risks within tolerable levels rather than avoiding risk.”

Our commitment to challenge, feedback and improvement is a key feature of our risk management policy. Our Clinicians take an active role in reviewing CCG practice and identifying areas where there is a potential risk to successful delivery of CCG business, for example, through clinical audits and Serious Incident (SI) Reviews. Clinical Leads are also responsible for suggesting clinical quality metrics, which are included in our service specifications and contracts. Our workstreams and enabler groups benchmark our data against neighbouring CCGs, to assess our performance, and undertake best practice research on a national level.

Our Audit Committee keeps an overview of our processes and governance and will test out our adherence to policies and operating principles throughout the year, choosing areas where they want to focus both their attention and that of our internal audit providers, RSM. We are fortunate


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in that as well as the three Lay Members on the Governing Body, we benefit from one Associate Lay Member who provides additional input and scrutiny through chairing part of our Local GP Provider Contracts Committee and supporting our decision-making structures.

Risk assessment

The CCG Governing Body monitors the financial risks escalated to them carefully, at each meeting. This includes the probability of the risk, its impact and mitigation. These risks feed through to the financial forecast, a detailed report on which is presented to each Governing Body meeting.

A number of key financial risks have evolved over the 2018/19 financial year, which have required careful monitoring and mitigating action. These include:

● The Homerton full-year reported position was £4.7m adverse to full year plan. In the main, this was due to a combination of over-performance in outpatient first, elective and day-case activity. A number of joint audits were undertaken with Homerton in 2018/19, to understand the demand. Further external audits will be carried out in 2019/20;

● The CCG reached a close down agreement with Barts Health NHS Trust with an over performance of £1.8million. The 2019/20 contract value was set in the main on the 2018/19 closing position with risks attached to on-going audits;

● Out-of-area Acute over-performance of £2.0m was managed and mitigated by reserves and under-spend in the portfolio, with the majority of the increased activity being at Guy's Hospital and London Ambulance Service;

● The CCG transferred £1.0m to Waltham Forest CCG, under the 2018/19 NEL Risk Share Framework, in support of the neighbouring health geography within the NEL system, ensuring the money stayed in the system to support the continuation of patient care and service. The Finance and Performance Committee is entrusted to provide in depth scrutiny of financial, contract and activity performance throughout the year and a rotating series of deep dive reports presented to the Committee on a monthly basis. This ensures the risk is effectively managed;

● A drawdown of £1.9m was approved by NHSE from the CCG’s cumulative brought-forward surplus. This non-recurrent drawdown funding was used to support a Learning Disabilities Pilot programme with the London Borough of Hackney, as part of a joint-funding collaboration.

We have reviewed our capacity to handle these levels of risk, which will be mitigated through the following actions and consideration:

● Uncommitted Funds; ● Contingency; ● Reserves; ● Further savings opportunities; ● Delay / reduce investment plans.

We have agreed a further level of mitigation via a risk-sharing agreement with other NEL CCGs. The level of risk, exposure and mitigation is reviewed by the Chief Finance Officer and respective CCG Directors of Finance. This is based on an agreed consistent methodology.


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EU-Exit Preparedness

The CCG Governing Body has retained close overview of the planning and preparations for the UK leaving the EU. The plans had particular focus on the possibility of leaving without a secure deal, but also the potential impact of the uncertainty created by EU-Exit and any possible effects in advance of the UK leaving the EU.

NHSE Issued Guidance in December 2018 to all NHS bodies and services in contract with or supplying the NHS. Commissioner and provider action cards within the guidance summarised the minimum expected preparations for every organisation.

The implementation of this guidance at local level was subject to regular NHSE assurance and the following steps taken to ensure compliance and readiness:

● Each STP area nominated an SRO for EU-Exit to co-ordinate activities for the CCGs and main NHS providers within the partnership. The individual acted as a contact point for NHSE regional / national teams, commissioners, providers and local authorities for data and information requests, queries and support;

● The NEL Commissioning Authority (NELCA) SRO hosted teleconferences between CCG emergency planners and also with local providers, to ensure all EU-Exit related activities for commissioners / providers were carried out to time, as required by NHS England / Improvement. The key domains for preparation covered were:

○ Operational readiness; ○ Communications and engagement – with Governing Bodies, key providers

(including primary care) staff and key stakeholders via local resilience forums; ○ Workforce; ○ Medicines & medicinal products; ○ Clinical consumables supplies; ○ Non clinical consumables; ○ Data sharing processes and access – security and continuity; ○ Reciprocal healthcare arrangements and health demand; ○ Finance; ○ Assurance via NHSE;

● Governing Bodies and Senior Executive teams were frequently updated and able to scrutinise activities in relation to EU-exit preparations;

● CCGs undertook review of their Business Continuity Plans and risk registers, with mitigation where necessary;

● CCGs worked with their Local Resilience Forums to identify and mitigate any potential system impacts;

● Daily and weekly situation reporting was completed by the CCG via the NHS Digital Strategic Data Collection Service.

EU-Exit preparations and contingency planning will continue into 2019/20, until such time as stood down by NHS England.

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.


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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.

In relation to our systems of internal control, we have implemented different levels of governance that provide assurance of our integrated commissioning work, through the following means:

● Governing Body; ● Integrated Commissioning Board (ICB); ● Audit Committee (AC); ● Finance and Performance Committee (FPC); ● Local GP Provider Contacts Committee (LGPPCC); ● Remuneration Committee (RC); ● Prioritisation and Investment Committee (PIC); ● Workstream Boards.

Control and assurance by the Governing Body is primarily done through the following mechanisms that are intertwined with the Committees and Boards in place:

● The Board Assurance Framework (BAF) – which sets out the strategic objectives, identifies the risks associated in relation to the objectives along with the controls in place and assurances available, to ensure the management of those risks;

● Workstreams and Enabler Groups - where ideas are debated and proposals developed with Public Health, Local Authority and patient/public involvement, with further input from clinicians and CCG commissioners. Each workstream holds regular forums where risk is discussed, including risk registers, actions, and any required escalation;

● Finance and Performance Committee - performs detailed scrutiny of financial and service performance and considers requests for the investment of funding that is available;

● Audit Committee – provides scrutiny and assurance of the robustness of the control processes in place, and supports the Governing Body;

● Our Governing Body meetings are held in public - promoting public scrutiny on all CCG business discussed at these meetings.

For any proposal to invest in a local GP provider, there is added scrutiny and assurance from our Local GP Provider Contracts Committee, with Associate Lay Member and Lay Member Chairs, meeting in public and excluding local GP members from any membership roles.

These checks and balances and recommendation / decision points are a critical feature of our internal control systems and we rely on the Audit Committee and our internal auditors, RSM to keep these processes under review and provide assurance to ourselves and the Governing Body that these are robust. We only release funding when we have agreed a service specification with clear outcomes and key performance indicators which are used as the basis of contract variations with providers. Performance is reviewed in-year by the Finance and Performance Committee, chaired by the Lay Member for Governance. We also ensure we remain a learning and challenging organisation by encouraging challenge from our Clinical Leads and Workstreams, and supporting the development of the Governing Body.


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Annual audit of conflicts of interest management

The revised statutory guidance on managing conflicts of interest for CCGs (published June 2016) requires CCGs to undertake an annual internal audit of conflicts of interest management. To support CCGs to undertake this task, NHS England has published a template audit framework.

The CCG’s internal audit provider RSM conducted an audit of the CCG’s processes and practices in March 2019, to evaluate the design and operating effectiveness of the arrangements that are in place, to manage conflicts of interest and gifts and hospitality, including compliance with NHSE’s statutory guidance on managing conflicts of interest for CCGs.

The audit found that the CCG Governing Body can take reasonable assurance that the controls in place to manage this risk are suitably-designed and consistently applied. However, the audit identified issues that needed to be addressed in order to ensure that the control framework is effective in managing the identified risk(s). One medium and three, low-priority actions were identified as needing to be addressed.

The CCG is addressing these actions and continues to work with its internal audit provider to refine and improve its internal processes. The recommendation to revisit the criteria against which we request conflicts of interest declarations is key to this process, as the current position is that we require these declarations from anyone attending a CCG meeting or working with us in any capacity. We are aiming to refine our policy to concentrate on colleagues involved in our decision-making processes, to produce a more useful and transparent Register of Interests. This will be twinned with work to tie in with the information on our website on contracts awarded, to present a full Register of Procurement Decisions in a single webpage, rather than the cross referencing required currently.

Data quality

We utilise data from a variety of sources in our Information, Quality, Performance and Evaluation reports used by our CCG Governing Body, Committees and in communications with other stakeholders. This includes data from NHS Digital, National Dashboards, Public Health England profiles and local systems. In addition, data submitted by our providers and included in national reporting figures/databases are managed on our behalf by the North East London Commissioning Support Unit (NELCSU). The NELCSU systems are reviewed by Deloitte, which is employed by NHS England to undertake a Service Auditor Report and we engage with other customers of the CSU to employ RSM to undertake quality assurance reviews.

Information governance

The NHS Information Governance Framework sets the processes and procedures by which the NHS handles information about patients and employees, in particular personal identifiable information. The NHS Information Governance Framework is supported by an information governance toolkit and the annual submission process provides assurances to the Clinical Commissioning Group, other organisations and to individuals that personal information is dealt with legally, securely, efficiently and effectively.

We place high importance on ensuring there are robust information governance systems and processes in place to help protect patient and corporate information. We have established an information governance management framework and are developing / have developed information governance processes and procedures in line with the information governance toolkit. We have ensured all staff undertake annual information governance training and have


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implemented a staff information governance handbook to ensure staff are aware of their information governance roles and responsibilities.

There are processes in place for incident reporting and investigation of serious incidents. We are developing information risk assessment and management procedures and a programme will be established to fully embed an information risk culture throughout the organisation against identified risks.

Business critical models

In line with the review of quality assurance of government models carried out by Sir Nicholas Macpherson in 2013, we have established a framework to ensure business critical models are effective and quality assured. The main critical model is our long term financial model, the output of which is subject to NHS England assurance and internal audit review as our annual operating plans. All other business critical models are held by third parties, in particular by the North East London Commissioning Support Unit (NELCSU). We are also an active participant in a quality assurance process with eleven other local CCGs and delivered by RSM to review the systems and models held within NELCSU. Further assurance is provided by a Service Audit Report on the NELCSU systems commissioned by NHS England, carried out by Deloitte and made available to all CCGs in contract with NELCSU.

Third party assurances

The CCG commissions NEL CSU to run elements of our commissioning function – such as contracting, business intelligence, communications and HR. The service standards are monitored as part of an SLA and the Audit Committee receives regular auditor reports on contracted-for services.

Control issues

We can confirm that the CCG has experienced no significant control issues this financial year.

Review of economy, efficiency and effectiveness of the use of resources

The CCG uses its resources economically, efficiently and effectively, proven through:

● Assurance from the Governing Body, Internal Audit carried out by RSM and the Prioritisation and Investment Committee (PIC), that the CCG has made appropriate arrangements for ensuring that it complies with generally-accepted principles of good governance as are relevant to it;

● Ratings for the Quality of Leadership indicator of the CCG IAF 2018/19, which was green; ● Robust financial planning and in-year performance monitoring by the Finance and

Performance Committee and Local GP Provider Contracts Committee; ● Continuing to operate a very lean back-office function and committing to a flat, non-

hierarchical and clinically-led structure which minimises bureaucracy. This enables us to contribute more resource from resources allocated for management and administration into direct, front-line services. This will continue to be reviewed in the light of us meeting our statutory duties, delivering key targets through improved health outcomes and being able to manage increased demands of assurance from NHS regulatory bodies.


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Delegation of functions

NEL CSU manages contracts with key providers on behalf of the CCG. The process is overseen by the CCG and regularly-reviewed, through the internal audit process and discussion at the Audit Committee. In addition, the Chief Finance Officer, Director of Finance and relevant directors meet with the CSU lead staff regularly to discuss performance and agree actions where there are concerns. Generally, the process has worked well over the past financial year.

The CCG has been delegated responsibility for the commissioning of primary care from NHS England. The CCG’s arrangements for managing this function are subject to regular review by internal audit. Internal audit of the way the CCG is managing the primary care contracts on behalf of NHS England found substantial assurance in January 2019 in regard to commissioning and procurement.

Counter fraud arrangements

We work with RSM to assess the adequacy of our arrangements to counter fraud. Periodically, RSM undertakes a fraud risk assessment, and establishes a programme of work to:

● Manage the risk of fraud occurring; ● Ensure awareness of the risk of fraud is communicated organisation-wide.

The fraud risk management function is overseen by our Audit Committee. Our 2018/19 Counter Fraud Workplan focussed on targeting resources in those areas which are considered most at risk from fraud and bribery, by working with staff and management. The Workplan was split into four, key fraud-related areas:

● Inform and involve - Raising awareness of crime risks against the NHS and working with NHS staff, stakeholders and the public to highlight the risks and consequences of crime against the NHS;

● Prevent and Deter - Discouraging individuals who may be tempted to commit crimes against the NHS and ensuring that opportunities for crime to occur are minimised;

● Hold to Account - Detecting and investigating crime, prosecuting those who have committed crimes and seeking redress; and,

● Strategic Governance - Set out the requirements in relation to the organisation’s strategic governance arrangements.

In developing our workplan, RSM ensured the standards set out from the NHS Counter Fraud Authority (the successor organisation to NHS Protect) were reflected, and compliance with these standards is reported to the Audit Committee.

B1(4) Head of Internal Audit Opinion Following completion of the planned audit work for the financial year for the CCG, the Head of Internal Audit issued an independent and objective opinion on the adequacy and effectiveness of the Clinical Commissioning Group’s system of risk management, governance and internal control. The Head of Internal Audit concluded that:


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The opinion

The organisation has an adequate and effective framework for risk management, governance and internal control.

However, our work has identified further enhancements to the framework of risk management, governance and internal control to ensure that it remains adequate and effective.

Internal audit reports

During the year, Internal Audit issued the following audit reports:

Area of audit Level of assurance given

Financial Planning, Budget Setting, Delivery and Reporting

Substantial Assurance

Primary Care Delegated Commissioning Substantial Assurance

QIPP - WELC CCGs joint report, City & Hackney CCG Effectiveness

Substantial Assurance

NEL CCGs joint report Commissioning and Contract Management

Reasonable Assurance

Conflicts of Interest Reasonable Assurance

Board Assurance Framework (draft) Reasonable Assurance

QIPP - WELC CCGs joint report, City & Hackney CCG Design and Application

Reasonable Assurance

Data Security Protection Toolkit Advisory Report

NELCA Governance and Workstreams Advisory Report

Whilst no significant control issues were identified as part of any of the abovementioned reviews, RSM have identified some areas for improvement and where those were highlighted, agreed actions are in place with CCG management with agreed deadlines for implementation. These are followed up on a regular basis and their status reported to each meeting of the Audit Committee. At the May 2019 meeting of the Audit Committee, there were no overdue outstanding management actions.

B1(5) Review of the effectiveness of governance, risk management and internal control As Accountable Officer I have responsibility for reviewing the effectiveness of the system of internal control within the CCG.

My review of the effectiveness of the system of internal control is informed by the work of the internal auditors, executive managers and clinical leads within the clinical commissioning group who have responsibility for the development and maintenance of the internal control framework. I


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have drawn on performance information available to me. My review is also informed by comments made by the external auditors in their annual audit letter and other reports.

Our assurance framework provides me with evidence that the effectiveness of controls that manage risks to the clinical commissioning group achieving its principles objectives have been reviewed.

I have been advised on the implications of the result of this review by:

● The Governing Body; ● The Audit Committee; ● The Finance and Performance Committee; ● The Chief Finance Officer, Managing Director and Director of Finance of the CCG; ● The internal audit provider, RSM.

Conclusion

We can confirm that during financial year 2018/19 no internal control breaches have been identified.

B2. Remuneration and Staff Report The remuneration and staff report sets out the CCG’s remuneration policy for directors and senior managers, reports on how that policy has been implemented and sets out the amounts awarded to directors and senior managers.

B2(1) Remuneration report

Remuneration Committee

Details of the membership of the Remuneration Committee and its remit is contained in the Governance Statement (see page 70).

Policy on the remuneration of senior managers

Remuneration is in line with the NHS Agenda for Change (AFC) framework.

The remuneration of senior managers is determined by the Remuneration Committee in line with national NHS ‘Agenda for Change’ and very senior manager pay guidance. The Committee reviews information about director and Governing Body members’ responsibilities, as well as comparing remuneration in similar organisations to set pay.

Remuneration of Very Senior Managers

One member of the CCG Governing Body, who was part time (left 30th June 2018), was paid in excess of £150,000 on a pro rata basis. This remuneration was advised by the Remuneration Committee to the Governing Body (which remains accountable for taking decisions on the remuneration and terms of service for senior managers). The recommendations of the


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Remuneration Committee reflect the guidance contained in the NHS England publication “Clinical Commissioning Group guidance on senior appointments, including accountable officers”.

In addition, one senior manager’s combined salary across NELCA was more than £150,000 per annum. The pay was determined by the joint remuneration committee in line with the national guidance for Very Senior Managers’ salaries. Salary levels have been benchmarked against equivalent roles in the other 4 London CCG Commissioning Alliances and London Providers. The Accountable Officer was appointed within 16 months, with the market tested through an open competitive process.

Contractual arrangements

The Chair, Clinical Leads and Lay Members are appointed by the CCG. Clinical directors and lay members are on fixed term contracts of up to five years in length, depending on individual circumstances. The Accountable Officer and other Executive Directors are on permanent contracts, subject to the notice periods of either three or six months.

Senior manager remuneration (including salary and pension entitlements) (subject to audit)

Notes

1. Dr Mark Rickets is also the Primary Care Clinical Lead. Salary information for this role is not included in the above table.

2. Siobhan Clarke is invoiced by Your Healthcare CIC.

3. The NEL Commissioning Alliance Accountable Officer is the appointed officer for 7 CCGs: NHS Barking and Dagenham, Havering, Redbridge, Waltham Forest, Newham, Tower Hamlets and City and Hackney. Her total salary in 2018/19 across all organisations was Salary: £140k to £145k; Performance Pay £10k to £15k; Pension Related Benefits: £62.5k to £65k; Total: £215k to £220k. Performance pay is aligned to delivery of specific objectives and may be withheld due to unsatisfactory performance.

4. The NEL Commissioning Alliance Chief Finance Officer is the appointed officer for 7 CCGs: NHS Barking and Dagenham, Havering, Redbridge, Waltham Forest, Newham, Tower Hamlets and City and Hackney with effect from 1st December 2018. Until 20th November 2018, the Chief Finance Officer was appointed across NHS Tower Hamlets and Waltham Forest CCG’s. His total salary in 2018/19 across all organisations was Salary: £135k to £140k; Pension Related Benefits: £70k to £72.5k; Total: £205k to £210k.

5. Sunil Thakker and Philippa Lowe were Joint CFOs until 30th June 2018. Thereafter, Sunil Thakker was Chief Finance Officer from 1st July 2018 to 30th November 2018.

6. Sunil Thakker is the appointed Director of Finance from 1st December 2018.

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

(bands of £5000)

(to nearest £100)

(bands of £5000)

(bands of £5000)

(bands of £2,500)

(bands of £5000)

(bands of £5000)

(to nearest £100)

(bands of £5000)

(bands of £5000)

(bands of £2,500)

(bands of £5000)

£000 £00 £000 £000 £000 £000 £000 £00 £000 £000 £000 £0001 Dr Mark Rickets CCG Governing Body Chair 70 - 75 0 0 0 0 70 - 75 01/04/2018 31/03/2019 0 0 0 0 0 0

Dr Gary Marlowe CCG Governing Body Clinical Vice Chair 20 - 25 0 0 0 0 20 - 25 01/04/2018 31/03/2019 15-20 0 0 0 0 15-20Dr Nikhil Katiyar CCG Governing Body GP 10 - 15 0 0 0 0 10 - 15 01/04/2018 31/03/2019 0 0 0 0 0 0

Catherine Macadam CCG Governing Body Public and Patient Involvement Lay Member 35 - 40 0 0 0 0 35 - 40 01/09/2018 31/03/2019 35-40 0 0 0 0 35-40

Sue Evans CCG Governing Body Lay Member for Governance 30 - 35 0 0 0 0 30 - 35 01/04/2018 31/03/2019 15-20 0 0 0 0 15-20Honor Rhodes CCG Governing Body Lay Member 25 - 30 0 0 0 0 25 - 30 12/09/2018 31/03/2019 25-30 0 0 0 0 25-30Jaime Bishop CCG Governing Body Associate Lay Member 0 - 5 0 0 0 0 0 - 5 01/09/2018 31/03/2019 0-5 0 0 0 0 0-5

2 Siobhan Clarke CCG Governing Body Nurse 5 - 10 0 0 0 0 5 - 10 01/04/2018 31/03/2019 5-10 0 0 0 0 5-10Chris Gallagher CCG Governing Body Consultant 5 - 10 0 0 0 0 5 - 10 01/04/2018 31/03/2019 0 0 0 0 0 0

3 Jane Milligan NELCA Accountable Officer 20 - 25 0 0 - 5 0 7.5 - 10 30 - 35 01/04/2018 31/03/2019 5-10 0 0 0 0-2.5 5-104 Henry Black NELCA Chief Finance Officer 5 - 10 0 0 0 2.5 - 5 10 - 15 01/12/2018 31/03/2019 0 0 0 0 0 05 Sunil Thakker Chief Finance Officer 75 - 80 0 0 0 10 - 12.5 85 - 90 01/04/2018 30/11/2018 110-115 0 0 0 20-22.5 135-1406 Sunil Thakker Director of Finance 35 - 40 0 0 0 0 35 - 40 01/12/2018 31/03/2019 0 0 0 0 0 0

David Maher Managing Director 130 - 135 0 0 0 75 - 77.5 205 - 210 01/04/2018 31/03/2019 30-35 0 0 0 50-52.5 80-855 Philippa Lowe Joint CFO 15 - 20 0 0 0 0 15 - 20 01/04/2018 30/06/2018 50-55 0 0 0 0 50-55

TitleNameNote

2018/19 Dates served

From

2017/18

To


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Where a member is a GP who is also paying into the NHS Pension scheme, the salary figures shown above include City and Hackney CCG's employer contribution to the scheme. This is in accordance with Department of Health guidance.

The Pensions Related Benefits (PRB) figure is calculated using the method set out in the Finance Act 2004(1), and includes using the member's current and prior year pension and lump sum figures. Where there has been only a small increase in pension and lump sum benefits, current year compared to last year, this formula can sometimes generate a negative figure. Where this is the case, Department of Health guidance states that a "zero" should be substituted for any negative figures.

Pension benefits at 31 March 2018 (subject to audit)

Notes 1. The NEL Commissioning Alliance Accountable officer and the NEL Commissioning Chief Finance Officer are the appointed officers for 7 CCGs. NHS Barking and Dagenham, Havering, Redbridge, Waltham Forest, Newham, Tower Hamlets and City and Hackney. Their total Pensions figures are shown above. 2. Chief Finance Officer's total pension figures are shown above although he was in post until 31/11/18.

Cash equivalent transfer values

A Cash Equivalent Transfer Value (CETV) is the actuarially assessed capital value of the pension scheme benefits accrued by a member at a particular point in time. The benefits valued are the member’s accrued benefits and any contingent spouse’s (or other allowable beneficiary’s) pension payable from the scheme. CETVs are calculated in accordance with SI 2008 No.1050 Occupational Pension Schemes (Transfer Values) Regulations 2008.

A CETV is a payment made by a pension scheme or arrangement to secure pension benefits in another pension scheme or arrangement when the member leaves a scheme and chooses to transfer the benefits accrued in their former scheme. The pension figures shown relate to the benefits that the individual has accrued as a consequence of their total membership of the pension scheme, not just their service in a senior capacity to which disclosure applies.

The CETV figures and the other pension details include the value of any pension benefits in another scheme or arrangement which the individual has transferred to the NHS pension scheme. They also include any additional pension benefit accrued to the member as a result of their purchasing additional years of pension service in the scheme at their own cost. CETVs are calculated within the guidelines and framework prescribed by the Institute and Faculty of Actuaries.


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Real increase in CETV

This reflects the increase in CETV effectively funded by the employer. It does not include the increase in accrued pension due to inflation, but does include contributions paid by the employee (including the value of any benefits transferred from another scheme or arrangement) and uses common market valuation factors for the start and end of the period.

Compensation on early retirement of for loss of office

There have been no early retirements.

Payments to past members

There have been no payments to past members.

Termination agreements or exit packages (subject to audit)

Termination arrangements are applied in accordance with statutory regulations as modified by national NHS conditions of service agreements (specified in Agenda for Change), and the NHS pension scheme. Specific termination arrangements will vary according to age, length of service and salary levels. The remuneration committee will agree any severance arrangements.

During the financial year there were no payments made in relation to payments to past members.

Pay multiples (subject to audit)

Reporting bodies are required to disclose the relationship between the remuneration of the highest-paid director/member in their organisation and the median remuneration of the organisation’s workforce.

The banded remuneration of the highest paid director/member in NHS City and Hackney CCG in the financial year 2018/19 was £155,000-£160,000 (2017/18: £155,000-£160,000). This was 2.21 times (2017/18: 2.15) the median remuneration of the workforce, which was £70,629 (2017/18: £73,716).

In 2018/19, zero employees received remuneration in excess of the highest-paid director/Member. Remuneration ranged from £23,000 to £156,000 (2017/18: £22,000 to £158,000).

Total remuneration includes salary, non-consolidated performance-related pay, benefits-in-kind, but not severance payments. It does not include employer pension contributions and the cash equivalent transfer value of pensions.


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B2(2) Staff report

Staff numbers, costs and composition (subject to audit)

Number of Senior Managers

Band Head count

VSM 0

9 3

8d 4

8c 13

8b 8

8a 9

Total 37

Senior Managers based on headcount as at 31/03/2019.

Excludes Governing Body members, Agency and Clinical Leads.

Staff Numbers and Costs

Number Cost (£000’s)

Other Number 21.93 4,349

Permanently employed Number

52.90 2,001

Total Number 74.83 6,350

Staff numbers based on average whole time equivalent for 2018/19.

Excludes Non-Executive GB Members but includes Agency under “Other”.


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Staff composition

GB SM Other Total

Male 8 16 7 31

Female 5 21 15 41

Total 13 37 22 72

Staff composition based on headcount as at 31/03/2019.

Covers all staff on the CCG payroll, excludes Agency and Clinical Leads.

CCG Staff, grouped by NHS occupation code

Occupation code Working Time Equivalent

G (Administration and estates staff) 50.54

M (Medical and dental staff) 0.36

N (Nursing, midwifery and health visiting staff)

1.60

S (Scientific, therapeutic and technical staff)

0.40

Z (General payment staff) 0

Staff numbers by occupation code are based on the average whole time equivalent of those permanently employed during 2018/19.

Excludes Non-Executive GB Members and Agency.


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Sickness absence data

2018/19 Number

Total Days Lost 125.0

Total Permanently Employed Number 52.72

Average Working Days Lost 2.4

*Staff Sickness absence data is based on average whole time equivalent for 2018/19.

Excludes Non-Executive GB Members and Agency.

Staff policies

We are committed to promoting equality, diversity and human rights for our staff. We recognise that everyone is different and want to make sure that our employment practices respect, promote and celebrate these differences. We want to make the most of people’s talent, ideas and commitments and to make them feel valued.

We are bound by, and stand by, national legislation as well as the rights and conditions for staff as set out by the NHS. We will always give full and fair consideration to applications for employment made by any disabled person and our recruitment policy states that “no applicant should receive less favourable treatment on the grounds of any protected characteristic or be disadvantaged by conditions or requirements which cannot be shown to be relevant to job performance, or when recruiting, the essential criteria.”

In the event of an employee becoming disabled while they are working for us, we will work with them, alongside Occupational Health, to give every opportunity to continue their career with us. We will always seek to be as flexible and helpful as possible and to consider all requests for modified working conditions where appropriate. All staff have access to high quality advice about their learning and development and are able to utilise time and money in the form of a Personal Learning Account. We provide additional support in terms of funding and time over and above that which is available through the Personal Learning Account, to help individuals to meet personal and professional learning aspirations where it can be demonstrated that it is justifiable to divert funds from clinical services to meet this aspiration and that such support is fair and equitable. Disabled employees have full and fair access to all of these opportunities and we give full consideration to any such applications for additional support.

Trade union facility time The CCG does not have any employees who fall under the relevant union officials as laid out in The Trade Union (Facility Time Publication Requirements) Regulations 2017. As such, no CCG employee time was spent on facility time and no CCG funding was used on our pay bill for these purposes or on paid trade union activities.


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Other staff matters

We want our staff to feel like the CCG is a great place to work. Ours is a high trust, minimum-supervision organisation. What is important to us is the quality of what our colleagues produce, not necessarily the means by which they achieve this. This is reflected in our staff policies, which are written as a plain-speaking guide for people working at the CCG. We promote flexible-working which can include, but is not limited to, working from home and from different sites. We also provide a wide range of different employment options to suit all personal circumstances; full time, part time or annualised hours.

To develop talent, we provide each colleague with a generous yearly learning allowance, which they are free to spend on any course of personal or professional development they wish, for their benefit and by extension, that of the organisation. Additional funding can be requested where more extensive personal development or training needs are identified as part of a person’s annual appraisal. On top of this, we provide peer support, coaching and mentoring where this is identified as beneficial. All of these measures help us to propel people to bigger and better things.

We strive to ensure we nurture and maintain a diverse workforce, which is reflective of the community we serve. We are fully-committed to meeting the NHS Workforce Race Equality Standards and our staff policies explicitly reflect our obligation for ensuring no individual is discriminated against on any grounds. This gives people assurance that they will receive equal treatment in their application to work at the CCG, their selection and subsequent employment.

Another important aspect of making people feel valued is great communication and engagement. We are a small organisation where people are well-known to each other across the CCG, so one-to-one communication is easy and is encouraged. But we reinforce this with a number of structured channels of communication:

● A weekly staff bulletin with news about what’s happening within the CCG, North East London and across the wider NHS. This also provides information about internal employment and training opportunities;

● A fortnightly-team briefing meeting, open to all, which is chaired by a different senior manager each time, where people are kept abreast of system-wide strategic developments and have the opportunity to ask questions;

● A quarterly staff council, of which everyone is a member, chaired and run by elected colleagues, where any issues of concern or thoughts and ideas for improving staff welfare can be discussed and decided on;

● Organisational away-days, where together we take stock of where we are as an organisation and map our direction of travel as the wider system in which we operate develops;

● Regular staff surveys, which test the temperature of our staff’s mood and give people a chance to offer candid, anonymous feedback.

Underpinning everything is our concern for the health and well-being of everyone who works here. Our staff have access to the full range of occupational health services provided by Bart’s Hospital. In addition, we provide staff with unlimited access to the Employee Assistance Programme (EAP) contracted by Bart’s which, amongst a range of support, includes access to:

● Confidential counselling; ● Debt counselling/financial advice.

Our efforts to make the working environment as good as we can has been rewarded by a Certificate of Commitment from the Mayor of London under the Health Workplace Charter, and we are set to go the next level of Achievement in the coming months.


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Expenditure on consultancy

Expenditure on consultancy for 2018/19 is shown in the table below.

£'000

Programme 78

Admin 96

Total 174

Off-payroll engagements

For all off-payroll engagements as of 31 March 2019, for more than £245 per day and that last for longer than six months:

Number of existing engagements as of 31 March 2019 16

Of which, the number that have existed:

For less than one year at the time of reporting 5

For between one and two years at the time of reporting 1

For between 2 and 3 years at the time of reporting 3

For between 3 and 4 years at the time of reporting 4

For 4 or more years at the time of reporting 3

B1: Off-payroll engagements longer than 6 months

For all new off-payroll engagements, or those that reached six months in duration, between 1 April 2018 and 31 March 2019, for more than £245 per day and that last longer than six months:

Number of new engagements, or those that reached six months in duration, between 1 April 2018 and 31 March 2019 5

Of which:

Number assessed as caught by IR35 4

Number assessed as not caught by IR35 1

and

Number engaged directly (via PSC contracted to department) and are on the departmental payroll 0

Number of engagements reassessed for consistency/ assurance purposes during the year. 0

Number of engagements that saw a change to IR35 status following the consistency review. 0


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B2: New off-payroll engagements

For any off-payroll engagements of Board members and / or senior officials with significant financial responsibility, between 1 April 2018 and 31 March 2019:

Number of off-payroll engagements of board members, and/or senior officers with significant financial responsibility, during the financial year 1

Total no. of individuals on payroll and off-payroll that have been deemed “board members, and/or, senior officials with significant financial responsibility”, during the financial year. This figure should include both on payroll and off-payroll engagements.

13

B3: Off-payroll engagements / senior official engagements

Exit packages, including special (non-contractual) payments

Termination arrangements are applied in accordance with statutory regulations as modified by national NHS conditions of service agreements (specified in Agenda for Change), and the NHS pension scheme. Specific termination arrangements will vary according to age, length of service and salary levels. The Remuneration Committee will agree any severance arrangements.

There are no exit packages, including special (non-contractual) payments to disclose this year.

B3. Parliamentary Accountability and Audit Report NHS City and Hackney CCG is not required to produce a Parliamentary Accountability and Audit Report. Disclosures on remote contingent liabilities, losses and special payments, gifts, and fees and charges are included as notes in the Financial Statements of this report at page 90. An audit certificate and report is also included in this Annual Report at section B3 (1) below.

B3(1) Audit certificate and report INDEPENDENT AUDITOR’S REPORT TO THE MEMBERS OF THE GOVERNING BODY OF NHS CITY AND HACKNEY CLINICAL COMMISSIONING GROUP

REPORT ON THE AUDIT OF THE FINANCIAL STATEMENTS

Opinion

We have audited the financial statements of NHS City and Hackney Clinical Commissioning Group (“the CCG”) for the year ended 31 March 2019 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 one.

In our opinion the financial statements:

Give a true and fair view of the state of the CCG’s affairs as at 31 March 2019 and of its income and expenditure for the year then ended; and


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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 and Social Care Group Accounting Manual 2018/19.

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

The Accountable Officer has prepared the financial statements on the going concern basis as they have not 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. They have also concluded that there are no material uncertainties that could have cast significant doubt over its ability to continue as a going concern for at least a year from the date of approval of the financial statements (“the going concern period”).

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 a year from the date of approval of the financial statements. In our evaluation of the Accountable Officer’s conclusions we considered the inherent risks to the CCG’s operations, including the impact of Brexit, and analysed how these risks might affect the CCG’s financial resources, or ability to continue its operations over the going concern period. We have nothing to report in these respects.

However, as we cannot predict all future events or conditions and as subsequent events may result in outcomes that are inconsistent with judgements that were reasonable at the time they were made, the absence of reference to a material uncertainty in this auditor's report is not a guarantee that the CCG will continue in operation.

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.

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.


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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 and Social Care Group Accounting Manual 2018/19.

Accountable Officer’s responsibilities

As explained more fully in the statement set out on page 64, 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 64, the Accountable Officer is responsible for ensuring that the CCG exercises its functions effectively, efficiently and

http://www.frc.org.uk/auditorsresponsibilities


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economically. We are required under section 21(1)(c) of the Local Audit and Accountability Act 2014 to be satisfied that the CCG has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources.

We are not required to consider, nor have we considered, whether all aspects of the CCGs arrangements for securing economy, efficiency and effectiveness in the use of resources are operating effectively.

We have undertaken our review in accordance with the Code of Audit Practice, having regard to the specified criterion issued by the Comptroller and Auditor General (C&AG) in November 2017, as to whether the CCG had proper arrangements to ensure it took properly informed decisions and deployed resources to achieve planned and sustainable outcomes for taxpayers and local people. We planned our work in accordance with the Code of Audit Practice and related guidance. Based on our risk assessment, we undertook such work as we considered necessary.

Statutory reporting matters

We are required by Schedule 2 to the Code of Audit Practice issued by the Comptroller and Auditor General (‘the Code of Audit Practice’) to report to you if:

We refer a matter to the Secretary of State under section 30 of the Local Audit and Accountability Act 2014 because we have reason to believe that the CCG, or an officer of the CCG, is about to make, or has made, a decision which involves or would involve the body incurring unlawful expenditure, or is about to take, or has begun to take a course of action which, if followed to its conclusion, would be unlawful and likely to cause a loss or deficiency; or

We issue a report in the public interest under section 24 of the Local Audit and Accountability Act 2014; or

We make a written recommendation to the CCG under section 24 of the Local Audit and Accountability Act 2014.

We have nothing to report in these respects.

THE PURPOSE OF OUR AUDIT WORK AND TO WHOM WE OWE OUR RESPONSIBILITIES

This report is made solely to the Members of the Governing Body of NHS City and Hackney CCG, as a body, in accordance with Part 5 of the Local Audit and Accountability Act 2014. Our audit work has been undertaken so that we might state to the Members of the Governing Body of the CCG, as a body, those matters we are required to state to them in an auditor’s report and for no other purpose. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the Members of the Governing Body, as a body, for our audit work, for this report or for the opinions we have formed.


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CERTIFICATE OF COMPLETION OF THE AUDIT

We certify that we have completed the audit of the accounts of NHS City and Hackney CCG in accordance with the requirements of the Local Audit and Accountability Act 2014 and the Code of Audit Practice.

Neil Thomas

for and on behalf of KPMG LLP, Statutory Auditor

Chartered Accountants

15 Canada Square

Canary Wharf

London

E14 5GL

24 May 2019


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Section C. ANNUAL ACCOUNTS

Jane Milligan

Accountable Officer

24 May 2019

NHS City and Hackney CCG - Annual Accounts 2018-19

The Primary Statements:

Statement of Comprehensive Net Expenditure for the year ended 31st March 2019Statement of Financial Position as at 31st March 2019Statement of Changes in Taxpayers' Equity for the year ended 31st March 2019Statement of Cash Flows for the year ended 31st March 2019

Notes to the Accounts Page NoAccounting policies 5- 8Other operating revenue 9Employee benefits and staff numbers 10Operating expenses 13Better payment practice code 14Operating leases 14Property, plant and equipment 15Trade and other receivables 16Other financial assets 16Other current assets 16Cash and cash equivalents 16Trade and other payables 17Other financial liabilities 17Provisions 17Contingencies 17Financial instruments 18Joint arrangements - interests in joint operations 19Related party transactions 20-22Events after the end of the reporting period 23Losses and special payments 23Financial performance targets 23Impact of IFRS 15 23

CONTENTS


Statement of Comprehensive Net Expenditure for the year ended31 March 2019

2018-19 2017-18Note £'000 £'000

Income from sale of goods and services 2 (140) (548)Other operating income 2 (785) (90)Total operating income (925) (638)

Staff costs 4 6,354 5,925Purchase of goods and services 5 453,233 427,699Other Operating Expenditure 5 234 222Total operating expenditure 459,821 433,846

Net Operating Expenditure 458,896 433,209

Comprehensive Expenditure for the year ended 31 March 2019. 458,896 433,209

Statement of Financial Position as at31 March 2019

2018-19 2017-18

Note £'000 £'000Non-current assets:Property, plant and equipment 8 68 -Total non-current assets 68 -

Current assets:Trade and other receivables 9 2,205 3,014Cash and cash equivalents 10 251 214Total current assets 2,456 3,228

Total assets 2,524 3,228

Current liabilitiesTrade and other payables 11 (71,234) (57,570)Total current liabilities (71,234) (57,570)

Non-Current Assets plus/less Net Current Assets/Liabilities (68,710) (54,342)

Assets less Liabilities (68,710) (54,342)

Financed by Taxpayers’ EquityGeneral fund (68,710) (54,342)Total taxpayers' equity: (68,710) (54,342)

The notes on pages 5 to 23 form part of this statement.

The financial statements on pages 1 to 23 were approved by the Governing Body on 24th May 2019 and signed on its behalf by:

Chief Accountable OfficerJane Milligan

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31 March 2019

General fundTotal

reserves£'000 £'000

Changes in taxpayers’ equity for 2018-19

Balance at 01 April 2018 (54,342) (54,342)Adjusted NHS Clinical Commissioning Group balance at 31 March 2018 (54,342) (54,342)

Changes in NHS Clinical Commissioning Group taxpayers’ equity for 2018-19Net operating expenditure for the financial year (458,896) (458,896)

Total revaluations against revaluation reserve (458,896) (458,896)

Net Recognised NHS Clinical Commissioning Group Expenditure for the Financial Year (458,896) (458,896)Net funding 444,528 444,528Balance at 31 March 2019 (68,710) (68,710)

General fundTotal

reserves£'000 £'000

Changes in taxpayers’ equity for 2017-18

Balance at 01 April 2017 (55,993) (55,993)Adjusted NHS Clinical Commissioning Group balance at 31 March 2018 (55,993) (55,993)

Changes in NHS Clinical Commissioning Group taxpayers’ equity for 2017-18Net operating costs for the financial year (433,208) (433,208)

Net Recognised NHS Clinical Commissioning Group Expenditure for the Financial Year (433,208) (433,208)Net funding 434,859 434,859Balance at 31 March 2018 (54,342) (54,342)


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Statement of Cash Flows for the year ended31 March 2019

2018-19 2017-18Note £'000 £'000

Cash Flows from Operating ActivitiesNet operating expenditure for the financial year (458,896) (433,208)Increase/(decrease) in trade & other receivables 9 809 (760)Increase/(decrease) in trade & other payables 11 13,596 (744)Net Cash Outflow from Operating Activities (444,491) (434,712)

Net Cash Outflow before Financing (444,491) (434,712)

Cash Flows from Financing ActivitiesGrant in Aid Funding Received 444,528 434,859Net Cash Inflow from Financing Activities 444,528 434,859

Net Increase in Cash & Cash Equivalents 10 37 147

Cash & Cash Equivalents at the Beginning of the Financial Year 214 67Cash & Cash Equivalents (including bank overdrafts) at the End of the Financial Year 251 214


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Notes to the financial statements

1 Accounting PoliciesNHS England has directed that the financial statements of NHS City and Hackney CCG 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 2018-19 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 NHS City and Hackney CCG, 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 NHS City and Hackney CCG for the purpose of giving a true and fair view has been selected. The particular policies adopted by NHS City and Hackney CCG are described below. They have been applied consistently in dealing with items considered material in relation to the accounts.

1.1 Going ConcernThese accounts have been prepared on a 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 ConventionThese 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 Critical accounting judgements and key sources of estimation uncertaintyIn the application of the clinical commissioning group's accounting policies, management is required to make various judgements,

estimates and assumptions. These are regularly reviewed.

1.3.1 Critical accounting judgements in applying accounting policies

The followings are the judgements, apart from those involving estimations, that management has made in the process of applying

the clinical commissioning group's accounting policies and that have the most significant effect on the amounts recognised in the

financial statements.

NHS City and Hackney CCG made no judgements that would have a material effect on the amounts recognised in the financial

statements.

1.3.2 Key Sources of Estimation Uncertainty

The followings are assumptions about the future and other major sources of estimation uncertainty that have a significant risk of

resulting in a material adjustment to the carrying amounts of assets and liabilities within the next financial year.

NHS City and Hackney CCG has no material key sources of estimation uncertainty.

1.4 RevenueThe transition to IFRS 15 has been completed in accordance with paragraph C3 (b) of the Standard, applying the Standardretrospectively recognising the cumulative effects at the date of initial application.In the adoption of IFRS 15 a number of practical expedients offered in the Standard have been employed. These are as follows;

• As per paragraph 121 of the Standard the CCG will not disclose information regarding performance obligations part of a contractthat has an original expected duration of one year or less,• The CCG is to similarly not disclose information where revenue is recognised in line with the practical expedient offered inparagraph B16 of the Standard where the right to consideration corresponds directly with value of the performance completed todate.

• The FReM has mandated the exercise of the practical expedient offered in C7(a) of the Standard that requires the CCG to reflectthe aggregate effect of all contracts modified before the date of initial application.

CCG does not have any such Contracts. Where income is received for a specific activity that is to be delivered in the following year, the income is deferred .

1.5 Employee Benefits1.5.1 Short-term Employee Benefits

Salaries, wages and employment-related payments, including payments arising from the apprenticeship levy, 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.

1.5.2 Retirement Benefit CostsPast and present employees are covered by the provisions of the NHS Pensions Schemes. These schemes are unfunded, definedbenefit schemes that cover NHS employers, General Practices and other bodies allowed under the direction of the Secretary ofState in England and Wales. The schemes are not designed to be run in a way that would enable NHS bodies to identify their shareof the underlying scheme assets and liabilities. Therefore, the schemes are accounted for as though they were defined contributionschemes: the cost to the NHS City and Hackney CCG of participating in a scheme is taken as equal to the contributions payable tothe scheme for the accounting period.

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For early retirements other than those due to ill health the additional pension liabilities are not funded by the scheme. The fullamount of the liability for the additional costs is charged to expenditure at the time the NHS City and Hackney CCG commits itself tothe retirement, regardless of the method of payment.The schemes are subject to a full actuarial valuation every four years and an accounting valuation every year.

Some employees are members of the Local Government Pension Scheme, which is a defined benefit pension scheme. The scheme assets and liabilities attributable to those employees can be identified and are recognised in City and Hackney CCG's accounts. The assets are measured at fair value and the liabilities at the present value of the future obligations. The increase in the liability arising from pensionable service earned during the year is recognised within operating expenses. The interest cost during the year arising from the unwinding of the discount on the scheme liabilities is recognised within finance costs. The interest earned during the year from scheme assets is recognised within finance income. Re-measurements of the defined benefit plan are recognised in the Income and Expenditure reserve and reported as an item of other comprehensive net expenditure.

1.6 Other ExpensesOther 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 NHS City and Hackney has a present legal or constructive obligation, which occurs when all of the conditions attached to the payment have been met.

1.7 LeasesLeases 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.

1.7.1 NHS City and Hackney CCG as LesseeProperty, plant and equipment held under finance leases are initially recognised, at the inception of the lease, at fair value or, if lower, at the present value of the minimum lease payments, with a matching liability for the lease obligation to the lessor. Lease payments are apportioned between finance charges and reduction of the lease obligation so as to achieve a constant rate on interest on the remaining balance of the liability. Finance charges are recognised in calculating the clinical commissioning group’s surplus/deficit.

Operating lease payments are recognised as an expense on a straight-line basis over the lease term. Lease incentives are recognised initially as a liability and subsequently as a reduction of rentals on a straight-line basis over the lease term.

Contingent rentals are recognised as an expense in the period in which they are incurred.Where a lease is for land and buildings, the land and building components are separated and individually assessed as to whether they are operating or finance leases.

1.8 Cash & Cash EquivalentsCash 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 NHS City and Hackney CCG's cash management.

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1.9 Clinical Negligence CostsNHS Resolution operates a risk pooling scheme under which City and Hackney CCG pays an annual contribution to NHS Resolution, which in return settles all clinical negligence claims. The contribution is charged to expenditure. Although NHS Resolution is administratively responsible for all clinical negligence cases, the legal liability remains with City and Hackney CCG.

1.10 Non-clinical Risk PoolingNHS City and Hackney CCG participates in the Property Expenses Scheme and the Liabilities to Third Parties Scheme. Both are risk pooling schemes under which City and Hackney CCG 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.

1.11 ContingenciesA 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 NHS City and Hackney CCG. 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.

1.12 Property, Plant & Equipment1.12.1 Recognition

Property, plant and equipment is capitalised if:· It is held for use in delivering services or for administrative purposes;· It is probable that future economic benefits will flow to, or service potential will be supplied to the clinical commissioning group;· It is expected to be used for more than one financial year;· The cost of the item can be measured reliably; and,· The item has a cost of at least £5,000; or,· Collectively, a number of items have a cost of at least £5,000 and individually have a cost of more than £250, where the assets are functionally interdependent, they had broadly simultaneous purchase dates, are anticipated to have simultaneous disposal dates and are under single managerial control; or,· Items form part of the initial equipping and setting-up cost of a new building, ward or unit, irrespective of their individual or collective cost.Where a large asset, for example a building, includes a number of components with significantly different asset lives, the components are treated as separate assets and depreciated over their own useful economic lives.

1.12.2 MeasurementAll property, plant and equipment is measured initially at cost, representing the cost directly attributable to acquiring or constructing the asset and bringing it to the location and condition necessary for it to be capable of operating in the manner intended by management. Assets that are held for their service potential and are in use are measured subsequently at their current value in existing use. Assets that were most recently held for their service potential but are surplus are measured at fair value where there are no restrictions preventing access to the market at the reporting dateRevaluations are performed with sufficient regularity to ensure that carrying amounts are not materially different from those that would be determined at the end of the reporting period. Current values in existing use are determined as follows:· Land and non-specialised buildings – market value for existing use; and,· Specialised buildings – depreciated replacement cost.IT equipment, transport equipment, furniture and fittings, and plant and machinery that are held for operational use are valued at depreciated historic cost where these assets have short useful economic lives or low values or both, as this is not considered to be materially different from current value in existing use.

Properties in the course of construction for service or administration purposes are carried at cost, less any impairment loss. Cost includes professional fees but not borrowing costs, which are recognised as expenses immediately, as allowed by IAS 23 for assets held at fair value. Assets are re-valued and depreciation commences when they are brought into use.IT equipment, transport equipment, furniture and fittings, and plant and machinery that are held for operational use are valued at depreciated historic cost where these assets have short useful economic lives or low values or both, as this is not considered to be materially different from current value in existing use.

1.13 Financial AssetsFinancial assets are recognised when City and Hackney CCG becomes party to the financial instrument contract or, in the case oftrade receivables, when the goods or services have been delivered. Financial assets are derecognised when the contractual rightshave expired or the asset has been transferred.

Financial assets are classified into the following categories:·Financial assets at amortised cost;·Financial assets at fair value through other comprehensive income and ;·Financial assets at fair value through profit and loss.

The classification is determined by the cash flow and business model characteristics of the financial assets, as set out in IFRS 9,and is determined at the time of initial recognition.

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1.13.1 Financial Assets at Amortised cost

Financial assets measured at amortised cost are those held within a business model whose objective is achieved by collectingcontractual cash flows and where the cash flows are solely payments of principal and interest. This includes most trade receivablesand other simple debt instruments. After initial recognition these financial assets are measured at amortised cost using theeffective interest method less any impairment. The effective interest rate is the rate that exactly discounts estimated future cashreceipts through the life of the financial asset to the gross carrying amount of the financial asset.

1.13.2 Financial assets at fair value through other comprehensive incomeFinancial assets held at fair value through other comprehensive income are those held within a business model whose objective isachieved by both collecting contractual cash flows and selling financial assets and where the cash flows are solely payments ofprincipal and interest.

1.13.3 Financial assets at fair value through profit and lossFinancial assets measure at fair value through profit and loss are those that are not otherwise measured at amortised cost or fairvalue through other comprehensive income. This includes derivatives and financial assets acquired principally for the purpose ofselling in the short term.

1.13.4 ImpairmentFor all financial assets measured at amortised cost or at fair value through other comprehensive income (except equity instrumentsdesignated at fair value through other comprehensive income), lease receivables and contract assets, the clinical commissioninggroup recognises a loss allowance representing the expected credit losses on the financial asset.City and Hackney CCG adopts the simplified approach to impairment in accordance with IFRS 9, and measures the loss allowancefor trade receivables, lease receivables and contract assets at an amount equal to lifetime expected credit losses. For otherfinancial assets, the loss allowance is measured at an amount equal to lifetime expected credit losses if the credit risk on thefinancial instrument has increased significantly since initial recognition (stage 2) and otherwise at an amount equal to 12 monthexpected credit losses (stage 1).HM Treasury has ruled that central government bodies may not recognise stage 1 or stage 2 impairments against other governmentdepartments, their executive agencies, the Bank of England, Exchequer Funds and Exchequer Funds assets where repayment isensured by primary legislation. The clinical commissioning group therefore does not recognise loss allowances for stage 1 or stage2 impairments against these bodies. Additionally DHSC provides a guarantee of last resort against the debts of its arm's lengthsbodies and NHS bodies and the clinical commissioning group does not recognise allowances for stage 1 or stage 2 impairmentsagainst these bodies. For financial assets that have become credit impaired since initial recognition (stage 3), expected credit losses at the reporting dateare measured as the difference between the asset's gross carrying amount and the present value of the estimated future cash flowsdiscounted at the financial asset's original effective interest rate. Any adjustment is recognised in profit or loss as an impairmentgain or loss.

1.14 Financial LiabilitiesFinancial liabilities are recognised on the statement of financial position when the NHS City and Hackney CCG becomes party tothe contractual provisions of the financial instrument or, in the case of trade payables, when the goods or services have beenreceived. Financial liabilities are de-recognised when the liability has been discharged, that is, the liability has been paid or hasexpired.

1.14.1 Financial Liabilities at Fair Value Through Profit and LossEmbedded 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.

1.14.2 Other Financial LiabilitiesAfter 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 amount of the financial liability. Interest is recognised using the effective interest method.

1.15 Value Added Tax

Most of the activities of City and Hackney CCG are outside the scope of VAT and, in general, output tax does not apply and inputtax on purchases is not recoverable. Irrecoverable VAT is charged to the relevant expenditure category or included in the capitalisedpurchase cost of fixed assets. Where output tax is charged or input VAT is recoverable, the amounts are stated net of VAT.

1.16 Joint OperationsJoint operations are activities undertaken by NHS City and Hackney CCG in conjunction with one or more other parties but which are not performed through a separate entity. NHS City and Hackney CCG records its share of the income and expenditure; gains and losses; assets and liabilities; and cash flows.

1.17 Operating Segment Income and expenditure are analysed in the Operating Segments note and are reported in line with management information used

within the CCG.

1.18 Accounting Standards That Have Been Issued But Have Not Yet Been Adopted

The DHSC GAM does not require the following IFRS Standards and Interpretations to be applied in 2018-19. These Standards are still subject to HM Treasury FReM adoption, with IFRS 16 being for implementation in 2019-20, and the government implementation date for IFRS 17 still subject to HM Treasury consideration.● IFRS 16 Leases – Application required for accounting periods beginning on or after 1 January 2019, but not yet adopted by the FReM: early adoption is not therefore permitted.● IFRS 17 Insurance Contracts – Application required for accounting periods beginning on or after 1 January 2021, but not yet adopted by the FReM: early adoption is not therefore permitted.● IFRIC 23 Uncertainty over Income Tax Treatments – Application required for accounting periods beginning on or after 1 January 2019.

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2 Other Operating Revenue2018-19 2017-18

Total Total£'000 £'000

Income from sale of goods and services (contracts)Non-patient care services to other bodies - 444Recoveries in respect of employee benefits 140 104Total Income from sale of goods and services 140 548

Other operating incomeCharitable and other contributions to revenue expenditure: non-NHS 21 49Other non contract revenue 764 41Total Other operating income 785 90

Total Operating Income 925 638

Due to IFRS 15 Implications, some of income have been reclassified under Non Contract Income for 2018-19.As per the guidance, we are not required to reclassify 2017-18 income.

3 Disaggregation of Income - Income from sale of good and services (contracts)

Recoveries in respect of employee

benefitsSource of Revenue £'000NHS 140Total 140

Recoveries in respect of employee

benefitsTiming of Revenue £'000Point in time 140Total 140

This income relates to salary recharges in respect of jointly funded post and secondment during the year.

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4. Employee benefits and staff numbers

4.1.1 Employee benefits Total 2018-19

Permanent Employees Other Total

£'000 £'000 £'000Employee BenefitsSalaries and wages 3,510 2,001 5,512 Social security costs 410 - 410 Employer Contributions to NHS Pension scheme 429 - 429 Apprenticeship Levy 4 - 4 Gross employee benefits expenditure 4,353 2,001 6,354

Less recoveries in respect of employee benefits (note 4.1.2) (140) - (140) Total - Net admin employee benefits including capitalised costs 4,213 2,001 6,214

Less: Employee costs capitalised - - -Net employee benefits excluding capitalised costs 4,213 2,001 6,214

4.1.1 Employee benefits Total 2017-18

Permanent Employees Other Total

£'000 £'000 £'000Employee BenefitsSalaries and wages 3,296 1,687 4,983 Social security costs 385 - 385 Employer Contributions to NHS Pension scheme 381 - 381 Apprenticeship Levy 2 - 2 Termination benefits 174 - 174 Gross employee benefits expenditure 4,238 1,687 5,925

Less recoveries in respect of employee benefits (note 4.1.2) (104) - (104)Total - Net admin employee benefits including capitalised costs 4,134 1,687 5,821

Less: Employee costs capitalised - - -Net employee benefits excluding capitalised costs 4,134 1,687 5,821

4.1.2 Recoveries in respect of employee benefits 2018-19 2017-18Permanent Employees Other Total Total

£'000 £'000 £'000 £'000Employee Benefits - RevenueSalaries and wages (140) - (140) (104)Total recoveries in respect of employee benefits (140) - (140) (104)

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4.2 Average number of people employed

Permanently employed Other Total

Permanently employed Other Total

Number Number Number Number Number Number

Total 53.00 22.00 75.00 53.00 8.00 61.00

Of the above:Number of whole time equivalent people engaged on capital projects - - - - - -

4.4 Exit packages agreed in the financial year

There were no exit packages in 2018-19

Number £ Number £ Number £Less than £10,000 1 4,622 - - 1 4,622£10,001 to £25,000 - - 1 20,640 1 20,640£150,001 to £200,000 1 160,000 - - 1 160,000Total 2 164,622 1 20,640 3 185,262

Analysis of Other Agreed Departures

Number £ Number £Contractual payments in lieu of notice - - 1 20,640Total - - 1 20,640

There were also no compulsory redundancies in 2018/19.

2018-19

2017-18 2017-18Other agreed departures

2018-19

Total

2017-18Other agreed departures

2017-18Compulsory redundancies

Other agreed departures

There were no redundancy or departures where special payments were made in 2018/19 and 2017/18.

Exit costs are accounted for in accordance with relevant accounting standards and at the latest in full in the year of departure.No early retirements were agreed in 2018/19. No non-contractual payments were made to individuals where the payment value was more than 12 months’ of their annual salary.

2017-18

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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 benefitspayable and rules of the Schemes can be found on the NHS Pensions website at www.nhsbsa.nhs.uk/pensions. Both areunfunded defined benefit schemes that cover NHS employers, GP practices and other bodies, allowed under the direction ofthe Secretary of State for Health in England and Wales. They are not designed to be run in a way that would enable NHSbodies to identify their share of the underlying scheme assets and liabilities. Therefore, each scheme is accounted for as if itwere a defined contribution scheme: the cost to the NHS body of participating in each scheme is taken as equal to thecontributions 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 thatwould be determined at the reporting date by a formal actuarial valuation, the FReM requires that “the period between formalvaluations shall be four years, with approximate assessments in intervening years”. An outline of these follows:

4.5.1 Accounting valuationA valuation of scheme liability is carried out annually by the scheme actuary (currently the Government Actuary’sDepartment) as at the end of the reporting period. This utilises an actuarial assessment for the previous accounting period inconjunction with updated membership and financial data for the current reporting period, and is accepted as providingsuitably robust figures for financial reporting purposes. The valuation of the scheme liability as at 31 March 2019, is based onvaluation data as 31 March 2018, updated to 31 March 2019 with summary global member and accounting data. Inundertaking this actuarial assessment, the methodology prescribed in IAS 19, relevant FReM interpretations, and thediscount 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 ofthe annual NHS Pension Scheme Accounts. These accounts can be viewed on the NHS Pensions website and are publishedannually. 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 intoaccount recent demographic experience), and to recommend contribution rates payable by employees and employers.

The latest actuarial valuation undertaken for the NHS Pension Scheme was completed as at 31 March 2016. The results ofthis valuation set the employer contribution rate payable from April 2019. The Department of Health and Social Care have recentlylaid Scheme Regulations confirming that the employer contribution rate will increase to 20.6% of pensionable pay from thisdate.

The 2016 funding valuation was also expected to test the cost of the Scheme relative to the employer cost cap set following the 2012 valuation. Following a judgment from the Court of Appeal in December 2018 Government announced a pause to that part of the valuation process pending conclusion of the continuing legal process

For 2018-19, employers’ contributions of £424,358 were payable to the NHS Pensions Scheme (2017-18: £380,699) were payable to theNHS Pension Scheme at the rate of 14.38% of pensionable pay. The scheme’s actuary reviews employer contributions, usually everyfour years and now based on HMT Valuation Directions, following a full scheme valuation. The latest review used data from 31 March2012 and was published on the Government website on 9 June 2012. These costs are included in the NHS pension line of note 4.1

12

http://www.nhsbsa.nhs.uk/pensions





























































































































5. Operating expenses2018-19 2017-18

Total Total£'000 £'000

Purchase of goods and servicesServices from other CCGs and NHS England 3,098 3,572Services from foundation trusts 254,037 243,981Services from other NHS trusts 56,049 51,736Services from Other WGA bodies 45 364Purchase of healthcare from non-NHS bodies 42,424 36,318Purchase of social care 14,971 11,246Prescribing costs 27,515 28,351General Ophthalmic services 157 56GPMS/APMS and PCTMS 48,452 46,776Supplies and services – general 630 427Consultancy services 174 256Establishment 464 411Transport 6 -Premises 3,449 3,325Audit fees 55 72· Other services 10 -Other professional fees 1,194 593Legal fees 255 126Education, training and conferences 247 89 Total Purchase of goods and services 453,232 427,699

Other Operating ExpenditureChair and Non Executive Members 229 217Clinical negligence 5 5Total Other Operating Expenditure 234 222

Total operating expenditure 453,466 427,922

The KPMG contract signed on 21st May 2018, states that the liability of KPMG, its members, partners and staff (whether in contract, negligence or otherwise) shall in no circumstances exceed £1m, aside from where the liability cannot be limited by law. This is in aggregate in respect of all services.

The fee to the CCG's external auditors, KPMG LLP, is £55k including VAT. The figures shown in note above includes irrecoverable VAT at 20%.

The City and Hackney CCG will be required to obtain assurance from the external auditors over reported compliance with the requirements of the Mental Health Investment Assessment Standard. The CCG has received £10,000 of resource allocation in relation to this work. The final fee is not yet confirmed.

13


6.1 Better Payment Practice Code

Measure of compliance 2018-19 2018-19 2017-18 2017-18Number £'000 Number £'000

Non-NHS PayablesTotal Non-NHS Trade invoices paid in the Year 7,548 104,332 7,154 97,774 Total Non-NHS Trade Invoices paid within target 7,275 102,043 6,940 90,226 Percentage of Non-NHS Trade invoices paid within target 96.38% 97.81% 97.01% 92.28%

NHS Payables Total NHS Trade Invoices Paid in the Year 3,344 311,110 3,208 305,178 Total NHS Trade Invoices Paid within target 3,171 303,750 3,006 289,672 Percentage of NHS Trade Invoices paid within target 94.83% 97.63% 93.70% 94.92%

7. Operating Leases

7.1 As lessee7.1.1 Payments recognised as an Expense 2018-19 2017-18

Land Buildings Other Total Land Buildings Other Total£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Payments recognised as an expenseMinimum lease payments - 3,371 5 3,376 - 3,268 8 3,276Total - 3,371 5 3,376 - 3,268 8 3,276

7.1.2 Future minimum lease payments 2018-19 2017-18Land Buildings Other Total Land Buildings Other Total£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Payable:No later than one year - 0 0 0 0 0 3 3Total - 0 - - - - 3 3

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 has not yet been agreed . Consequently this note does not include future minimum lease payments for the arrangements only

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8 Property, plant and equipments

2018-19Information technology Total

£'000 £'000Cost or valuation at 01 April 2018 - -

Additions purchased 68 68Cost/Valuation at 31 March 2019 68 68

Depreciation at 31 March 2019 - -

Net Book Value at 31 March 2019 68 68

Purchased 68 68Total at 31 March 2019 68 68

Asset financing:

Owned 68 68

Total at 31 March 2019 68 68

(There were no PPE in 2017/18)

8.1 Economic lives

Information technology 3 5

Minimum Life (years)

Maximum Life (Years)

15


9.1 Trade and other receivables Current Non-current Current Non-current2018-19 2018-19 2017-18 2017-18

£'000 £'000 £'000 £'000

NHS receivables: Revenue 654 - 1,158 -NHS prepayments 676 - 1,011 -NHS accrued income 417 - 670 -Non-NHS and Other WGA receivables: Revenue 23 - 35 -Non-NHS and Other WGA prepayments 43 - 5 -Non-NHS and Other WGA accrued income 357 - - -VAT 26 - 124 -Other receivables and accruals 9 - 11 -Total Trade & other receivables 2,205 - 3,014 -

Total current and non current 2,205 3,014 -

9.2 Receivables past their due date but not impaired2018-19 2018-19 2017-18 2017-18

DHSC Group Bodies

Non DHSC Group Bodies

DHSC Group Bodies

Non DHSC Group Bodies

£'000 £'000 £'000 £'000By up to three months 87 16 79 28By three to six months - - 18 -Total 87 16 97 28

9.3 Impact of Application of IFRS 9 on financial assets at 1 April 2018

Cash and cash equivalents

Trade and other receivables -NHSE bodies

Trade and other receivables - other DHSC

group bodies

Trade and other receivables -

external

Other financial

assets Total£000s £000s £000s £000s £000s

Classification under IAS 39 as at 31st March 2018Financial Assets held at Amortised cost 214 1,086 742 35 10 2,087Total at 31st March 2018 214 1,086 742 35 10 2,087

Total at 1st April 2018 214 1,086 742 35 35 2,077

Changes due to change in measurement attribute - - - - - -Other changes - - - - - -Change in carrying amount - - - - - -

10 Cash and cash equivalents

2018-19 2017-18£'000 £'000

Balance at 01 April 2018 214 67Net change in year 37 147Balance at 31 March 2019 251 214

Made up of:Cash with the Government Banking Service 251 214Cash and cash equivalents as in statement of financial position 251 214

Balance at 31 March 2019 251 214

16


11 Trade and other payables Current Current2018-19 2017-18

£'000 £'000

NHS payables: Revenue 11,561 8,109 NHS accruals 9,140 11,879 NHS deferred income 77 763 Non-NHS and Other WGA payables: Revenue 7,982 8,671 Non-NHS and Other WGA payables: Capital 68 - Non-NHS and Other WGA accruals 34,506 25,636 Non-NHS and Other WGA deferred income 159 - Social security costs 55 59 Tax 55 68 Other payables and accruals 7,631 2,385 Total Trade & Other Payables 71,234 57,570

Total current and non-current 71,234 57,570

Other payables include outstanding Pension contributions at 31 March 2019 596 477

11.1 Impact of Application of IFRS 9 on financial liabilities at 1 April 2018

Trade and other

payables - NHSE bodies

Trade and other

payables - other DHSC

group bodies

Trade and other

payables - external

Other financial liabilities Total

£000s £000s £000s £000s £000sClassification under IAS 39 as at 31st March 2018Financial Assets held at Amortised cost 696 29,541 24,058 2,385 56,680Total at 31st March 2018 696 29,541 24,058 2,385 56,680

12 ProvisionsThe CCG does not have any provisions (2017-18: Nil).

13 Contingent Assets/LiabilitiesThe CCG does not have any Contingent Assets or Liabilities (2017-18: Nil).

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14 Financial instruments14.1 Financial risk management

14.1.1 Currency risk

14.1.2 Interest rate risk

14.1.3 Credit risk

14.1.4 Liquidity risk

14.1.5 Financial Instruments

14.2 Financial instruments 14.2.1 Financial assets

Financial Assets measured at

amortised cost Total2018-19 2018-19

£'000 £'000Trade and other receivables with NHSE bodies 664 664Trade and other receivables with other DHSC group bodies 764 764Trade and other receivables with external bodies 23 23Other financial assets 9 9Cash and cash equivalents 251 251Total at 31 March 2019 1,711 1,71114.2.3 Financial liabilities

Financial Liabilities

measured at amortised cost Total

2018-19 2018-19£'000 £'000

Trade and other payables with NHSE bodies 1,050 1,050Trade and other payables with other DHSC group bodies 38,286 38,286Trade and other payables with external bodies 23,922 23,922Other financial liabilities 7,631 7,631Total at 31 March 2019 70,889 70,889

As the cash requirements of NHS England are met through the Estimate process, financial instruments play a more limited role in creating and managing risk than would apply to a non-public sector body. The majority of financial instruments relate to contracts to buy non-financial items in line with NHS England's expected purchase and usage requirements and NHS England is therefore exposed to little credit, liquidity or market risk.

The clinical commissioning group 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. The clinical commissioning group therefore has low exposure to interest rate fluctuations.

Because the majority of the NHS clinical commissioning group and revenue comes parliamentary funding, NHS clinical commissioning group has low exposure to credit risk. The maximum exposures as at the end of the financial year are in receivables from customers, as disclosed in the trade and other receivables note.

NHS clinical commissioning group is required to operate within revenue and capital resource limits, which are financed from resources voted annually by Parliament. The NHS clinical commissioning group draws down cash to cover expenditure, as the need arises. The NHS clinical commissioning group is not, therefore, exposed to significant liquidity risks.

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.

Because NHS clinical commissioning group is financed through parliamentary funding, it is not exposed to the degree of financial risk faced by business entities. Also, financial instruments play a much more limited role in creating or changing risk than would be typical of listed companies, to which the financial reporting standards mainly apply. The clinical commissioning group has limited powers to borrow or invest surplus funds and financial assets and liabilities are generated by day-to-day operational activities rather than being held to change the risks facing the clinical commissioning group in undertaking its activities.

Treasury management operations are carried out by the finance department, within parameters defined formally within the NHS clinical commissioning group standing financial instructions and policies agreed by the Governing Body. Treasury activity is subject to review by the NHS clinical commissioning group and internal auditors.

The NHS clinical commissioning group is principally a domestic organisation with the great majority of transactions, assets and liabilities being in the UK and sterling based. The NHS clinical commissioning group has no overseas operations. The NHS clinical commissioning group and therefore has low exposure to currency rate fluctuations.

18


15 Joint arrangements - interests in joint operations15.1 Interests in joint operations

Amounts

recognised in

Entities books ONLY

Name of arrangement Parties to the arrangement Description of principal activities

Expenditure Expenditure

£'000 £'000Better Care Fund London Borough of Hackney / NHS

City and Hackney CCGBetter Care Fund

19,419 19,057 Better Care Fund City of London / NHS City and

Hackney CCGBetter Care Fund

623 612

15.2 Interests in entities not accounted for under IFRS 10 or IFRS 11

Name of entity Description of principal activities Basis for treatment e.g. materiality

0 0 0

Amounts

recognised in

Entities books

ONLY2018-19 2017-18

19


16 Related party transactions

16 Related Party Transactions 2018-19 (Non NHS)NHS City and Hackney CCG is required to disclose transactions and outstanding balances with its related parties.

Payments to Related Party

Receipts from

Related Party

Amounts owed to Related

Party

Amounts due from

Related Party

£'000 £'000 £'000 £'000

CITY & HACKNEY GP CONFEDERATION 12,717 - 1,716 -


Receipts from

Related Party


Party

Amounts due from

Related Party

£'000 £'000 £'000 £'000ABNEY HOUSE MEDICAL CENTRE 368 - - - ALLERTON ROAD MEDICAL CENTRE 834 - - - ATHENA MEIDCAL CENTRE 615 - - - BARTON HOUSE GROUP PRACTICE 1,760 - - - BEECHWOOD MEDICAL CENTRE 510 - - - BROOKE ROAD SURGERY 486 - - - CEDAR PRACTICE 900 - - - CLAPTON SURGERY 662 - - - DALSTON PRACTICE 777 - - - DE BEAUVOIR SURGERY 1,332 - - - ELM PRACTICE 366 - - - ELSDALE STREET SURGERY 1,223 - - - FOUNTAYNE ROAD HEALTH CENTRE 621 - - - GREENHOUSE WALK-IN 603 - - - HEALY MEDICAL CENTRE 799 - - - HERON PRACTICE 1,479 - - - HOXTON SURGERY 1,230 - - - KINGSMEAD MEDICAL CENTRE 877 - - - LATIMER HEALTH CENTRE 1,107 - - - LAWSON PRACTICE 2,104 - 46 - LEA SURGERY 1,703 - - - LONDON FIELDS MEDICAL CENTRE 1,292 - - - LOWER CLAPTON GROUP PRACTICE 1,878 - - - NEAMAN PRACTICE 1,451 - - - NIGHTINGALE PRACTICE (THE) 2,028 - - - QUEENSBRIDGE GROUP PRACTICE 1,405 - - - RICHMOND ROAD MEDICAL CENTRE 1,137 - - - RIVERSIDE PRACTICE (THE) 764 - - - ROSEWOOD PRACTICE 252 - - - SANDRINGHAM PRACTICE 700 - - - SHOREDITCH PARK SURGERY 1,300 - - - SOMERFORD GROVE HEALTH CENTRE 1,640 - - - SORSBY HEALTH CENTRE 697 - - - SOUTHGATE ROAD MEDICAL CENTRE 1,036 - - - THE SURGERY - CRANWICH ROAD SURGERY 838 - - - SPRINGFIELD HEALTH CENTRE 2,054 - - - STAMFORD HILL GROUP PRACTICE 1,958 - - - STATHAM GROVE SURGERY 1,137 - - - THE SURGERY (BARRETTS GROVE) 516 - - - TOLLGATE LODGE PRACTICE 22 - - - TROWBRIDGE PRACTICE 862 - - - WELL STREET SURGERY 2,245 - - - WICK HEALTH CENTRE 928 - - - YOUR HEALTHCARE CIC 6 - - -

The members of City and Hackney Clinical Commissioning Group are contained within the constitution. Payments to these practices are listed below. The majority of the payments are in relation to agreed extended primary care services.

Details of related party transactions with individuals are as follows:

HM Treasury considers Government Departments and their agencies, and Department of Health Ministers, their close families and entities controlled or influenced by them, as being parties related to NHS bodies.

Voting members of the Governing Body have declared their interests, which are shown in the Annual Report section of this document. This information is also on the CCG's website.The transactions listed below are in relation to interests declared, other than those relating to member general practices, where payments were over £100,000:

Clinical commissioning groups are clinically led membership organisations made up of general practices. The members of the clinical commissioning group are responsible for determining the governing arrangements for their organisations, which they are required to set out in a constitution.

20


16.1 Related Party Transactions 2017-18 (Non NHS)

Payments to Related

Party

Receipts from Related

Party


Party

Amounts due from

Related Party

£'000 £'000 £'000 £'000Acorn Lodge Care Home 394 - 34 - City & Hackney GP Confederation 8,650 59 234 1 City & Hackney Urgent Healthcare Social Enterprise 3,122 - 35 -

Payments to Related

Party

Receipts from Related

Party


Party

Amounts due from

Related Party

£'000 £'000 £'000 £'000Abney House Medical Centre 360 - - - Allerton Road Medical Centre 792 - - - Athena Medical Centre 651 - - - Barton House Group Practice 1,722 - - - Beechwood Medical Centre 486 - - - Brooke Road Surgery 419 - - - Cedar Practice 863 - - - Clapton Surgery 642 - - - Dalston Practice 770 - - - De Beauvoir Surgery 1,289 - - - Elm Practice 358 - - - Elsdale Street Surgery 1,173 - - - Gadhvi Fountayne Road Health Centre 576 - - - Greenhouse Walk In 704 - - - Healy Medical Centre 732 - - - Heron Practice 1,408 - - - Hoxton Surgery 1,079 - - - Kingsmead Medical Centre 835 - - - Latimer Health Centre 1,011 - 1 - Lawson Practice 2,058 - 26 - Lea Surgery 1,561 - - - London Fields Medical Centre 1,261 - 6 - Lower Clapton Group Practice 1,664 - - - Neaman Practice 1,456 - - - Nightingale Practice (The) 1,907 - - - Queensbridge Group Practice 1,371 - - - Richmond Road Medical Centre 821 - - - Riverside Practice (The) 748 - - - Rosewood Practice 238 - - - Sandringham Practice 685 - - - Shoreditch Park Surgery 1,213 - - - Somerford Grove Health Centre 1,593 - - - Sorsby Health Centre 716 - - - Southgate Road Medical Centre 954 - - - Spitzer Practice- Cranwich Road Surgery 797 - - - Springfield Health Centre 1,400 - - - Stamford Hill Group Practice 1,881 - - - Statham Grove Surgery 1,031 - - - The Surgery (Barretts Grove) 404 - - - Tollgate Lodge Practice 1,056 - - - Trowbridge Practice 842 - - - Well Street Surgery 2,215 - - - Wick Health Centre 826 - - -

Clinical commissioning groups are clinically led membership organisations made up of general practices. The members of the clinical commissioning group are responsible for determining the governing arrangements for their organisations, which they are required to set out in a constitution.

The members of City and Hackney Clinical Commissioning Group are contained within the constitution. Payments to these practices are listed below. The majority of the payments are in relation to agreed extended primary care services.

21


16 Related Party Transactions cont'd16.2 Related party transactions 2018-19 (NHS and Other Government)


Receipts from Related Party

Amounts owed to

Related Party

Amounts due from Related

Party£'000 £'000 £'000 £'000

Barts Health NHS Trust 31,462 - 341 - East London NHS Foundation Trust 50,077 - 2,726 - Guy's & St Thomas' NHS Foundation Trust 3,841 - 833 - Homerton University Hospital NHS Foundation Trust 166,887 79 10,086 287 London Ambulance Service NHS Trust 12,792 - 879 - Moorfields Eye Hospital NHS Foundation Trust 7,162 - 209 - NHS England 73 2 77 471 NHS NEL CSU 2,912 - 489 - NHS Tower Hamlet CCG 6 148 262 - NHS Waltham Forest CCG 1,020 - 0 96 North Middlesex University Hospital NHS Trust 1,583 - 0 156 Royal Free London NHS Foundation Trust 3,190 - 533 14 Tavistock & Portman NHS Foundation Trust 979 - 116 - University College London Hospitals NHS Foundation Trust 16,052 - 498 367 Whittington Health NHS Trust 5,613 - 382 7



Amounts owed to

Related Party


Party£'000 £'000 £'000 £'000

Hackney London Borough Council 19,209 430 4167 373

16.2.1 Related party transactions 2017-18 (NHS and Other Government)



Amounts owed to

Related Party


Party£000 £000 £000 £000

Barts Health NHS Trust 28,889 - 2,011 - East London NHS Foundation Trust 49,098 33 3,044 - Guy's & St Thomas' NHS Foundation Trust 2,968 - 7 21 Homerton University Hospital NHS Foundation Trust 161,415 78 8,910 601 London Ambulance Service NHS Trust 11,282 - 155 - Moorfields Eye Hospital NHS Foundation Trust 7,158 - 152 - NHS NEL CSU 2,951 - 137 - NHS Property Services 1,255 - 1,079 - North Middlesex University Hospital NHS Trust 1,700 - 274 - Royal Free London NHS Foundation Trust 2,660 - 84 - Tavistock & Portman NHS Foundation Trust 1,200 73 140 - University College London Hospitals NHS Foundation Trust 16,444 - 1,333 381 Whittington Health NHS Trust 5,699 - 674 101



Amounts owed to

Related Party


Party£000 £000 £000 £000

Hackney London Borough Council 16,979 151 6,895 19

In addition, NHS City and Hackney CCG has had a number of material transactions with other government departments and other central and local government bodies. The disclosure below relates to bodies where payments or receipts were over £1m .

In addition, NHS City and Hackney CCG has had a number of material transactions with other government departments and other central and local government bodies. The disclosure below relates to bodies where payments or receipts were over £1m .

NHS City and Hackney CCG is a part of a risk share agreement across the North East London CCG's(Barking & Dagenham CCG, City and Hackney CC, Havering CCG, Newham CCG, Redbridge CCG, Tower Hamlets CCG and Waltham Forest CCG). In 2018/19 NHS City and Hackney CCG paid £1 million to NHS Waltham Forest CCG as part of the Risk Share Agreement.

22


17 Events after the end of the reporting periodThere are no events after the end of the reporting period to report.

18 Losses and special paymentsThere were no reported Losses and Special Payments in 2018-19.

19 Financial performance targetsNHS Clinical Commissioning Group have a number of financial duties under the NHS Act 2006 (as amended).NHS Clinical Commissioning Group performance against those duties was as follows:

2018-19 2018-19 2017-18 2017-18Target Performance Target Performance

Expenditure not to exceed income 459,824 459,821 436,028 433,846Capital resource use does not exceed the amount specified in Directions 83 68 - -Revenue resource use does not exceed the amount specified in Directions 458,899 458,896 435,390 433,208Revenue administration resource use does not exceed the amount specified in Directions 6,295 4,995 6,218 4,915

20 There is no IFRS 15 impact to be reported.

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city and hackney us/2018-19 annua… · bhr barking and dagenham, havering and redbridge ......

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