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Merton

NHS Merton CCGAnnual Report 2017/2018

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ContentsPerformance Report 4

Welcome 4

Performance Overview 4

Who we are and what we do 6

Our partners 6

Merton's health and wellbeing 11

Delivering outcomes in 2017/18 13

Performance Analysis 21

How we manage performance 21

How we measure performance 21

Constitutional Standards 22

Quality Premiums 24

Better Care Fund 24

Financial performance 27

Sustainable development 29

Improving quality 29

Safeguarding 34

Public and patient involvement 35

Reducing health inequalities 39

Accountability Report 42

Corporate Governance Report 42

Members Report 42

Statement of Accountable Officer’s Responsibilities 43

Governance Statement 45

Risk Assessment 51

Remuneration and Staff Report 55

Remuneration Report 55

Remuneration Committee 55

Remuneratin Policy 55

Staff Report 62

Parliamentary Accountability and Audit Report 65

Annual Accounts 66

NHS Merton CCG Annual Report4

Our South West London Health and CarePartnership published our refreshed strategydocument for discussion with local organisationsand stakeholders in November 2017. This reflectsthe feedback we have received over the last yearfrom local people and our partners. We havestrengthened our focus on partnership, preventionand keeping people well – the greatest influenceson our health and well-being are factors such aseducation, employment, housing, healthy habits inour communities and social connections.

We will continue to work together in partnershipwith the local NHS, local authority, voluntarysector and Healthwatch in Merton to develop our‘local health and care plans’ overseen by theMerton Health and Wellbeing Board. These planswill provide clear and detailed actions to addressthe local challenges we have set out in thediscussion document and will be published inNovember 2018.

In 2017 the South West London Health and CarePartnership made a joint commitment tochampion children and young people’s mentalhealth and well-being as a shared healthpromotion and prevention priority. We lookforward to this work taking further shape over theyear to come so that collectively we can supportchildren to have the best start in life.

Our joint focus will help build on the strong healthpromotion and prevention activities that take placein each of our health and care organisations inMerton including stopping smoking, alcohol andobesity.

Looking ahead our financial challenges acrosssouth west London remain significant. Ineverything we do we will need to continue tofocus on improving the quality of all our servicesand prioritising our limited resources to address

Welcome

Welcome to NHS Merton Clinical CommissioningGroup’s (CCG) Annual Report for the financial year2017/18.

The year has been a year of progress for the CCG– the plans we set out to achieve in previous yearsare starting to come to fruition and delivering realbenefits to our patients. We are very proud of thedevelopments to our primary care servicesincluding our offer of access to a GP seven days aweek, from 8am to 8pm. The social prescribingpilot has also proven to be a great success and Iam delighted that we are now rolling it out tomore practices across Merton.

This year, we have also worked with our providersand Merton Health, our local GP Federation, toensure more services are available locally so thatlocal people can access more of their health andcare appointments closer to home. Partnershipworking – with our CCG neighbours, NHSproviders, our local authority, voluntary sector,patient groups and the public – has been key toour success in 2017/18.

This has been our fifth year as a CCG and our firstyear as part of the South West London Alliancewith our partners Kingston, Richmond andWandsworth CCGs. Merton and WandsworthCCGs also came together to form a Local DeliveryUnit within the Alliance headed by James Blythe asManaging Director. Richmond and Kingston CCGshave also been operating in this way.

Working together as an alliance in this first yearhas already helped us share expertise and use ourresources more effectively. We are very pleased towelcome Sutton CCG to the alliance as of 1 April2018 to further increase the benefits of this way ofworking. In this first year we have come a longway, and have huge potential to do more togetherin the coming years.

1 Performance Report

NHS Merton CCG Annual Report 5

the needs of local people. We still have a long wayto go, however, we are proud of the work we haveachieved this year.

As the NHS is turning 70 on 5 July this year, we arelooking forward to marking this occasion. Many ofour staff have worked for the NHS for a long timeand this will be the perfect time to celebrate theachievements of one of the nation’s most lovedinstitutions, to appreciate the vital role the serviceplays in our lives, and to recognise and thank ourextraordinary NHS staff.

Finally, we would like to say that we could nothave achieved anything without the dedication ofour GP members, staff, health providers and ourkey partners and stakeholders, and we lookforward to working with them and the publicagain next year to continually provide the besthealthcare we can for the people of Merton.

Sarah BlowAccountable OfficerNHS Merton CCG

Dr Andrew MurrayClinical ChairNHS Merton CCG


You can find out more about us and our work onour website.

Our corporate objectives

1 Improving outcomes and reducinginequalities: Ensuring access to high qualityand sustainable care.

2 Leading with ambition for ourcommunities, driving transformationthrough innovation: Delivering better careand a better patient experience.

3 Working together: Continually improvedelivery by listening to and collaborating withour patients, members, partners, communitiesand other stakeholders.

4 Meeting our performance and financialobjectives: Make the best use of our resourcesto benefit our patients and communities.

5 Supporting our people: Provide the tools and environment for a healthy workplace and support our staff to do a great job. Be a learning organisation that encouragescontinuing improvement.

Our partners

We work with a variety of partners to improvehealth and wellbeing in Merton and to reduceinequalities in health across the borough.

Merton Council

i Public Health The London Borough of Merton leads on helpinglocal people to stay healthy. We work together tosupport and encourage people to make healthierchoices whatever their circumstances. The publichealth team at the council provide informationand expertise to support our work and theDirector of Public Health for Merton is a memberof our governing body. More information about

Who we are and what we do

Merton Clinical Commissioning Group (CCG) isresponsible for planning, buying (commissioning)and monitoring health services for the people wholive or work in Merton. This includes:

� Hospital care (for example outpatientappointments and routine operations)

� Services for people with mental healthconditions

� Services for people who need long term care(for example people with learning disabilitiesand those who are physically frail)

� Urgent and emergency care (for example urgentcare centres and A&E)

� Community health services (for example districtnursing).

We are also responsible for commissioning coreGP services. Our GP practices work together withNHS partners to improve health and wellbeing,reduce health inequalities and make sure everyonehas equal access to healthcare services. Thesepartners include pharmacists, hospitals and mentalhealth providers, the London Borough of Merton,and local community groups. We also work withNHS England which commissions health servicesfrom dentists and pharmacists, and specialisedservices such as transplant surgery and manyscreening programmes.

The governing body oversees the delivery of ourcommissioning plan, leads and sets the strategyfor the CCG, and is accountable for the delivery ofour functions as a statutory body. All GP practicesare entitled, through their memberrepresentatives, to elect members to the Board.This means that members are represented andcontribute clinical expertise at the highest levelwithin the CCG.

Performance overview


we will reflect on our staff surveys and 360 degreefeedback to identify how we can continue toimprove on that over the next year.

The LDU Executive Team, led by the ManagingDirector, ensures that we engage at the right levelson the right issues, from locality, to borough, toLDU, with our colleagues across south westLondon and the wider NHS.

South West London Alliance of CCGs

The South West London Alliance is the result offive CCGs (Kingston, Merton, Richmond, Suttonand Wandsworth) in south west London havingchosen to work together to share expertise anduse resources more effectively. Kingston, Merton,Richmond and Wandsworth joined together as analliance on 1 April 2017 with Sutton CCG joiningon 1 April 2018. We remain close partners withCroydon CCG who are part of our South WestLondon Health and Care Partnership, but notformally part of the alliance with their ownaccountable officer.

Working together helps us to make strongercollective commissioning decisions, share bestpractice and expertise across a wider footprint,and reduce duplication. It also enables us to learnfrom our neighbours, bringing everyone up to thesame high standards when planning and buyinghealthcare services.

Making joint commissioning decisions forsouth west London

Effectively commissioning healthcare servicessometimes requires decisions to be made for morethan just the residents of a single borough.Governing Body members from each of the sixCCGs in south west London meet regularly inpublic as the ‘Committees in Common’ to makedecisions on issues that affect every borough.

A recent example of a collective decision we havemade is all six CCGs unanimously agreeing how tocollectively fund transformation of primary care for2018/19 across south west London.

the London Borough of Merton’s public health rolecan be found here: www.merton.gov.uk/health-social-care/publichealth

ii Merton Health and Wellbeing Board (HWB)Health and wellbeing boards are designed todeliver strategic joined-up local leadership onhealth and care. The work of the Merton HWB iscentral to the commissioning of health and socialcare services in Merton. The Board brings togetherMerton Council, Merton CCG, HealthwatchMerton and the voluntary and community sectorwith a shared focus on improving health andwellbeing in Merton, tackling health inequalitiesand encouraging a greater focus on helpingpeople to stay healthy and make healthier choices.

Our Joint Health and Wellbeing Strategy sets outour shared approach to improving the health andwellbeing of everyone in Merton and reducinghealth inequalities between communities.

A Local Delivery Unit with Wandsworth CCG

Merton shares its management team withWandsworth CCG through a structure called theLocal Delivery Unit (LDU). There are clear benefitsto closer working between the two CCGs,particularly when it comes to managing our largercontracts and the relationship with St George’sUniversity Hospitals NHS Foundation Trust.

The LDU structure provides an opportunity tospend more of our running cost allowance ontransformation. Both CCGs have benefitted fromshared experience, expertise and resources in areassuch as tackling delayed transfers of care, mentalhealth placements, primary care resilience andsocial prescribing.

The combined team brings out the strengthswhich both CCGs have brought to the LDU. At thesame time, this change, like any, has attracted anumber of challenges. Engagement – of ourpartners at borough level, our staff, and ourgoverning bodies and membership – is critical, and


South West London Health and CarePartnership (SWLHCP)

Over the last year the NHS, local councils,Healthwatch and the voluntary sector in southwest London have strengthened their commitmentto working together to deliver better care for localpeople as the SWLHCP.

People told us, and we agreed, that a localapproach works best. To support this theorganisations providing health and care in our sixLondon boroughs have come together as fourlocal partnerships, acting as one team to keeppeople healthy and well in Merton, Wandsworth,Croydon, Sutton, Richmond and Kingston.

We published our sustainability andtransformation plan in November 2016 and spentthe following year speaking to stakeholders andlocal people about what it means to them. Led bythis feedback we refreshed our strategy and inNovember 2017 we published our draft refreshedstrategy document ‘The South West LondonHealth and Care Partnership: One year on’ fordiscussion with local organisations andstakeholders. This discussion document reflectsthe feedback we received over the last year, andwe have strengthened our focus on partnership,prevention and keeping people well – the greatestinfluences on our health and well-being arefactors such as education, employment, housing,healthy habits in our communities and socialconnections.

We will continue to work together in partnershipwith the local NHS, local authorities, the voluntarysector and Healthwatch to develop boroughhealth and care plans. These plans will provideclear and detailed actions to address the localchallenges we set out in the discussion document.The final local plans will be published in November2018.

The General Practice Forward View set out arequirement for all CCGs in the country to ensurepeople can access primary care services from 8amto 8pm, seven days a week. In 2017/18, southwest London received £4.58 million to implementthis change. Using this funding CCGs have madeit easier to access GP services through a range ofmodels which have created around 18,000 extraappointments each month.

For the year to come, south west London CCGswill receive £8 million which equates to £5.41 perhead of the population. This will be used tocontinue to develop extended GP services,ensuring the extra appointments available are forpatients with routine needs, such as managing along-term condition or reviewing an existingcondition, as well as urgent needs. The fundingwill also be used to enable NHS 111 and A&Edepartments to book appointments directly intoprimary care services for patients who would bebetter served by primary care.

We will also use some of this funding to look atnew ways of supporting primary care to work atscale across south west London. This is a way ofmeeting demands placed on individual GPpractices by working together in a new way. Withour support, our practices are working together todesign how this will work for each area andtogether we will find the best way to deliverworking at scale. The potential benefits topractices, and our population, is that this way ofworking can help to spread best practice, offermore personalised and preventative care, tackleworkforce issues and manage a range ofadministrative functions more efficiently.

Working together gives us flexibility to use themoney we will receive as a system. Making onedecision across all six CCGs also ensures thateveryone is able to make progress towards ourcollective vision.


Patient and public engagement

We are committed to ensuring that the views andexperiences of local people are at the heart of ourplans. Conversations with local people areongoing and help ensure that the needs of peoplewho live and work in Merton are central to whatwe do. There are a number of ways that localpeople have been involved in shaping our plans in2017/18:

� Direct engagement 25 patient and public representatives fromacross south west London take part in ourclinical workstreams. The representatives aresupported by the South West LondonEngagement Manager and a ‘buddy’ on theirworkstream to ensure they can meaningfullycontribute to meetings. A Patient and PublicEngagement Steering Group (comprisingHealthwatch, CCG lay representatives and thevoluntary sector) oversees this work.

� Wider engagement An extensive programme to engage with localgrassroots communities is also on-going. Theengagement team visit groups across southwest London to speak to local people we don’tnormally hear from. Local organisations whosupport seldom heard groups are invited toapply for a small sum of money to run anactivity that their community will enjoy. Theengagement team then attends the session tospeak to people in an environment they feelcomfortable in about their experience of localservices. This work is delivered with the helpand support of local Healthwatch organisations.

Since the grassroots programme began in April2016 the SWLHCP engagement team, togetherwith CCG colleagues, have attended more than110 sessions and reached over 6,000 people. A‘You said, we did…and are doing’ report detailswhat we are doing as a result of the feedbackreceived.

To support this work, we have established fourLocal Transformation Boards (LTBs) across southwest London:

� Croydon

� Kingston and Richmond

� Merton and Wandsworth

� Sutton

This local approach has been welcomed by ourlocal authority partners. To further strengthen ourpartnerships with them we will be giving furtherconsideration to how health and wellbeing boardscan play a bigger role in the development of localborough health and care plans and have strongerlinks to the LTBs. It is essential that the boroughhealth and care plans are co-produced with all ofour partners, including the voluntary sector, andwe look forward to doing this over the comingmonths.

Merton and Wandsworth LocalTransformation Board (LTB)

Our achievements in 2017/18 included:

� making it easier for patients who need help toprevent their blood clotting (anticoagulation) toreceive their treatment closer to home

� monthly meetings by health and care workersto share information relating to the quality ofcare being provided in care homes. This meanswe can respond more quickly to concerns andagree action plans where appropriate.

� the roll out of a health and social carereablement/rehabilitation pathway at StGeorge’s University Hospitals NHS FoundationTrust. This uses a ‘discharge to assess’ principle.All agencies ensure support is put in place forthe patient to go home and assessments forcare are made in the patients’ home rather thanin hospital. In the initial three month pilot allsocial care referrals made by participating wardswere responded to with a decision within twohours.


prostate specific antigen (PSA) levels. Attendeeswere able to share their prostate cancer treatmentexperiences, highlighting what worked well forthem and what could be improved. We thenasked everyone what would be a helpful tool forthem to enable them to take more control overtheir care. The men were also invited to join theProstate Cancer Working Group as patientrepresentatives. As a result two of the men arenow members of the working group, havingjoined in August 2017. The feedback from thefocus group gave us the detail we needed todevelop a PSA passport. The first draft of the PSApassport was circulated to the who attended thefocus group and their comments will beincorporated into the next iteration which will betested by 100 men from across south westLondon. A report from the session can be foundhere.

Healthy London Partnership (HLP)

Merton CCG, along with all London CCGs andNHS England (London), funded HLP in 2017/18 tobring together the NHS in London and ourpartners to deliver the capital’s 10 ambitions totransform health and care. HLP supports the aimto make London the healthiest global city in theworld by uniting all of London to deliver theambitions set out in Better Health for London:Next Steps and the national NHS Five Year ForwardView.

During 2017, HLP set up the Urgent andEmergency Care Improvement Collaborative totransform the way that Londoners receiveunplanned urgent care and support. Thecollaborative aims to bring together leaders fromhealth and social care to define what work needsto happen in London, drawing on best practicefrom across the country.

Highlights for 2017/18 included:

� Thrive LDN – an initiative to improve mentalhealth and wellbeing. Community workshopsand problem solving booths were held across

To complement the outreach work we held ahealth and care forum in each borough in2017/18. This give interested members of thepublic an opportunity to share their views with us.Feedback from both the outreach work and theforums can be found here

Phase two of the grassroots 2018/19 programme,which began in May 2018, will inform thedevelopment of the borough health and careplans.

� Targeted pieces of engagement work toshape specific services/pathwaysSometimes we need to do specific pieces ofwork to shape local services – and we tailor ourapproach to the needs of each project. Forexample, we may run a focus group or hold oneto one interviews with people affected by aparticular condition or service.

Community perinatal mental health serviceIn August 2017 we worked with women who hadexperience of mental health services during orafter pregnancy to help inform a bid to provide acommunity perinatal mental health service. Southwest London does not currently have a specialistperinatal community mental health team thatmeets national guidance set out by the RoyalCollege of Psychiatrists (RCPsych). To ensure thatthe voice of women and families were at the heartof the bid we undertook a three-fold engagementexercise to develop what the model of care couldlook like. The engagement included a focus group,one-to-one interviews and a workshop withvoluntary sector colleagues. We will continue toinvolve women and families in the implementationand delivery of the new service. A report from thework so far can be found here

Prostate cancer passportIn July 2017, we ran a focus group with 12 menfrom across south west London who hadexperience of prostate cancer. The aim was tocodesign and test a new patient held record (a‘passport’) to help men keep a record of their


ensure that the hospitals continue to deliver highquality, safe and sustainable services for localpeople in the years ahead. As the trust is raisingsignificant concerns, it is right that commissionersundertake a rigorous assessment and carefullyconsider their response.

The CCGs have already said that they are clearthat there will continue to be a need for bothhospitals. Together, the three CCGs will look at allthe evidence and work with the trust, clinicians inprimary and secondary care and local people todecide the best way forward.

Merton’s health and wellbeing

In 2018, Merton has an estimated residentpopulation of 210,250 which is projected toincrease by about 3.5% to 217,550 by 2025.

The age profile is predicted to shift over this time,with notable growth in the proportions of youngpeople between the ages of 11 and 15 years(17%), and those over 50 years old (10%). Theyoung and the old have more complex healthneeds. Increasing numbers of our local populationare living into older age with multiple long-termconditions such as heart disease, diabetes, cancer,mental health conditions, and dementia.

Merton has developed a falls prevention service,an older people’s memory clinic and a HolisticAssessment and Rapid Investigation Service (HARI)to better support the needs of older residents. TheHARI service was widened in 2017/18 to support abroader age group of people with complex needs.The service also now also offers diabetic eyescreening.

Currently, 37% of Merton’s population are from aBlack, Asian, or Minority Ethnic (BAME) group. By2025 this is predicted to increase slightly to 38%with a greater proportion living in the east of theborough. Children and young people from BAMEbackgrounds make up 67.9% of those attending aMerton school which is lower than the London

London as part of Thrive’s ‘Are we okayLondon?’ campaign which reached 15.5 millionpeople in 2017/18

� Great Weight Debate - The findings fromHLP’s year-long engagement with Londoners onchildhood obesity were published in 2018. Nineout of 10 Londoners who responded to theGreat Weight Debate survey said tacklingLondon’s childhood obesity epidemic should beeither the top or a high priority for the capital.The findings are informing every Londonborough’s childhood obesity strategy andinformed the Mayor’s London Plan whichincludes a policy to prevent new hot foodtakeaways from opening within 400 metres of aschool.

� In 2017 HLP developed and published onlinetraining for GP receptionists to help peoplewho are homeless access GP practices. Morethan 60,000 ‘my right to access healthcare’cards were also distributed for people who arehomeless to make sure they can get equalaccess to healthcare given that they are morelikely to use emergency services.

� A plan to cut rates of new HIV infection andeliminate associated discrimination and stigmawas launched in early 2018 with the Mayor’sOffice, NHS London and Public Health England.

Acute sustainability - working with Suttonand Surrey Downs CCGs

Epsom and St Helier University Hospitals NHS Trusthas faced significant challenges for many years interms of the suitability of its buildings and how itsacute services are organised. In autumn 2017 thetrust set out its own view of these challenges andhow it believed commissioners should respond tothem.

Merton, Sutton and Surrey Downs CCGs are nowworking together to look in detail at thechallenges faced by the trust and how to best


Health and wellbeing strategy

Merton has longstanding health inequalitiesbetween the east and the west of the borough.Our commissioning activities and our primary carestrategy acknowledge these inequalities and seekto ensure that services address these needs andthat prevention is built into all of our plans. Keyareas of work to support prevention in primarycare include:

� improving uptake of bowel screening

� identification of frailty with a view to proactivelypreventing ill health

� ensuring strong uptake of immunisations inboth children and adults

� prevention of diabetes complications byfocussing on those with the least well controlleddiabetes.

In addition, we have developed schemes to focuson frequent users of urgent care and patients withchronic obstructive pulmonary disease. Both ofthese issues are more prominent in the east of theborough and are linked to higher rates of longterm conditions, smoking, deprivation and mentalhealth problems.

Wilson Campus development

The model of health and wellbeing for the east ofthe borough will be delivered from new premisesbased at the old Wilson hospital site in Mitcham.We hope that the combination of a health andwellbeing campus with easy access to communitybased medical care will reduce health inequalitiesin the east of the borough by addressing the maindeterminants of ill-health in one model. There hasbeen significant community input into the futuredesign and work is ongoing with practices in theeast of the borough to develop the primary careprovision.

We have had conversations with the community,doctors, nurses, local politicians, public healthprofessionals, voluntary sector organisations and

average (72.2%) but higher than England (30%).The CCG increased its engagement with minorityethnic groups in 2017/18 to ensure weunderstand their experience of healthcare andtheir health and wellbeing needs.

Overall, Merton’s population is comparativelyhealthy and life expectancy is higher than thenational and London average for both men andwomen. However, there are stark differencesbetween different areas of the borough and lifeexpectancy is significantly lower in the mostdeprived areas in East Merton. A key focus forMerton in 2017/18 was the development of theeast Merton model of health and wellbeing and asocial prescribing pilot to help address theseinequalities.

The main causes of ill health and prematuredeaths in Merton are cancer and circulatorydisease (including coronary heart disease andstroke). Known risk factors (unhealthy diet,smoking, lack of physical activity, and alcohol)account for around 40% of total ill health.Consequently, changing patterns of unhealthybehaviour is an important focus for preventionefforts. In 2017/18, the CCG workedcollaboratively with London Borough of Merton’spublic health team to support initiatives to tacklechildhood obesity and encourage people to makehealthier lifestyle choices (for example bloodpressure checks, stopping smoking, getting moreexercise and reducing alcohol consumption). TheCCG is also actively working with local communitygroups to improve diabetes awareness anddiagnosis and to develop better service userinvolvement to improve clinical outcomes forpatients with diabetes.

Full data on Merton’s health needs is taken fromthe Joint Needs Strategic Assessment whichinforms the Council and the CCG to develop itsshared strategy for health and wellbeing


An independent evaluation, supported by thesouth west London Health Innovation Network,showed an increase in health gains reported bypatients and a statistically significant reduction inGP visits.

For more details on our work to reduce healthinequalities see page 39-40.

Delivering outcomes in 2017/18

Primary care

Local people told us that they struggle to get anappointment with a GP. They also told us thatother healthcare professionals, such aspharmacists, could play a greater role in primarycare but that more would need to be done tobuild public confidence in their remit. Manypeople, including carers, said that they found thehealth system difficult to navigate. Given whatwe’ve heard, and in line with delivering the keyaims set out in the General Practice Forward View,we have focussed on the following:

� Developing schemes (including Care Navigatorsand Medical Assistants) to support non-clinicalstaff in the community with better training sothat they can be more patient facing. We thinkthis will both support patients to navigate thesystem more effectively and help GPs tomanage their time more efficiently when seeingpatients. These schemes are being piloted andco-ordinated across south west London by ourborough based Community Education ProviderNetworks (CEPNs). CEPNs support the trainingneeds of health and social care communities ina local area).

� Delivering 100% extended access to GPappointments allowing local people to bookroutine GP appointments in the evening, atweekends and over bank holidays.

many others. They have told us of the services thatthey want the Wilson Campus to deliver. As aresult, we plan to offer:

� Bookable GP appointments from 8am – 8pm,seven days a week

� Adult mental health services

� Support for people with long term conditionslike diabetes and lung disease

� Community café

� X-ray and other diagnostics like ultrasound andphlebotomy

� Physiotherapy – to treat conditions that affectjoints, bones and muscles

� Rehabilitation services

� Children’s development centre

� Lifestyle and preventative services.

We hope the campus will open its doors to localpeople in summer 2021. Before then there are anumber of steps to take in the planning process.

Social prescribing

Social prescribing is a way of linking patients inprimary care with sources of non-medical supportwithin the community. It helps free up theprofessional time of GPs while connecting peopleto their community and its resources. It is animportant tool to help address some of the non-medical determinants of health such as socialisolation and employment issues.

A pilot has been underway since January 2017with a social prescribing navigator working out ofWide Way and Tamworth House GP practices. Thepilot is supported by the London Borough ofMerton and Merton Voluntary Services Council. Aseparate but parallel care navigation service is alsoavailable at the Nelson Health Centre. The pilothas focused on supporting patients with low levelsof anxiety and stress, and those experiencingsocial isolation and loneliness, to help improvetheir health and wellbeing.


help vulnerable groups. The scheme’s contentwas designed using feedback from patients(both locally and using the national patientsurvey) and with suggestions from MertonHealthwatch. This work comprises four modulesand seeks to improve the understanding andskills of frontline staff. The modules focus ontelephone skills, improving the experience ofcarers and making registration easier forvulnerable groups such migrants and homelesspeople.

Proactive care

There is a continued focus on proactive care toimprove outcomes for vulnerable patients andhigh users of services through earlier inventions.Key achievements in 2017/18 were:

� the introduction of a service to ensure that allcategories of frailty are identified on primarycare registers so that patients can be offeredself-care support and education

� A funded Frequent A&E Attenders Scheme foradults and children to offer these patients alonger appointment in primary care to see iftheir needs can be met more appropriatelyelsewhere

� A chronic obstructive pulmonary disease (COPD)winter scheme identifying patients at higher riskand working with them to prevent hospitaladmission

� A care home scheme open to GP practices whoare caring for a significant number of patients incare homes. The scheme provides resources tosupport advanced care planning and improvedend of life care for the most severely frailpatients to help prevent unnecessary hospitalattendances and admissions.

Estates improvement

Modern, fit for purpose primary care estates arevital for the provision of high quality care. TheMerton primary care team has supported practiceapplications to NHS England’s Estates and

� Progressing our work towards providing onlineconsultations. We have had additional fundingof over £400,000 approved across south westLondon to support the roll out of the GPForward View for online consultations.

Key achievements in Merton include:

� Increased investment to provide increased andbetter quality access to primary care services.Merton GPs offered around 50,000 extra GPappointments in 2017/18 (around 4,000 extraappointments every month).

� Two new GP hubs. Over 90% of patients usingthe hubs say they feel they have easy access tothe new service and 95% would recommendthe service to friends and family.

Improving access to primary care

� Extended hours – we fund all Mertonpractices to offer more appointments in bothcore and extended hours, including dedicatedslots for children needing same day access.Some practices have used the additionalfunding to employ new team members, such asnurse practitioners and physician assistants, andto extend the role of existing staff, such ashealth care assistants. The primary care teamhave also supported a Merton wide bid,involving 12 practices for clinical pharmacistswhich is being considered by NHS England.

� Hubs – The two hubs offer on the day andadvance appointments and are open Monday toFriday 5pm-8pm and 8am-8pm on a Saturday.One hub is also open 8am-8pm on a Sunday.Both are open 8am-8pm on bank holidays.Wound care is delivered by nurses on site.Clinicians in the hub have full access to medicalrecords (with patient consent). This improvespatient safety and experience and ensures thathub consultations are offered in an integratedway rather than as a stop gap or duplication.

� Help for vulnerable groups – We are fundingan access scheme to support frontline staff to


their own care and providing them with integratedhealth and social care services. The scheme allowsmore care to be offered out of hospital, to reducehospital admissions and supporting timelydischarges.

The Improved Better Care Fund (iBCF) was firstannounced in the 2015 Spending Review and ispaid as a direct grant to local government with acondition that it is pooled into the local BCF plan.The iBCF funding can be spent on three purposes:meeting adult social care needs, reducingpressures on the NHS including supporting morepeople to be discharged from hospital when theyare ready, and ensuring that the local social careprovider market is supported.

In September 2017, we transferred £5.5m to thecouncil to support the BCF and iBCF. In addition tothe CCG’s contribution, the London Borough ofMerton has also been allocated iBCF funding of£2.745m.

Together, we decided that there are three priorityworkstreams for the next two years:

� Integrated locality teams (which will includeboth social care and health workers)

� Intermediate care and rapid response

� Enhanced support to care homes.

Merton GP practices have agreed to work in fourclusters to support the development of integratedlocality teams. Merton Community Services(delivered by Central London Community Health)and some functions of the London Borough ofMerton are also in the process of aligning theirteams to these four clusters to further supportgreater integration of services.

Support for patients with complex needs

We have improved the proactive identification ofpeople with frailty concerns and their onwardreferral to appropriate support services, forexample falls prevention, case management or theHolistic and Rapid Investigation Service (HARI) at

Technology Transformation Fund (ETTF) to helpthem to improve their premises. The ETTF is amulti-million pound investment (revenue andcapital funding) in general practice facilities andtechnology across England (between 2015/16 and2019/20). It is part of the NHS commitment formore modernised buildings and better use oftechnology to help improve GP services forpatients.

Key projects undertaken in 2017 included:

� Central Medical Centre - a loft extension withground floor extension and other improvements

� James O’Riordan Medical Centre - introductionof automated door-closer equipment

� Wide Way Surgery - six new consulting rooms.

Successful ETTF bids have also been secured forColliers Wood Surgery’s co-location to newpremises at Merton Vision on Clarendon Road,and for Princes Road Surgery’s relocation torefurbished premises at Patrick Doody Clinic onPelham Road.

Training and education - workforcedevelopment

Training and education is central to our strategy todeliver a highly skilled primary care workforce andevidence based care. We have prioritised educatedevents called Protected Learning Time for teamsand provided learning and developmentopportunities for all clinical and non-clinicalprimary care staff. Subjects covered includediabetes, cardiology and mental health. DementiaFriend training has also been provided.

Integrated care

Better Care Fund (BCF) plan

The Better Care Fund (BCF) joins up health andcare services so that people can manage their ownhealth and wellbeing, and live independently intheir communities. The BCF supports the mostvulnerable people by placing them at the centre of


help us reduce the time care home residents spendin hospital and to make their stay less stressful.

When a care home resident needs to go intohospital a red bag is packed for them. The bagholds their personal details, information abouttheir health conditions, supplies of regularmedicine, personal items (such as glasses anddentures) and a change of clothes for when theyare ready to be discharged. The bag is handed toambulance staff who give it to hospital staff. Thisguarantees that essential documents and itemsfollow the resident from arrival at hospital todischarge back to their care home. Vitalinformation in the red bag enables hospital staffto provide quicker effective care and treatmentand reduces delays in getting patients home fromhospital.

The scheme has initially been rolled out at Mertonnursing and residential homes for older residents.We intend to expand it further in 2018/19 tocover homes that support people with learningdisabilities and mental health conditions.

Fire, Safe and Well Merton is one of five boroughs in London chosento pilot ‘Fire, Safe and Well’. This London FireBrigade initiative will see visits being carried out toolder and vulnerable Merton residents to reducetheir risk from fire as well as from slips, trips andfalls.

Two community safety advisors have beenrecruited and trained by London Fire Brigade tocarry out the visits and a cross-Merton group setup to support the project. The advisors can referpeople directly to the Merton Community FallsPrevention Service and will consider health, socialand lifestyle factors alongside the physical risks offire in someone’s home. There can be a clear linkbetween these factors and someone’s vulnerabilityto fire. We hope that this initiative will help reducehospital admissions by identifying those at riskearlier alongside improving home fire safety.

the Nelson Health Centre. Alongside this weadapted the Age UK Healthy Ageing booklet toinclude local voluntary support services for frail,elderly and vulnerable people and gave it to allMerton GP practices, community services, locallibraries, social care staff and the voluntary sector.

Improving hospital discharge

Once people no longer need hospital care, beingat home or in a community setting (such as a carehome) is the best place to continue recovery butsometimes there are delays to the person beingdischarged. We have worked hard this year toreduce unnecessary delays.

Throughout the year agencies across Mertonworked with local acute trusts to identify patientswho might require support following a hospitaladmission. As a result, a new pathway started inFebruary 2018 for patients who may be eligible forNHS continuing healthcare. Patients who may beeligible for NHS continuing healthcare are nowassessed out of hospital in order to help bringtheir care back into the community and reduceunnecessary time in hospital.

Practitioners across Merton review patients on adaily basis to see what support can be offered tosupport discharge. As a result of this, and in spiteof increased pressures over 2017/18, Mertonachieved the second lowest delayed transfers ofcare in London in January 2018. This was secondonly to the City of Westminster.

We are also introducing a national programme,‘Enhanced support to care homes’, in Merton. Amulti–agency Merton Joint Intelligence Group hasbeen established and the Merton Care HomeForum has been reinvigorated. The Merton CareHome Forum is a multi-agency support forum runin conjunction with local community group,Merton Seniors.

The Red Bags Scheme

We introduced red bags into 21 Merton carehomes in January 2018. The bags are a tool to


engagement with local people. Theneurodevelopmental pathway for children receivedadditional investment to ensure open access fordiagnostic assessments. Local engagement andlistening events were held for local families andstakeholders to contribute to the future planningprocess for an improved neurodevelopmentalpathway.

We have also continued to invest in services tosupport young people’s mental health in thecommunity. This includes counselling servicesoffered by local agencies Off-the-record and TheWish Centre.

You can read more about progress during 2017/18and priorities for the next four years in Merton’sChildren and Young People’s Transformation Plan.

In 2017 the South West London Health and CarePartnership made a joint commitment tochampion children and young people’s mentalhealth and well-being as a shared healthpromotion and prevention priority. Merton isplaying a leading role in this work. The project isbeing led by Merton GP and CCG Chair DrAndrew Murray, London Borough of Merton ChiefExecutive Ged Curran and John Goulston ofCroydon Health Services NHS Trust.

Other work with our south west London CCGpartners has included:

� Developing a specialist eating disorder servicewhich is now operational and improvingoutcomes for young people. Work is alsounderway to develop a service model in linewith national targets for assessment andtreatment of eating disorders in 2017/18

� Consistent 24/7 crisis care for children acrosssouth west London in line with new guidelinespublished by Healthy London Partnership inOctober 2016

� Developing transition services for young peopleaged 18-25 who are suffering from neuro-developmental disorders.

Maternity

Local people told us that their care would beimproved if they had the same midwifethroughout their maternity journey. Peoplewanted to be empowered to have more choice intheir care. Above all, people told us that theirsafety and the safety of their child was ofparamount importance.

This feedback informed the maternity plan forsouth west London that we submitted to NHSEngland in January 2018. The plan focuses onaction being taken across south west London. Thisincludes making sure women have a choice aboutwhere to have their baby and access toinformation to help them make decisions abouttheir care, including where they can get supportcentred on their individual needs.

To help us to achieve this we have launched a pilotfor a new My Maternity Journey booklet acrosssouth west London. The booklet is designed tosupport choice for pregnant women by setting outall the services available across south west Londonto help them navigate their pregnancy care.

Children and young people

We have continued to work with the LondonBorough of Merton to develop joined-up servicesfor children and young people. Two CCG staff arenow co-located with the Children, Schools andFamilies team and the Public Health team at theLondon Borough of Merton to make sure ourwork is integrated.

Child and adolescent mental health services(CAMHS)

Our CAMHS Local Transformation Plan wasrefreshed in 2017 and is focused on ensuringpeople have better access to services and thatthese services are of a high quality.

An autism strategy has been developed by thelocal authority in partnership with the CCG. Thestrategy was developed following extensive


year. The Recovery Café, and its sister site inTooting, have proved to be extremely popular. Youcan find details of the cafés here

Online talking therapies service

In early 2018, we added weekend and eveningonline talking therapies to the current talkingtherapies offer in Merton. The provider, IESO,provides Cognitive Behaviour Therapy (CBT) with afully qualified therapist in real time over theinternet. Online talking therapy helps meetdemand for ‘out of office hours’ appointmentsand offers valuable access for patients withmobility or social anxiety issues.

The online CBT sessions follow the same format astraditional face-to-face therapy but take place in asecure online therapy room. This allows people tohave the therapy from wherever they feel mostcomfortable and means the sessions can beaccessed discreetly with no need to visit a GP. Forsome people talking online can also help alleviatethe pressure of having a face-to-face conversation.

The service is free, confidential and is designed tohelp with many mental health problems includingdepression (including perinatal), fears and phobias,panic attacks and social anxiety and shyness.

Transforming care

Transforming care is all about making health andcare services better so that more people with alearning disability, autism or both can live in thecommunity, with the right support, and close tohome.

We have continued to work with providers toensure that the recommendations made in‘Transforming Care: A national response toWinterbourne View Hospital’ are implemented.

Working with local providers and when necessarythose that are out of area we continue to makesure that the recommendations from ‘The FiveYear Forward View for Mental Health’ areimplemented and incorporated into day to daycare.

Mental health

Local people told us that they were worried thatnot enough money was being invested in mentalhealth services in order to meet the growingdemand. People felt more should be done toprovide 24/7 crisis support for adults and childrenwith mental health conditions and their families.We have listened to what local people want andare committed to improving how we prevent,support and care for people experiencing mentalhealth problems and make sure we treat theirmental and physical health together.

Examples of our key successes in south westLondon include:

� Providing 24/7 psychiatric liaison services in allour A&E departments from April 2018 due tonearly £1.5 million of funding received

� Faster access to crisis mental health care withSt. George’s NHS Foundation Trust and CroydonUniversity Hospital Trust offering access tospecialist mental health staff 24/7 with a onehour response to emergency referrals – knownas the Core 24 standard. Kingston Hospital NHSFoundation Trust and Epsom and St HelierUniversity Hospitals Trust also began providingthis from April 2018.

We have also put in a bid for national funding fornew specialist perinatal community mental healthteams to support women experiencing mentalhealth problems in the few weeks before or aftergiving birth. The teams will help women and theirfamilies, and work with other healthcareprofessionals, to provide education and trainingaround perinatal mental health.

Sunshine Recovery Café

A Recovery Café, provided through South WestLondon St George’s Mental Health Trust, launchedin Wimbledon in April 2017. The café offers a safeand welcoming space for those struggling to copeand aims to reduce anxieties and crisis. It is opento all south west London residents 365 days a


In 2017/18 Merton’s Cancer Task Group joinedwith Wandsworth Cancer Clinical ReferenceGroup to bring a more streamlined and joined upapproach to planning, commissioning andmonitoring of local cancer services. It has alsohelped us improve communication with primarycare and other key stakeholder groups.

Over 2017/18 we have increased the number ofout of hours clinics to give women greater andmore convenient access to cervical screening. Wehave also worked hard to increase the number ofCancer Care Reviews carried out in primary care.The reviews help identify early signs ofcomplications or poorly controlled symptoms. Wealso worked with local hospitals to ensure thatHealth Needs Assessments are completed andreturned to GPs and that Treatment Summariescontain all the necessary information to supporteffective management in primary care.

Planned care

Musculoskeletal services (MSK)

From April 2017 patients registered with MertonGPs became able to self-refer to the Mertonmusculoskeletal service. This is instead of waitingto be referred by their GP or another healthcarepractitioner. This speeds up access to assessmentand treatment in the service, plus the service canarrange any injections, scans or onward referrals(i.e. orthopaedic consultants) if required in a timelymanner.

Over 600 people have taken advantage of thisnew way to access treatment.

Initially patients book a phone consultation tospeak to a physiotherapist within a few days. Thephysiotherapist can then email (or post) themexercise videos (or sheets), education leaflets andother resources so they can start helpingthemselves straight away. The patient andphysiotherapist can also agree the appropriatenext steps in their care and get this in motion

Cancer

Local people told us that getting an early diagnosisis really important in order to avoid the need formore aggressive forms of treatment. People valuedscreening programmes but felt more could bedone to reach all parts of our diverse community.Once diagnosed, people felt that the NHS providesexcellent clinical care but more training could begiven around delivering news sensitively.

Working together across south west London, weare focusing on:

� Ensuring early and timely diagnosis andtreatment and consistently meeting nationalstandards of receiving first treatment within 62days following an urgent referral

� Working alongside Royal Marsden Partners tosecure transformation funding for further rollout of follow-ups in primary care for prostatecancer

� Improving uptake of bowel screening as rates insouth west London are lower than the nationalaverage. We are introducing a Bowel CancerScreening Communication Service to contactpatients directly to talk them through thescreening process, why it is important and toaddress any concerns they have

� Reviewing a project that is underway inKingston to increase screening uptake forpeople with learning disabilities – this willinform a potential roll out across south westLondon

� Putting in place a follow-up programme forprostate cancer patients. GPs and practicenurses will regularly follow-up care and monitorpatients so that they do not need to attendhospital for unnecessary appointments. This isalready in place in Croydon and Sutton and hasbeen shown to improve care and patientexperience. It will be rolled out across southwest London.


possible, and those with more serious oremergency needs are treated in centres with thevery best expertise and facilities.

These are some examples of how we are achievingthese aims:

� Introducing an extended NHS 111 service tohelp our residents receive the most appropriatehealthcare. Our new 111 service has employedmore clinicians so that over half of calls are nowhandled by a clinician. The service can also nowbook patients directly into their local GPpractice.

� Improving ‘front door streaming’ at A&Es whichmeans finding the best ways of patients beinginitially triaged, treated or referred onto themost appropriate service for them as swiftly aspossible

� Establishing new locality teams to offermultidisciplinary support both to patients withlong terms conditions and those who aredischarged from hospital and need additionalsupport. As part of these teams there will be ‘inreach’ teams who actively go into hospitals toensure that patients who are ready to go homeare not delayed.

Ambulatory care

Ambulatory care is a service which provides sameday emergency care to patients at our acute trusts.This means that patients are assessed, diagnosed,treated and are able to go home the same day,without being admitted overnight. It is a way toavoid unnecessary hospital admissions. In2017/18, St George’s University Hospitals NHS FThave expanded their existing ambulatory careservice, almost doubling its capacity. It will nowmeet NHS England standards in delivering aservice that is available to our patients seven daysa week, 14 hours a day.

straight way. This could include face to faceassessment with a rehabilitation therapist, into ourfully equipped rehabilitation gym or oureducational seminars.

The pathway is endorsed by the Charted Societyof Physiotherapy and NICE. Self-referral pathwaysare shown to be safe, effective, reduce waitingtimes and decrease GP workload and costs.

Diabetes

The Community Diabetes Services (Tier 3) wasexpanded in 2017/18 and we focussed on makingit easier for people to access advice and supportfrom primary care when they needed it.

We also worked with primary care services toboost the number of people offered structureddiabetes education programmes to help patientslearn about their condition and how to maintain ahealthy lifestyle.

Neurology

We have agreed five pilot areas as part of for thedevelopment of an Integrated Neurology Service.We are now working on proposals for furtherinvestment into community neuro-psychologysupport services.

Urgent and emergency care

Local people told us that too many people useA&E because they can’t get an appointment withtheir GP or don’t know where else to go. Peoplesaid that it is hard to change behaviours and weshould consider co-locating other services in A&Edepartments. Concerns were also raised aboutdischarge from hospital - with some people beingdischarged late at night and without carepackages in place when they returned home.

We are committed to improving services forpeople when they are at their sickest and are inneed of urgent or emergency care ensuring that,for those with non-life threatening but urgentneeds they are treated as close to home as


How we measure performance

We measure and monitor quality and performancemetrics with all our health service providers,framed around the NHS Constitution and localquality measures. The CCG performance andinformation team reviews performance metricsalongside commissioning and contractingmanagers on a regular basis. These metrics arecombined with local intelligence and informationto produce a monthly Performance Report,presented to our Integrated Governance andQuality Committee, and our CCG AssuranceReport which we present to our Governing Bodyand publish on our website:www.mertonccg.nhs.uk/

The format of the report has changed to showlonger term trends, benchmarking informationand areas to note by exception across the healtheconomy. Root causes relating to issues of concernare distilled with the mitigating actions detailed.

The performance report provides:

� An update on CCG and related providers’operational performance against national andlocally agreed standards. This includes 18 weeksreferral to treatment (RTT), cancer waits, A&Ewaits and ambulance handover times, delayedtransfers of care

� Detailed information on underachievingindicators including trends and direction oftravel are included where there are measurablethresholds.

How we manage performance

We are committed to ensuring that NHS care isprovided safely and to the highest quality possiblefor all patients. We measure performance andquality standards based upon the national CCGAssurance and Assessment Framework 2017/18,which focuses on key constitutional pledges forpatients including key waiting times targets.

In an environment where NHS organisations acrossthe country have experienced unprecedentedgrowth in demand for NHS care with a tighterlimit on resources, we have worked hard tomaintain and improve the performance andquality of care for Merton patients by setting firmexpectations of standards with our healthcareproviders.

Our Governing Body has ultimate responsibility formaking the final decisions and ensuring the CCGis performing as it should. It is accountable to NHSEngland and to member practices, as well as tothe public.

We report performance and quality standards eachmonth to our Governing Body and hold monthlymeetings with our key acute, mental health andcommunity care providers to review performance.Where we feel closer involvement is required, wemeet providers on a regular basis to work withthem to bring about performance improvementand ensure plans are effective.

Performance is monitored and measured throughthe Integrated Governance and QualityCommittee held in common with WandsworthCCG. The committee scrutinises performance forboth CCGs and reviews areas of concern andreports to the Governing Bodies as appropriate.

Performance analysis


Constitution Standards

The NHS Constitution includes a set of pledges which the NHS is committed to achieve. The Constitutionstates that while these ‘are not legally binding, and cannot be guaranteed for everyone all of the time,they express an ambition to improve’. In our role as a commissioner of health services, Merton CCGworks closely with service providers; assessing how well they are performing against these standards, andidentifying where improvements need to be made.

The table below summarises the end year position against each of the Constitution standards.

Performance Measure 2016/17 2017/18

Referral To Treatment 18 weeks (incomplete pathways) 92.1% 90.1%

Diagnostics test waiting time 98.5% 99.1%

A&E waiting times 91.6% 88.4%

Cancer two weeks 93.0% 92.5%

Breast symptoms 2 weeks 94.6% 94.7%

Cancer first definitive treatment 31 days 97.0% 96.2%

Cancer subsequent treatment 31 days, surgery 97.8% 94.8%

Cancer subsequent treatment 31 days, drug treatment 99.7% 100%

Cancer subsequent treatment 31 days, radiotherapy 98.6% 96.3%

Cancer composite, 62 days first treatment plus rare cancers 84.1% 84.6%

Cancer first treatment 62 days, screening 96.8% 89.4%

Ambulance red 1 – 8 minute response 86.7% *(Month 9: Dec-17) 80.7%

Mixed sex accommodation breaches 0 10

RTT 52 weeks (incomplete pathways) 17 15

MRSA (PIR assigned) 2 0

C Difficile 30 26

Improving Access to Psychological Therapies – recovery rate 49.8% 47.9%

Improving Access to Psychological Therapies – entering treatment 9.3% 10.64%

Improving Access to Psychological Therapies – Treatment within 6 weeks 86.1% 79.6%

Improving Access to Psychological Therapies – Treatment within 18 weeks 97.5% 98.0%

Dementia diagnosis rate 71.1% 71.0%

Early Intervention in Psychosis 73.5% 59.7%


underway to help improve performance levels aswell as provide better outcomes for our patients.The work streams underway include:

� The Unplanned and Admitted Patient Careprogramme aims to provide patients withalternatives to emergency admission and toaccelerate discharge to reduce overall bedoccupancy

� A new Ambulatory and Acute Assessmentpathway has been developed.

� SAFER bundle is being rolled out to improvepatient safety and remove delays for inpatients.

Waiting times for cancer treatment

There are eight cancer waiting times standards forpatients with, or suspected to have cancer. Fiveof the eight standards are currently being met,with the remaining three measures marginallymissing the standards. While the two-week cancerwait standard did not meet target, improvedperformance levels for the later part of thefinancial year were seen with this measureconsistently remaining above target for eachmonth from August 2017 to March 2018.

Continuous efforts to maintain and improvecancer performance are being led by the southwest London System Leadership Forum (SLF).

Ambulance response times London AmbulanceService NHS Trust (LAS)

The London Ambulance Service continues todeliver good response times for the residents ofMerton with the majority of months during thefinancial year remaining above the Londonaverage. The London Ambulance Serviceimplemented the Ambulance ResponseProgramme (ARP) effective from 1 November2017. The new performance standards associatedwith ARP will not be reported until April 2018.

Mixed-sex accommodation breaches

All providers of NHS funded care are expected toeliminate mixed-sex accommodation, except

Referral to Treatment (RTT)

The NHS Constitution includes the Referral toTreatment (RTT) operational standards. Thisincludes the target that 92% of patients who havenot yet started treatment should have beenwaiting no more than 18 weeks.

The CCG’s main provider, St George’s UniversityHospitals NHS Foundation Trust, took the decisionto suspend national RTT reporting in June 2016,due to significant concerns about the quality ofdata. An extensive programme of waiting list datavalidation has taken place since then. In February2018, the trust introduced a new patient pathwaymanagement system and is working towards thestandards required to recommence formalreporting.

The trust established a Clinical Harm ReviewGroup. This provides a process for reviewingwhether any patients who had long waitsexperienced harm as a result of their wait. TheCCG participates in this group together with NHSEngland and other CCGs.

In conjunction with Wandsworth CCG, wecommissioned additional capacity for two of themost challenged specialties to treat long-waitingpatients. We have introduced new models ofpatient review and new advice and guidanceoptions to support GPs. The CCG has also beensupported the deployment of capacity alerts onthe e-Referral system, which highlight serviceswith limited capacity and suggest alternativeproviders with shorter waiting times.

The RTT performance issues emphasise theimportance of ensuring that, where appropriate,clinical pathways are designed to provide out-of-hospital options which are convenient to accessfor patients.

A&E waiting times

Despite not achieving the 95% target throughoutthe year, St George’s University Hospital’s NHSFoundation Trust have a number of work streams


Better Care Fund (BCF)

The Better Care Fund (BCF) is a programmespanning both the NHS and local governmentwhich seeks to join-up health and care services, sothat people can manage their own health andwellbeing, and live independently in theircommunities for as long as possible.

The BCF has been created to improve the lives ofsome of the most vulnerable people in our society,placing them at the centre of their care andsupport, and providing them integrated healthand social care services, resulting in an improvedexperience and better quality of life.

Merton’s BCF Plan for 2017/18 sought to continueto build on the work already undertaken andstrengthen the relationships and collaborationbetween multiple providers in Merton with a focuson the following key areas:

‘where it is in the overall best interest of thepatient’. There have been ten breaches of thisstandard for Merton CCG patients where thisambition was not achieved. Each breach isinvestigated by the relevant Clinical Quality ReviewGroup (CQRG). Patients are advised of the issuesat the time of the breach.

Infection prevention and control

The NHS is committed to reducing the incidenceof avoidable harm, including infections fromMethicillin-resistant Staphylococcus aureus (MRSA)& Clostridium Difficile (C Difficile). As part of this,infection control has been a high priority for allNHS providers, and each case of MRSA or CDifficile is investigated and reviewed at therelevant provider CQRG. There have been no casesof MRSA for Merton CCG patients. There were 26cases of C Difficile.

Quality Premiums – improvinghealth outcomes

The Quality Premium (QP) scheme is aboutrewarding CCGs for improvements in the qualityof the services they commission. The scheme alsoincentivises CCGs to improve patient healthoutcomes and reduce inequalities in healthoutcomes and improve access to services. The2017/18 scheme has been designed to supportthe delivery of the major priorities for the NHS, aswell as local priorities identified for Merton. TheCCG Improvement and Assessment Framework isthe mechanism by which progress is monitored;therefore the national QP indicators are alignedwith those in the CCG Improvement andAssessment Framework. By taking this approach,the scheme focuses on those things alreadyidentified as critical to delivering the vision.


Performance Metric Rationale 2017/18

Non-elective admissions Good management of long term conditions Quarter 3(aligned to the Merton require effective collaboration across health and (Oct-Dec)Health & Wellbeing care system to support people managingBoard) conditions and promote swift recovery and 5,333 admissions

reablement after acute illness. There should be shared responsibility across the system so that all parts of the health and care system improve the quality of care and reduce the frequency and necessity for non-elective admissions.

Admissions to residential Avoiding permanent placements in residential and Quarter 3and nursing care homes nursing care homes is a good measure of (year to date) of older people delaying dependency, and the inclusion of this (65 and over) measure in the BCF framework supports local health

and social care services to work together to reduce 68 patientsavoidable admissions.

Proportion of older There is strong evidence that reablement services Annual reportingpeople (65 and over) lead to improved outcomes and value for money Not yet availablewho were still at home across the health and social care sectors. 91 days after discharge Reablement seeks to support people and maximise from hospital into their level of independence, in order to minimisereablement / their need for ongoing support and dependencerehabilitation services on public services.

Delayed transfers of Measuring delayed transfers of care is an important Quarter 3care - delayed bed days marker of the effective joint working of partners, (Oct-Dec)(aligned to the Merton and is a measure of effectiveness of the interfaceHealth and Wellbeing between health and social care services. 500.3 per 100,000 Board) Minimising delayed transfers of care, enabling population

timely discharge to the most appropriate care setting and promoting smooth flow through the system for medically optimised patients, is one of the desired outcomes of social care.


Merton’s performance is in the best quartilenationally.

Improvement and Assessment Framework(IAF)

Our performance as a clinical commissioninggroup is monitored by NHS England through theCCG IAF which assesses us against four domains:Better Health; Better Care; Sustainability andLeadership

The CCG is given an annual assessment ratingagainst the IAF based upon performance of keyperformance indicators (KPIs) during 2017/18covering Quality, Constitutional Targets, EffectiveLeadership and Commissioning and FinancialSustainability.

We anticipate our 2017/18 assessment results willbe published in June 2018.

Key IAF 2017/18 highlights at time of publishing

We are achieving good results (best quartilenationally) in the areas of:

� appropriate prescribing of antibiotics in primarycare;

� provision of high quality care for adult socialcare;

� reducing delayed transfers of care attributableto NHS; and

� increasing the percentage of the GP-registeredpopulation who are able to benefit fromextended access to pre-bookable appointments.

Additionally, under the clinical priority areas ofmental health, cancer, dementia, diabetes,learning disabilities and maternity, the CCGperformance in these areas at the time ofpublishing, shows that one-year survival from allcancers; people with an urgent GP referral havingfirst treatment for cancer within 62 days ofreferral; reducing the reliance of specialistinpatient care for people with a learning disabilityand/or autism, continued prioritisation of action to

BCF Performance

There were challenges in meeting the Health andWellbeing Board targets for non-electiveadmissions during 2017/18. While Quarter 3(October - December) shows performance close totarget and in-line with the previous financial year,year-to-date performance (April – December)shows a larger variance and increased activityreported particularly in the earlier periods of theyear in comparison with 2016/17 reporting period(as seen in the below graph). The final Year End2017/18 is not yet available at the time ofpublishing this report.

Reablement services provide personal care andhelp with daily living activities. This is usually in thepatient’s home, and they are offered to peoplewith disabilities and those who are frail orrecovering from an illness or injury. They areintended to encourage people to develop theconfidence and skills to carry out these activitiesthemselves and continue to live at home.

The reablement performance indicator ‘Proportionof older people (65 and over) who were still athome 91 days after discharge from hospital intoreablement / rehabilitation services’, is collected onan annual basis based on clients dischargedbetween 1 October and 31 December and ofthose clients, the number that were still at home91 days later. At the time of publishing this reportthe 2017/18 Year End position is not yet available.

We are on track to meet the target for permanentadmissions of older people to residential andnursing care homes, although the final year endposition is not yet available.

While there are continued challenges withensuring the most-timely discharges from hospitaland stretching targets were set for 2017/18,Merton’s overall performance has been better thanthe London average throughout winter with thelowest level in London for social care delays inJanuary 2018. The number of delayed daysattributable to the NHS has also improved and


reduce smoking at delivery (maternal/pregnancy)and choices in maternity services are all achievingresults within the best quartile nationally.

The CCG estimated diagnosis rate for people withdementia aged 65 is currently 70.4% placingMerton above the national 66.7% benchmark forthis measure. Performance information fordiabetes measures for 2017/18 at the time ofpublishing this report are not yet available forcomment and are expected to be published byNHS England in June 2018.

Financial Performance

Overview

Our main financial objective is the delivery offinancial performance against our allocation.Performance against this allocation is monitoredthroughout the year, allowing prompt action to betaken to alleviate any particular financial pressuresthat should arise.

In all but exceptional cases, CCGs are set a targetto achieve a surplus against their annual allocation(known as their Revenue Resource Limit or RRL).This ensures that the NHS as a whole has a degreeof flexibility for unforeseen events. In 2017/18Merton CCG was set a target of a break-evenposition.

The year has been challenging for us financially,due to increasing cost pressures, driven byincreased demand for health services attributableto demographic growth and an increasingprevalence of long term health conditions amongour population. Despite this, we have achieved therequired breakeven position for the year againstour overall budget of £282.7m.

Expenditure

In 2017/18, we spent £282.7m on thecommissioning and provision of healthcareservices as shown in the chart below:

investing £0.35m in 2017/18, with the balance of£0.35m to be invested in 2018/19.

Mental Health Investment Standard

We are also required to invest to improve qualityand access to Mental Health services, with anincrease at least equal to its overall increase inRRL. We have met this requirement, spending anadditional £3.4m on mental health in 2017/18, a15% increase compared to 2016/17, principallydriven by investment in IAPT and moreplacements.

Additional statutory requirements

� Within its allocation, there is a specificallocation for running costs, which CCGs arerequired to not exceed. The running costallowance (RCA) is calculated centrally by NHSEngland, and is based on a starting point of £25per head of population in 2013/14, which hasreduced by 10% every year since. The CCGs hasmet its running cost target for 2017/18, with anunderspend of £0.1m against the target of£4.5m.

� The CCG has also achieved the Better PaymentPractice Code (BPPC), which is a requirement topay 95% of invoices in total within 30 days.

� The CCG has a requirement to hold a cashbalance at the end of every month of no morethan 1.25% of the cash it has drawn downfrom NHS England to pay for its monthly costs.The CCG has complied with this requirementthroughout 2017/18.

Looking ahead

The financial climate in the NHS remainschallenging going into 2018/19. We haveidentified a similar level of cost pressure as for thisyear and we are planning to deliver a £12.2m QIPPprogramme to ensure the CCG hits its requiredsurplus of £1.9m. We remain confident that wecan achieve this plan, although it will require agreat deal of hard work and innovation from all


The CCG’s largest providers of healthcare are:

� St George's University Hospitals NHSFoundation Trust (acute hospital and communityservices),

� Epsom and St Helier University Hospitals NHSTrust (acute hospital services),

� South West London and St George's MentalHealth NHS Trust (mental health services),

� Central London Community Healthcare NHSTrust (adult community services).

Release of the 0.5% non-recurrent reserve

As set out in the 2017/18 NHS Planning Guidance,CCGs were required to hold a 0.5% reserveuncommitted from the start of the year, created bysetting aside the monies that CCGs wereotherwise required to spend non-recurrently. Inline with national guidance, Merton CCG hasreleased its 0.5% reserve to the bottom line. Thisadditional surplus has been offset against othercost pressures from the current financial year, inparticular relating to the availability and price ofpharmacy stocks.

Quality, Innovation, Productivity andPrevention programme (QIPP)

Every year we are required to generate efficiencysavings and improve value for money as part of itsQIPP programme. For 2017/18, the QIPPrequirement was £11.2m (net), which weachieved, this equates to 4.0% of the CCG’s RRL.

General Practice Forward View Investment

We are required to invest £3 per head ofpopulation across 2017/18 and 2018/19 inprimary care over and above its previous spendinglevels. This is to support the General PracticeForward View by improving patient care andaccess, and investing in new ways of providingprimary care. For Merton, this equates to £0.7mover two years. We have met this requirement,


colleagues, both management and clinicians,across the CCG, Local Delivery Unit and southwest London.

Sustainable development

As an NHS organisation, and as a spender ofpublic funds, we have an obligation to work in away that has a positive effect on the communitieswe serve. Sustainability means spending publicmoney well, the smart and efficient use of naturalresources and building healthy, resilientcommunities.

We are committed to sustainability and toreducing our carbon footprint. We achieve this byworking with our landlord and suppliers toimprove utilisation and functionality in all areas ofthe business and day-to-day operations.

Estates120 The Broadway, Wimbledon, where we arebased, is managed by NHS Property Services. Weare one of several tenants in the building and wework with the landlord to ensure we comply withenvironmental requirements and best practice inrelation to recycling and energy consumption.Waste and recycling points are available.

Paper free at point of care We are working hard to improve our performancein relation to ‘paper-free’ at the point of care.Average electronic prescribing for Mertonpractices as of March 2018 was 63% which isabove the national average. There is a target forthis to reach 70% in 18/19 and 80% by 19/20.We are also working with GP practices andproviders to increase the use of an e-referralsystem with a view to going paperless by mid-2018.

CCG paper freeThe CCG is also reducing its reliance on paper byreducing the amount of printing it requests andencouraging senior managers and Governing Bodymembers to use tablets and laptops duringmeetings.

Improving quality

We have sought to secure continuousimprovement in the quality of services provided toindividuals for or in connection with theprevention, diagnosis and treatment of illness. Thisdrive to secure positive health outcomes for localpeople and continuously improve the quality ofservices is at the heart of our work.

Nationally, the NHS quality agenda sets out thethree key elements for commissioning high-qualitycare:

� Patient safety: commissioning high quality carewhich is safe and prevents all avoidable harmand risks to the individual’s safety, and havingsystems in place to protect patients

� Clinical effectiveness: commissioning highquality care which is delivered according to thebest evidence as to what is clinically effective inimproving an individual’s health outcomes, andmaking sure care and treatments achieve theirintended outcome

� Patient experience: commissioning high qualitycare which looks to give the individual aspositive as possible an experience of receivingcare, including being treated according to whatthe individual wants or needs, and withcompassion, dignity and respect, and listeningto the patient’s own perception of their care

These three elements for high-quality care arefundamental to the CCG and our work inmonitoring and improving the quality of services.

Quality Assurance Framework

We aim to raise the quality of services wecommission through robust contract monitoringwith our providers. We monitor and review thequality of the services to ensure that the needs ofour population are being met. Learning fromprevious failures in quality across the NHS hasemphasised the important role commissionersshould play in preventing failures and drivingimprovements.

This ensures there is clear sight of all emergingissues and that any concerns raised can be swiftlyinvestigated and assurance provided. The ClinicalQuality Committee/ Integrated Governance andQuality Committee identifies any emergingconcerns and ensures these are investigated andwill raise a challenge/assurance to the GoverningBodies as necessary.

In 2017/18 the CCG continued to focus onstrengthening processes to help deliver ourmission of putting quality at the heart ofeverything we do and ensuring we meet ourstatutory duties in respect of the quality of serviceswe commission.

GP Alerts

All 23 GP practices in Merton, as well as carehomes, have access to a quality alert system(Amber Alerts) to help them easily raise qualityissues. The system managed via the NELCommissioning Support Unit allows GPs to raiseconcerns – and also praise providers that haveprovided a good service.

Common themes for alerts raised in 2017/18included communication, referral/appointmentissues and concerns regarding the standard ofcare. Alerts that are classified as ‘high’ or ‘severe’risks are sent to providers for investigation. During2017/18 we requested that all alerts, whatevertheir classification were forwarded to theappropriate provider to enhance learning as evenlow risk alerts can have a positive impact onsafety, effectiveness and patient experience.

In 2018/19 we will review the amber alert systemto ensure that a high quality, high impact system isenabled across the South West London Alliance ofCCGs. This will enable a universal approach andimprove the sharing of intelligence about ourproviders. This will also include the launch of a‘reverse alert’ system, where alerts can be raisedabout GP practices by providers.


A wide range of quality intelligence is used againstidentified ‘early warning’ quality outcomeindicators in order to form a picture of the qualityof each commissioned service. Where we identifyareas of concern, these are addressed directly withproviders to understand the causes and to supportimprovements.

We hold providers to account for the delivery ofhigh quality care through Clinical Quality ReviewMeetings (CQRMs) which are established throughthe NHS standard contract. As well as monitoringperformance of contracts, the CCG also obtainsupdates regarding the quality and safety ofservices via an alert system and through visits,both announced and unannounced, to servicesenabling the exploration of patient experience tounderstand the reality behind the data.

From February 2018 the previous Merton CCGClinical Quality Committee and the NHSWandsworth CCG Integrated GovernanceCommittee have been working together as anLDU Integrated Governance and QualityCommittee. The work of the CQRMs is reported tothe LDU Integrated Governance and QualityCommittee, which provides assurance to theBoard. The remit and further details about theIntegrated Governance and Quality Committeecan be found on page 61.

The CCG has ensured the patient experience isconsidered and their voice heard at the CCGClinical Quality Committee and the LDU IntegratedGovernance and Quality Committee meetingsthrough patient stories. Patient EngagementGroup meeting notes are also presented, ensuringthe patient voice is a thread through thecommittee process.

The Integrated Governance and QualityCommittee is co-chaired by the Clinical Chairs ofthe two CCGs. The Merton CCG Governing BodyLay Member, Patient and Public Engagement Leadis a member of the committee.


Complaints and Patient Advice and LiaisonService (PALS)

Complaints, queries and concerns provide valuableinformation about our population’s viewsregarding the quality of services and careprovided. The CCG Clinical Quality Committee/Integrated Governance and Quality Committeeregularly reviews complaints and PALS to identifythemes and potential issues.

We are committed to an open and transparentapproach and will respond in full to complaintsand queries and ensure that where possible thingsare put right and lessons learnt. The learning fromour investigations helps us ensure that ourproviders improve the quality of patient care andhelps to prevent a repeat of failings within theorganisation.

PALS offers confidential advice, support andinformation on health-related matters for patients,their families and carers. You can find your nearestPALS office on the NHS Choices website or youcan also ask your GP surgery, hospital or phoneNHS 111 for details of your nearest PALS.

Complaints are managed via the NELCommissioning Support Unit (NELCSU) on behalfof the CCG. During 2017/18 the CCG has workedwith NELCSU to investigate and respond tocomplaints received. Complaints to the CCG canbe about the commissioning of services by theCCG or about services delivered by providers thatare commissioned by the CCG.

There were 90 PALs enquiries registered in2016/17 and 50 in 2017/18. There were 57complaints registered in 2016/17 and 39 in2017/18. This is a significant reduction for bothcomplaints and PALs enquiries and the CCG areinvestigating the reasons for this and will beundertaking some awareness raising work toencourage the Merton population to providefeedback during 2018/19.

The CCG seeks to respond to a complaint within atimescale agreed with the complainant with 25

days set as a default and to respond to PALsenquiries as soon as practical.

In 2017/18 there was one breach inacknowledging a complaint at four days. Therange was zero to four days with the mode at twodays. For PALS enquiries there were three breachesin acknowledging an enquiry – two enquiries tookfour days and one enquiry took 16 days.

Of the 39 complaints received in 2017/18, 32(82%) are closed. Of the 32 closed complaints 19(59%) breached the agreed timescale (25 days).The range for closure of complaints was 0 – 217days. Of the seven complaints that remain open,four (66%) are already breaching the agreedtimescale, with the range (as at 14th March 2018)at 13 – 108 days.

Of the 50 PALs enquiries received in 2017/18, 46(92%) are closed within a range of 0 – 80 days.

The top three themes from complaints for2017/18 were; access to services, ContinuingHealthcare and provider services, similar to2016/17. The top three themes for PALs enquirieswere; Continuing Healthcare, commissioning andaccess to services.

As a result of complaints and PALs enquiries,primarily concerns around eligibility for CHCfunding and the quality of care provided by theCHC service, together with other intelligence, theCCG has focused on striving to improve theContinuing Healthcare (CHC) service delivered viaCentral London Community HealthCare NHS Truston behalf of the CCG.

During 2017/18 the CCG developed a trainingresource regarding dealing with complaints forCCG staff and this will be shared with other CCGcolleagues and providers in 2018/19.

In 2018/19 we will review the complaintsmanagement system to ensure that a high quality,high impact system is enabled across NHS Mertonand NHS Wandsworth CCGs, ensuring that thestandards set are fully adhered to and addressingthe response time issues identified above.

Clinical Quality Review Group (CQRG) to monitorand discuss all aspects of the quality of careprovided. The CQRG meeting is chaired by theSouth West London Mental Health TransformationChair who is also the GP Clinical Lead for mentalhealth in Kingston CCG. The CQRG meeting formspart of our quality oversight and scrutiny process.It allows the transparent and open discussion ofissues and monitoring of improvements. A numberof issues that the CQRG meeting for South WestLondon and St George’s Mental Health NHS Trustdiscussed in 2017/18 led to tangibleimprovements:

� The Trust has opened two recovery cafes (inWimbledon and Tooting) to support adultsexperiencing mental health issues.

� Scrutiny into serious incident themes such asrestricted practice and self-harm.

� Triangulation and visibility of complaints,incidents, quality alerts and other intelligenceon a regular basis

� Focus on suicide: South West London and StGeorge’s Mental Health NHS Trust haveundertaken a comprehensive review of allunexpected deaths of service users known tothe Trust during a set period of time. The reportwas presented to the South West London andSt George’s Mental Health NHS Trust CQRG inMarch 2018 and the CCG will now work withthe trust to progress the implementation ofrecommendations. The CCG endorses the aimof reducing the number of suicides within theMerton population via partnership working viathe Borough Suicide Prevention Strategy.

This responsibility will transfer to Kingston andRichmond Local Delivery Unit in 2018/19.

Central London Community Healthcare NHSTrust (CLCH)

The CCG commissions community servicesincluding Continuing Healthcare (CHC) fromCentral London Community Healthcare NHS Trust


Parliamentary Health Services Ombudsman(PHSO) decisions

The PHSO make final decisions on complaints thathave not been resolved by the NHS in England andUK government departments and other publicorganisations. They do this fairly and withouttaking sides. Their service is free. Furtherinformation is available on their website:https://www.ombudsman.org.uk/

Merton PHSO One – upheld. cases in Recommendations made 2017/18 and followed by CCG

One – PHSO decided not to investigate

In the one case concluded during 2017/18 theOmbudsman made recommendations that theCCG apologise to the complainant and pay arecompense and forward information aboutchanges to systems that the CCG has made as aresult of the case. We have sought to complywith the requirements of the PHSO.

Ravensbury Park Medical Practice

The practice was inspected by the CQC in January2017, with a report published on 30 March 2017.An overall rating of ‘Inadequate’ was given andthe practice placed in special measures. The CCGhas worked with NHS England and the RoyalCollege of General Practitioners (RCGP) PracticeSupport Programme to support the practice. Thepractice is now working in partnership withanother local practice to secure the necessaryimprovements to care.

South West London and St George’s MentalHealth NHS Trust

In 2017/18, Merton CCG was the leadcommissioner for South West London and StGeorge’s Mental Health NHS Trust and held aformal dedicated meeting each month of the


(CLCH) and holds a formal dedicated meetingeach month of the CQRG to monitor and discussall aspects of the quality of care provided. TheCQRG Meeting is chaired by the Director ofQuality and Governance. The CQRG meetingforms part of our quality oversight and scrutinyprocess. It allows the transparent and opendiscussion of issues and monitoring ofimprovements. A number of issues that the CQRGmeeting for CLCH discussed in 2017/18 led totangible improvements:

� The 90% target for Routines (adult) assessedwithin 20 working days was the subject of aReview Meeting in May 2017 and a remedialplan was instigated resulting in improvements.This has had a positive impact on patientexperience.

� Scrutiny into serious incident themes

� Continuing Healthcare: During 2017/18 theCCG has monitored the service and hascommissioned an external consultant to provideexpertise in CHC from both a clinical andmanagerial basis. Processes and systems havebeen reviewed and CLCH supported to bringlocal practice in line with the NHS NationalFramework for Continuing Healthcare and NHS-Funded Nursing Care (Department of Health,2014). This work is ongoing.

Associate Commissioner

We are an associate commissioner for otherproviders such as St George’s University HospitalsNHS Foundation Trust, Epsom and St HelierUniversity Hospitals NHS Trust and Kingston NHSFoundation Trust. We send a representative tomeetings and quality is monitored in associationwith colleagues from the Lead Commissioner CCG

St George’s University Hospitals NHSFoundation Trust

St George’s University Hospital NHS FT started theyear with financial challenges which had been

continuing from the previous year. The CareQuality Commission (CQC) inspected the trust inJune 2016 and gave a rating of ‘Inadequate’resulting in the Trust being put in special measuresfor quality. Throughout 2017/18 the CCG hasbeen working with the trust together with anumber of agencies such as NHS Improvement(NHSI), CQC, and NHSE to support the trust withits quality improvement programme (QIP). TheCQC has revisited the trust since its last inspectionand some progress is being seen in some areaswith ongoing actions being monitored via CQRGand other platforms.

Clinical Harm Review Process

In line with the waiting list reporting issuesidentified in 2016/17 at St George’s UniversityHospitals NHS FT, the CCG has worked with thetrust to ensure a robust clinical harm reviewprocess is in place. This is overseen by an externalClinical Harm Group (CHG), independently chairedby an Associate Medical Director from NHSEngland. The group includes representatives fromCCG commissioners, Quality Leads, GP ClinicalLeads, the CQC, NHSI and the trust seniorclinicians, and has leadership and oversight of theclinical review process, ensuring the internal teamare adequately resourced and are tackling thepertinent issues and high risk groups. The CHGreports to the trust’s acute Clinical Quality ReviewGroup (which is chaired by a Wandsworth GP).

The trust has made significant progress sinceidentification of the referral to treatment (RTT)issues in 2016 and manages severe harm cases toensure they are adequately investigated andactions are put in place to address issuesidentified.

Clinical Quality Review Meeting (CQRMs)

CQRMs are formal dedicated monthly meetingswith our major providers to monitor and discuss allaspects of the quality of care provided. CQRMs arechaired by GP leads and form part of our detailed

Framework 2015 and this is embedded within allcontracts. These also apply to those servicescommissioned by healthcare providerorganisations.

The CCG ensures that organisations commissionedto provide healthcare services have systems inplace that safeguard children, young people andadults at risk in line with section 11 of theChildren Act 2004 and Care Act 2014. Thisincludes clear accessible policy and procedures,safer recruitment, training and governancesystems, which are monitored by Merton CCG,Head of Safeguarding / Designated NurseSafeguarding Children and DesignatedSafeguarding Adult Lead through performancereporting frameworks.

Merton CCG meets the statutory requirements inregard to safer recruitment practices. Disclosureand Barring Service (DBS) checks are undertakenfor new staff and repeated for existing staff. Thesefunctions and duties are managed through theCCG’s human resources function which iscommissioned through the NHS North EastLondon Commissioning Support Unit (NELCSU).

The CCG ensures all staff complete relevantsafeguarding training at a level appropriate totheir role and this training is regularly reviewedand updated. Training of staff is as follows:

� Safeguarding Children: Level 1 (all staff) 90%

� Safeguarding Adults: Level 1 (all staff) 88%

All safeguarding professionals requiring level 4 andabove safeguarding training have accessedtraining.

In addition, 82% of staff received the counterterrorism training Prevent during the year.

We publish our safeguarding statement forchildren and adults and the Governing Bodyreceives an annual report on both safeguardingadults and safeguarding children.


quality oversight and scrutiny process. They allowa transparent and open discussion of issues totake place and improvements to be monitored.Wandsworth CCG is the lead commissioner in thecontract with St. George’s University Hospitals NHSFT, and has responsibility for chairing the CQRM. Anumber of issues that the CQRM at the trustdiscussed in 2017/18 led to tangibleimprovements:

� Increased scrutiny into serious incident themessuch as failure to follow up, early warning signsand managing deteriorating patients, falls andpressure ulcers

� Increased triangulation and visibility ofcomplaints, incidents, quality alerts and otherintelligence on a regular basis

� Scrutiny into infection control processes,safeguarding and other quality areas such asstaffing

� Review into the process for cancer referrals andpathway management, in particular 100 daybreaches and link with RTT programme workand clinical harm process

� CQRG oversight and feedback from clinicalharm group and patient safety and qualityboard

Safeguarding

Safeguarding children, young people andadults at risk of abuse and neglect

We are committed to protecting and safeguardingchildren, young people and adults at risk of abuseand neglect and are fully engaged in the work ofthe Merton Local Safeguarding Children Boardand Merton Safeguarding Adult Board.

As a commissioner of health services we are fullycompliant with the Safeguarding VulnerablePeople in the NHS Accountability and Assurance


Patient and Public Involvement(PPI)

This year we have continued to ensure thatpatients, residents and carers are actively engagedand involved in helping us commission, review andimprove local services. We have also reviewed thepatient engagement work undertaken and soughtto develop and enhance the role played by ourPatient Engagement Group (PEG).

Assurance

The Governing Body Lay Member for PPI providesassurance and challenge on work undertaken onPPI and how it has improved patient experience byengaging and listening to patients andstakeholders. She provides a link between issuesand concerns expressed by patients and serviceusers and the ability to listen and address these bythe Governing Body and our staff.

The Patient Engagement Group minutes arereviewed at the Clinical Quality and GovernanceCommittee. The Lay Member PPI has regularmeetings with both the Chair of the GoverningBody and the Director of Quality and Governancewhich gives the opportunity for any questions orconcerns to be raised directly.

Patient Stories

To ensure that patient and service user’s voices areheard at the highest level within the CCG ‘PatientStories’ are shared at the CCG board meetingswhich are held in public. In July 2017 the storyfrom a local young woman allowed for an in-depth discussion of the experiences that she - andothers – had of accessing and using mental healthservices in Merton. The talk provided a movingand passionate account of her personal experienceof using mental health services areas andimportantly, where changes could be made to helpimprove the experience and outcomes for youngpeople accessing the mental health services wecommission.

In January 2018, the CCG invited a carer fromAdults First to talk to the governing body abouther experience of looking after her adult son whohad a learning disability and their experience ofusing and accessing NHS services since he was achild. She explained how care and treatment hadimproved since he had first started using NHSservices and this was due to some excellent workwith staff trained on learning disability at StGeorge’s University Hospitals NHS FT. However,she felt that there still needed to be a joined upapproach between health and social care agencies

The Governing Body meeting also includes anopportunity for local people to ask questions. Thisyear this has included questions andrepresentations on possible changes to acuteservices across south west London and thepossible impact of the withdrawal of over-the-counter medicines and gluten free products.

Co-production

During 2017/18 CCG and NHS colleagues havecontinued to undertake work to involve andengage patients and service users oncommissioning and service improvement work.This has included co-design work on a healthyliving guide for older people. In September, over30 local patients and stakeholders came togetherto co-design materials with NHS England to helppatients make an informed choice on whatprovider to choose for secondary care referrals.

In November 2017 CCG commissioning staffundertook a wide and varied listening exercise togain feedback on commissioning priorities as partof the CCG’s commissioning intentionsdevelopment. The CCG met with over 300 peoplefrom groups and communities in Merton.

Patient Engagement Group

Our patient engagement group continues to growand diversify its membership and has alsobenefited from an increase in membership fromlocal service users and from representatives from

intelligence from patients from primary caresettings across the borough. PPG representativesare involved in the Patient Engagement Group andthe PPI Manager for Merton CCG began in2017/18 to help support and enhance the work ofPPGs in Merton. This work will continue in2018/19.

Digital engagement

We have continued to use digital channels as ameans of communicating and engaging with localpeople. Our website acts as a source ofinformation and engagement for patients, thepublic and all local stakeholders. People can sendfeedback via email or by using an online form, findout about up-coming opportunities to hear aboutour work or get involved in engagement activity.

See www.mertonccg.nhs.uk

We also use social media including Twitter andFacebook to ensure local people can find outabout the work we are doing and to ask questionsor give feedback. We use our social mediaaccounts to help promote local health and careinitiatives, events and job opportunities by partnerorganisations. This can include re-tweeting publicmeeting dates, calls for patient participation orhelping to raise awareness of local initiatives suchas help for victims of domestic violence or hatecrime. In this way Merton seeks to show supportacross the broadest spectrum of health and well-being locally.

Follow us @NHSMertonCCG or find us onfacebook

Meeting the Collective Duty

This section explains how the CCG has ensuredpublic involvement and consultation incommissioning processes and decisions, whichinclude involvement of the public, patients andcarers in: commissioning activities, planning ofproposed changes to services monitoring, insightand evaluation.


local groups. This has included representationfrom Kids First, Merton Muslim Women’s Groupand Hearts and Minds.

This year the group has been involved incontributing to the development of local initiativessuch as the development of a new diabetespathway to support both Type 1 and Type 2patients. The group was also able to helpcommissioners develop a new access andinformation pathway to allow patients to getreferred to a provider. The membership alsohelped to review and suggest changes toengagement plans and patient facing materials inrelation to Merton’s Autism Strategy, NHSEngland’s Choice Framework, self-care andsupport for the frail elderly booklet, and morerecently supporting changes to local podiatryservices.

Group members have used their experience toprovide support to specific areas of work such asimproving access to health checks within GPpractices for Black, Asian and Minority Ethnic(BAME) communities, which included specificwork with BAME PEG members to understandhow best to promote this initiative to targetgroups and communities.

The PEG continues to advise CCG staff andpartners on the production and development ofwritten material using the guidance from theaccessible information standard. This year theyhave contributed to the development of easy readmaterial to support engagement on a new autismstrategy. They also advised on signposting tocommunity and voluntary organisations to ensurethat messaging and information on new servicesreaches a variety of communities and individuals.This has been assisted by organisations such as theMerton Talking Newspaper.

Supporting and Developing our GP PatientGroups (PPGs)

A key part of the CCG’s engagement work is tosupport Practice Patient Participation Groups. TheCCG values the contribution and health


Mitcham Health Hub 2017

We hosted a Health Hub at Mitcham Carnival onSaturday 10 June 2017 where we promoted localhealth and wellbeing services and organisationsacross Merton. We invited many of our localgroups to join us. The event gave us and ourpartners the opportunity to:

� Engage and communicate with local people onpromoting health and wellbeing and providinginformation on the new GP hubs

� Promote when, where and how to accessservices, gain sign-up to initiatives including theExpert Patient programme

� Raise awareness of general health andwellbeing services available within the borough,including the development of the Wilson Healthand Wellbeing campus

� Encourage patients, public and carers to takepart in opportunities to get information onhealthy eating, advice on blood pressure, howto avoid strokes and practical support toindividuals and families on health andwellbeing.

We attracted over 1,000 people into the hub andmany of the visitors took away leaflets andinformation about local services and support. Inaddition 25 local residents signed up to get moreinvolved in the development of the Wilson Healthand Wellbeing Campus and over 100 localresidents answered our short questionnaire ontheir experience of GP hubs and out of hours GPservices.

Autism Pathway Engagement

As part of the CCG’s work to listen and engageparents and families on their views and experienceof the autism pathway in south west London, thePPI Manager and CCG commissioners workedwith a number of local groups including Kids First,Merton National Autistic Society, Eagle HouseSchool and Merton Carers. The events helped theCCG and local authority staff listen to the

experiences of families using the current pathway.As a result the CCG was able to engage withapproximately 30 families.

As a result of the feedback we are looking at thesupport that parents require when children arefirst diagnosed, and how families can quickly andeasily access services to help them understandautism and support their child. The feedback willhelp commissioners across south west London aswell as in Merton.

Co-production with NHS England on patientchoice

In September 2017 we hosted an event with NHSEngland to help us improve patient choice acrosssouth west London. The event involved a numberof local groups and individuals from Mertonincluding:

� BAME Voice

� Merton Islamic Community Association

� Merton National Autistic Society

� Merton Elders Forum

� Merton Residents Health Forum

� Merton Tamil Elderly Group.

As a result of this co-design session NHS Englandrefined the way they were communicating andpromoting information to people about patientchoice. They changed the wording and format ofthe material being presented and also includedmore information about waiting times anddistance to locations.

Meeting the individual duty

This section explains how Merton CCG haspromoted the involvement of patients and carersin decisions which relate to their care ortreatment, including diagnosis, care planning,treatment and care management. This dutyrequires CCGs and commissioners to ensure thatthe services commissioned promote involvement

Stay Well This Winter

This year the CCG supported the national NHSand Public Health England winter campaign andundertook targeted engagement work to ensurekey ‘at risk’ and vulnerable groups were aware ofthe free flu vaccination and where to go for adviceand help over winter. In particular we targeted:

� Families with younger children (particularlythose aged two and three)

� The frail and elderly

� Those with long term conditions includingadults and children

� (partnered with the local authority) school agechildren

� Pregnant women.

Merton CCG worked with community andvoluntary sector partners to make sure keymessages on using the right service were sharedconsistently across the borough. This includedmessages about the GP hubs. We took flyers andposters to a number of events informing patientsand communities of where to go if they were ill orneeded medical advice over winter. This includedsending out information via schools and children’scentres in the borough as well as agencies such asJobcentre Plus.

GP survey

During 2017/18, we used information from GPsurveys to help refine our primary care strategy.Improving access is a key element of the CCGprimary care strategy and an area where localpeople have stated they want to see improvement.Feedback from the survey helped the CCG refineits plans to improve GP access and has supporteddevelopment of our 8am to 8pm seven day aweek service and the introduction of telephoneconsultations.


of patients in their own care, including:personalised care planning, shared decisionmaking, self-care and self-management supportinformation with targeted support.

Diabetes Truth Programme

With an increase in the prevalence of diabetesacross Merton, the Health and Wellbeing Boardundertook an innovative approach to finding outabout the experience of patients with diabetes.The Health and Wellbeing Board worked withlocal people with diabetes to ‘buddy’ them upwith members of the Board, so they could get anin depth understanding of living day to day withdiabetes and the particular challenges patients andcarers face. It is hoped that this work will help toinform new approaches and lead to a long-termimprovement in the clinical outcomes for patientsacross the borough.

Expert Patients Programme

The Expert Patients Programme (EPP) is a six weekprogramme for people with one or more long-term health conditions. The EPP is peer-led bytutors who have previously completed the courseand then trained as a tutor due to the positiveeffect it has had on their daily lives.

This peer-led approach allows tutors to supportthe participants by acting as role models in self-management and sharing their experiences ofliving with a long-term health condition. It alsohelps them encourage peer support within theroom, which allows for relationships to build andcontinue once the participants have completed thesix week programme.

The EEP offers three different courses:

� The Expert Patients Programme: A genericcourse for anyone living with any long-termcondition

� Looking After Me: a course for anyone who is acarer

� New Beginnings: a course for anyone living witha mental health condition.


Reducing health inequalities

In 2017/18, Merton CCG refreshed its equalityobjectives following engagement withcommissioning teams, the Patient EngagementGroup, Executive Team and Governing Body. Thenew set of equality objectives for the period 2017-2021 were developed following a review of theCCG’s Equality Delivery System (EDS2) andWorkforce Race Equality Standard results since2015.

Progress against the refreshed equality objectiveswill be reported in the Public Sector Equality DutyReport for 2018/19. The equality objectives will berefreshed annually in keeping with the changinghealth commissioning environment.

The Equality Objectives for 2017 to 2021 areas follows:

i Health inequalities: Increase overall access toMerton Improving Access to PsychologicalTherapies services to 15% of the morbidpopulation, with 25% of the referrals fromBlack Asian and Minority Ethnic (BAME)communities by March 2018

ii Provider assurance: Ensure all providersprovide clear information by March 2018 onhow services commissioned have led to betteroutcomes and access for groups protected bythe Equality Act

iii Patient/public engagement: Undertakeengagement with young people to raiseawareness of mental health support servicesand remove barriers to accessing them over thenext 12 months

iv Staff engagement/development: Improvestaff wellbeing, engagement and developmentto ensure the workforce is supported and well-represented by implementing Merton andWandsworth staff survey action plan by March2018.

The CCG delivered a comprehensive work plan toreduce inequalities, which included completing

equality analyses (EA) on over 20 different Quality,Innovation, Productivity and Prevention (QIPP)schemes. In addition, Merton CCG also completedan EA on the Community Dermatology Serviceand Community Ear, Nose and Throat Service.

Annually Merton CCG reviews at least twocommissioning priorities using the refreshed EDS2performance improvement tool as part of itsprogramme to reduce inequalities.

In 2017/18, as part of the assessment for Goals 1and 2 Merton CCG reviewed Merton ImprovingAccess to Psychological Therapy (MIAPT) Serviceand the Latent Tuberculosis Screening and TestingService. The services were reviewed foraccessibility and focus on improving patientoutcomes for groups protected under the EqualityAct at an engagement event with service users,carers and community groups on 7 December2017. The workshop graded each priority andidentified areas for improvement which have beencarried forward into the commissioningmonitoring framework for the services reviewed.

Key outcomes included:

For Latent Tuberculosis Screening and TestingService:

� Plans to undertake outreach to promote theservice to targeted population groups (migrantswho have been in the UK for five years),working with community and faith groups toraise awareness, dispel misinformation andaddress stigma associated with latenttuberculosis screening.

� Use of social media to promote screeningservice and the progress it has made.

� Through outreach – also ensure increased GPregistrations and screening for additional healthconditions (such as cervical screening and HIV).GP registrations should cover appointments forall types of screening as a way of securingconsent.

addressing inequality. Detail on Merton CCG’sprogress on equality and diversity can be found inits annual public sector equality duty report for theperiod January to December 2017. For moreinformation visit the CCG website

Priorities for 2018/19 include:

� To ensure providers co-operate with the CCG inproviding information on their employmentpractices and health outcomes andimprovement by protected characteristics

• The CCG continues to be transparent andaccountable to its staff, patients and localpopulation in its employment andcommissioning practices and decision-makingprocesses

� Equality objectives are reviewed annually toassess for change and improvement

� The EDS2 actions for latent tuberculosisscreening and testing and MIAPT areimplemented.

� Staff and Governing Body members continue topromote and support the CCG’s commitment toequality, diversity and inclusion.

Workforce Race Equality Standard (WRES)

The CCG currently uses the NHS StandardConditions of Contract with all providers, whichincludes specific clauses on equality and diversity.Since April 2016, the standard conditions ofcontract it is mandatory for providers holdingcontracts over £200,000 to publish (andcommunicate to the CCG) their Workforce RaceEquality Standard metrics and implement the EDS.

Merton CCG has published an internal report onthe WRES for 2017/18, which was approved bythe Clinical Quality Committee and has developeda provider assurance framework whereby keyproviders report progress against their WRESmetrics annually through the Clinical QualityReview Group. The WRES Action Plan will beintegrated with the EDS2 Action Plan for the yearand is available on the CCG website.


For MIAPT a service plan is being developedto:

� Identify which BAME communities are accessingthe service.

� Promote the service to young people, especiallyweb-based services and information portals.

� Manage transition from children’s services toadult services smoothly

� Review access and outcomes for people withlearning disabilities.

� Improve collaboration with social housingproviders.

The assessment of EDS2 Goal 3 and Outcome 4.3focuses on staff experiences and inclusiveleadership and was concluded in April 2018. In2017 Merton CCG participated in the NHS StaffSurvey for the first time and the results fed intostaff engagement for EDS2 Goal 3. For EDS2 Goal4, an engagement workshop has been planned toidentify diversity targets for Governing Body boardmembers. Board papers for the past year have alsobeen reviewed for consideration of equality anddiversity risks.

Merton CCG staff can participate in the Mertonand Wandsworth Joint Staff Forum. The Forumhas monitored the Staff Survey Action Plan whichwas informed by the EDS2 results for Goal 3 in2016/17. The EDS2 Report and Action Plan ispublished on the CCG’s website.

Merton and Wandsworth Equality andDiversity Steering Group

The equality and diversity work programme ismonitored by the joint Merton and WandsworthEquality and Diversity Steering Group (EDG), whichincludes Governing Body members,commissioning and patient and public involvementteams and representatives from the Public HealthTeams from London Borough of Merton andRichmond Council. The EDG makesrecommendations for strategic decisions related to

Corporate Governance Report


2 Accountability Report

Members Report

Details of Membership

For the year ending 31 March 2018 the CCG had23 member practices organised into two localities.Each locality is led by a nominated GP clinical lead,who is a member of the CCG’s ExecutiveManagement Team and Clinical Reference Group.This is integral to how we ensure that all decisionshave clinical review, input and challenge. Inaddition, a Clinical Reference Group (CRG) made

up of primary care clinicians including GPs andnurses, further enhances clinical decision makingon wider transformational and system-widechange.

East Merton: The Locality Lead is Dr KarenWorthington In 2017/18 there were eight member practiceswithin the locality

West Merton – The Locality and Clinical Leadis Dr Tim HodgsonIn 2017/18 there were 15 member practices withinthe locality

Merton CCG Member Practices

Name Address

Alexandra Surgery 39 Alexandra Road, Wimbledon SW19 7JZ

Francis Grove Surgery 8 Francis Grove, London, SW19 4DL

Grand Drive Surgery 132 Grand Drive, Raynes Park, SW20 9EA

James O’Riordan Medical Centre 70 Stonecot Hill, Sutton SM3 9HE

Lambton Road Medical Practice 1 Lambton Road, Raynes Park, SW20 0LW

Morden Hall Medical Centre 256 Morden Hall Road, London SW19 3DA

The Nelson Medical Practice 220 Kingston Road, London SW20 8DA

Princes Road Surgery 51 Princes Road, Wimbledon, SW19 8RA

Stonecot Surgery 115 Epsom Road, Sutton SM3 9EY

Vineyard Hill Road Surgery 67 Vineyard Hill Road, Wimbledon SW19 7JL

Wimbledon Village Surgery 35A High Street, Wimbledon SW19 5BY

Central Medical Centre 42-46 Central Road, Morden SM4 5RT

Merton Medical Centre 12-17 Abbey Parade, Merton High Street SW19 1DG

Colliers Wood Surgery 58 High Street, Colliers Wood, SW19 2BY

Figges Marsh Surgery 182 London Road, Mitcham CR4 3LD

Mitcham Family Practice 55 Mortimer Road, Mitcham, CR4 3HW

Ravensbury Park Medical Centre Ravensbury Lane, Morden Road, Mitcham CR4 4DQ

The Rowans Surgery 1 Windermere Road, Streatham SW16 5HF

Tamworth House Medical Centre 341 Tamworth Lane, Mitcham CR4 1DL

Cricket Green Surgery 75-79 Miles Road, Mitcham CR4 3DA

Mitcham Medical Practice 81 Haslemere Ave, Mitcham CR4 3PR

Riverhouse Surgery East Road, Wimbledon, SW19 1YG

Wide Way Surgery 15 Wide Way, Mitcham CR4 1BP


Statement of Accountable Officer’sResponsibilities

The National Health Service Act 2006 (asamended) states that each Clinical CommissioningGroup shall have an Accountable Officer and thatOfficer shall be appointed by the NHSCommissioning Board (NHS England). NHSEngland has appointed Sarah Blow to be theAccountable Officer of Merton CCG.

The responsibilities of an Accountable Officer areset out under the National Health Service Act2006 (as amended), Managing Public Money andin the Clinical Commissioning Group AccountableOfficer Appointment Letter. They includeresponsibilities for:

� The propriety and regularity of the publicfinances for which the Accountable Officer isanswerable,

� For keeping proper accounting records (whichdisclose with reasonable accuracy at any timethe financial position of the ClinicalCommissioning Group and enable them toensure that the accounts comply with therequirements of the Accounts Direction),

� For safeguarding the Clinical CommissioningGroup’s assets (and hence for taking reasonablesteps for the prevention and detection of fraudand other irregularities).

� The relevant responsibilities of accountingofficers under Managing Public Money,

� Ensuring the CCG exercises its functionseffectively, efficiently and economically (inaccordance with Section 14Q of the NationalHealth Service Act 2006 (as amended)) and witha view to securing continuous improvement inthe quality of services (in accordance withSection14R of the National Health Service Act2006 (as amended)),

Governing Body

The Governing Body oversees the delivery of theCCG’s commissioning plan, sets and leads thestrategy for the CCG and is accountable for thedelivery of our functions as a statutory body. Thereare three GPs on the Governing Body including theClinical GP Chair.

See page 59 for details of the Chair andAccountable Officer and composition of theGoverning Body.

Register of InterestsThe Register of interests for Merton CCG ispublished on the CCG website.

Personal data related incidentsThere have been no serious internal incidents orinformation governance issues and one providerincident requiring reporting to the InformationCommissioner’s Office for Merton CCG.

Statement of Disclosure to AuditorsEach individual who is a member of the CCG atthe time the Members’ Report is approvedconfirms:

� so far as the member is aware, there is norelevant audit information of which the CCG’sauditor is unaware that would be relevant forthe purposes of their audit report

� the member has taken all the steps that theyought to have taken in order to make him orherself aware of any relevant audit informationand to establish that the CCG’s auditor is awareof it.

Modern Slavery ActMerton CCG fully supports the Government’sobjectives to eradicate modern slavery and humantrafficking but does not meet the requirements forproducing an annual Slavery and HumanTrafficking Statement as set out in the ModernSlavery Act 2015

http://www.mertonccg.nhs.uk/News-Publications/Documents/CCG-Register-of-Interest-17-18.pdf


I also confirm that:

� as far as I am aware, there is no relevant auditinformation of which the CCG’s auditors areunaware, and that as Accountable Officer, Ihave taken all the steps that I ought to havetaken to make myself aware of any relevantaudit information and to establish that theCCG’s auditors are aware of that information.

� the annual report and accounts as a whole isfair, balanced and understandable and that Itake personal responsibility for the annualreport and accounts and the judgmentsrequired for determining that it is fair, balancedand understandable

Sarah Blow, Accountable Officer for NHS Merton CCG

NHS England Core Standards for EPRR

Merton CCG is a tier 2 responder in any majorincident or emergency, which means we may becalled to help NHS England who takes the lead onany major incidents in London. We discharge thisresponsibility via a formal arrangement with NELCommissioning Support Unit. Merton andWandsworth Local Delivery Unit ManagingDirector and directors take their part in the SWLondon CCG Directors on call rota.

We certify that the clinical commissioning grouphas incident response plans in place, which arefully compliant with the NHS CommissioningBoard Emergency Preparedness Framework 2013.The clinical commissioning group regularly reviewsand makes improvements to its major incidentplan and has a programme for regularly testingthis plan, the results of which are reported to theGoverning Body

� Ensuring that the CCG complies with itsfinancial duties under Sections 223H to 223J ofthe National Health Service Act 2006 (asamended).

Under the National Health Service Act 2006 (asamended), NHS England has directed each ClinicalCommissioning Group to prepare for eachfinancial year financial statements in the form andon the basis set out in the Accounts Direction. Thefinancial statements are prepared on an accrualsbasis and must give a true and fair view of thestate of affairs of the Clinical CommissioningGroup and of its net expenditure, changes intaxpayers’ equity and cash flows for the financialyear.

In preparing the financial statements, theAccountable Officer is required to comply with therequirements of the Group Accounting Manualissued by the Department of Health and inparticular to:

� Observe the Accounts Direction issued by NHSEngland, including the relevant accounting anddisclosure requirements, and apply suitableaccounting policies on a consistent basis;

� Make judgements and estimates on areasonable basis;

� State whether applicable accounting standardsas set out in the Group Accounting Manualissued by the Department of Health have beenfollowed, and disclose and explain any materialdepartures in the financial statements; and,

� Prepare the financial statements on a goingconcern basis.

To the best of my knowledge and belief, I haveproperly discharged the responsibilities set outunder the National Health Service Act 2006 (asamended), Managing Public Money and in myClinical Commissioning Group Accountable OfficerAppointment Letter.


national recommendations in order to ensure thatwe have an effective system in place to meetstatutory requirements.

The CCG Constitution takes account of the Nolanprinciples, the Good Governance Standards forpublic services and the key principles of the NHSConstitution.

UK Corporate Governance Code

We are not required to comply with the UKCorporate Governance Code. However, we havereported on our corporate governancearrangements by drawing upon best practiceavailable, including those aspects of the UKCorporate Governance Code we consider to berelevant to the clinical commissioning group andbest practice.

Discharge of Statutory Functions

The clinical commissioning group has reviewed allof the statutory duties and powers conferred on itby the National Health Service Act 2006 (asamended) and other associated legislative andregulations. As a result, I can confirm that theclinical commissioning group is clear about thelegislative requirements associated with each ofthe statutory functions for which it is responsible,including any restrictions on delegation of thosefunctions. Responsibility for each duty and powerhas been allocated to a lead Director. Directorateshave confirmed that their structures provide thenecessary capability and capacity to undertake allof the clinical commissioning group’s statutoryduties.

Risk management arrangements andeffectiveness

Merton CCG has developed a comprehensive riskmanagement framework which identifies specificrisks, responsibilities and mitigating actions atboth a strategic and operational level, and thenthrough various committees escalating the mostimportant of these to the Governing Body via theBoard Assurance Framework.

Governance Statement

Introduction and context

Merton CCG is a body corporate established byNHS England on 1 April 2013 under the NationalHealth Service Act 2006 (as amended). As at 1April 2018, the clinical commissioning group is notsubject to any directions from NHS England issuedunder Section 14Z21 of the National HealthService Act 2006.

Scope of responsibility

As Accountable Officer, I have responsibility formaintaining a sound system of internal controlthat supports the achievement of the clinicalcommissioning group’s policies, aims andobjectives, whilst safeguarding the public fundsand assets for which I am personally responsible,in accordance with the responsibilities assigned tome in Managing Public Money. I also acknowledgemy responsibilities as set out under the NationalHealth Service Act 2006 (as amended) and in myClinical Commissioning Group Accountable OfficerAppointment Letter. I am responsible for ensuringthat the clinical commissioning group isadministered prudently and economically and thatresources are applied efficiently and effectively,safeguarding financial propriety and regularity. Ialso have responsibility for reviewing theeffectiveness of the system of internal controlwithin the clinical commissioning group as set outin this governance statement.

Governance arrangements and effectiveness

The main function of the governing body is toensure that the group has made appropriatearrangements for ensuring that it exercises itsfunctions effectively, efficiently and economicallyand complies with such generally acceptedprinciples of good governance as are relevant to it.

The sections below describe how we dischargethese responsibilities. We have based ourgovernance systems on best practice guidance and


The Board Assurance Framework (BAF) provides acomprehensive method for effective and focusedmanagement of the principal risks that arise inmeeting the CCG’s objectives and ensures that theCCG Governing Body:

� is confident that the organisation’s corporateobjectives can be achieved

� has a process in place for identifying,minimising and prioritising risks that mayprevent the achievement of corporate objectives

� ensures strategic controls are in place tomanage those risks

� is satisfied with the assurance received thatthese controls are effective and risks aremanaged appropriately

The reporting of the Board Assurance Frameworkaccurately reflects the management of the currentrisks facing the CCG. The Board AssuranceFramework is regularly reviewed to ensure it is inline with the risk management needs of the CCG.

At an operational level, supported by NELCommissioning Support Unit, the executivemanagement team (EMT) reviews all risks to theorganisation on a cyclical basis. This ensures thatrisks are effectively identified, assessed, managedand monitored and provides assurance andtracking of effective internal controls that providereasonable assurance of effective and efficientoperations, financial stewardship, probity andcompliance with laws and policies. Risk appetitesare determined by individual risk owners andmoderated by the executive management teamduring the monthly review of the BAF.

The Audit Committee and Governing Bodyapprove the BAF periodically, as set out in theconstitution, including the risk appetite scores.Control mechanisms have been chosen accordingto best practice and management approachesagreed as appropriate by risk leads. The riskcontrols in place, enable the CCG to determinewhether the risks are being managed effectivelythrough:

At a strategic level, the Governing Bodydetermines the CCG’s overall risk appetite whichenables a consistent approach when developingoperational policies and provides assurance to theGoverning Body and management that objectivesare pursued within reasonable risk limits.

The Audit Committee reviews the establishmentand maintenance of an effective system ofintegrated governance, risk management andinternal control across all organisational activities,both clinical and non-clinical, which support theachievement of the CCG’s objectives.

All directors, as part of the Executive ManagementTeam and the Governing Body, have aresponsibility for identifying and managingstrategic risks for the organisation. Additionally,the executive directors are accountable formanaging operational risks associated with theirareas of responsibility. Each director is responsiblefor ensuring that the assurance framework reflectskey risks, controls and assurances related tostrategic objectives, and that these are reviewedregularly. Risks go through the following regularreview cycle:

� risk leads and the Risk Manager review andupdate risks on a regular basis throughout theyear;

� risk owners (Executive Directors) review risks;

� the Executive Management Team considers thecorporate risk register;

� risks are reviewed by their relevant committee ateach meeting (Integrated Governance, Finance,Primary Care Committees);

� The Integrated Governance Committee retainsoverall management of the risk managementframework;

� the Governing Body approves the RiskAssurance Framework, with amendments;

� Audit Committee provides independentoversight of the Risk Assurance Frameworkprocess.


Committee Structure

The Governing Body undertakes a proportion of itswork through committees. Each committee has aset of terms of reference, which have beenformally adopted by the Governing Body. Theapproved minutes of the committees arepresented to the Governing Body meetings,together with a verbal summary on any meetingsthat have occurred, but for which approvedminutes are not yet available.

Governing Body

The Governing Body oversees the delivery of theCCG’s commissioning plan, sets and leads thestrategy for the CCG and is accountable for thedelivery of Merton CCG’s functions as a statutorybody. It monitors performance against objectives,provides effective financial stewardship andensures high standards of corporate governanceare achieved. There are three GPs on theGoverning Body, including the Clinical GP Chair.

� Policies/guidelines

� Education and training

� Equipment

� Staff Competency

� Induction Programme

� Any other measures deemed necessary.

Sharing the learning through risk related issues,incidents, complaints and claims is an essentialcomponent to maintaining the risk managementculture within the CCG. Learning is acquired froma variety of sources which include:

� Analysis of incidents, complaints, claims andacting on the findings of investigations

� Internal and external audit reports

� Outcome of investigations and inspectionsrelating to other organisations

Capacity to Handle Risk

The responsibilities of Directors and committeesare set out in the CCG Constitution and theaccompanying Scheme of Delegation, as well asthe governance reporting lines. Timely andaccurate information, to assess risk and ensurecompliance with the CCGs statutory obligations, issubmitted in line with the CCGs annual plan ofcommittee work. The Governing Body hasrigorous oversight of the performance of the CCG,via formal Governing Body meetings, seminars,assurance from committees and audits.

Governance structure 2017/18

Integrated Governance& Quality Committee

Finance ResourcesCommittee

Primary CareCommittee

RemunerationCommittee

Audit &Governance

Governing Body

http://www.mertonccg.nhs.uk/about-us/Governance/Pages/default.aspx


Membership of the Governing Body

Name Role From To

Voting Members

Dr Andrew Murray Clinical Chair Apr 17 Mar 18

Sarah Blow Accountable Officer Apr 17 Mar 18

James Blythe Managing Director May 17 Mar 18

James Murray Chief Finance Officer South West London Alliance and Merton CCG Apr 17 Mar 18

Dr Karen Worthington GP Member May 17 Mar 18

Dr Tim Hodgson GP Member Apr 17 Mar 18

Peter Derrick Lay Member: Audit and Finance /Vice Chair Apr 17 Dec 17

Andrew Leigh Lay Member: Audit Nov 17 Mar 18

David Smith Lay Member: Finance Jan 18 Mar 18

Clare Gummett Lay Member: Patient & Public Engagement Lead Apr 17 Mar 18

Julie Hall Independent Nurse Member Apr 17 Mar 18

Prof. Stephen Powis Secondary Care Consultant Apr 17 Dec 18

Dr Dagmar Zeuner Director of Public Health, LBM Apr 17 Mar 18

Non-Voting Members

Neil McDowell LDU Finance Director Apr 17 Mar 18

Anthony Farnsworth Director of Commissioning Operations Apr 17 May 17

Josh Potter Director of Commissioning Operations Jun 17 Mar 18

John Atherton Director of Performance Improvement Nov 17 Mar 18

Andrew McMylor Director of Primary Care Transformation Apr 17 Mar 18

Julie Hesketh Director of Quality and Governance Apr 17 Mar 18

Dr Marek Jarzembowski Chair, Local Medical Committee Apr 17 Mar 18


Meeting Planned Meetings Meetings Additional QuorateNumber Held Cancelled Meetings

Governing Body 6 + 6 17 0 5 100%Seminars

Audit & Governance Committee 5 5 0 0 100%

Remuneration Committee 0 *1 0 0 100%

Finance Committee 12 11 1 0 89%

Clinical Quality Committee (10)

Integrated Governance and Quality Committee (2) 12 12 0 0 83%

Primary Care Committee 6 5 1 0 60%

Executive Management Team 27 25 2 0 100%*

* The Remuneration committee was held as a committee in common across SWL attended by CCGmembers.

Merton Clinical Quality Committee (MCQC)and Integrated Governance and QualityCommittee (IGQC)

Chair: Clare Gummett (for MCQC)

The MCQC has met monthly throughout the year,with the remit of providing assurance to theGoverning Body that commissioned services arebeing delivered in a high-quality and safe manner.The MCQC has been vital in ensuring that qualitysits at the heart of everything the CCG does.

Each month the committee has a key focus. Overthe year this has included: patient experience,safety (including infection control) and qualityconcerns at our acute trusts, mental health servicesincluding South West London and St George’sMental Health NHS Trust and Improving Access toPsychological Therapies (IAPT), ContinuingHealthcare and Community Services (CLCH) - a sixmonth review.

From January 2018 the Clinical Quality Committeetransitioned to the shared Integrated Governanceand Quality Committee (IGQC) with Wandsworth

CCG. A quality sub-committee is being establishedto ensure to retain an ongoing focus on detailedquality metrics.

Audit and Governance Committee

Chair: Peter Derrick/Andrew Leigh

The Audit and Governance Committee has metquarterly during the year and provides theGoverning Body with a means of independent andobjective review of financial and corporategovernance, assurance processes and riskmanagement across the whole of the CCG’sactivities (clinical and non-clinical).

The committee is composed entirely of non-executive members.

The committee’s main activities through the yearhave been focused on financial controls,procurement, corporate risks, board assurance andthe external audit report. The committee alsolooked at issues around continuing healthcare andtender waivers.

Executive Management Team

This is a Local Delivery Unit meeting and as suchcovers both Wandsworth and Merton CCGbusiness. The meetings are attended by theexecutive management team and lead cliniciansand are chaired by the Managing Director.

This group is authorised by the Governing Body topursue any activity within the terms of referenceand scheme of reservation and delegation in orderto fulfil the responsibilities of the CCG and toenable the development and delivery of corporatedirection. This includes:

� Consideration of key strategic issues

� National policy initiatives

� Corporate responsibilities and leadership

� Overseeing operational management of theCCG

� Consideration of risks and priorities across thedirectorates and organisation

� Identifying and monitoring the implementationof remedial action plans as appropriate.

South West London Committees in Common(CiC):

The South West London Clinical CommissioningGroups have agreed the establishment ofCommittees in Common (CiC) for the purpose ofstrategic decision making, with particularreference to the South West London Five YearForward Plan or any successor strategy as agreedby the CCGs.

The role of a CiC is to take decisions on behalf ofthe CCGs as set out in the EstablishmentAgreement. Decisions will be taken by therepresentatives of each CCG on behalf of theirindividual CCG and will be taken only afterconsideration of the issues by the CCG GoverningBody and the engagement of the CCGmembership.

Finance Committee

Chair: Peter Derrick/David Smith

The finance committee was established by theGoverning Body to scrutinise financial planningand performance for Merton CCG, review areas ofconcern and report to the Governing Body asappropriate. It works alongside the audit andgovernance committee to ensure financial probityin the CCG.

Primary Care Commissioning Committee

Chair: Clare Gummett

This is a committee of the Governing Body asprescribed by schedule 1A of the ‘NHS Act’relating to delegated commissioning.

The committee functions as a corporate decision-making body for the management of thedelegated primary care commissioning functionsand the exercise of the delegated powers. Thecommittee has been established to enable theMembers to make collective decisions on thereview, planning and procurement of primary careservices in Merton, under delegated authorityfrom NHS England.

It is a committee comprising representatives ofMerton CCG, NHS England, London Borough of Merton, Local Medical Committee andHealthwatch Merton.

Remuneration and Nominations Committee

This committee advises and assists the GoverningBody in meeting its responsibilities to ensureappropriate terms of service, remuneration andallowances for the Accountable Officer, ManagingDirector, Chair, clinical leads, directors and anyother senior manager remunerated under the VerySenior Manager Pay Framework or other locallydetermined arrangements.

In addition to the above committees the CCG issupported by the following operational group:



Risk Assessment

Our risk profile reflects both the wide range ofservices we are responsible for commissioning andour responsibilities as leaders of the local healtheconomy.

The CCG Risk Register sets out all the current risksdescribing the nature of these risks, the existingcontrols in place and also actions required tomanage the risks.

New risks identified for inclusion on the CCG RiskRegister are assessed for their ‘Likelihood andConsequence’ using a 5x5 risk matrix inaccordance with the Integrated Risk ManagementFramework.

Risks rated 15 and above are reported to theIntegrated Governance and Quality Committeemonthly. The Governing Body has overallresponsibility for risk, and the Board AssuranceFramework which includes principal risks likely toimpact on the achievement of strategic objectivesis reviewed on a quarterly basis. The assuranceframework classifies principal risks as those thathave been assessed at the point of identification(prior to consideration of mitigating controls) witha risk score of 15 or above.

During 2017/18 there were a total of 10 risks onthe risk register that were initially given a score of15 or above (prior to mitigation). Following theconsideration of control mechanisms in place andthrough the implementation of controlimprovements during the year five of those riskscores have been significantly reduced and arebeing managed at a reduced level. The five keyhigh level risks currently on the risk registerinclude:

� Capacity of Central London CommunityHealthcare NHS Trust (CLCH) to delivercommissioned service related to integrated carebeds (current score 16)

� Failure to meet required standards against theImprovement and Assessment Framework(current score 16)

� Failure to deliver 'constitutional pledges' andother priority performance goals (current score 16)

� Financial and clinical challenges across southwest London require organisations to altercurrent ways of working (current score 16)

� If current internal and external structuralchanges are not managed well, this may impactupon staff morale and staff retention at MertonCCG (current score 16)

During the year the Board Assurance Framework(BAF) has been reviewed by Internal Audit. Thereview considered the extent to which thedocument remained live throughout the year andhow risks progressed during the period. TheInternal Audit Opinion concluded the currentsystems and controls provided reasonableassurance, though further improvements havebeen identified which will be taken forward.

Other sources of assurance

Internal Control Framework

A system of internal control is the set of processesand procedures in place in the clinicalcommissioning group to ensure it delivers itspolicies, aims and objectives. It is designed toidentify and prioritise the risks, to evaluate thelikelihood of those risks being realised and theimpact should they be realised, and to managethem efficiently, effectively and economically. The system of internal control allows risk to bemanaged to a reasonable level rather thaneliminating all risk; it can therefore only providereasonable and not absolute assurance ofeffectiveness.

Information Governance

The NHS Information Governance Framework setsthe processes and procedures by which the NHShandles information about patients andemployees, in particular personal identifiableinformation. The NHS Information GovernanceFramework is supported by an informationgovernance toolkit and the annual submissionprocess provides assurances to the clinicalcommissioning group, other organisations and toindividuals that personal information is dealt withlegally, securely, efficiently and effectively. Weplace high importance on ensuring there arerobust information governance systems andprocesses in place to help protect patient andcorporate information.

We have established an information governancemanagement framework and are developinginformation governance processes and proceduresin line with the information governance toolkit.We have ensured all staff undertake annualinformation governance training and haveimplemented a staff information governancehandbook to ensure all staff are aware of theirinformation governance roles and responsibilities.There are processes in place for incident reportingand investigation of serious incidents.

We are developing information risk assessmentand management procedures and a programmewill be established to fully embed an informationrisk culture throughout the organisation againstidentified risks. A comprehensive informationgovernance action plan is agreed at the beginningof each year, and implementation is monitored bythe information governance steering group,chaired by the Senior Information Risk Owner(SIRO), to ensure any gaps are identified andimprovements made. The action plan has anemphasis on ensuring that staff complete themandated modules of the IG e-learningprogramme and raises the importance of securityand confidentiality, in accordance with the CareRecords Guarantee.

Annual audit of conflicts of interestmanagement

The revised statutory guidance on managingconflicts of interest for CCGs (published June2016 and further updated in June 2017) requiresCCGs to undertake an annual internal audit ofconflicts of interest management. To supportCCGs to undertake this task, NHS England haspublished a template audit framework.

An Internal Audit review was carried out inDecember 2017 on the Conflicts of Interestprocesses set in place within the CCG. Theoutcome of the review noted that the Board cantake reasonable assurance that the controls uponwhich the organisation relies to manage theidentified risk(s) are suitably designed, consistentlyapplied and operating effectively.

Data Quality

In line with the need to know principles set out inthe Caldicott Information Governance ReviewReport, the CCG ensures that informationpresented to the Governing Body and othergovernance forums does not identify individualsand is fully anonymised.

Senior management diligently reviews informationto be set out in governance and decision makinginformation prior to consideration andpresentation to the relevant governance forums.

The quality of information that the GoverningBody and other governance forums receive toconsider and direct decision making is also assuredthrough the service level specificationarrangements with the NEL CommissioningSupport Unit and the use of contractualarrangements with the commissioned providers.The Governing Body and Membership Body aresatisfied that the quality of data provided to themis of a good standard.



During this year we worked with our informationgovernance expert service, NEL CommissioningSupport Unit, to achieve level 2 compliance in theinformation governance toolkit with a compliancescore of 86%.

We continue to develop our information riskassessment and management procedures andprogrammes to fully embed an appreciation ofinformation risk in the culture of the CCG, andwill continue in our diligence during the comingyear.

Business Critical Models

The CCG confirms that no business critical modelshave been identified that would requireinformation about quality assurance processes forthose models to be provided to the AnalyticalOversight Committee, chaired by the Chief Analystin the Department of Health.

Third party assurances

The CCG uses the NHS Standard Contract whichincludes the requirement that providers cannotenter sub-contracts without the prior approval ofthe coordinating commissioner. The approval mayinclude the terms of the sub-contract. Theprovider remains responsible for the performanceof sub-contractors. Any positive obligation or dutyon the part of the provider includes an obligationor duty to ensure that sub-contractors complywith that positive obligation or duty. The processfor receiving assurance about the performance ofsub-contractors will vary depending on the specificcase, but can for example include where asubstantial portion of contracted activity is to beprovided by a sub-contractor that routine contractmonitoring information is disaggregated by themain provider and the sub-contractor(s).

Control issues

No significant control issues have been identifiedduring 2017/18.

Review of economy, efficiency andeffectiveness of the use of resources

We have effective processes in place to ensurethat resources are used economically, efficientlyand effectively. The Board approves the annualaccounts, considers a finance report at eachmeeting, and discusses any risks in relation to theuse of resources. The Finance ResourcesCommittee supports the board in this role byensuring that the financial strategy is beingdelivered and by applying best value tests to areasof spend.

An Accredited Counter Fraud Specialist iscontracted to undertake counter fraud workproportionate to identified risks. This service isprovided in accordance with the standards for NHShealthcare commissioners relating to fraud, briberyand corruption published by NHS Counter FraudAuthority (NHS CFA) covering the four keysections: Strategic Governance, Inform andInvolve, Prevent and Deter and Hold to Account. Aproportionate proactive work plan addressesidentified risks and appropriate action is takenregarding NHS CFA quality assurancerecommendations.

The Audit Committee receives an annual reportfrom the Counter Fraud Specialist.

Head of Internal Audit Opinion

Following completion of the planned audit workfor the financial year for the clinical commissioninggroup, the Head of Internal Audit issued anindependent and objective opinion on theadequacy and effectiveness of the clinicalcommissioning group’s system of riskmanagement, governance and internal control.The Head of Internal Audit concluded that:

Head of Internal Audit Opinion 2017/18

Our opinion, based on work undertaken up to16th May 2018, is set out as follows:

The organisation has an adequate and effective

framework for risk management, governance andinternal control.

Our work has, however, identified furtherenhancements to the framework of riskmanagement, governance and internal control toensure that it remains adequate and effective.

Based on the work undertaken in 2017/18 there isa generally sound system of internal control,designed to meet the CCG’s objectives, andcontrols are generally being applied consistently.

Based on the work undertaken on the CCG’ssystem on internal control, the Head of InternalAudit did not consider that within these areasthere are any issues that need to be flagged assignificant control issues within the AnnualGovernance Statement (AGS).

During the year, Internal Audit issued thefollowing audit reports:

Area of Audit Level of Assurance Given

Financial Planning and QIPP Delivery Reasonable Assurance

Risk Management and Assurance Reasonable Assurance

Primary Care Payments Reasonable Assurance

Conflicts of Interest Reasonable Assurance

Continuing Healthcare Reasonable Assurance

Joint Working across SWL Primary Care Reasonable Assurance

Information Governance Toolkit Reasonable Assurance

Joint Working across SWL Cyber Assurance Advisory


Review of the effectiveness of governance,risk management and internal control

Our assurance framework provides me withevidence that the effectiveness of controls thatmanage risks to the clinical commissioning groupachieving its principles objectives have beenreviewed. I have been advised on the implicationsof the result of this review by:

� The Governing Body

� The audit committee

� If relevant, the risk / clinical governance / qualitycommittee

� Internal audit

� Other explicit review/assurance mechanisms

Conclusion

Internal Audit has not identified any issues thatneed to be flagged as significant control issueswithin the Annual Governance Statement.

Sarah Blow, Accountable Officer


Remuneration and Staff Report Remuneration ReportRemuneration Committee

The Remuneration Committee comprises of fourmembers. As there has been no pertinent businessin 2017/18, the Committee has not had cause tomeet during the past year. Matters pertinent to theremuneration of the Local Delivery Unit’s seniormanagers have been conducted by aRemuneration Committee in Common across SWLondon. Chair of the committee is now AndrewLeigh and was previously Peter Derrick. A full list ofmembers and their roles is below.

Name of Member Role Date joined Date leftcommittee committee

Andrew Leigh (Chair) Lay member for Audit and Governance 01.01.18 N/A

Peter Derrick Lay member for Audit and Governance 01.04.13 31.12.17

Julie Hall Independent Nurse Member 27.07.16 NA

Clare Gummett Lay member for Public Patient 01.04.13 NAInvolvement

Dr Andrew Murray Clinical Chair 01.04.16 NA

Remuneration Policy

The Committee’s deliberations are carried outwithin the context of national pay andremuneration guidelines, local comparability andtaking account of independent advice regardingpay structures. NHS Merton CCG will be using thenational pay and remuneration guidelines for thecoming financial year.

Senior Managers’ Performance Related Pay -Merton CCG does not have a policy ofperformance related pay for senior managers.

Senior Managers’ Service contracts - All seniormanagers’ at Merton CCG follow the national payand remuneration guidelines.


Senior Managers Remuneration (Audited)

2017/18 2016/17

Name & Title Note Salary & All Pension Total Salary & All Pension TotalFees (Bands Related Fees (Bands Relatedof £5,000) Benefits £5,000) Benefits

Dr. Andrew Murray – Chair 1 100-105 37.5-40 135-140 95-100 0 95-100

Sarah Blow – Accountable Officer 4 25-30 27.5-30 55-60

Clare Gummett – Lay person with

responsibility for patient and public

involvement 10-15 0 10-15 10-15 0 10-15

Professor Stephen Powis – Secondary

Care Consultant to 31/12/17 2 0 0 0 0 0 0

Dr Tim Hodgson – GP Member 15-20 0-2.5 20-25 15-20 5-7.5 25-30

Julie Hall- GP Independent Nurse –

from 21/7/16 5-10 0 5-10 10-15 0 10-15

Dagmar Zeuner- Director of

Public Health (LBM) 0 0 0 0 0 0

Dr Karen Worthington - GP

Clinical Board Member from 25/5/17 3 110-115 15-17.5 125-130

David Smith - Lay person with

responsibility for Finance &

Governance from 1/1/18 0-5 0 0-5

Andrew Leigh – Lay person with

responsibility for Audit from 8/11/17 0-5 0 0.5

James Blythe- Managing Director f

rom 1/5/17 3 40 -45 10-12.5 50-55

John Atherton – Director of

Performance from 1/5/17 4 35- 40 7.5-10 40-45

Neil McDowell – Local Director

of Finance 4 45- 50 7.5-10 50-55

Josh Potter- Director of

Commissioning from 10/7/17 4 25-30 10-12.5 35-40

Andrew McMylor – Director of

Primary Care 4 40-45 12.5-15 50-55

Julie Hesketh –Director of Quality

& Governance 4 35-40 17.5-20 50-55

Jonathan Bates Director of

Strategic Commissioning 4 25-30 15-17.5 45-50


2017/18 2016/17

Name & Title Note Salary & All Pension Total Salary & All Pension TotalFees (Bands Related Fees (Bands Relatedof £5,000) Benefits £5,000) Benefits

Charlotte Gawne Director ofCommunications 4 15-20 15-17.5 30-35

James Murray Director of Finance 5 65-70 0 65-70

Louise Fleming –Director of Quality & Governance 6 15-20 Not available 15-20

Anthony Farnsworth – Interim Director of Commissioning from 1/4/17 to 31/7/17 7 35-40 0 35-40

Chris Moreton - Acting Chief Financial Officer from 14/1/17 to 26/5/17 8 15-20 0-2.5 15-20 40-45 790-792.5 835-840

Chris Clarke – Director of Performance, Planning & Informatics from 1/10/16 to 30/4/17 5-10 0-2.5 5-10 80-85 10-12.5 100-105

No senior managers are paid any other taxable benefits, annual performance bonuses or long term performance related bonuses.Note 1 – Includes arrears of pension contributions not paid in three previous yearsNote 2 – The post holder receives no remuneration or benefits, although their employing hospital is reimbursed any costs incurredthrough their absence on Merton CCG dutiesNote 3 – Total remuneration from Merton CCG is shown; £15-20k relates to GB membership and £95-100k relates to role asClinical LeadNote 4 – The post holder is paid by Wandsworth CCG and the remuneration relevant to their time on Merton CCG duties ischarged to Merton CCG and appears above. The total banded remuneration paid by Wandsworth CCG to each individual in ashared post in 17/18 is :

Name Total Banded Total All Pension TotalRemuneration Bands Related Benefits Bands £5,000’s£5,000’s Bands £2,500’s

Sarah Blow 140-145 140-142.5 280-285

James Blythe 100-105 25-27.5 130-135

John Atherton 85-90 20-22.5 105-110

Neil McDowell 105-110 25-27.5 135-140

Josh Potter 65-70 25-27.5 90-95

Andrew McMylor 105-110 37.5-40 140-145

Julie Hesketh 95-100 47.5-50 145-150

Jonathan Bates 115-120 65-67.5 180-185

Charlotte Gawne 90-95 80-82.5 170-175

Louise Fleming 75-80 Not available 75-80

James Murray 300-305 0 300-305

Note 5 -- Payment was made to a corporate body and includes agency fees and VAT. The table reflects the costs to Merton CCG as the post was shared across five CCGs. Total costs to the NHS were in the band £300-304kNote 6 – On secondment from NHS Improvement, pension disclosures will be contained in the annual report of this bodyNote 7 – Payment was made to a corporate body and includes agency fees and VAT. The table reflects the costs to Merton CCG as the post was shared with Wandsworth CCG. Total costs to the NHS were in the band £75-80 (000’s)Note 8 – On secondment to NHS England from 1 June 2017


NHS organisations are required to disclose the pension benefits for those persons disclosed as seniormanagers of the organisation, where the clinical commissioning group has made a direct contribution to apension scheme. Due to the nature of clinical commissioning groups, some GPs have served as office holdersof NHS

Merton CCG. However, for GPs who work under a contract for services with the CCG, they are notconsidered to hold a pensionable post and so no pension disclosure is required. From 1 April 2013, NHSEngland became the employing agency for all types of GPs and pensions contributions have been made byNHS England rather than the CCG.

Pension benefits as at 31 March 2018 (Audited)

Pension benefits related to senior managers remunerated directly by Merton CCG and members of the NHSpension scheme are as below:

Name & title Real Real Total Lump sum Cash Cash Real Employer’sincrease increase accrued at age 60 Equivalent Equivalent increase contirbutionin pension in pension pension related to Transfer Transfer in Cash on toat age 60 lump sum at age 60 accrued Value at Value at Equivalent partnership

at age 60 at pension 31/3/18 31/3/17 Transfer pension31/3/18 at 31/3/18 Value

(bands of (bands of (bands of (bands of£2,500) £2,500) £5,000) £5,000)£000 £000 £000 £000 £000 £000 £000 £000

Christopher Clark –

Director of Performance

Planning and Informatics

to 30/4/17 0-2.5 0 0-5 0 15 5 10 0

Chris Moreton –

Acting Chief Finance

Officer to 31/05/17 0-2.5 0 40-45 0 522 476 46 0

Timothy Hodgson –

GP Member 0-2.5 0-2.5 10-15 40-45 221 205 16 0


For completeness, the following information regarding the pension information relating to the jointexecutive team and the senior managers of the South West London Alliance who supported Merton CCGwhich are disclosed in the remuneration report for Wandsworth CCG is shown below:

Name & title Real Real Total Lump sum Cash Cash Real Employer’s

increase increase accrued at age 60 Equivalent Equivalent increase contirbution

in pension in pension pension related to Transfer Transfer in Cash on to

at age 60 lump sum at age 60 accrued Value at Value at Equivalent partnership

at age 60 at pension 31/3/18 31/3/17 Transfer pension

31/3/18 at 31/3/18 Value

(bands of (bands of (bands of (bands of

£2,500) £2,500) £5,000) £5,000)

£000 £000 £000 £000 £000 £000 £000 £000

Sarah Blow -Accountable Officer 5-7.5 12.5-15 35-40 80-85 609 457 147 20

James Blythe- Managing Director from 1/5/17 5-7.5 0-2.5 10-15 0 113 90 22 14

John Atherton – Director of Performance Improvement from 1/5/17 0-2.5 5-7.5 20-25 40-45 247 226 18 16

Neil McDowell – Local Director of Finance 0-2.5 0-2.5 25-30 80-85 577 529 53 15

Josh Potter- Director of Commissioning from 10/7/17 0-2.5 0.2.5 10-15 25-30 147 123 23 10

Andrew McMylor – Director of Primary CareTransformation 2.5-5 0-2.5 15-20 35-40 197 161 34 15

Julie Hesketh –Director of Quality & Governance 2.5-5 7.5-10 30-35 100-105 656 565 85 13

Jonathan Bates – Director of StrategicCommissioning 2.5-5 5-7.5 35-40 90-95 557 471 82 16

Louise Fleming – Director of Quality &Governance *

Charlotte Gawne – Director of Communications 2.5-5 5-7.5 25-30 70-75 441 372 66 13

On secondment from NHS Improvement, the annual report of the NHSTDA will contain pension disclosures.

remuneration are calculated and provided by theNHS Business Services Authority.

Pay multiples (Audited)

Reporting bodies are required to disclose therelationship between the remuneration of thehighest paid director in their organisation and themedian remuneration of the organisation’sworkforce.

The banded annualised full time remuneration ofthe highest paid director in the financial year2017/18 was £185-190k (2016/17 - £180-185k).This was 3.5 times (2016/17 – 4.4 times) themedian remuneration of the workforce, whichwas £53k (2016/17 - £41).

In 2017/18 (and 2016/17), no other employeereceived remuneration in excess of the annualisedfull time remuneration of the highest paidmember of the Governing Body. Remunerationranged from 18k to £187k (2016/17 £10-185k).

For the purposes of calculating pay multiples,remuneration includes salary, non- consolidatedperformance-related pay and benefits-in-kind. Itdoes not include severance payments, employerpension contributions and the cash equivalenttransfer value of pensions.

Cash equivalent transfer values

A cash equivalent transfer value (CETV) is theactuarially assessed capital value of the pensionscheme benefits accrued by a member at aparticular point in time. The benefits valued arethe member’s accrued benefits and any contingentspouse’s (or other allowable beneficiary’s) pensionpayable from the scheme.

A CETV is a payment made by a pension schemeor arrangement to secure pension benefits inanother pension scheme or arrangement whenthe member leaves a scheme and chooses totransfer the benefits accrued in their formerscheme. The pension figures shown relate to thebenefits that the individual has accrued as aconsequence of their total membership of thepension scheme, not just their service in a seniorcapacity to which disclosure applies.

The CETV figures and the other pension detailsinclude the value of any pension benefits inanother scheme or arrangement which theindividual has transferred to the NHS pensionscheme. They also include any additional pensionbenefit accrued to the member as a result of theirpurchasing additional years of pension service inthe scheme at their own cost. CETVs arecalculated within the guidelines and frameworkprescribed by the Institute and Faculty ofActuaries.

Real increase in CETV

This reflects the increase in CETV effectivelyfunded by the employer. It takes account of theincrease in accrued pension due to inflation,contributions paid by the employee (including thevalue of any benefits transferred from anotherscheme or arrangement) and uses commonmarket valuation factors for the start and end ofthe period.

All information relating to the pensions elementsof the Greenbury disclosures of senior managers



Number of engagements reassessedforconsistency/assurance purposes during the year 0

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

Off-payroll engagement of Governing Bodymembers, and senior officials with ‘significantfinancial responsibility’between 1 April 2017 and 31 March 2108

Number of Off-payroll engagements of Governing Body members, and senior officials with ‘significant financial responsibility’ during the financial year 1

Number of individuals who have been deemed Governing Body members, and senior officials with ‘significant financial responsibility’ during thefinancial year (payroll and off-payroll) 22

No individuals who are Governing Body membersor senior officials with ‘significant financialresponsibility’ are currently engaged through off-payroll arrangements.

The post holder above was the Interim Director ofCommissioning from April 2017 until July 2017and was engaged through a staffing agency. Thecontract was for short tenure awaiting the currentsubstantive director to be able to take up post andwas market tested as being consistent with themarket rate payable for such managers as at thattime.

Exit Packages

The CCG has agreed 1 exit package in 2017/18which was a payment paid in lieu of notice.

Headcount Amount

1 £ 1,795

Off-payroll Engagements

The following tables relate solely to off payrollengagements paid directly by Merton CCG. Off-payroll engagements existing at 31st March 2018for more than £245 per day and which have lastedlonger than six months are:

The number that have existed: Number

Number of existing arrangements at 31st March 2018 and over six months duration at time of reporting (29th May 2018) and morethan £245 per day 3

For more than six months but less than one year on 29.5.2108 1

For between one and two years 2

For two years and three years 0

For between three and four years 0

Total number of engagements that existed at 31.3.2107 5

All existing off-payroll engagements, outlinedabove, have at some point been subject to a riskbased assessment as to whether the position iswithin the remit of IR35.

For all off-payroll engagements in 2017/18 formore than £245 per day where new or whichexisted for six months or longer:

Number of new engagements, or those that reached six months in duration, between 1/4/17 and 31/3/18 16

No. assessed as being in scope of IR35 0

No. assessed as being out of scope of IR35 16

Number engaged directly via PSC contracted to the CCG on the CCG payroll 0


Excluding the Executive Team (above), thecomposition of the workforce of Merton CCG is:

Substantive Employees Only

Employee Group Headcount WTE

Employee Group 41 39.05

Fixed Term 4 3.38

Grand Total 45 42.43

Governing Body Members / Office Holders -Setup on ESR

Employee Group Headcount WTE

GB Member 7 1.79

Office Holder 13 2.85

Grand Total 20 4.64

Senior Managers - Substantive Employees(excluding Governing Body Members / OfficeHolders (Clinical Leads)

Senior Manager Headcount WTE

Band 8C - Band 9 6 5.6

VSM 1 0.18

Grand Total 7 6.78

Senior Managers - Governing Body Members

Senior Manager Headcount WTE

Senior Manager - GB 2 0.70

Staff Report

Communicating and engaging

There are a number of ways in which the CCGcommunicates and engages with its staff. Theseinclude:

� A South West London Staff Partnership Forumwhere managers and staff from the six southwest London CCGs meet to discuss and consulton issues

� Regular team briefings with the staff andExecutive Management Team

The CCG ran a bespoke Staff Survey in 2017 andan action plan has been put in place based on theresults of the survey.

Training and development

There is a requirement for staff to undertakestatutory and mandatory training, which they can complete either via e-learning from Skills forHealth or through in-house sessions. Trainingcompliance is reported back to the CCG on aregular basis

Composition of the workforce

Number of senior staff by band – as at 31 March 2018

Following the establishment of the Local DeliveryUnit, the executive team is comprised of jointappointments with Wandsworth CCG,remunerated by Wandsworth CCG andproportionately recharged to Merton CCG. Thecomposition is:

� 1 Managing Director (Male) on VSM

� 5 Directors (4 male and 1 female) on AFC Band 9


Staff Composition – Governing BodyMembers/Office Holder (Clinical Leads)

Gender Pay Group Headcount WTE

Female Medical - Consultant 1 1.00

Medical - Local 5 0.70

VSM 2 0.19

Female Total 8 1.89

Male Band 9 1 0.10

Local - Other 3 0.25

Medical - Consultant 2 0.40

Medical - Local 5 1.35

VSM 1 0.60

Male Total 12 2.70

Grand Total 20 4.59

Expenditure on Consultancy

Expenditure on consultancy for 2017/18 was£8,195 (2016/17 £171,551), incurred for theprovision of legal consultancy.

Sickness Absence Data - April 2017 to February 2018

Absence Absence Absence Estimated Days FTE per FTE Cost

183 0.83 1.36% £13,230

Staff Composition by Gender - SubstantiveEmployees (excluding Governing Body Members/Office Holders/Executive Team)

Gender Pay Group Headcount WTE

Female Band 5 3 3.00

Band 6 3 2.60

Band 7 4 3.60

Band 8A 10 9.45

Band 8B 8 8.00

Band 8C 2 1.60

Band 8D 2 2.00

VSM 1 0.18

Female Total 33 30.43

Male Band 5 1 1.00

Band 6 2 2.00

Band 7 3 3.00

Band 8A 2 2.00

Band 8B 2 2.00

Band 8C 2 2.00

Band 9 0 0.00

Male Total 12 12

Grand Total 45 42.43


Employee consultation

Organisational change is managed in accordancewith the principles and procedures containedwithin the CCG's Organisational Change Policy.The CCG also informally communicates andconsults with employees via global emails andregular staff briefings. Staff were consulted as partof the arrangements to create the Merton andWandsworth Local Delivery Unit.

Policy on disabled employees

Disabled employees are protected under the‘protected characteristics’ of the Equality Act2010, one of which is disability. The CCG’sEquality and Diversity Strategy supports the CCGin ensuring that the requirements and reasonableadjustments necessary for employees withdisabilities are taken into account during theiremployment and that people with disabilities arenot discriminated against on the ground of theirdisability at any stage of the recruitment processor in their employment with the CCG.

The CCG's Sickness Absence Policy confirms thatwhere an employee becomes disabled as a resultof sickness, the CCG will make any necessaryreasonable adjustments, as required, and inaccordance with the Equality Act to enable theemployee to return to work. The types ofadjustments may include adjustments to workbase, working hours, redeploying the employee toanother suitable position and providing anynecessary equipment to assist the employee toperform their role.

Total Staff Costs for the year ended 31 March 2018

Staff Costs Total Permanent OtherEmployees

£'000 £'000 £'000

Employee Benefits

Salaries and wages 4,732 3,426 1,296

Social security costs 281 291

Employer Contributions to NHS Pension scheme 285 285

Net employee benefits excluding capitalisedcosts 5,308 4,012 1,296

The CCG sickness absence percentage rate ispresented monthly as part of the key performanceindicators (KPIs). The Human Resources BusinessPartner works with managers to ensure thatsickness absence cases are being managed in atimely way and in accordance with the CCGssickness absence policy.

An Occupational Health (OH) service is available toprovide professional medical advice to the CCG.Staff can access OH for a self-referral and canaccess the OH Counselling service.

The CCG also has access to an EmployeeAssistance Programme which is provided by RightManagement, which offers confidential access toemotional and practical support, 24 hours a day,seven days a week, including legal and financialadvice.

Staff policies

The CCG has a full suite of up to date HR policiesin place based on best practice, employmentlegislation and national terms and conditions, andare available to all staff on the CCG intranet.


Disability (Substantive Employees)

Disabled % Headcount

No 74% 33

Not Declared 26% 12

Total 45

Equalities for Staff

The CCG’s Equality and Diversity Strategy supportsthe promotion of a working environment in whichall parties and procedures relating to recruitment,selection, training, promotion and employmentare free from unfair discrimination, ensuring thatno employee or prospective employee isdiscriminated against, whether directly orindirectly on the grounds of any protectedcharacteristic: age; disability; gender reassignment;pregnancy and maternity; race including ethnic ornational origins, colour or nationality; religion orbelief; sex (gender); sexual orientation; marriageand civil partnership; or trade union membership;responsibility for dependents or any othercondition or requirement which cannot be shownto be justifiable.

Parliamentary Accountability and Audit Report

Merton CCG is not required to produce aParliamentary Accountability and Audit Report.Disclosures on remote contingent liabilities, lossesand special payments, gifts, and fees and chargesare included as notes in the Financial Statementsof this report. An audit certificate and report isalso included in this Annual Report.

Entity name: NHS MERTON CCGThis year 2017-18Last year 2016-17This year ended 31-March-2018Last year ended 31-March-2017This year commencing: 01-April-2017Last year commencing: 01-April-2016

NHS MERTON CCG - Annual Accounts 2017-18

Page Number

The Primary Statements:

Auditor's report on accounts 1Statement of Comprehensive Net Expenditure for the year ended 31st March 2018 5Statement of Financial Position as at 31st March 2018 6Statement of Changes in Taxpayers' Equity for the year ended 31st March 2018 7Statement of Cash Flows for the year ended 31st March 2018 8

Notes to the AccountsAccounting policies 9Other operating revenue 16Revenue 16Employee benefits and staff numbers 17Operating expenses 20Better payment practice code 21Operating leases 22Property, plant and equipment 23Intangible non-current assets 24Trade and other receivables 25Cash and cash equivalents 26Trade and other payables 27Commitments 28Financial instruments 28Operating segments 30Pooled budgets 31Related party transactions 32Events after the accounting period 33Financial performance targets 33Accountability - Staff 34Accountability - Losses and Special Payments 35

CONTENTS

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Independent auditor's report to the members of the Governing Body of NHS Merton Clinical Commissioning GroupReport on the Audit of the Financial Statements

OpinionWe have audited the financial statements of NHS Merton Clinical Commissioning Group (the ‘CCG’) for the year ended 31 March 2018 which comprise the Statement of Comprehensive Net Expenditure, the Statement of Financial Position, the Statement of Changes in Taxpayers Equity, the Statement of Cash Flows and notes to the financial statements, including a summary of significant accounting policies. The financial reporting framework that has been applied in their preparation is applicable law and the Department of Health and Social Care Group Accounting Manual 2017-18 and the requirements of the Health and Social Care Act 2012.

In our opinion the financial statements:· give a true and fair view of the financial position of the CCG as at 31 March 2018 and of its expenditureand income for the year then ended; and· have been properly prepared in accordance with International Financial Reporting Standards (IFRSs) asadopted by the European Union, as interpreted and adapted by the Department of Health and Social CareGroup Accounting Manual 2017-18; and· have been prepared in accordance with the requirements of the Health and Social Care Act 2012.

Basis for opinionWe conducted our audit in accordance with International Standards on Auditing (UK) (ISAs (UK)) and applicable law. Our responsibilities under those standards are further described in the Auditor’s responsibilities for the audit of the financial statements section of our report. We are independent of the CCG in accordance with the ethical requirements that are relevant to our audit of the financial statements in the UK, including the FRC’s Ethical Standard, and we have fulfilled our other ethical responsibilities in accordance with these requirements. We believe that the audit evidence we have obtained is sufficient and appropriate to provide a basis for our opinion.

Who we are reporting toThis report is made solely to the members of the Governing Body of the 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 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 CCG and the members of the Governing Body of the CCG, as a body, for our audit work, for this report, or for the opinions we have formed.

Conclusions relating to going concernWe have nothing to report in respect of the following matters in relation to which the ISAs (UK) require us to report to you where:· the Accountable Officer’s use of the going concern basis of accounting in the preparation of the financialstatements is not appropriate; or· the Accountable Officer has not disclosed in the financial statements any identified material uncertaintiesthat may cast significant doubt about the CCG’s ability to continue to adopt the going concern basis ofaccounting for a period of at least twelve months from the date when the financial statements are authorisedfor issue.

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Other informationThe Accountable Officer is responsible for the other information. The other information comprises the information included in the Annual Report set out on pages **xx to xx**, other than the financial statements and our auditor’s report thereon. Our opinion on the financial statements does not cover the other information and, except to the extent otherwise explicitly stated in our report, we do not express any form of assurance conclusion thereon.

In connection with our audit of the financial statements, our responsibility is to read the other information and, in doing so, consider whether the other information is materially inconsistent with the financial statements or our knowledge obtained in the course of our work including that gained through work in relation to the CCG’s arrangements for securing value for money through economy, efficiency and effectiveness in the use of its resource or otherwise appears to be materially misstated. If we identify such material inconsistencies or apparent material misstatements, we are required to determine whether there is a material misstatement in the financial statements or a material misstatement of the other information. If, based on the work we have performed, we conclude that there is a material misstatement of this other information, we are required to report that fact.

We have nothing to report in this regard.

Other information we are required to report on by exception under the Code of Audit Practice

Under the Code of Audit Practice published by the National Audit Office on behalf of the Comptroller and Auditor General (the Code of Audit Practice) we are required to consider whether the Governance Statement does not comply with the guidance issued by the NHS Commissioning Board or is misleading or inconsistent with the information of which we are aware from our audit. We are not required to consider whether the Governance Statement addresses all risks and controls or that risks are satisfactorily addressed by internal controls.

We have nothing to report in this regard.

Opinion on other matters required by the Code of Audit Practice In our opinion:· the parts of the Remuneration Report and Staff Report to be audited have been properly prepared inaccordance with IFRSs as adopted by the European Union, as interpreted and adapted by the Department ofHealth and Social Care Group Accounting Manual 2017-18 and the requirements of the Health and Social CareAct 2012; and· based on the work undertaken in the course of the audit of the financial statements and our knowledge ofthe CCG gained through our work in relation to the CCG’s arrangements for securing economy, efficiency andeffectiveness in its use of resources, the other information published together with the financial statements inthe annual report for the financial year for which the financial statements are prepared is consistent with thefinancial statements.

Opinion on regularity required by the Code of Audit Practice 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 in the financial statements conform to the authorities which govern them.

Matters on which we are required to report by exceptionUnder the Code of Audit Practice we are required to report to you if:· we have reported a matter in the public interest under Section 24 of the Local Audit and AccountabilityAct 2014 in the course of, or at the conclusion of the audit; or

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· we have referred a matter to the Secretary of State under Section 30 of the Local Audit andAccountability Act 2014 because we had reason to believe that the CCG, or an officer of the CCG, was aboutto make, or had made, a decision which involved or would involve the body incurring unlawful expenditure, orwas about to take, or had begun to take a course of action which, if followed to its conclusion, would beunlawful and likely to cause a loss or deficiency; or· we have made a written recommendation to the CCG under Section 24 of the Local Audit andAccountability Act 2014 in the course of, or at the conclusion of the audit.

We have nothing to report in respect of the above matters.

Responsibilities of the Accountable Officer and Those Charged with Governance for the financial statementsAs explained more fully in the Statement of Accountable Officer's responsibilities set out on pages x to x, the Accountable Officer, is responsible for the preparation of the financial statements in the form and on the basis set out in the Accounts Directions, for being satisfied that they give a true and fair view, and for such internal control as the Accountable Officer determines is necessary to enable the preparation of financial statements that are free from material misstatement, whether due to fraud or error.

In preparing the financial statements, the Accountable Officer is responsible for assessing the CCG’s ability to continue as a going concern, disclosing, as applicable, matters related to going concern and using the going concern basis of accounting unless the CCG lacks funding for its continued existence or when policy decisions have been made that affect the services provided by the CCG.

The Accountable Officer is responsible for ensuring the regularity of expenditure and income in the financial statements.

The Audit and Governance Committee is Those Charged with Governance.

Auditor’s responsibilities for the audit of the financial statementsOur objectives are to obtain reasonable assurance about whether the financial statements as a whole are free from material misstatement, whether due to fraud or error, and to issue an auditor’s report that includes our opinion. Reasonable assurance is a high level of assurance, but is not a guarantee that an audit conducted in accordance with ISAs (UK) will always detect a material misstatement when it exists. Misstatements can arise from fraud or error and are considered material if, individually or in the aggregate, they could reasonably be expected to influence the economic decisions of users taken on the basis of these financial statements.A further description of our responsibilities for the audit of the financial statements is located on the Financial Reporting Council’s website at: www.frc.org.uk/auditorsresponsibilities. This description forms part of our auditor’s report.

We are also responsible for giving an opinion on the regularity of expenditure and income in the financial statements in accordance with the Code of Audit Practice.

Report on other legal and regulatory requirements – Conclusion on the CCG’s arrangements for securing economy, efficiency and effectiveness in its use of resources

Matter on which we are required to report by exception - CCG’s arrangements for securing economy, efficiency and effectiveness in its use of resources

http://www.frc.org.uk/auditorsresponsibilities





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Under the Code of Audit Practice we are required to report to you if, in our opinion we have not been able to satisfy ourselves that the CCG has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources for the year ended 31 March 2018.

We have nothing to report in respect of the above matter.

Responsibilities of the Accountable OfficerAs explained in the Governance Statement, the Accountable Officer is responsible for putting in place proper arrangements for securing economy, efficiency and effectiveness in the use of the CCG's resources.

Auditor’s responsibilities for the review of the CCG’s arrangements for securing economy, efficiency and effectiveness in its use of resourcesWe are required under Section 21(3)(c) and Schedule 13 paragraph 10(a) 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 and to report where we have not been able to satisfy ourselves that it has done so. We are not required to consider, nor have we considered, whether all aspects of the CCG's arrangements for securing economy, efficiency and effectiveness in its use of resources are operating effectively.

We have undertaken our review in accordance with the Code of Audit Practice, having regard to the guidance on the specified criterion issued by the Comptroller and Auditor General in November 2017, as to whether in all significant respects, the CCG had proper arrangements to ensure it took properly informed decisions and deployed resources to achieve planned and sustainable outcomes for taxpayers and local people. The Comptroller and Auditor General determined this criterion as that necessary for us to consider under the Code of Audit Practice in satisfying ourselves whether the CCG put in place proper arrangements for securing economy, efficiency and effectiveness in its use of resources for the year ended 31 March 2018, and to report by exception where we are not satisfied.We planned our work in accordance with the Code of Audit Practice. Based on our risk assessment, we undertook such work as we considered necessary to be satisfied that the CCG has put in place proper arrangements for securing economy, efficiency and effectiveness in its use of resources.

Report on other legal and regulatory requirements – Certificate

We certify that we have completed the audit of the financial statements of NHS Merton Clinical Commissioning Group in accordance with the requirements of the Local Audit and Accountability Act 2014 and the Code of Audit Practice.

SignatureSarah Ironmongerfor and on behalf of Grant Thornton UK LLP

Grant Thornton UK LLP2nd Floor | St Johns House | Haslett Avenue West | Crawley | RH10 1HSDate

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2017-18 2016-17Note £'000 £'000

2 (5,621) (8,314)2 (1,790) (616)

(7,411) (8,930)

4 5,308 5,2365 284,289 276,0565 201 2005 301 139

290,100 281,631

282,689 272,701

0 0. 0 0

282,689 272,7010 0

282,689 272,701

282,689 272,701


Statement of Comprehensive Net Expenditure for the year ended 31 March 2018

Income from sale of goods and servicesOther operating incomeTotal operating income

Staff costsPurchase of goods and servicesDepreciation and impairment chargesOther Operating ExpenditureTotal operating expenditure

Net Operating Expenditure

Finance incomeFinance expenseNet expenditure for the yearNet Gain/(Loss) on Transfer by AbsorptionTotal Net Expenditure for the yearOther Comprehensive Expenditure

Comprehensive Expenditure for the year ended 31 March 2018

The notes on pages 11 to 36 form part of this statement.

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2017-18 2016-17

Note £'000 £'000

8 625 6719 78 0

10 0 014 0 0

703 671

10 5,538 4,95911 44 17

5,582 4,976

0 0

5,582 4,976

6,285 5,647

12 (23,895) (21,162)(23,895) (21,162)

(17,610) (15,515)

12 0 00 0

(17,610) (15,515)

(17,610) (15,515)(17,610) (15,515)


Statement of Financial Position as at31 March 2018

Non-current assets:Property, plant and equipmentIntangible assetsTrade and other receivablesOther financial assetsTotal non-current assets

Current assets:Trade and other receivablesCash and cash equivalentsTotal current assets

Non-current assets held for sale

Total current assets

Total assets

Current liabilitiesTrade and other payablesTotal current liabilities

Non-Current Assets plus/less Net Current Assets/Liabilities

Non-current liabilitiesTrade and other payablesTotal non-current liabilities

Assets less Liabilities

Financed by Taxpayers’ EquityGeneral fundTotal taxpayers' equity:


The financial statements on pages 7 to 10 and the notes on pages 11 to 36 were approved by Audit Committee as delegated by the Governing Body on 22nd May 2018 and signed on its behalf by:

Sarah BlowChief Accountable Officer

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Statement of Changes In Taxpayers Equity for the year ended31 March 2018

General fundRevaluation

reserveOther

reservesTotal

reserves£'000 £'000 £'000 £'000

Changes in taxpayers’ equity for 2017-18

Balance at 01 April 2017 (15,515) 0 0 (15,515)Adjusted NHS Clinical Commissioning Group balance at 31 March 2018 (15,515) 0 0 (15,515)

Changes in NHS Clinical Commissioning Group taxpayers’ equity for 2017-18Net operating expenditure for the financial year (282,689) 0 0 (282,689)

Total revaluations against revaluation reserve 0 0 0 0

Net Recognised NHS Clinical Commissioning Group Expenditure for the Financial Year (298,204) 0 0 (298,204)

Net funding 280,594 0 0 280,594

Balance at 31 March 2018 (17,610) 0 0 (17,610)

General fundRevaluation

reserveOther

reservesTotal

reserves£'000 £'000 £'000 £'000

Changes in taxpayers’ equity for 2016-17

Balance at 01 April 2016 (13,670) 0 0 (13,670)Adjusted NHS Clinical Commissioning Group balance at 31 March 2017 (13,670) 0 0 (13,670)

Changes in NHS Clinical Commissioning Group taxpayers’ equity for 2016-17Net operating costs for the financial year (272,701) 0 0 (272,701)

Total revaluations against revaluation reserve 0 0 0 0

Net Recognised NHS Clinical Commissioning Group Expenditure for the Financial Year (286,372) 0 0 (286,372)Net funding 270,857 0 0 270,857Balance at 31 March 2017 (15,515) 0 0 (15,515)


Taxpayers' equity represents the aggregate of all reserves held by the CCG and change represents the net effect of movements year on year.

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2017-18 2016-17Note £'000 £'000

(282,689) (272,701)5 201 20010 (579) (1,866)12 2,733 3,451

(280,334) (270,916)

(155) 0(78) 0

(233) 0

(280,567) (270,916)

280,594 270,857280,594 270,857

11 27 (59)

17 76

44 17


Statement of Cash Flows for the year ended31 March 2018

Cash Flows from Operating ActivitiesNet operating expenditure for the financial yearDepreciation and amortisation(Increase)/decrease in trade & other receivablesIncrease/(decrease) in trade & other payablesNet Cash Inflow (Outflow) from Operating Activities

Cash Flows from Investing Activities(Payments) for property, plant and equipment(Payments) for intangible assetsNet Cash Inflow (Outflow) from Investing Activities

Net Cash Inflow (Outflow) before Financing

Cash Flows from Financing ActivitiesGrant in Aid Funding ReceivedNet Cash Inflow (Outflow) from Financing Activities

Net Increase (Decrease) in Cash & Cash Equivalents

Cash & Cash Equivalents at the Beginning of the Financial Year

Cash & Cash Equivalents (including bank overdrafts) at the End of the Financial Year


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Notes to the financial statements

1 Accounting PoliciesNHS England has directed that the financial statements of clinical commissioning groups shall meet the accounting requirements of the Group Accounting Manual issued by the Department of Health and Social Care. Consequently, the following financial statements have been prepared in accordance with the Group Accounting Manual 2017-18 issued by the Department of Health and Social Care. The accounting policies contained in the Group Accounting Manual follow International Financial Reporting Standards to the extent that they are meaningful and appropriate to clinical commissioning groups, as determined by HM Treasury, which is advised by the Financial Reporting Advisory Board. Where the Group Accounting Manual permits a choice of accounting policy, the accounting policy which is judged to be most appropriate to the particular circumstances of the clinical commissioning group for the purpose of giving a true and fair view has been selected. The particular policies adopted by the clinical commissioning group are described below. They have been applied consistently in dealing with items considered material in relation to the accounts.

1.1 Going ConcernThese accounts have been prepared on the going concern basis.Public sector bodies are assumed to be going concerns where the continuation of the provision of a service in the future is anticipated, as evidenced by inclusion of financial provision for that service in published documents.Where a clinical commissioning group ceases to exist, it considers whether or not its services will continue to be provided (using the same assets, by another public sector entity) in determining whether to use the concept of going concern for the final set of Financial Statements. If services will continue to be provided the financial statements are prepared on the going concern basis.

1.2 Accounting 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 Acquisitions & Discontinued OperationsActivities are considered to be ‘acquired’ only if they are taken on from outside the public sector. Activities are considered to be ‘discontinued’ only if they cease entirely. They are not considered to be ‘discontinued’ if they transfer from one public sector body to another.

1.4 Movement of Assets within the Department of Health and Social Care GroupTransfers as part of reorganisation fall to be accounted for by use of absorption accounting in line with the Government Financial Reporting Manual, issued by HM Treasury. The Government Financial Reporting Manual does not require retrospective adoption, so prior year transactions (which have been accounted for under merger accounting) have not been restated. Absorption accounting requires that entities account for their transactions in the period in which they took place, with no restatement of performance required when functions transfer within the public sector. Where assets and liabilities transfer, the gain or loss resulting is recognised in the Statement of Comprehensive Net Expenditure, and is disclosed separately from operating costs.Other transfers of assets and liabilities within the Department of Health and Social Care Group are accounted for in line with IAS 20 and similarly give rise to income and expenditure entries.

1.5 Charitable FundsUnder the provisions of IAS 27: Consolidated & Separate Financial Statements, those Charitable Funds that fall under common control with NHS bodies are consolidated within the entities’ accounts.

1.6 Pooled BudgetsWhere the clinical commissioning group has entered into a pooled budget arrangement under Section 75 of the National Health Service Act 2006 the clinical commissioning group accounts for its share of the assets, liabilities, income and expenditure arising from the activities of the pooled budget, identified in accordance with the pooled budget agreement.If the clinical commissioning group is in a “jointly controlled operation”, the clinical commissioning group recognises:· The assets the clinical commissioning group controls;· The liabilities the clinical commissioning group incurs;· The expenses the clinical commissioning group incurs; and,· The clinical commissioning group’s share of the income from the pooled budget activities.If the clinical commissioning group is involved in a “jointly controlled assets” arrangement, in addition to the above, the clinical commissioning group recognises:· The clinical commissioning group’s share of the jointly controlled assets (classified according to the nature of the assets);· The clinical commissioning group’s share of any liabilities incurred jointly; and,· The clinical commissioning group’s share of the expenses jointly incurred.In 2017/18 NHS Merton CCG had a pooled budget with the London Borough of Merton for the Better Care Fund and Integrated CommunityEquipment Services. Both these pooled budgets are jointly controlled operations where the fund is hosted and accounted for by the London Borough of Merton.

1.7 Critical Accounting Judgements & Key Sources of Estimation UncertaintyIn the application of the clinical commissioning group’s accounting policies, management is required to make judgements, estimates and assumptions about the carrying amounts of assets and liabilities that are not readily apparent from other sources. The estimates and associated assumptions are based on historical experience and other factors that are considered to be relevant. Actual results may differ from those estimates and the estimates and underlying assumptions are continually reviewed. Revisions to accounting estimates are recognised in the period in which the estimate is revised if the revision affects only that period or in the period of the revision and future periods if the revision affects both current and future periods.

1.7.1 Critical Judgements in Applying Accounting PoliciesThe following are the critical judgements, apart from those involving estimations (see below) that management has made in the process ofapplying the clinical commissioning group’s accounting policies that have the most significant effect on the amounts recognised in the financial statements:The accounting arrangements for balances transferred from predecessor PCTs ("legacy balances") are determined by the Accounts Direction issued by NHS England on 12 February 2014. The Accounts Directions state that the only legacy balances to be accounted for by the CCG are in respect of property, plant and equipment (and related liabilities) and inventories.

1.7.2 Key Sources of Estimation UncertaintyThe following are the key estimations that management has made in the process of applying the clinical commissioning group’s accounting policies that have the most significant effect on the amounts recognised in the financial statements:The single largest estimated cost in the CCG's accounts relates to the February and March 2018 prescribing accrual. This accrual has been calculated at £3.8m and is a best estimate based on the spend from April 2017 to January 2018. Another estimate has been made regarding expenditure with St. Georges NHST on activity for March, based on previous trends.

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1.8 RevenueRevenue in respect of services provided is recognised when, and to the extent that, performance occurs, and is measured at the fair value of the consideration receivable.Where income is received for a specific activity that is to be delivered in the following year, that income is deferred.

1.9 Employee Benefits1.9.1 Short-term Employee Benefits

Salaries, wages and employment-related payments are recognised in the period in which the service is received from employees, including bonuses earned but not yet taken.The cost of leave earned but not taken by employees at the end of the period is recognised in the financial statements to the extent that employees are permitted to carry forward leave into the following period.

1.9.2 Retirement Benefit CostsPast and present employees are covered by the provisions of the NHS Pensions Scheme. The scheme is an unfunded, defined benefit scheme that covers NHS employers, General Practices and other bodies, allowed under the direction of the Secretary of State, in England and Wales. The scheme is not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities. Therefore, the scheme is accounted for as if it were a defined contribution scheme: the cost to the clinical commissioning group of participating in the scheme is taken as equal to the contributions payable to the scheme for the accounting period.For early retirements other than those due to ill health the additional pension liabilities are not funded by the scheme. The full amount of the liability for the additional costs is charged to expenditure at the time the clinical commissioning group commits itself to the retirement, regardless of the method of payment.

1.10 Other 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 the clinical commissioning group has a present legal or constructive obligation, which occurs when all of the conditions attached to the payment have been met.

1.11 Property, Plant & Equipment1.11.1 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 undersingle 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.

1.11.2 ValuationNHS Merton CCG does not own any land or buildings. On the dissolution of the former Sutton & Merton Primary Care Trust, all land and buildings were transferred to NHS Property Services Limited.

1.11.3 Subsequent ExpenditureWhere subsequent expenditure enhances an asset beyond its original specification, the directly attributable cost is capitalised. Where subsequent expenditure restores the asset to its original specification, the expenditure is capitalised and any existing carrying value of the item replaced is written-out and charged to operating expenses.

1.12 Intangible Assets1.12.1 Recognition

Intangible assets are non-monetary assets without physical substance, which are capable of sale separately from the rest of the clinical commissioning group’s business or which arise from contractual or other legal rights. They are recognised only:· When it is probable that future economic benefits will flow to, or service potential be provided to, the clinical commissioning group;· Where the cost of the asset can be measured reliably; and,· Where the cost is at least £5,000.Intangible assets acquired separately are initially recognised at fair value. Software that is integral to the operating of hardware, for example an operating system, is capitalised as part of the relevant item of property, plant and equipment. Software that is not integral to the operation of hardware, for example application software, is capitalised as an intangible asset. Expenditure on research is not capitalised but is recognised as an operating expense in the period in which it is incurred. Internally-generated assets are recognised if, and only if, all of the following have been demonstrated:· The technical feasibility of completing the intangible asset so that it will be available for use;· The intention to complete the intangible asset and use it;· The ability to sell or use the intangible asset;· How the intangible asset will generate probable future economic benefits or service potential;· The availability of adequate technical, financial and other resources to complete the intangible asset and sell or use it; and,· The ability to measure reliably the expenditure attributable to the intangible asset during its development.

1.12.2 MeasurementThe amount initially recognised for internally-generated intangible assets is the sum of the expenditure incurred from the date when the criteria above are initially met. Where no internally-generated intangible asset can be recognised, the expenditure is recognised in the period in which it is incurred.Following initial recognition, intangible assets are carried at current value in existing use by reference to an active market, or, where no active market exists, at the lower of depreciated replacement cost or the value in use where the asset is income generating . Internally-developed software is held at historic cost to reflect the opposing effects of increases in development costs and technological advances.

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1.13 Depreciation, Amortisation & ImpairmentsFreehold land, properties under construction, and assets held for sale are not depreciated.Otherwise, depreciation and amortisation are charged to write off the costs or valuation of property, plant and equipment and intangible non-current assets, less any residual value, over their estimated useful lives, in a manner that reflects the consumption of economic benefits or service potential of the assets. The estimated useful life of an asset is the period over which the clinical commissioning group expects to obtain economic benefits or service potential from the asset. This is specific to the clinical commissioning group and may be shorter than the physical life of the asset itself. Estimated useful lives and residual values are reviewed each year end, with the effect of any changes recognised on a prospective basis. Assets held under finance leases are depreciated over their estimated useful lives.At each reporting period end, the clinical commissioning group checks whether there is any indication that any of its tangible or intangible non-current assets have suffered an impairment loss. If there is indication of an impairment loss, the recoverable amount of the asset is estimated to determine whether there has been a loss and, if so, its amount. Intangible assets not yet available for use are tested for impairment annually.A revaluation decrease that does not result from a loss of economic value or service potential is recognised as an impairment charged to the revaluation reserve to the extent that there is a balance on the reserve for the asset and, thereafter, to expenditure. Impairment losses that arise from a clear consumption of economic benefit are taken to expenditure. Where an impairment loss subsequently reverses, the carrying amount of the asset is increased to the revised estimate of the recoverable amount but capped at the amount that would have been determined had there been no initial impairment loss. The reversal of the impairment loss is credited to expenditure to the extent of the decrease previously charged there and thereafter to the revaluation reserve.

1.14 Donated AssetsDonated non-current assets are capitalised at their fair value on receipt, with a matching credit to Income. They are valued, depreciated and impaired as described above for purchased assets. Gains and losses on revaluations, impairments and sales are as described above for purchased assets. Deferred income is recognised only where conditions attached to the donation preclude immediate recognition of the gain.

1.15 Government GrantsThe value of assets received by means of a government grant are credited directly to income. Deferred income is recognised only where conditions attached to the grant preclude immediate recognition of the gain.

1.16 Non-current Assets Held For SaleNon-current assets are classified as held for sale if their carrying amount will be recovered principally through a sale transaction rather than through continuing use. This condition is regarded as met when:· The sale is highly probable;· The asset is available for immediate sale in its present condition; and,· Management is committed to the sale, which is expected to qualify for recognition as a completed sale within one year from the date of classification.Non-current assets held for sale are measured at the lower of their previous carrying amount and fair value less costs to sell. Fair value is open market value including alternative uses.The profit or loss arising on disposal of an asset is the difference between the sale proceeds and the carrying amount and is recognised in the Statement of Comprehensive Net Expenditure. On disposal, the balance for the asset on the revaluation reserve is transferred to the general reserve.Property, plant and equipment that is to be scrapped or demolished does not qualify for recognition as held for sale. Instead, it is retained as an operational asset and its economic life is adjusted. The asset is de-recognised when it is scrapped or demolished.

1.17 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.

1.17.1 The Clinical Commissioning Group 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.

1.17.2 The Clinical Commissioning Group as LessorAmounts due from lessees under finance leases are recorded as receivables at the amount of the clinical commissioning group’s net investment in the leases. Finance lease income is allocated to accounting periods so as to reflect a constant periodic rate of return on the clinical commissioning group’s net investment outstanding in respect of the leases.Rental income from operating leases is recognised on a straight-line basis over the term of the lease. Initial direct costs incurred in negotiating and arranging an operating lease are added to the carrying amount of the leased asset and recognised on a straight-line basis over the lease term.

1.18 Private Finance Initiative TransactionsHM Treasury has determined that government bodies shall account for infrastructure Private Finance Initiative (PFI) schemes where the government body controls the use of the infrastructure and the residual interest in the infrastructure at the end of the arrangement as service concession arrangements, following the principles of the requirements of IFRIC 12. The clinical commissioning group therefore recognises the PFI asset as an item of property, plant and equipment together with a liability to pay for it. The services received under the contract are recorded as operating expenses.The annual unitary payment is separated into the following component parts, using appropriate estimation techniques where necessary:· Payment for the fair value of services received;· Payment for the PFI asset, including finance costs; and,· Payment for the replacement of components of the asset during the contract ‘lifecycle replacement’.

1.18.1 Services ReceivedThe fair value of services received in the year is recorded under the relevant expenditure headings within ‘operating expenses’.

1.18.2 PFI AssetThe PFI assets are recognised as property, plant and equipment, when they come into use. The assets are measured initially at fair value in accordance with the principles of IAS17. Subsequently, the assets are measured at fair value, which is kept up to date in accordance with the clinical commissioning group’s approach for each relevant class of asset in accordance with the principles of IAS 16.

1.18.3 PFI LiabilityA PFI liability is recognised at the same time as the PFI assets are recognised. It is measured initially at the same amount as the fair value of the PFI assets and is subsequently measured as a finance lease liability in accordance with IAS 17.An annual finance cost is calculated by applying the implicit interest rate in the lease to the opening lease liability for the period, and is charged to ‘finance costs’ within the Statement of Comprehensive Net Expenditure.

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The element of the annual unitary payment that is allocated as a finance lease rental is applied to meet the annual finance cost and to repay the lease liability over the contract term.An element of the annual unitary payment increase due to cumulative indexation is allocated to the finance lease. In accordance with IAS 17, this amount is not included in the minimum lease payments, but is instead treated as contingent rent and is expensed as incurred. In substance, this amount is a finance cost in respect of the liability and the expense is presented as a contingent finance cost in the Statement of Comprehensive Net Expenditure.

1.18.4 Lifecycle ReplacementComponents of the asset replaced by the operator during the contract (‘lifecycle replacement’) are capitalised where they meet the clinical commissioning group’s criteria for capital expenditure. They are capitalised at the time they are provided by the operator and are measured initially at their fair value.The element of the annual unitary payment allocated to lifecycle replacement is pre-determined for each year of the contract from the operator’s planned programme of lifecycle replacement. Where the lifecycle component is provided earlier or later than expected, a short-term finance lease liability or prepayment is recognised respectively.Where the fair value of the lifecycle component is less than the amount determined in the contract, the difference is recognised as an expense when the replacement is provided. If the fair value is greater than the amount determined in the contract, the difference is treated as a ‘free’ asset and a deferred income balance is recognised. The deferred income is released to the operating income over the shorter of the remaining contract period or the useful economic life of the replacement component.

1.18.5 Assets Contributed by the Clinical Commissioning Group to the Operator For Use in the SchemeAssets contributed for use in the scheme continue to be recognised as items of property, plant and equipment in the clinical commissioning group’s Statement of Financial Position.

1.18.6 Other Assets Contributed by the Clinical Commissioning Group to the OperatorAssets contributed (e.g. cash payments, surplus property) by the clinical commissioning group to the operator before the asset is brought into use, which are intended to defray the operator’s capital costs, are recognised initially as prepayments during the construction phase of the contract. Subsequently, when the asset is made available to the clinical commissioning group, the prepayment is treated as an initial payment towards the finance lease liability and is set against the carrying value of the liability.

1.19 InventoriesInventories are valued at the lower of cost and net realisable value.

1.20 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 the clinical commissioning group’s cash management.

1.21 ProvisionsProvisions are recognised when the clinical commissioning group has a present legal or constructive obligation as a result of a past event, it is probable that the clinical commissioning group will be required to settle the obligation, and a reliable estimate can be made of the amount of the obligation. The amount recognised as a provision is the best estimate of the expenditure required to settle the obligation at the end of the reporting period, taking into account the risks and uncertainties. Where a provision is measured using the cash flows estimated to settle the obligation, its carrying amount is the present value of those cash flows using HM Treasury’s discount rate as follows:· Timing of cash flows (0 to 5 years inclusive): Minus 2.420% (previously: minus 2.70%)· Timing of cash flows (6 to 10 years inclusive): Minus 1.85% (previously: minus 1.95%)· Timing of cash flows (over 10 years): Minus 1.56% (previously: minus 0.80%)

When some or all of the economic benefits required to settle a provision are expected to be recovered from a third party, the receivable is recognised as an asset if it is virtually certain that reimbursements will be received and the amount of the receivable can be measured reliably.

A restructuring provision is recognised when the clinical commissioning group has developed a detailed formal plan for the restructuring and has raised a valid expectation in those affected that it will carry out the restructuring by starting to implement the plan or announcing its main features to those affected by it. The measurement of a restructuring provision includes only the direct expenditures arising from the restructuring, which are those amounts that are both necessarily entailed by the restructuring and not associated with on-going activities of the entity.

1.22 Clinical Negligence CostsThe NHS Resolution operates a risk pooling scheme under which the clinical commissioning group pays an annual contribution to the NHS Resolution which in return settles all clinical negligence claims. The contribution is charged to expenditure. Although the NHS Resolution is administratively responsible for all clinical negligence cases the legal liability remains with the clinical commissioning group.

1.23 Non-clinical Risk PoolingNHS Merton CCG participates in the Property Expenses Scheme and the Liabilities to Third Parties Scheme. Both are risk pooling schemes under which the clinical commissioning group pays an annual contribution to the NHS Resolution and, in return, receives assistance with the costs of claims arising. The annual membership contributions, and any excesses payable in respect of particular claims are charged to operating expenses as and when they become due.

1.24 Continuing healthcare risk poolingIn 2014-15 a risk pool scheme was been introduced by NHS England for continuing healthcare claims, for claim periods prior to 31 March 2013. Under the scheme clinical commissioning group contributed annually to a pooled fund, which is used to settle the claims. This scheme has now discontinued.

1.25 Carbon Reduction Commitment SchemeCarbon Reduction Commitment and similar allowances are accounted for as government grant funded intangible assets if they are not expected to be realised within twelve months, and otherwise as other current assets. They are valued at open market value. As the clinical commissioning group makes emissions, a provision is recognised with an offsetting transfer from deferred income. The provision is settled on surrender of the allowances. The asset, provision and deferred income amounts are valued at fair value at the end of the reporting period.

1.26 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 the clinical commissioning group. A contingent asset is disclosed where an inflow of economic benefits is probable.Where the time value of money is material, contingencies are disclosed at their present value.

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1.27 Financial AssetsFinancial assets are recognised when the clinical commissioning group becomes party to the financial instrument contract or, in the case of trade receivables, when the goods or services have been delivered. Financial assets are derecognised when the contractual rights have expired or the asset has been transferred.Financial assets are classified into the following categories:· Financial assets at fair value through profit and loss;· Held to maturity investments;· Available for sale financial assets; and,· Loans and receivables.The classification depends on the nature and purpose of the financial assets and is determined at the time of initial recognition.

1.27.1 Financial Assets 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 assets at fair value through profit and loss. They are held at fair value, with any resultant gain or loss recognised in calculating the clinical commissioning group’s surplus or deficit for the year. The net gain or loss incorporates any interest earned on the financial asset.

1.27.2 Held to Maturity AssetsHeld to maturity investments are non-derivative financial assets with fixed or determinable payments and fixed maturity, and there is a positive intention and ability to hold to maturity. After initial recognition, they are held at amortised cost using the effective interest method, less any impairment. Interest is recognised using the effective interest method.

1.27.3 Available For Sale Financial AssetsAvailable for sale financial assets are non-derivative financial assets that are designated as available for sale or that do not fall within any of the other three financial asset classifications. They are measured at fair value with changes in value taken to the revaluation reserve, with the exception of impairment losses. Accumulated gains or losses are recycled to surplus/deficit on de-recognition.

1.27.4 Loans & ReceivablesLoans and receivables are non-derivative financial assets with fixed or determinable payments which are not quoted in an active market. After initial recognition, they are measured at amortised cost using the effective interest method, less any impairment. Interest is recognised using the effective interest method.Fair value is determined by reference to quoted market prices where possible, otherwise by valuation techniques.The effective interest rate is the rate that exactly discounts estimated future cash receipts through the expected life of the financial asset, to the initial fair value of the financial asset.At the end of the reporting period, the clinical commissioning group assesses whether any financial assets, other than those held at ‘fair value through profit and loss’ are impaired. Financial assets are impaired and impairment losses recognised if there is objective evidence of impairment as a result of one or more events which occurred after the initial recognition of the asset and which has an impact on the estimated future cash flows of the asset.For financial assets carried at amortised cost, the amount of the impairment loss is measured as the difference between the asset’s carrying amount and the present value of the revised future cash flows discounted at the asset’s original effective interest rate. The loss is recognised in expenditure and the carrying amount of the asset is reduced through a provision for impairment of receivables.If, in a subsequent period, the amount of the impairment loss decreases and the decrease can be related objectively to an event occurring after the impairment was recognised, the previously recognised impairment loss is reversed through expenditure to the extent that the carrying amount of the receivable at the date of the impairment is reversed does not exceed what the amortised cost would have been had the impairment not been recognised.

1.28 Financial LiabilitiesFinancial liabilities are recognised on the statement of financial position when the clinical commissioning group becomes party to the contractual provisions of the financial instrument or, in the case of trade payables, when the goods or services have been received. Financial liabilities are de-recognised when the liability has been discharged, that is, the liability has been paid or has expired.

1.28.1 Financial Guarantee Contract LiabilitiesFinancial guarantee contract liabilities are subsequently measured at the higher of:· The premium received (or imputed) for entering into the guarantee less cumulative amortisation; and,· The amount of the obligation under the contract, as determined in accordance with IAS 37: Provisions, Contingent Liabilities and Contingent Assets.

1.28.2 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.

1.28.3 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.

1.29 Value Added TaxMost of the activities of the clinical commissioning group are outside the scope of VAT and, in general, output tax does not apply and input tax on purchases is not recoverable. Irrecoverable VAT is charged to the relevant expenditure category or included in the capitalised purchase cost of fixed assets. Where output tax is charged or input VAT is recoverable, the amounts are stated net of VAT.

1.3 Foreign CurrenciesThe clinical commissioning group’s functional currency and presentational currency is sterling. Transactions denominated in a foreign currency are translated into sterling at the exchange rate ruling on the dates of the transactions. At the end of the reporting period, monetary items denominated in foreign currencies are retranslated at the spot exchange rate on 31 March. Resulting exchange gains and losses for either of these are recognised in the clinical commissioning group’s surplus/deficit in the period in which they arise.

1.31 Third Party AssetsAssets belonging to third parties (such as money held on behalf of patients) are not recognised in the accounts since the clinical commissioning group has no beneficial interest in them.

1.32 Losses & Special PaymentsLosses and special payments are items that Parliament would not have contemplated when it agreed funds for the health service or passed legislation. By their nature they are items that ideally should not arise. They are therefore subject to special control procedures compared with the generality of payments. They are divided into different categories, which govern the way that individual cases are handled.Losses and special payments are charged to the relevant functional headings in expenditure on an accruals basis, including losses which would have been made good through insurance cover had the clinical commissioning group not been bearing its own risks (with insurance premiums then being included as normal revenue expenditure).

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1.33 SubsidiariesMaterial entities over which the clinical commissioning group has the power to exercise control so as to obtain economic or other benefits are classified as subsidiaries and are consolidated. Their income and expenses; gains and losses; assets, liabilities and reserves; and cash flows are consolidated in full into the appropriate financial statement lines. Appropriate adjustments are made on consolidation where the subsidiary’s accounting policies are not aligned with the clinical commissioning group or where the subsidiary’s accounting date is not co-terminus.Subsidiaries that are classified as ‘held for sale’ are measured at the lower of their carrying amount or ‘fair value less costs to sell’.

1.34 AssociatesMaterial entities over which the clinical commissioning group has the power to exercise significant influence so as to obtain economic or other benefits are classified as associates and are recognised in the clinical commissioning group’s accounts using the equity method. The investment is recognised initially at cost and is adjusted subsequently to reflect the clinical commissioning group’s share of the entity’s profit/loss and other gains/losses. It is also reduced when any distribution is received by the clinical commissioning group from the entity.Joint ventures that are classified as ‘held for sale’ are measured at the lower of their carrying amount or ‘fair value less costs to sell’.

1.35 Joint VenturesMaterial entities over which the clinical commissioning group has joint control with one or more other parties so as to obtain economic or other benefits are classified as joint ventures. Joint ventures are accounted for using the equity method.Joint ventures that are classified as ‘held for sale’ are measured at the lower of their carrying amount or ‘fair value less costs to sell’.

1.36 Joint OperationsJoint operations are activities undertaken by the clinical commissioning group in conjunction with one or more other parties but which are not performed through a separate entity. The clinical commissioning group records its share of the income and expenditure; gains and losses; assets and liabilities; and cash flows.

1.37 Research & DevelopmentResearch and development expenditure is charged in the year in which it is incurred, except insofar as development expenditure relates to a clearly defined project and the benefits of it can reasonably be regarded as assured. Expenditure so deferred is limited to the value of future benefits expected and is amortised through the Statement of Comprehensive Net Expenditure on a systematic basis over the period expected to benefit from the project. It should be re-valued on the basis of current cost. The amortisation is calculated on the same basis as depreciation.

1.38 Accounting Standards That Have Been Issued But Have Not Yet Been AdoptedThe DHSC Group accounting manual does not require the following Standards and Interpretations to be applied in 2017-18. These standards are still subject to FREM adoption and early adoption is not therefore permitted.· IFRS 9: Financial Instruments ( application from 1 January 2018)· IFRS 14: Regulatory Deferral Accounts ( not applicable to DH groups bodies)· IFRS 15: Revenue for Contract with Customers (application from 1 January 2018)· IFRS 16: Leases (application from 1 January 2019)· IFRS 17: Insurance Contracts (application from 1 January 2021)· IFRIC 22: Foreign Currency Transactions and Advance Consideration (application from 1 January 2018)· IFRIC 23: Uncertainty over Income Tax Treatments (application from 1 January 2019)The application of the Standards as revised would not have a material impact on the accounts for 2017-18, were they applied in that year.

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2 Other Operating Revenue2017-18 2017-18 2017-18 2016-17

Total Admin Programme Total£'000 £'000 £'000 £'000

Education, training and research 83 73 10 54Non-patient care services to other bodies 5,538 317 5,221 8,171Rental revenue from operating leases 0 0 0 89Other revenue 1,790 78 1,712 616Total other operating revenue 7,411 468 6,943 8,930

.

3 Revenue2017-18 2017-18 2017-18 2016-17


From rendering of services 7,411 468 6,943 8,930From sale of goods 0 0 0 0Total 7,411 468 6,943 8,930

Revenue is totally from the supply of services. The clinical commissioning group receives no revenue from the sale of goods.

Administrative revenue is revenue received that is not directly attributable to the provision of healthcare or healthcare services.

Programme revenue is revenue received that is directly attributable to the provision of healthcare or healthcare services.

For other revenue, the figure relates to income from Merton Borough Council (£1,115k) for a high cost placement.

Revenue in this note does not include cash received from NHS England, which is drawn down directly into the bank account of the clinical commissioning group and credited to the General fund.

Within Non-patient care servicse to other bodies, the CCG has received £4,154k from Merton Borough Council in relation to Central London Community Healthcare services hosted by Merton CCG. The proportion of services hosted by the CCG and those paid directly by LBM to the provider changed over the two years under analysis.

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4. Employee benefits and staff numbers

4.1.1 Employee benefits 2017-18

TotalPermanent Employees Other

£'000 £'000 £'000Employee BenefitsSalaries and wages 4,732 3,436 1,296Social security costs 291 291 0Employer Contributions to NHS Pension scheme 285 285 0Gross employee benefits expenditure 5,308 4,012 1,296

Less recoveries in respect of employee benefits 0 0 0Total - Net admin employee benefits including capitalised costs 5,308 4,012 1,296

Less: Employee costs capitalised 0 0 0Net employee benefits excluding capitalised costs 5,308 4,012 1,296


TotalPermanent Employees Other

£'000 £'000 £'000Employee BenefitsSalaries and wages 4,687 2,470 2,216Social security costs 277 277 0Employer Contributions to NHS Pension scheme 273 273 0Gross employee benefits expenditure 5,236 3,020 2,216

Less recoveries in respect of employee benefits 0 0 0Total - Net admin employee benefits including capitalised costs 5,236 3,020 2,216

Less: Employee costs capitalised 0 0 0Net employee benefits excluding capitalised costs 5,236 3,020 2,216

In 17/18 Merton CCG consolidated its staffing structure through creating a joint management unit with Wandsworth CCG and was able to fill vacancies and reduce reliance on interims.

Total

Total

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4.2 Average number of people employed2016-17

TotalPermanently

employed Other TotalNumber Number Number Number

Total 55 45 10 46

Of the above:Number of whole time equivalent people engaged on capital projects 0 0 0 0

4.3 Exit packages agreed in the financial year

2017-18 2017-18 2017-18

Number £ Number £ Number £Less than £10,000 0 0 1 1,795 1 1,795Total 0 0 1 1,795 1 1,795

Number £ Number £ Number ££10,001 to £25,000 0 0 1 17,121 1 17,121Total 0 0 1 17,121 1 17,121

Analysis of Other Agreed Departures

Number £ Number £Contractual payments in lieu of notice 1 1,795 1 17,121Total 1 1,795 1 17,121

2017-18

Other agreed departures

These tables report the number and value of exit packages agreed in the financial year. The expense associated with these departures may have been recognised in part or in full in a previous period.

Compulsory redundancies Other agreed departures Total

2016-17 2016-17

2017-18 2016-17Other agreed departures

Exit costs are accounted for in accordance with relevant accounting standards and at the latest in full in the year of departure.

No non-contractual payments (£0,000) were made to individuals where the payment value was more than 12 months’ of their annual salary.The Remuneration Report would include the disclosure of exit payments payable to individuals named in that Report had there been any.

2016-17Compulsory redundancies Other agreed departures Total

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4.4 Pension costs

Past and present employees are covered by the provisions of the two NHS Pension Schemes. Details of the benefits payable and rules of the Schemes can be found on the NHS Pensions website at www.nhsbsa.nhs.uk/pensions.

Both are unfunded defined benefit schemes that cover NHS employers, GP practices and other bodies, allowed under the direction of the Secretary of State in England and Wales. They are not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities.

Therefore, each scheme is accounted for as if it were a defined contribution scheme: the cost to the NHS body of participating in each scheme is taken as equal to the contributions payable to that scheme for the accounting period.

In order that the defined benefit obligations recognised in the financial statements do not differ materially from those that would be determined at the reporting date by a formal actuarial valuation, the FReM requires that “the period between formal valuations shall be four years, with approximate assessments in intervening years”. An outline of these follows:

4.4.1 Accounting valuation

A valuation of scheme liability is carried out annually by the scheme actuary (currently the Government Actuary’s Department) as at the end of the reporting period. This utilises an actuarial assessment for the previous accounting period in conjunction with updated membership and financial data for the current reporting period, and is accepted as providing suitably robust figures for financial reporting purposes. The valuation of the scheme liability as at 31 March 2018, is based on valuation data as 31 March 2017, updated to 31 March 2018 with summary global member and accounting data. In undertaking this actuarial assessment, the methodology prescribed in IAS 19, relevant FReM interpretations, and the discount rate prescribed by HM Treasury have also been used.

The latest assessment of the liabilities of the scheme is contained in the report of the scheme actuary, which forms part of the annual NHS Pension Scheme Accounts. These accounts can be viewed on the NHS Pensions website and are published annually. Copies can also be obtained from The Stationery Office.

4.4.2 Full actuarial (funding) valuation

The purpose of this valuation is to assess the level of liability in respect of the benefits due under the schemes (taking into account recent demographic experience), and to recommend contribution rates payable by employees and employers.

The last published actuarial valuation undertaken for the NHS Pension Scheme was completed for the year ending 31 March 2016. The Scheme Regulations allow for the level of contribution rates to be changed by the Secretary of State for Health, with the consent of HM Treasury, and consideration of the advice of the Scheme Actuary and employee and employer representatives as deemed appropriate.

This sets the employer contribution rate payable from April 2019 and will consider the cost of the Scheme relative to the employer cost cap. There are provisions in the Public Service Pension Act 2013 to adjust member benefits or contribution rates if the cost of the Scheme changes by more than 2% of pay. Subject to this ‘employer cost cap’ assessment, any required revisions to member benefits or contribution rates will be determined by the Secretary of State for Health after consultation with the relevant stakeholders.

For 2017-18, employers’ contributions of £284,886 were payable to the NHS Pensions Scheme (2016-17: £272,705) at the rate of14.38% of pensionable pay. The scheme’s actuary reviews employer contributions, usually every four years and now based on HMTValuation Directions, following a full scheme valuation. The latest review used data from 31 March 2012 and was published on theGovernment website on 9 June 2012. These costs are included in the NHS pension line of note 4.1.

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5. Operating expenses2017-18 2017-18 2017-18 2016-17


Gross employee benefitsEmployee benefits excluding governing body members 4,736 1,142 3,594 4,260Executive governing body members 572 572 0 976Total gross employee benefits 5,308 1,714 3,594 5,236

Other costsServices from other CCGs and NHS England 5,193 1,864 3,329 5,912Services from foundation trusts 95,379 0 95,379 91,166Services from other NHS trusts 89,305 8 89,297 87,578Purchase of healthcare from non-NHS bodies 33,897 0 33,897 33,726Purchase of social care 217 0 217 0Chair and Non Executive Members 301 121 180 139Supplies and services – clinical 7 0 7 1Supplies and services – general 1,474 507 967 183Consultancy services 0 0 0 172Establishment 659 186 473 671Transport 12 2 10 12Premises 3,160 252 2,908 1,988Impairments and reversals of receivables 1 0 1 0Depreciation 201 0 201 200Audit fees 32 32 0 57Other non statutory audit expenditure· Internal audit services 24 24 0 0Prescribing costs 23,527 0 23,527 23,510GPMS/APMS and PCTMS 31,012 0 31,012 30,355Other professional fees excl. audit 80 0 80 316Legal fees 77 61 17 0Education and training 234 129 105 83CHC Risk Pool contributions 0 0 0 326Total other costs 284,791 3,187 281,604 276,395

Total operating expenses 290,099 4,901 285,198 281,631

Audit fees in amount of £32,350 were paid to Grant Thornton LLP.

Note 5.3 Limitation on auditor's liability

Administrative expenditure is expenditure incurred that is not a direct payment for the provision of healthcare or healthcare services.

Programme expenditure is expenditure incurred that is directly attributable to the provision of healthcare or healthcare services.

In accordance with the terms of engagement with the CCG's external auditors, Grant Thornton UK LLP, its members, partners and staff (whether contract, negligence or otherwise) in respect of services provided in connection with or arising out of the audit shall in no circumstances exceed £2million in the aggregate in respect of all such services.

The increase of expenditure for services from foundation trusts and healthcare from non-NHS bodies is due to the impact of new tariffs.

The increase in premises cost is due to void costs increasing along with the revaluation of market rents on 120 The Broadway and Nelson Health Centre.

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6.1 Better Payment Practice Code

Measure of compliance 2017-18 2017-18 2016-17 2016-17Number £'000 Number £'000

Non-NHS PayablesTotal Non-NHS Trade invoices paid in the Year 10,254 71,372 9,661 64,634Total Non-NHS Trade Invoices paid within target 9,835 67,363 9,522 63,643Percentage of Non-NHS Trade invoices paid within target 95.91% 94.38% 98.56% 98.47%

NHS PayablesTotal NHS Trade Invoices Paid in the Year 2,707 189,627 2,626 186,848Total NHS Trade Invoices Paid within target 2,616 188,464 2,545 185,809Percentage of NHS Trade Invoices paid within target 96.64% 99.39% 96.92% 99.44%

The Better Payment Practice Code requires the CCG to aim to pay all valid invoices by the due date or within 30 days of receipt, whichever is later. Although NHS Merton CCG achieved the code in aggregate, it did not achieve the element relating to the value of non NHS payables.

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7. Operating Leases

7.1 As lessee

7.1.1 Payments recognised as an Expense 2017-18 2016-17Land Buildings Other Total Land Buildings Other Total£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Payments recognised as an expenseMinimum lease payments 0 3,036 0 3,036 0 0 0 0Contingent rents 0 0 0 0 0 0 0 0Sub-lease payments 0 0 0 0 0 0 0 0Total 0 3,036 0 3,036 0 0 0 0

.

7.1.2 Future minimum lease payments 2017-18 2016-17Land 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 - - 0Between one and five years 0 0 0 0 0 - - 0After five years 0 0 0 0 0 - - 0Total 0 0 0 0 0 0 0 0

7.2 As lessor7.2.1 Rental revenue 2017-18 2016-17

£'000 £'000Recognised as incomeRent 0 0Contingent rents 0 89Total 0 89

7.2.2 Future minimum rental value 2017-18 2016-17£'000 £'000

Receivable:No later than one year 0 0Between one and five years 0 0After five years 0 0Total 0 0

NHS Merton Clinical Commissioning Group is liable for future costs relating to properties owned by NHS Property Services and Community Health Partnerships where the building or space within the building is not occupied (called a void space). However if this space gets occupied NHS Merton Clinical Commissioning Group is not liable for any costs relating to those properties unless it has leased the building or space under a formal agreement which will then be accounted for as per any operating lease. This is assessed on an annual basis so NHS Merton Clinical Commissioning Group is unable to estimate with any certainty potential liabilities over a 1 year time span.

.

Since July 2014, NHS Merton Clinical Commissioning Group has been a lessee for the 5th Floor, 120 The Broadway, London SW19. The lessor is NHS Property Services.

The operating lease commitments disclosed below also include payments to NHS Property Services Limited and Community Health Partnerships Limited for void space at various clinical estate within the borough for which NHS Merton Clinical Commissioning Group is liable to pay charges if this space is not utilised.

Whilst our arrangements with Community Health Partnerships 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.

The current year lease payment includes a one-off payment to South West London and St George's Mental Health NHS Trust.

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8 Property, plant and equipment

2017-18Information technology

£'000Cost or valuation at 01 April 2017 1,001

Additions purchased 155Cost/Valuation at 31 March 2018 1,156

Depreciation 01 April 2017 330

Charged during the year 201Depreciation at 31 March 2018 530

Net Book Value at 31 March 2018 625

Purchased 625Total at 31 March 2018 625

Asset financing:

Owned 625

Total at 31 March 2018 625

Additions purchased:

8.1 Additions to assets under constructionThere were no additions to assets under construction in 2017-18

8.2 Donated assetsNo assets were donated to Merton CCG in 2017-18

8.3 Government granted assetsNo Government granted assets were received by Merton CCG in 2017-18

8.4 Property revaluationThere was no property revaluation in 2017-18

8.5 Compensation from third parties

8.6 Write downs to recoverable amount

8.7 Economic lives

Information technology 5 5

Expenditure is on the purchase and implementation of a cloud based solution including hardware, software and licences.

No compensation from third parties for assets impaired, lost or given up was received and included in the Statement of Comprehensive Net Expenditure.

No assets were written down to recoverable amounts and no reversals of previous write-downs took place.

Minimum Life (years)

Maximum Life (Years)

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9 Intangible non-current assets

2017-18

Computer Software: Purchased Total

£'000 £'000Cost or valuation at 01 April 2017 0 0

Additions purchased 78 78Cost / Valuation At 31 March 2018 78 78

Amortisation 01 April 2017 0 0

Amortisation At 31 March 2018 0 0

Net Book Value at 31 March 2018 78 78

Purchased 78 78Total at 31 March 2018 78 78

9.1 Donated assetsNo donated assets were received in year by Merton CCG

9.2 Government granted assets No government granted assets were received in 2017-18.

9.4 Compensation from third parties

9.5 Write downs to recoverable amount

9.6 Non-capitalised assets

No compensation from third parties for assets impaired, lost or given up is included in the Statement of Comprehensive Net Expenditure.

No assets were written down to recoverable amounts and no reversals of previous write-downs took place.

No intangible assets are controlled by the NHS Merton Clinical Commissioning Group but not recognised as assets because they do not meet the recognition criteria of IAS 38.

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10 Trade and other receivables Current Non-current Current Non-current2017-18 2017-18 2016-17 2016-17

£'000 £'000 £'000 £'000

NHS receivables: Revenue 1,423 0 1,592 0NHS prepayments 1,003 0 1,189 0NHS accrued income 955 0 1,114 0Non-NHS and Other WGA receivables: Revenue 1,530 0 1,020 0Non-NHS and Other WGA prepayments 236 0 0 0Non-NHS and Other WGA accrued income 294 0 0 0VAT 68 0 42 0Other receivables and accruals 29 0 2 0Total Trade & other receivables 5,538 0 4,959 0

Total current and non current 5,538 4,959

10.1 Receivables past their due date but not impaired 2017-18 2017-18 2016-17£'000 £'000 £'000

DH Group Bodies

Group Bodies

All receivables prior years

By up to three months 509 413 193By three to six months 0 577 239By more than six months 334 373 340Total 843 1,363 772

£91,556 of the amount above has subsequently been recovered post the statement of financial position date.

The majority of trade is with NHS Organisations and Local Authorities. As NHS organisations and Local Authorities are ultimately funded by Government, no credit scoring of them is considered necessary. Concentration of credit risk is limited due to the fact that the customer base is large and composed of unrelated/government bodies. Due to this, the Governing Body believes that there is no future risk provision required in excess of the normal provision for doubtful receivables.

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11 Cash and cash equivalents

2017-18 2016-17£'000 £'000

Balance at 01 April 2017 17 76Net change in year 27 (59)Balance at 31 March 2018 44 17

Made up of:Cash with the Government Banking Service 44 17Cash and cash equivalents as in statement of financial position 44 17

Total bank overdrafts 0 0

Balance at 31 March 2018 44 17

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Current Non-current Current Non-current2017-18 2017-18 2016-17 2016-17

£'000 £'000 £'000 £'000

Interest payable 0 0 0 0NHS payables: revenue 5,430 0 1,138 0NHS accruals 1,391 0 4,217 0NHS deferred income 66 0 0 0Non-NHS and Other WGA payables: Revenue 3,742 0 6,106 0Non-NHS and Other WGA accruals 6,623 0 6,864 0Social security costs 48 0 44 0Tax 32 0 43 0Other payables and accruals 6,565 0 2,750 0Total Trade & Other Payables 23,895 0 21,162 0

Total current and non-current 23,895 21,162

Other payables include £319,917 outstanding pension contributions at 31 March 2018 (£251,599, 31 March 2017).

12 Trade and other payables

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13 Commitments

14 Financial instruments

14.1 Financial risk management

14.1.1 Currency risk

14.1.2 Interest rate risk

14.1.3 Credit risk

14.1.3 Liquidity risk

The clinical commissioning group had not entered into non-cancellable contracts (which are not leases, private finance initiative contracts or other service concession arrangements).

NHS Merton 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 Merton clinical commissioning group and revenue comes from parliamentary funding, NHS Merton 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 Merton clinical commissioning group is required to operate within revenue and capital resource limits, which are financed from resources voted annually by Parliament. The NHS Merton 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 Merton 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 Merton clinical commissioning group is principally a domestic organisation with the great majority of transactions, assets and liabilities being in the UK and sterling based. NHS Merton clinical commissioning group has no overseas operations. The NHS Merton clinical commissioning group and therefore has low exposure to currency rate fluctuations.

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14 Financial instruments cont'd

14.2 Financial assets

At ‘fair value through profit and

loss’Loans and

ReceivablesAvailable for

Sale Total2017-18 2017-18 2017-18 2017-18

£'000 £'000 £'000 £'000

Receivables:· NHS 0 2,378 0 2,378· Non-NHS 0 1,824 0 1,824Cash at bank and in hand 0 44 0 44Other financial assets 0 29 0 29Total at 31 March 2018 0 4,275 0 4,275


loss’Loans and

ReceivablesAvailable for

Sale Total2016-17 2016-17 2016-17 2016-17

£'000 £'000 £'000 £'000

Receivables:· NHS 0 2,705 0 2,705· Non-NHS 0 1,020 0 1,020Cash at bank and in hand 0 17 0 17Other financial assets 0 2 0 2Total at 31 March 2018 0 3,745 0 3,745

14.3 Financial liabilities


loss’ Other Total2017-18 2017-18 2017-18

£'000 £'000 £'000

Payables:· NHS 0 6,820 6,820· Non-NHS 0 16,929 16,929Total at 31 March 2018 0 23,749 23,749


loss’ Other Total2016-17 2016-17 2016-17

£'000 £'000 £'000

Payables:· NHS 0 5,355 5,355· Non-NHS 0 15,720 15,720Total at 31 March 2018 0 21,075 21,075

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15 Operating segments

Gross expenditure Income Net expenditure Total assets Total liabilities Net assets

£'000 £'000 £'000 £'000 £'000 £'000Commissioning of Healthcare 290,214 (7,526) 282,689 6,285 (23,895) (17,610)Total 290,214 (7,526) 282,689 6,285 (23,895) (17,610)

15.1 Reconciliation between Operating Segments and SoCNE

2017-18£'000

Total net expenditure reported for operating segments 282,689

Reconciling items:Total net expenditure per the Statement of Comprehensive Net Expenditure

282,689

15.2 Reconciliation between Operating Segments and SoFP

2017-18£'000

Total assets reported for operating segments 6,285

Reconciling items:Total assets per Statement of Financial Position 6,285

2017-18£'000

Total liabilities reported for operating segments (23,895)

Reconciling items:Total liabilities per Statement of Financial Position (23,895)

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16 Pooled budgets

2017-18 2016-17£'000 £'000

Income 0 0Expenditure (5,525) (5,555)

The NHS Merton clinical commissioning group shares of the income and expenditure handled by the pooled budget in the financial year were:

The clinical commissioning group had entered into a pooled budget with London Borough of Merton. The pool is hosted by London Borough of Merton.

Under the joint arrangement, funds are pooled under Section 75 of the NHS Act 2006 for the Better Care Fund and Integrated Community Equipment Services.

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17 Related party transactions

Payments to Related Party

Receipts from

Related Party

Amounts owed to Related Party

Amounts due from Related Party

Payments to Related Party

Receipts from

Related Party

Amounts owed to Related Party

Amounts due from Related Party

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

St George's University Hospitals NHS Foundation Trust 69,288 -36 1,251 -736 66,660 -36 154 -905Epsom & St Helier University Hospitals NHS Trust 37,444 0 1,076 -145 37,276 0 127 -862Central London Community Healthcare NHS Trust 22,690 -22 499 -43 21,277 -22 76 -63South West London & St George's Mental Health NHS Trust 17,834 -61 799 -54 17,660 -7 1,164 -19Kingston Hospital NHS Foundation Trust 11,995 0 144 -168 10,980 0 416 -208London Ambulance Service NHS Trust 6,811 0 238 0 6,779 0 196 0Moorfields Eye Hospital NHS Foundation Trust 3,955 0 0 -61 4,102 0 93 0NHS NEL CSU 3,146 -51 126 0 0 0 0 0NHS Property Services 3,114 0 0 -233 1,452 0 1,372 0Guy's & St Thomas' NHS Foundation Trust 2,656 0 5 -427 2,560 0 0 -244Croydon Health Services NHS Trust 2,589 0 381 -26 2,179 0 9 -138The Royal Marsden NHS Foundation Trust 1,850 0 216 0 1,360 0 1,125 0Chelsea And Westminster Hospital NHS Foundation Trust 1,335 0 1 -62 1,388 0 30 0King's College Hospital NHS Foundation Trust 1,312 0 184 0 1,069 0 4 -43NHS Wandsworth CCG 1,268 -314 331 -237 1,297 -1,370 314 -256NHS England 287 -389 18 -1,248 492 -1,025 2 -941

The Nelson Medical Practice 4,374 0 0 0 4,006 0 0 0Lambton Road Medical Practice 2,166 0 0 0 1,973 0 1 0Morden Hall Medical Centre 1,934 0 0 0 1,772 0 0 0Cricket Green Surgery 1,840 0 0 0 1,709 0 0 0Francis Grove Surgery 1,557 0 0 0 1,443 0 0 0Wimbledon Village Surgery 1,474 0 0 0 1,447 0 8 0Mitcham Medical Practice 1,321 0 0 0 1,328 0 0 0Tamworth House Medical Centre 1,293 0 0 0 1,350 0 0 0Colliers Wood Surgery 1,167 0 0 0 1,101 0 2 0Wide Way Surgery 1,157 0 0 0 1,075 0 0 0Stonecot Surgery 1,153 0 0 0 1,162 0 2 0Central Medical Centre 1,118 0 0 0 1,048 0 1 0The Rowans Surgery 1,079 0 0 0 1,222 0 0 0Grand Drive Surgery 1,040 0 0 0 1,048 0 3 0Figges Marsh Surgery 1,029 0 0 0 936 0 2 0Princes Road Surgery 973 0 0 0 995 0 0 0Ravensbury Park Medical Centre 876 0 0 0 808 0 0 0James O'Riordan Medical Centre 855 0 0 0 788 0 0 0Merton Medical Centre 846 0 0 0 832 0 0 0Riverhouse Surgey 681 0 0 0 687 0 0 0Alexandra Surgery 595 0 0 0 580 0 2 0Vineyard Hill Road Surgery 456 0 0 0 478 0 0 0

In addition, the clinical commissioning group has had a number of material transactions with other government departments and other central and local government bodies. Most of these transactions have been with the London Borough of Merton.

2017-18 2016/17

Details of related party transactions with individuals are as follows:

During the year none of the Department of Health Ministers, Clinical Gommission Group Body members or members of the key management staff, or parties related to any of them, has undertaken any material transactions with the clinical commissioning group. The clinical commissioning group is reporting total related party transactions with NHS organisations where transactions have exceeded £1.2k and all transactions for non-NHS organisations and GP board member practices.

The Department of Health is regarded as a related party. During the year the clinical commissioning group has had a significant number of meterial transactions with entities for which the Department is regarded as the parent department, which are listed below:

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18 Events after the end of the reporting period

19 Financial performance targets

NHS Merton Clinical Commissioning Group has a number of financial duties under the NHS Act 2006 (as amended).NHS Merton Clinical Commissioning Group performance against those duties was as follows:

2017-18 2017-18 2016-17 2016-17Target Performance Target Performance£'000's £'000's £'000's £'000's

Expenditure not to exceed income 290,374 290,333 283,733 281,631Capital resource use does not exceed the amount specified in Directions 233 233 0 0Revenue resource use does not exceed the amount specified in Directions 282,730 282,689 274,803 272,701Capital resource use on specified matter(s) does not exceed the amount specified in Directions 0 0 0 0Revenue resource use on specified matter(s) does not exceed the amount specified in Directions 0 0 0 0Revenue administration resource use does not exceed the amount specified in Directions 4,451 4,433 4,425 4,387

There are no material events arising after the end of the accounting period.

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20. Employee benefits and staff numbers


TotalPermanent Employees Other Total

Permanent Employees Other Total

Permanent Employees Other

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000Employee BenefitsSalaries and wages 4,732 3,436 1,296 1,560 1,118 443 3,172 2,319 853Social security costs 291 291 0 72 72 0 219 219 0Employer contributions to the NHS Pension Scheme 285 285 0 82 82 0 203 203 0Gross employee benefits expenditure 5,308 4,012 1,296 1,714 1,272 443 3,594 2,741 853

Less recoveries in respect of employee benefits (note 4.1.2) 0 0 0 0 0 0 0 0 0Total - Net admin employee benefits including capitalised costs 5,308 4,012 1,296 1,714 1,272 443 3,594 2,741 853

Less: Employee costs capitalised 0 0 0 0 0 0 0 0 0Net employee benefits excluding capitalised costs 5,308 4,012 1,296 1,714 1,272 443 3,594 2,741 853


TotalPermanent Employees Other Total

Permanent Employees Other Total

Permanent Employees Other

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000Employee BenefitsSalaries and wages 4,687 2,470 2,216 1,652 616 1,036 3,035 1,855 1,180Social security costs 277 277 0 69 69 0 208 208 0Employer contributions to the NHS Pension Scheme 273 273 0 80 80 0 192 192 0Gross employee benefits expenditure 5,236 3,020 2,216 1,802 766 1,036 3,435 2,254 1,180

Less recoveries in respect of employee benefits (note 4.1.2) 0 0 0 0 0 0 0 0 0Total - Net admin employee benefits including capitalised costs 5,236 3,020 2,216 1,802 766 1,036 3,435 2,254 1,180

Less: Employee costs capitalised 0 0 0 0 0 0 0 0 0Net employee benefits excluding capitalised costs 5,236 3,020 2,216 1,802 766 1,036 3,435 2,254 1,180

Total Admin Programme

Total Admin Programme

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21 Losses and special payments

21.1 Losses

Total Number of

CasesTotal Value

of CasesTotal Number

of CasesTotal Value of Cases

2017-18 2017-18 2016-17 2016-17Number £'000 Number £'000

Administrative write-offs 1 1 0 0

Total 1 1 0 0

This relates to one bad debt with Croydon Voluntary Action in amount of £637.78p.

The total number of NHS Merton clinical commissioning group losses and special payments cases, and their total value, was as follows: