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NHS ENFIELD CCG
ANNUAL REPORT AND ACCOUNTS
For 2017/2018
Website: www.enfieldccg.nhs.uk
Twitter: @EnfieldCCG
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CONTENTS
Performance Overview ........................................................................................................................ .4
Performance summary ............................................................................................................... 15
Performance analysis ........................................................................................................................ .15
Sustainable Development .......................................................................................................... 19
Improve quality ............................................................................................................................ 20
Engaging people and communities .......................................................................................... 22
Reducing health inequality ......................................................................................................... 27
Health and wellbeing strategy – Working with local partners ............................................... 28
ACCOUNTABILITY REPORT .................................................................................................33
Corporate Governance Report .......................................................................................................... 33
Members Report ................................................................................................................................. . 33
Member profiles ........................................................................................................................... 33
Member practices ........................................................................................................................ 33
Composition of Governing Body ............................................................................................... 33
Committee(s), including Audit Committee ............................................................................... 35
Register of Interests .................................................................................................................... 35
Personal data related incidents ................................................................................................. 35
Statement of Disclosure to Auditors ......................................................................................... 35
Modern Slavery Act ..................................................................................................................... 35
Statement of Accountable Officer’s Responsibilities ..................................................................... 35
Governance Statement ...................................................................................................................... 38
Introduction and context ............................................................................................................. 38
Scope of responsibility ................................................................................................................ 39
Governance arrangements and effectiveness ........................................................................ 39
UK Corporate Governance Code .............................................................................................. 50
Discharge of Statutory Functions .............................................................................................. 51
Risk management arrangements and effectiveness.............................................................. 51
Risk Assessment ......................................................................................................................... 57
Other sources of assurance ...................................................................................................... 59
Control Issues .............................................................................................................................. 62
Review of economy, efficiency & effectiveness of the use of resources ............................ 62
Delegation of functions ............................................................................................................... 63
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Counter fraud arrangements ..................................................................................................... 63
Head of Internal Audit Opinion .................................................................................................. 64
Review of the effectiveness of governance, risk management and internal control ........................................................................................................................................... 65
Conclusion .................................................................................................................................... 65
Remuneration and Staff Report ....................................................................................................... . 67
Remuneration Report ........................................................................................................................ . 67
Remuneration and Terms of Service Committee ................................................................... 67
Policy on the remuneration of senior managers ..................................................................... 67
Remuneration of Very Senior Managers ................................................................................. 67
Contractual arrangements ........................................................................................................... 68
Senior manager remuneration (including salary and pension entitlements) ...................... 69
Senior manager remuneration (including salary and pension entitlements) 2016/2017 ..................................................................................................................................... 71
Pensions .............................................................................................................................................. 72
Cash equivalent transfer values ................................................................................................ 72
Real increase in CETV ............................................................................................................... 73
Salary and pension entitlements of directors and senior managers ................................... 73
Pension benefits as at 31 March 2018 .....................................................................................73
Pension benefits as at 31 March 2017 ..................................................................................... 75
Compensation on early retirement of for loss of office .......................................................... 75
Payments to past members ....................................................................................................... 75
Pay multiples ................................................................................................................................ 75
Staff Report ......................................................................................................................................... . 76
Number of senior managers ...................................................................................................... 76
Staff composition, Staff numbers and costs ............................................................................ 76
Sickness absence data .............................................................................................................. 77
Staff policies ................................................................................................................................. 77
Expenditure on consultancy ........................................................................................................ 78
Off-payroll engagements ............................................................................................................ 78
Exit packages, including special (non-contractual) payments .............................................. 80
ANNUAL ACCOUNTS ........................................................................................................... 88
Financial Context ................................................................................................................... 88
Financial position in 2017/2018 ................................................................................................ 88
Financial Position in 2018/2019 ............................................................................................. 91
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NHS Enfield Clinical Commissioning Group - Annual Accounts 2017-18 ............................. 93
16.2 Related party transactions - 2016-17 ...........................................................................113
Payments to Related Party ..................................................................................................113
PERFORMANCE REPORT
Performance Overview
Statement from the Accountable Officer for North Central London CCGs Welcome to the 2017-2018 annual report for Enfield Clinical Commissioning Group (CCG).
This opening performance overview provides a summary of what Enfield CCG has achieved in the past 12 months, as well as looking at some of our future priorities and how we have discharged our functions.
I was appointed the new Chief Officer and Accountable Officer for the North Central London (NCL) clinical commissioning groups (CCGs) – Barnet CCG, Enfield CCG, Islington CCG, Haringey CCG and Camden CCG in March 2017 and started in post on Monday 3 April 2017. As the Accountable Officer, I have signed all five CCG annual reports and accounts for 2017-2018.
This year 2017-2018 has been an exciting, challenging year. Our first working together as a North Central London CCG partnership. Good progress has been made and the NCL CCGs are in a much stronger position to progress the priorities and tackle the challenges in the year ahead.
Together we have developed our Sustainability and Transformation Partnership Plan to deliver the triple aims of improved health and wellbeing, transformed quality of care delivery, and sustainable finances across primary, community and acute care.
We have made it possible for residents to access GP services 8am-8pm. We are starting to set up Care and Health Integrated Networks across North London, based around the population. These networks bring GPs and other health and social care partners together and are supported by Quality Improvement Support Teams (QISTs), which are focusing on reducing unwarranted variation in primary care. We are also one of the first areas nationally to launch the new integrated urgent care model.
We have a shared vision and a collective commitment to work together in new ways to change and improve health and care services in North London for the benefit of our residents.
Overview from the Chief Operating Officer Clinical Commissioning Groups (CCGs) were created by the Health and Social Care Act 2012.This is Enfield CCG’s fifth year as an organisation. As more than 90% of patients’ contact with the NHS is with their GP, CCGs were created to enable GPs to buy most of the services that their patients are referred to such as hospital, mental health and community services. Our role as a CCG is to plan, buy (commission) and continuously improve the quality of these services for local people. Our vision since we became an organisation in 2013 has been to work with residents and stakeholders to continually improve the health and well-being of our population and reduce health inequalities.
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Enfield CCG is a membership organisation made up of GPs from 48 practices. They have signed our Constitution which describes the governance of our organisation and how we work together to plan, buy and monitor health services. The member practices are grouped into four localities: North East, South East, North West and South West. GP practices in each locality meet regularly and work closely together to improve the health of their local populations.
The majority of members of our Governing Body are local doctors. We have eight elected GPs representing our four localities. During this year we have had some important changes to the membership of our Governing Body. A full list of our Governing Body members can be found on our website.
Last year we invested £455m buying health services for people living in Enfield. With a growing population, rising demand for services and a financial deficit, we have to evaluate every service we commission.
Our challenges The challenge faced by organisations across the NHS is how to spend the allocated budgets in a way that benefits the health of the whole population, whilst ensuring that services meet the needs of individuals and deliver value for money.
Enfield CCG has historically been a financially challenged CCG that was put under Legal Directions by NHS England on 10 August 2015. The CCG has a brought forward cumulative deficit of £37.2m.
In December 2013, NHS England confirmed that Enfield CCG was materially underfunded for the needs of its local population. At that time, the level of underfunding was £26.5m (8.43%) against the actual allocation. This historic funding gap is a key contributory factor to the financial challenges and cumulative deficit faced by Enfield CCG today.
NHS England has since addressed the underfunding through increased allocations bringing Enfield CCG to within 2.2% (£9.1m) of its national target allocation in 2017/2018. However, it will take a number of years for the required infrastructure to be in place to address historic high cost drivers such as acute services overspends. By 2020-21 there will still be a gap of 1.7% or £7.6m as compared to required funding.
In 2017/2018, the CCG reported an in-year deficit of £3.4m. In reaching this position, the CCG delivered £15.4m of efficiency savings, against a target of £22.5m. Of the achieved £15.4m of efficiencies made, £8.4m related to acute contracts and £7m related to non-acute productivity improvements, largely in prescribing services.
This £3.4m deficit is an improvement from last year’s £3.8m. However, it is still £5.5m adrift against the control target set by NHS England of £2.1m surplus and takes the CCG’s cumulative deficit to £40.63m.
Looking ahead, our financial challenge is set to increase further. To achieve financial balance, the CCG will need to make £23.8m of savings in our commissioning budget
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(5.2% of total allocation) in 2018/2019. In everything we do, we will need to prioritise our limited resources to make sure we balance all the health needs of local people to make sure we maximize resources to have maximum impact on the local population.
Further details are in the Annual Accounts section of this report.
How we buy NHS services The NHS is funded through taxation. This provides a budget to buy health services for the population. Enfield CCG is responsible for assessing the needs of people living in the London Borough of Enfield and deciding which hospital, community and mental health services to purchase for our population. NHS England is responsible for buying services outside the remit of CCGs, namely primary care, public health, offender health, military and veteran health and other specialised services such as transplants and dialysis.
In July 2017 the Governing Bodies of NHS Barnet Clinical Commissioning Group, NHS Camden Clinical Commissioning Group, NHS Enfield Clinical Commissioning Group, NHS Haringey Clinical Commissioning Group and NHS Islington Clinical Commissioning Group established the North Central London (NCL) Joint Commissioning Committee (‘Committee’).
The Committee’s role is to jointly commission the following services as these are most effectively commissioned collaboratively across the five CCGs:
All acute services including core contracts and other out of sector acutecommissioning; All learning disability contracting associated with the Transforming Careprogramme; All integrated urgent care (including 111/ GP Out-of-Hours services) Any specialised services not commissioned by NHS England.
The Committee includes clinicians, lay members, senior NHS management staff, councillors, Healthwatch and Public Health. More details can be found on our website.
Our achievements for 2017/2018:
Care Closer to Home Local GPs have come together to form a GP Federation called Enfield Healthcare
Cooperative Limited. This Federation is delivering out of hospital services to theentire patient population of Enfield and will be integral to offering patients agreater range of services as part of Enfield CCG’s aim to bring care closer tohome.
Since December 2016 we have opened GP Hubs in 3 locations across Enfieldproviding 6.30-8pm access on weekday evenings, and 8am-8pm access onweekends and public holidays.
We have opened walk in services in 3 locations across Enfield, providing walk inappointments 8am-8pm on weekends and public holidays.
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The North East Alliance (NEA) Limited, an umbrella organisation for the 13practices in the North East Locality, has established a pilot Long Term Conditions(LTC) Service at Eagle House surgery, providing extended access 8am to 8pmMonday to Sunday for routine and “on the day” booking for patients with longterm conditions. The service provides speciality clinics focused around key longterm conditions with the aim of preventing A&E admissions, optimisingmanagement and health promotion.
In 2016/2017 the CCG commissioned a Community Anticoagulation Service thatencompasses the needs of Enfield patients and delivers care closer to home.This service has seen a shift of 30% of patients requiring follow up appointmentspreviously provided in the hospital into the primary/community setting.
We have been working with the Royal Free London Hospital NHS FoundationTrust to transform and standardise their internal practices across Barnet andChase Farm hospital sites. This work has seen a monthly spend reduction from£65k/month to £40k/month over an 18 month period and a reduction in secondarycare activity from 2,600/month to 1,500/month.
Planned Care & Long Term Conditions Between 1st October 2016 and 30th September 2017 we commissioned a Locally
Commissioned Service (LCS) focused on Atrial Fibrillation (AF) which hasidentified 929 patients with AF as well as focusing on reducing variation acrossprimary care in the detection and management of AF. Clinical evidence showsthat for every 100 patients with unmanaged AF 3-5% of them will experience astroke and therefore the scheme will have prevented more than 30 patients (andthe corresponding impact on their families and carers) from experiencing astroke. At an average cost of £12k per episode this has also saved the healtheconomy around £360k.
Improved compliance to the North Central London (NCL) Procedures of LimitedClinical Effectiveness (PoLCE) Policy has realised more than £1.5m of savingsagainst previous spend, money that will be better placed supporting patients withprocedures and treatments that will have a significant impact on outcomes.
Enfield CCG completed a Public Consultation on 13 clinical procedures under ourAdherence to Evidence Based Medicine (AEBM) programme and the outcomesof this exercise are now being implemented. Enfield CCG is also leading the NCLrollout of this work and the expansion of procedures included within the NCLPoLCE Policy.
Through redesigning the pathway for Direct Access Medical Resonance Imaging(MRI) and routing referrals through the Enfield Referral Service (ERS), the CCGhas been able to reduce the spend from £975k to £875k/year and reducedactivity by more than 500 MRI scans.
Full mobilisation of a new Community Ophthalmology Service that is seeing onaverage 1,277 patients per month and realising savings of £86k per month andwhich is in excess of the planned saving.
We have developed a robust Cancer Improvement Plan that was approved by theCCG’s Clinical Reference Working Group (CRWG). NHS England data from July2017 shows that Enfield CCG is achieving the highest early detection rates inNCL and therefore contributing to reducing costs. For example, the costs of
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treating Colon Cancer at Stage 1 is ~£3.4k whereas if it is treated at Stage 4 the cost increases to £12.5k, as well as having much worse outcomes for patients.
A Multidisciplinary Diagnostic Centre (MDC) opened at North MiddlesexUniversity Hospital NHS Trust (NMUH) in October 2017 led by University CollegeLondon Hospital NHS Trust (UCLH). This allows GPs to refer patients with‘vague’ symptoms that could indicate Cancer and provides faster specialistassessment and rapid diagnosis. The previous pilot saw Cancer ConversionRates increase from 2.4% to 3.0% which has a positive impact for patients.
88% of Enfield GP practices now use e-Referrals for 2 Week Waits for suspectedCancer and this will rise to 100% from January 2018. This is significantly inadvance of the nationally mandated date of 1st October 2018.
The Locally Commissioned Service for Stable Prostate Cancer has been fullymobilised to benefit 450 patients a year from April 2018 through care providedcloser to home for follow up appointments.
The tele-dermatology service operated by the Royal Free London Hospital NHSTrust is fully mobilised and delivering savings in excess of plan. On average, 22%of referrals for dermatology are returned to GPs with a management plan ratherthan requiring secondary care support. In addition, an average of 34% of referralsare returned to GPs as no treatment was required and therefore no secondarycare costs are incurred (other than the tele-dermatology tariff). The service iscontributing to identifying patients with Melanoma (1% of referred patients) andCancer (2% of referred patients) as well as ensuring that 94% of patients beingseen on time and with 91% of them saying they would recommend the service.This service will be expanded during 2018 to include Basal Cell Carcinoma(BCC), Paediatrics and Inflammatory Conditions. In addition, we will be seekingfor Roaccutane follow up appointments to be seen in a community setting.
Urgent & Emergency Care We have seen a 38% increase in the number of patients being treated by
Ambulatory Care at North Middlesex University Hospital (NMUH) between2016/17 and 2017/2018, contributing to reducing pressure for beds at the hospitalas well as reducing costs. In addition, there has been a 13% reduction in thenumber of patients needing a follow up appointment. GPs are able to directlyaccess this service.
The Paediatric Assessment Unit (PAU) at Chase Farm Hospital site wasdecommissioned in June 2017 and a new model of care introduced which hasimproved outcomes for children and realised £323k savings and contributing to areducing conversion rate for children being admitted.
We have established an integrated model of care across Primary, Secondary andCommunity care for Children with Asthma and/or Allergy related conditions.Whilst the savings associated with this service are modest, it is helping EnfieldCCG to reduce its outlier status for Asthma related mortality.
Mental Health Effective management and support of Female Psychiatric Intensive Care Unit
(PICU) patients has led to a reduction of bed days from 902 to 529 bed days
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between 2016/17 and 2017/2018. This has reduced costs by £346,534 and we have contained the budget for 2018/2019 even with an expected increase in patient activity.
In addition, we have worked with Islington CCG to develop a NCL Female PICUresource provided by Camden and Islington Foundation Trust (C&IFT) whichopened on 13th November 2017. This will reduce Length of Stay (LoS) further andwill improve outcomes for patients by ensuring local provision of services. As it isunusual for Female PICU to be commissioned directly by CCGs, Barnet, Enfieldand Haringey Commissioners are seeking to devolve budgets to Barnet, Enfieldand Haringey Mental Health Trust (BEHMHT) on the basis of the newarrangements with C&IFT for 2018/2019.
We have successfully resolved the Older Peoples longer term Continuing HealthCare (CHC) beds provided by BEHMHT at Chase Farm Hospital andcommissioned 12 CHC beds in the community as well as re-engineering thepathway to ensure that patients with CHC dementia health needs are supportedwell in a community setting.
We have worked with BEHMHT, the Council, patients and their carers totransition 23 longer stay patients back to the community and the ward closed on18th December 2017. This has produced a saving of £461,300 for 2017/2018and £474,600 for 2018/2019.
By effective management of the Complex Care Rehabilitation for Out of AreaPlacements pathway we have reduced the average patient cohort from 32patients to 21 patients from September 2016 to November 2017. This isanticipated to reduce further to 10-15 patients by the end of April 2018 with adischarge trajectory of 7 over the next 3-4 months. The expected saving for2017/2018 is £595,420.
We have commissioned BEHMHT through an Official Journal of European Union(OJEU) procurement process to develop a new ward at Chase Farm Hospitalwhich will provide complex care rehabilitation services for 14 inpatients. Thismeans that Length of Stay (LoS) should reduce further as patients will havegreater access to health and care professionals that are closest to them and thiswill improve outcomes for patients by ensuring the local provision of services.
We have met our Parity of Esteem obligations.
Primary Care We have commissioned Domestic Violence & Abuse Services. We have led the Primary Medical Services (PMS) Review & Special Allocation
Service (previously Violent Patients Scheme) commissioning. Information Technology: Community EMIS & Data Sharing Agreement to
support continuity of care for patients being seen in extended accessservices, i.e.: hubs, walk-in services and LTC services.
Estates: Silverpoint opened and we achieved a reduction in void space withinpractice premises.
Workforce: General Practice Nurse (GPN) and Advanced Nurse Practitioner(ANP) Training Programmes, Health Care Assistant (HCA) apprenticeships,and leading on NCL Medical Assistants’ pilot.
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Medicines Management We have reduced prescribing of “Over the Counter” drugs and stopped Gluten
Free prescribing realising savings of more than £400k since 2016/17. Through a detailed medicines wastage campaign the CCG has encouraged
appropriate use of medicines and safe disposal of unused medications. This workhas also encouraged patients to order their repeat prescriptions themselves fromthe GP and where ordered via a Third Party (such as a pharmacy) we haverequired verification that the patient does need the medications ordered. This hascontributed directly to a reduction in medication spend for Enfield CCG of minus3.5%, which is the 7th Lowest Growth in England.
Through a continued focus on helping GPs to make the correct prescribingdecisions and to switch patients where possible to cheaper, clinically appropriate,alternative medicines the Medicines Management Team will have realised nearly£3m of savings between 2016/17 and 2017/2018 (after deducting the impact ofuncontrollable price rises).
One highly successful switching campaign focused on blood glucose testingwhere Enfield CCG avoided £179k of cost by prescribing Mylife strips which were30% cheaper than other strips.
Community Services Successful mobilisation of a Community Heart Failure (HF) Nurse Service in
Quarter Three 2017/2018 is already providing more care out of hospital and willreduce costs by £133k over the year to Quarter Three 2018/2019.
Investment has eliminated the backlog in Diabetes Structured Education with750 patients offered support and 332 already completed the educationprogramme in the first two months.
The Community Chronic Obstructive Pulmonary Disease (COPD) servicecontinues to contribute to reducing respiratory based emergency admissionswhich remain the lowest in North Central London (adjusted for age anddemographic factors).
Service Transformation and Other Efficiencies Through proactive management of the CCG funded Estates (including voids) we
have realised around £600k in 2017/2018 and a further £300k is planned for2018/2019.
The CCG has reduced running costs by nearly £300k during 2017/2018. This isagainst a backdrop of restructuring and the need to bolster commissioningresource to deliver a challenging Quality, Innovation, Productivity and Prevention(QIPP) Programme.
The organisation has reduced its dependency on non-recurrent QIPP. In2016/2017 the CCG delivered ~£13m of net QIPP of which ~£9m was non-recurrent (i.e. not transformational). In 2017/2018 the CCG is set to realise~£16m of net QIPP of which nearly £13m is transformational (i.e. recurrent). Thisis set to increase further in 2018/2019.
The number of QIPP Schemes that were recurrent from 2016/17 into 2017/2018was 6. The numbers that are recurrent from 2017/2018 into 2018/2019 are 19.
This shows that the CCG is increasing the number of transformational schemes and generating recurrent benefits. These numbers exclude Sustainability and Transformation Plan (STP) related schemes which would increase the number of recurrent schemes between 2017/2018 and 2018/2019 further.
The move toward transformational QIPP can be seen at a Treatment FunctionCode (TFC) level where in 2016/2017 Enfield CCG were above the NorthCentral and East London (NCEL) average for secondary care activity (whennormalised to per 1,000 population) in 34 of the top 50 TFCs. This equated tospend of £22m above the NCEL average. By December 2017 this had reducedto 28/50 TFCs and spend of £18m above the NCEL average.
The CCG has a robust and well developed plan for 2018/2019 that is fullyaligned to our RightCare priorities and includes a full pipeline of schemes atvarying levels of development. This is in contrast to 2016/2017 where there wasonly a limited pipeline and very little alignment between our QIPP Plan andRightCare priorities.
Through all of the above the CCG was taken out of Special Measures during2017/2018.
Future Delivery Plans for 2018/2019 include: GP Federation delivering further phases of the Single Offer – Care Closer to
Home; Establishing a Care and Health Integrated Network (CHIN) in each locality; Developing Quality Improvements Support Teams (QISTs); Establishment of Medicus Health Partnership – super partnership; IT: Utilisation of EMIS Community, all practices using EMIS, deployment of
Docman 10 and Practice Wi-Fi; Estates: Developing new primary care premises – e.g. Meridian Water;
Developing existing primary care premises; Reduction in void space;Establishment of CHIN facilities;
Workforce: Deployment of care navigators/health champions for socialprescribing; Practice-based pharmacists; Developing Practice ManagementSkills; Improving clinical quality within General Practice.
Working as partners to deliver the North Central London sustainability
partnership
The CCG is an integral part of the North London Health and Care Partnership, made up of health and care organisations from the five London boroughs of Barnet, Camden, Enfield, Haringey and Islington.
Together, we have developed our Sustainability and Transformation Partnership Plan (STP) to deliver the triple aims of improved health and wellbeing, transformed quality of care delivery, and sustainable finances as set out in the national Five Year Forward View. Locally as partners, we have a shared vision, a collective agenda and
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the commitment to work together in new ways to transform the health and care services of North London.
The driving force behind our partnership is for our communities to be happier, healthier and to live longer in good health. We are conscious that the community includes our dedicated workforce – many of whom call North London your home and use the same health and care services as the local population they serve.
As a group of organisations, we have developed plans to improve services and to reduce the pressure on the health and care system. We aim to do this through:
Increasing our prevention programmes with the aim of supporting people tostay well and when people become unwell, to recover quickly;
Partnering with people and organisations to help our residents to remainindependent for as long as possible as they age, and to have more controlover their own health and wellbeing;
Giving our children and their mothers, families and their care givers the rightsupport so they can have the best possible start in life;
Providing care closer to home so people only go to hospital when it isclinically necessary;
Giving mental health services equal priority to physical health services; Improving our cancer services; Providing a consistent standard of care available to everyone and reduce
variation; and Attracting people to live and work in North London so we have the best
possible workforce to deliver high quality services to our community
Details of the plan and partnership can be found here: http://www.northlondonpartners.org.uk/about/our-Aims.htm
In 2017 we have worked with our partners to engage with the public and begin to implement shared plans to deliver improvements to health and care and spend money wisely. Some highlights of this include: 1. Making it possible for residents to access GP services 8am-8pm through
extended access from April 2017;2. Following capital investment of £1million by Camden & Islington Foundation
NHS Trust we opened the Women’s Psychiatric Intensive Care Unit on 13November 2017. This ensures that women who require intensive care in NCLare not placed out of area as a first response to their crisis and need forintensive care;
3. Being one of the first areas nationally to launch the new integrated urgent caremodel, which includes the following:o Mental Health patients able to ring 111 and be transferred directly transfer
to a crisis team for advice and support;
o Clinical staff are able to get through to a clinical expert for urgent adviceand support by dialling the appropriate number;
o Enhanced mental health liaison services implemented in A&E atUniversity College Hospital in 2017-2018 and to be rolled out to the NorthMiddlesex University Hospital in 2018-2019;
o A specialist Perinatal mental health service for mothers across NorthCentral London was launched, following a successful first wave bid fornational funding; and
o Making it quicker and safer for patients to get home from hospital byworking at agree standard ways of working and working more effectivelywith social care.
You can find out more about our work here: http://www.northlondonpartners.org.uk/
In 2018/2019 we want to set ourselves up for success by: Working with all our partners to co-design plans Ensuring plans are clinically led and evidence based Communicating with our stakeholders and communities about the changes
ahead Aligning our plans and ensure these contribute to financial sustainability Continuing to explore scope for NCL working closer together and having
greater impact
Healthy London Partnership - London CCGs working together to support the delivery of better health in London NHS Enfield CCG, along with all London CCGs and NHS England (London), funded Healthy London Partnership in 2017/2018 to bring together the NHS in London and our partners to deliver London’s 10 ambitions to transform health and care for all Londoners.
Our partners include the Mayor of London, Greater London Authority, Public Health England, London Councils and Health Education England. We believe that collectively we can make London the healthiest global city in the world by uniting all of London to deliver the ambitions set out in Better Health for London: Next Steps and the national NHS Five Year Forward View.
During 2017, we, the Healthy London Partnership, were tasked with setting up the Urgent and Emergency Care Improvement Collaborative on behalf of NHS England (London), NHS Improvement (London) and The Association of Directors of Adult Social Services to transform the way that Londoners receive unplanned urgent care and support. This includes preventing the need to go to hospital, supporting them to become medically fit and well in hospital and then helping them to go home as soon as possible. The aim of the collaborative is to bring together leaders from health and social care, working to define what improvement work needs to happen in
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London, drawing on the best practice around sustainable improvement and working with the leaders in this field. Key to this, has been providing data to drive change, and as part of this work we ran three days of surveys of hospital bed occupants across 17 London hospital sites to understand where our improvement efforts need to be targeted.
Other highlights during 2017/2018 have included working with partners to launch Thrive LDN, a joint new citywide movement with the Mayor of London to improve mental health and wellbeing. Community workshops and problem solving booths were held across London as part of Thrive’s ‘Are we okay London?’ campaign which has reached 15.5 million people so far.
The findings from our year-long engagement with Londoners on childhood obesity, the Great Weight Debate, were published in 2018. Nine out of 10 Londoners who responded to the Great Weight Debate survey said tackling London’s childhood obesity epidemic should be either the top or a high priority for the capital. The findings are being used to inform every London borough’s childhood obesity strategy including Enfield’s and have informed the Mayor’s London Plan which includes a policy to prevent new hot food takeaways from opening within 400 metres of a school. Following on from this, we are now working with fast food shops, businesses and communities in three London boroughs (Southwark, Lambeth and Haringey) to pilot their ideas for making high streets healthier for children and young people through the Healthy High Streets Challenge. The outcomes of this work will then be shared with the London Boroughs, so Enfield can gain the benefit from this work.
In 2017 we worked with Bexley and north and central London CCGs, along with NHS England, to trial the first NHS online pilots in the country. NHS online offers local people an alternative way to contact their GP and access online GP consultations when necessary. We also worked on behalf of London CCGs with NHS England (London region) to raise awareness of GP online services and GP extended access services across London. Nearly two million Londoners are now registered for GP online services and every London borough offers evening and weekend appointments to people in their local area.
Through our partnership working, the Mayor of London, Secretary of State for Health, London Councils and NHS, Public Health and wider health and care leaders signed the London Health and Care Devolution Memorandum of Understanding in November 2017. This deal paves the way for improving the health and wellbeing of all nine million Londoners. Devolution provides the foundations to enable us to improve the way health and care services are delivered in the capital at a faster pace. Through the work of the pilots over the past year we have learned much more can be done to prevent ill-health, support people to make healthier choices and to join up health and care particularly when we work closely together. We are now leading engagement with system leaders to co-design the future of health and care across London which began with an event in December 2017. The London Health
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and Care Strategic Partnership Board (SPB) has been established to provide strategic and operational leadership for London-level health and care activities. Healthy London Partnership will continue to support the Board and the wider system to implement devolution and wider health and care transformation goals. We are committed to ensuring health and care leaders are updated on progress and are also involved in shaping the next steps for London.
In 2017 we developed and published online training for GP receptionists to help people who are homeless access GP practices and produced 60,000 ‘my right to access healthcare’ cards for people who are homeless to make sure they can get equal access to healthcare given that they are much more likely to use A&E services than other Londoners.
Finally, at the beginning of 2018 we began working with partners including the Mayor of London, London Councils, Public Health England and the NHS, on a joint plan to cut rates of new HIV infection and eliminate associated discrimination and stigma. This followed the signing of the 'Paris Declaration on Fast-Track Cities Ending the AIDS Epidemic' in January 2018.
During 2018 Healthy London Partnership will evolve to formally support all of the health and care partners to work together and strengthen their governance and delivery arrangements, so as a city we can implement the devolution agreement and our wider health and care transformation goals, to make sure we deliver on our commitments to make London the world's healthiest city.
Performance summary
Enfield CCG met the NHS Constitution standards in 2017/2018 for: NHS Constitution Standards for 2017/2018 Diagnostics waiting times- 6+ week waiters Six of the eight cancer waiting time standards Delayed Transfer of Care for both Acute and Non-Acute care Eating Disorders Waiting Times -1 week urgent appointments New Children and Young People receiving treatment form NHS funded
community services Hospital Acquired Infections- C. Difficile Improving Access to Psychological Therapies waiting times for 6-weeks and 18-
weeks Dementia diagnosis rate – exceeded the two-thirds national ambition Wheelchair Service – Children’s wheelchairs referral to treatment within 18
weeks
Further information is provided in the next section.
Performance analysisThe CCG Governing Body assumes ultimate responsibility for the performance of the organisation and receives assurance through a detailed Integrated Performance
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and Quality Report that is presented and reviewed at its bi-monthly public meetings. To strengthen and support the delivery on our statutory duties, a new performance management framework was implemented across the organisation during 2017/2018. The remit of the Finance & Performance Committee of the CCG Governing Body ensures that both finance and performance are monitored and aligned to providing assurance to the Governing Body.
The Finance and Performance Committee and the CCG Governing Body receive a detailed Integrated Performance and Quality Report on a monthly basis. Copies of these reports, included Governing Body papers, are published on the CCG website: http://www.enfieldccg.nhs.uk/about-us/ccg-board-meetings.htm. In addition, information on acute contract performance reported to the North Central London CCGs Joint Commissioning Committee. This report is published on the CCG website http://www.enfieldccg.nhs.uk/about-us/ncl-joint-commissioning-committee.htm
This report is regularly supplemented by detailed analysis of key performance areas concern and actions being taken to address these to the Committee. The report is informed by the NHS Constitution standards, the CCG’s Improvement and Assessment Framework, Quality Premium and the Operating Plan for 2017/2018. These ambitions also reflect the NHS Five Year Forward View. In addition to providing extensive commentary on areas of under achievement covering root cause analysis and recovery action plans the report highlights areas of potential risk and mitigating actions.
As a coordinating commissioner to our main local hospitals, the CCG has worked with the respective coordinating commissioners (Barnet CCG for Royal Free London NHS Foundation Trust and Haringey CCG for North Middlesex University Hospital) to maintain significant focus on performance during the year. This has delivered improvements in a range of areas whilst others remain challenged
Key Challenges in relation to delivery of the NHS Constitution standards and the steps being taken to improve performance in 2017/2018
Urgent & Emergency Care Urgent & Emergency Care remained challenged throughout 2017/2018 with increased demand experienced in the winter period. Enfield CCG has both a daily and weekly reporting system in place to ensure individuals are discharged appropriately from the hospital. We, with the lead commissioners in North Central London, have supported the Accident & Emergency Delivery Boards to support improvements in urgent and emergency care provided at both North Middlesex University Hospital and Royal Free London Foundation NHS Trust. This work is also reviewed by both NHS Improvement and NHS England to ensure our providers receive support to implement good practice from other hospitals that are seen to be making continued improvement against the national standards.
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National Cancer Standards – 62 day waiting time The CCG has continued to work closely with the lead commissioners to secure improvements on the national cancer standards, with additional scrutiny to address issues in meeting the 62-day cancer standard. The CCG established a local Cancer Action Group in 2017/2018, chaired by Dr. Nitika Silhi, GP Macmillan Lead, which includes representatives from General Practice; Macmillan Nurse Specialists from North Middlesex University Hospital and Royal Free London Hospital and North Central London CCGs Cancer Performance Leadership Group.
In the last quarter of 2017/2018, we have continued to engage with our lead commissioners to identify key areas for improvement at North Middlesex University Hospital, which include:
Improvements in capacity focusing on prostate and gastro-intestinalpathways,
CCG has continued to engage primary care clinicians to ensure patients areinformed in relation to the two week wait pathway for urgent referrals,
Improving booking of patients for diagnostics services to reduce the numberof patients not attending appointments
Children & Young People Mental Health receiving treatment by NHS funded community services The CCG has undertaken further work with Barnet, Enfield & Haringey Mental Health NHS Trust and London Borough of Enfield who provide mental health services for Children & Young People (CYP). We have continued to work in partnership with our service providers including those provided in the community & voluntary sector as part of our ongoing development of the CYP mental health local transformation plan. Our main focus on improving access to these services continues to be: Improving the 13 week waiting time position for children and young people
receiving their first appointment for treatment in community based services,
London Ambulance Service (LAS) Performance standards for ambulance response times are monitored on a Sustainability and Transformation Plan (STP) footprint, for the London Ambulance Service. Enfield CCG is part of the North Central London STP performance footprint for 2017/2018.
Enfield CCG continues to engage in the London-wide commissioners group through the North Central London STP. Key areas of focus are summarised below:
• Hospital Handover continues to have a direct impact on NCL STPperformance, particularly across the C3 and C4 categories as ambulances areoften tied up in queues at A&E departments with North Middlesex UniversityHospital, Royal Free London Hospital and University College London Hospitalranked 4th, 5th and 6th respectively against the hospitals with the most hourslost from arrival to handover, across London.
• LAS is currently working through their operational resourcing model to meetthe new requirements of the Ambulance Response Programme (ARP). Anexample being a fleet logistics review to ensure adequate levels of FastResponse Units and Double Crewed Ambulances are available to respond topatients requiring conveyance.
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• It has been recognised nationally that ambulance services will not be inposition to meet ARP standards immediately which has delayed contractualsanctions and performance management until September 2018. Similarly,national work is being undertaken to review call determinants within the C1and C2 categories to review the increase being seen across C2. A review onthese requirements will be undertaken in quarter 1 of 2018/2019 to provideinformation in terms of progress against these standards.
• Key areas of demand for LAS over the winter period 2017 across the NCLsector level includes patients over 75 years, patients 40-55 years, and peoplesuffering falls, stroke and breathing difficulties.
NHS Enfield CCG Performance against National Standards in 2017/2018 National Standard
2017/2018 Performance
Referral To Treatment waiting times for non-urgent consultant-led treatment - Patients on incomplete non-emergency pathways (yet to start treatment) should have been waiting no more than 18 weeks from referral
92% 87.7%
A&E Waits - Patients should be admitted, transferred or discharged within 4 hours of their arrival at an A&E department
Enfield CCG A&E waits North Middlesex University Hospital A&E waits Royal Free London NHS Trust A&E waits
95% 83.9% 81.0% 86.6%
Diagnostic test waiting times - Patients waiting for a diagnostic test should have been waiting less than 6 weeks from referral
1% 0.5%
Cancer Waits – 2 week wait Maximum two week wait for first outpatient
appointment for patients referred urgently withsuspected cancer by a GP
Maximum two week wait for first outpatient appointmentfor patients referred urgently with breast symptoms(where cancer was not initially suspected)
93%
93%
93.8%
94.2%
Cancer Waits – 31 days Maximum 31 day wait from diagnosis to first definitive
treatment for all cancers
Maximum 31 day wait for subsequent treatmentwhere that treatment is surgery
Maximum 31 day wait for subsequent treatment wherethat treatment is an anti-cancer drug regimen
Maximum 31 day wait for subsequent treatmentwhere the treatment is a course of radiotherapy
96%
94%
98%
94%
97.5%
97.4%
100%
98.2%
Cancer Waits – 62 days Maximum 62 day wait from urgent GP referral to first
definitive treatment for cancer 85% 80.6%
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Maximum 62 day wait from referral from an NHSscreening service to first definitive treatment for allcancers
90% 90.8%
Sustainable Development Enfield CCG has an obligation to work in a way that has a positive effect on the communities for which we commission and procure healthcare services. Sustainability means spending public money well, making smart use of natural resources and building healthy, resilient communities. The CCG acknowledges this responsibility to our patients, local communities and the environment by working hard to minimise our footprint.
Enfield CCG is committed to continual and progressive compliance with statutory, regulatory and local policy requirements to bring about change; this includes the Climate Change Act, National Adaptation Programme and the Carbon Reduction Commitment.
The CCG leases office space at Holbrook House, with meeting rooms and shared reception facilities. Our facilities management is provided by NHS Property Services.
In 2017/2018, Enfield CCG continued its plans to enhance performance and aims to meet sustainability objectives by:
Smarter working; Agile and flexible working with a focus on flexible hours, hotdesking across different sites or home working thus aiming to reduce ourcarbon footprint.
Promoting a ‘paper-lite’ CCG; Continued implementation of use of technologyto reduce paper. For our board meetings we switched software resulting inless paper being used. This will be rolled out across the CCG during2018/2019
Health, Safety and Wellbeing; we signed up to the ‘Healthy WorkplaceCharter’ to support staff in their working environment. We currently holdweekly walks, a staff forum and promote events regularly. We also encouragecycling to work with an on-site bike storage facility, including lockers andshowers.
Managing confidential waste; secure document destruction arrangements arein place. All paper documents go into tamper-proof containers where 100% ofthe paper is destroyed and recycled, safely and securely.
For 2018/2019, Enfield CCG aims are: Consider options for further site recycling A total ‘paper-lite’ CCG Adopt the Sustainable Development Assessment (SDU) tool; an online self-
assessment tool aiding understanding of our sustainable development work,measure progress and help make plans for the future. It uses four cross
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cutting themes 'Governance & Policy', 'Core responsibilities', 'Procurement and Supply chain' and 'Working with Staff, Patients & Communities'
Implementation of our new strategy for Health, Safety and Wellbeing Be innovative and smarter in our working Put sustainability on everyone’s agenda
Improve quality In line with its statutory duties, Enfield CCG maintained a significant focus on quality of services provided to its population during 2017/2018 in order to secure continuous improvements in patient outcomes. The CCG’s approach to quality is outlined in its Governing Body approved Quality Strategy underpinned by the Five Year Forward View, 2017/2018 CCG Improvement and Assessment Framework, NHS Operational Planning, Contracting Guidance and Sustainability and Transformation Partnerships (STPs) which are all driven by the pursuit of better quality for all patients. The 2017/2018 CCG Improvement and Assessment Framework include Better Care priorities and the provision of high quality for hospitals, primary medical services and adult social care.
Our commitment to quality of services was reinforced by putting in place improved governance arrangements that ensured decision-making groups were clinically chaired and/or had a clinical voting majority.
The CCG uses a model for quality which includes the three domains of quality, as set out below in High Quality Care for All in 2008, following the NHS Next Stage review led by Lord Darzi.
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The three key models for evaluating quality are set out in our Governing Body approved strategy. The focus of Enfield CCG’s Quality Strategy and annual work plan is local quality challenges. We provide an Integrated Quality and Performance Report to the bi-monthly Quality & Safety Committee and a quality report to every Governing Body meeting. The quality report to the Governing Body provides an overview of Quality of our main service providers, highlights any good practice that has been identified and ensures that there is a focus on the key quality issues. The report provides assurance to the Governing Body that the CCG understands the quality issues and that appropriate action is being taken to improve quality.
We hold all of our providers to account through the work of the Quality & Safety Committee. As the coordinating commissioner, we lead the management of the Barnet, Enfield and Haringey Mental Health Trust (BEHMHT) Clinical Quality Review Group (CQRG) on behalf of Barnet, Enfield and Haringey CCGs. The CQRG reports into our Quality and Safety Committee. We also ensure quality metrics for community and local contracts are monitored and reported. Enfield CCG is the Lead Commissioner for Integrated Urgent Care (provided by London Central & West Unscheduled Care Collaborative) and monitors the quality of services through the monthly clinical quality review group meeting.
Our quality highlights in 2017/2018 include: Ensuring Commissioner assurance is received on the quality and safety
concerns identified in the BEHMHT Care Quality Commission (CQC)Improvement plan
Agreed and implemented a programme of Commissioner Led Insight &Learning Visits of BEHMHT. This included visits to the District NursingService, Magnolia Unit, Fairlands Ward and Dorset Ward
Implementation of revised terms of reference from the Joint Performance &Quality Committee to a quality CQRG to strengthen the focus on quality
Improving the number of outstanding Serious Incident Reports and FurtherInformation Requests with quarterly Serious Incident meetings introduced forBEHMHT
Participated in the BEHMHT Service deep dives on quality Quality metrics in place for community and local contracts are monitored and
reported on Relaunched the Quality Alerts process to monitor safety of commissioned
services, inform provider discussions and drive service quality improvements Developed an infection prevention and control and E.coli action plan Development and implementation of Commissioning for Quality and
Innovation (CQUIN) and schedule 4 and 6 of the contracts aligned to theannual commissioning round for BEHMHT
Improvement in C.difficile targets for Enfield. The target was 76 cases a year,however at the end of quarter 3 Enfield had reported 55 cases
Increase in the number of patient compliments received by the CCGComplaints Team
Participated in London Central & West (LCW) Unscheduled CareCollaborative Insight visits
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Engaging people and communities There is strong evidence that effective communication and engagement with patients, carers, stakeholders, partners and the public helps to improve commissioning decisions, quality of services, patient satisfaction and a better understanding of how to use the NHS. Enfield CCG has a corporate Communications and Engagement Strategy that explains our approach to embedding engagement throughout the commissioning cycle and the methods of communicating and engaging with our members, stakeholders and the public. Our Patient and Public Engagement (PPE) Committee, which is a sub-committee of the Governing Body, reviewed and updated this three year strategy in 2017.
Patient and Public Engagement Committee Our Patient and Public Engagement (PPE) Committee is one of six sub-committees of our Governing Body. The PPE Committee meets six times a year and members include Healthwatch, a voluntary sector representative, public health, three Patient Participation Group (PPG) locality champions, CCG staff and Governing Body members. Together the elected PPG representative and the three PPG locality champions ensure that patients from our member practices in each of our four localities are represented at the PPE Committee.
The PPE Committee oversees the discharge of the CCG’s statutory collective and individual participation duties in the Health and Social Care Act 2012, as well as the delivery of our equality and diversity duties. The PPE Committee also receives regular reports from the CCG’s commissioning leads and transformation programmes which explain how engagement activities are aligned to each workstream. More information on the PPE Committee’s work this year is available in the Corporate Governance Report.
Engagement The CCG hosts three corporate PPE events a year. These events are open to all our stakeholders and members of the public. The objective of these events is to gather feedback on our commissioning plans and support quality improvements in local NHS services. Based on the feedback we have received from patients, these events are clinician led with group work and fewer presentations/speakers. A report is prepared after every event and published on our website along with the slides from the event. This year we used these events to invite feedback on a number of key work programmes including: our Adherence to Evidence Based Medicine consultation, primary care, mental health, our commissioning intentions, Care and Health Integrated Networks (CHINS), developing our patient offer, the North Central London Sustainability and Transformation Plan (STP) and our service transformation plans.
Enfield CCG has an extensive list of stakeholders and takes a proactive approach to networking and communicating with them. We work closely with patient groups and networks around planned service redesign,
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gathering feedback through focus groups, surveys and patient involvement on steering groups. As a commissioner we contract with our providers to gather patient experience data through routine surveys that can be used to support service improvements. We also gather general feedback by attending a number of externally organised events. This year we were invited to events including: the Over 50s Forum Falls event, local area forums, the Over 50s Forum Winter Fair; Patient Participation Group meetings, Enfield Diabetes Support Group and Enfield Carers Rights Day.
Social media We have continued to actively use social media this year to promote events, services and engagement opportunities to stakeholders and to local residents, particularly our Primary Care Access hubs, GP online services and to support NHS England’s Winter Well campaign. Our Twitter followers increased to 3,651 this year.
Consultations During this year we consulted on our Adherence to Evidence Based Medicine Programme. This consultation began on 1 March 2017 and due to the General Election in 2017, was extend to 30 June 2017. Along with the consultation document and questionnaire, the full clinical evidence packs were published online. During the consultation period, Enfield CCG held events, attended meetings as requested and commissioned two independently hosted and facilitated events from Enfield Voluntary Action and Healthwatch Enfield. A full list of the consultation activities, including event reports is available on our website. At the end of the consultation an independent organisation called The Campaign Company reviewed all the feedback and produced a report which was considered along with the clinical evidence by our committees. Feedback from the consultation shaped and influenced the final decision on the outcome of the consultation, which was taken by our Governing Body at the September 2017 meeting in public.
Developing our Patient Participation Group (PPG) Network
We host a network for our GP member practices’ Patient Participation Groups (PPGs). Currently the meetings are quarterly and support for the network is provided by the Communications and Engagement Team. The meetings are chaired by the elected PPG representative Litsa Worrall who also sits on the PPE Committee and the Governing Body. The PPG network is made up of volunteers and the elected representative, who can raise any issues with the CCG.
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This year PPG volunteers have been involved in developing their own work plan for focusing on:
� Reducing did not attend (DNA) rates at their practices,� Supporting healthy living,� Recruiting new PPGs members to their member practices and from
different practices to the network,� Sharing best practice.
Last year the PPG network nominated three locality representatives (the elected PPG representative acts as the locality representative for her own area). These volunteers provide extra support for PPGs in their local area. There is currently a vacancy for the North East locality.
Enfield CCG ensures that the PPG network is a key stakeholder in our engagement activities and we contact the groups and their members where we have individual’s details on file regularly with news and updates. The CCG also has a webpage on our website about the PPG network which we keep up to date with all the details of their meetings and activities. The PPG network can be contacted at [email protected]
Enfield CCG Voluntary and Community Stakeholder Reference Group Enfield Clinical Commissioning Group (Enfield CCG) set up a Voluntary and Community Stakeholder Reference Group in September 2015. Details about the group’s meetings and membership as well as its terms of reference are available on the CCG’s website. Its aim is to enable voluntary and community sector representatives to provide the patient, service user and public perspective, on the development, planning, implementation and evaluation (success and challenges) of health services commissioned by Enfield CCG. This year, issues discussed at this group included: sexual health services in Enfield, services for carers, primary care, the patient offer, North Central London digital solution, accessible services, the Adherence to Evidence Based Medicine consultation, Section 75 agreement between the CCG and London Borough of Enfield, and the outcome of the Paediatric Assessment Unit consultation.
Examples of how Enfield CCG discharged our duty to involve individuals and communities in commissioning decisions and improving quality of care
Mental Health Commissioning Enfield CCG is the lead commissioner for Barnet, Enfield and Haringey Mental Health Trust (BEHMHT). This year, the CCG worked with BEHMHT to review the provision of longer term inpatient care services for older people at the Chase Farm Hospital (Cornwall Villas and Silver Birches wards). The review resulted in longer term Continuing Health Care (CHC) services being re-provided at the new high specification registered care home, Bridgewood House, and individual nursing homes in accordance with choice and need. The review was completed in two Phases:
- Cornwall Villa (December 2016 - March 2017)
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- Silver Birches (March 2017- April 2017)
The following steps were taken to engage patients, carers and stakeholders in line with the jointly agreed communications and engagement plan:
- Regular engagement events were held with patients, carers and stakeholdersat the hospital site attended by the CCG, Trust and the Council
- Individual meetings with patients, carers and families- An independent advocate was commissioned through a procurement process
and this service was provided by Mind in Enfield. The advocate was essentialto ensuring that the patient voice was heard
- Update letters were sent out which provided information to relatives, patients,staff and stakeholders
- We held a monthly Steering Group and Drop-in sessions at the ward that washosted by the Independent Advocate
- Fortnightly Multi-disciplinary Team meetings were held on the ward betweencommissioners, ward staff and the Council to ensure that there wereconsistent messages to minimise anxiety
- Information packs were sent to patients and their families that explained theCare Act assessment process including Income assessment, and the CHCprocess
Primary Care Access Hubs Following the introduction of the GP Forward View in April 2016 and availability of General Practice Access Funding in October 2016, Enfield CCG commissioned new Primary Care Access Hubs from December 2016 that provide extended hours for patients to access routine and urgent GP appointments. Three Access Hubs were commissioned to provide services from 18:30pm – 20:00pm Mondays to Fridays and 8:00am – 20:00pm on Saturdays, Sundays and Public Holidays. A communications campaign supported the launch of the new service:
The CCG invested in an advertising campaign which included localadvertising along with outdoor bus shelter, underground and train stationadverts to raise awareness of the new service. The outdoor campaignprovided an estimated 3,760,000 ‘views’
Over 100,000 text messages were sent to Enfield patients informing them ofthese new services
The CCG assisted member practices with advertising the new service on theirwebsites and answerphone messages
The CCG used social media to boost advertising. Tweets about the hubs hadthe highest impressions of all posts during this year
The CCG used public events to tell residents and service users about thehubs
The primary care hubs service has collected over 2,500 questionnaire responses, the largest engagement survey commissioned by Enfield CCG. Analytical data from patient experiences confirms:
o 82% of patients would recommend the service to a friend and/or familymember;
o Over 50% of patients gave our service 10/10 – less than 5% of patientsprovided a poor satisfaction rating;
o 95% of patients using the service felt they received an appointmentconvenient for them;
o Over 50% of patients were seen within 5 minutes of their allocatedappointment time, with 2% waiting more than 30 minutes;
o On average, patients provided a 94% positive rating for the following ‘5 care’indicators:
Giving you enough time Listening to you Explaining the test/treatment and/or condition(s) Involving you in decisions about your care Treating you with care and concern.
During the year, the Primary Care Access Hubs averaged an 84% utilisation of appointments, and demand has continued to rise. Due to the increasing uptake of appointments and positive feedback from local people, a walk-in service was commissioned in the North East and the previously ‘appointments only’ Primary Care Access Hubs now offer walk-in services at weekends. The hubs service has calculated it has saved 13,423 Accident & Emergency (A&E) and Urgent Care Centre attendances since December 2016. The CCG will continue to engage with local people and plans to enhance the Primary Care Access Hubs in the future.
NHS England assurance In previous years, the CCG has been required to produce an Annual Patient and Public Engagement Report. In April 2017 NHS England published revised statutory guidance for CCGs and NHS England commissioners on Patient and Public Participation in Commissioning Health and Care. It sets out ten key actions and links to the Guide to annual reporting on the legal duty to involve patients and the public in commissioning.
The 10 ‘key’ actions for CCGs on how to embed involvement in their work are: 1. Involve the public in governance2. Explain public involvement in commissioning plans3. Demonstrate public involvement in Annual Reports4. Promote and publicise public involvement5. Assess, plan and take action to involve6. Feedback and Evaluate7. Implement assurance and improvement systems8. Advance equality and reduce health inequality9. Provide support for effective engagement10. Hold providers to account
NHS England carried out a desktop assessment against five domains: Governance; Annual Reporting; Practice; Feedback and Evaluation; Equalities and health inequalities. Enfield CCG was rated green. This is an excellent score which demonstrates the organisation’s commitment to high quality communications and engagement with our local community.
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The PPE Committee will continue to drive this work forward and provide assurance to the Governing Body that we are not only meeting our statutory duties but also using engagement in ways that help deliver the CCG’s strategic objectives.
Looking forward to 2018/2019 In January 2018, the Enfield CCG Communications and Engagement team became a joint team with Barnet CCG. This new way of working is part of a new approach to share corporate services functions and best practice across the five CCGs in North Central London. The newly merged team will be looking to enhance and develop current engagement structures across both organisations, strengthening the approach and sharing best practice.
We will also review the results of our 360 Degree Stakeholder Survey 2018 as well our recent NHS England assessment of Patient and Community Engagement Indicator within the CCG Improvement and Assessment Framework (IAF) and develop an improvement action plan that addresses any concerns raised so that we can continue to improve our commissioning decisions, quality of services, increase patient satisfaction and develop a better understanding of how to use the NHS. With the support of our PPE Committee, our Voluntary and Community Stakeholder Reference group and the PPG Network members, we will seek new opportunities to improve and increase levels of participation of all our stakeholders, including the establishment of a Patient Reference Group in Enfield to continually improve the health and wellbeing of our population and reduce health inequalities.
Reducing health inequality The Equality Act 2010 gives us the opportunity to work towards eliminating discrimination and reducing inequalities in care.
In Enfield CCG we are committed to meeting our equality and diversity duty across all our policies and functions. Over the last year we have been working with patients, partners and providers to address issues relating to health inequalities in the community particularly amongst protected groups.
We recognise that while we set and implement equality objectives and publish our annual equality performance report to meet the public sector equality duty, we must continue to work with our patients, staff and stakeholders to ensure continuous improvement in advancing equality.
Reducing local health inequalities is our top priority. The way we do this is by ensuring due regard is given to the need to reduce health inequalities in access to services and outcomes achieved. A summary of how we fulfil our duty is given below:
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We produce our annual commissioning intentions based on robust analysisand scrutiny - and we commission services, some of which are jointlycommissioned with the local authority.
We demonstrate due regard to the public sector equality duty through routineequality analysis of our proposals and policies. This ensures a robustapproach to addressing existing health inequalities amongst our protectedand vulnerable groups.
Continuously assessing our performance by using NHS England’s bestpractice tool, the Equality Delivery System (EDS2).
We have an effective governance process where committees and the Boardensure our commissioning delivers on our objectives around healthinequalities and public sector equality duty, the equality objectives.
The next section on the Health and Wellbeing Strategy explains in detail how we work locally to address health inequalities. More information is also available on our website.
Health and wellbeing strategy – Working with local partners The Enfield Health and Wellbeing Board was established under the Health and Social Care Act 2012 to create a forum where the key leaders from the local health and care system can work together to improve the health and wellbeing of the local population and reduce health inequalities. Health and wellbeing boards play a key role to:
Ensure stronger democratic legitimacy and involvement, Strengthen working relationships between health and social care, and, Encourage the development of more integrated commissioning of services.
The Board also aims to help give communities a greater say in understanding and addressing their local health and social care needs.
Enfield CCG plays a key role on the Enfield Health and Wellbeing Board (HWBB), which provides the strategic leadership to inform the overarching priorities and strategic objectives to inform the development of the Enfield Health and Wellbeing Strategy.
The Health and Wellbeing Board meets bi-monthly and is chaired by the Leader of London Borough of Enfield. Enfield CCG is represented by the Chair (Vice-chair of the HHWB) and the Chief Operating Officer, with regular contributions from other officers. The membership of the Board includes senior executives and officers:
Director of Public Health, Chief Executive, North Middlesex University Hospital NHS Trust, Chief Executive, Barnet, Enfield and Haringey Mental Health NHS Trust, Enfield Healthwatch, Cabinet Members and Executive Officers, London Borough of Enfield Executive Director of Children’s Services, London Borough of Enfield,
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Enfield Voluntary Sector Enfield Youth Parliament
Full details of all members of the Enfield Health & Wellbeing Board and meeting papers can be found on the Enfield Health & Wellbeing Board website: https://governance.enfield.gov.uk/mgCommitteeDetails.aspx?ID=640
The Enfield Joint Health and Wellbeing Strategy (JHWS) 2014-2019 sets the vision of Enfield’s Health and Wellbeing Board. This is informed by NHS national guidance to support our aim for our residents to live longer, healthier, happier lives. The Ensuring the best start in life,
Enabling people to be safe, independent and well and delivering high quality health and care services, Creating stronger, healthier communities, Reducing health inequalities – narrowing the gap in life expectancy, Promoting healthy lifestyles and making healthy choices.
The strategy’s evidence base is the Joint Strategic Needs Assessment (JSNA) which is a key resource of health and wellbeing information produced by the public health team at Enfield Council in partnership with the CCG.
Having regard to the JHWS, Enfield CCG has continued to embed these five priorities in its commissioning of health and care services for the local population. They are reflected in the Enfield CCG strategic objectives for 2017/2018: Deliver financial sustainability Improve the quality of local health services Value and look after staff Work across health and social care to deliver seamless care for our patients Do things once either locally or across NCL Engage patients, carers and stakeholders
In addition, all CCGs are monitored against the new Improvement and Assessment Framework which includes the following four domains and six clinical priorities:
Domains Better Health Better Care Sustainability Leadership
Six clinical priorities Mental Health Dementia Learning Disabilities Cancer Diabetes Maternity
The Improvement and Assessment Framework both contributes to the delivery of the
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Enfield JHWS as well as the NHS 5 Year Forward View.
Enfield CCG continues to work closely with the London Borough of Enfield, placing the people of Enfield at its heart. We continue to respond to the changing expectations and needs of local residents, ensuring greater access to GP services and community based services and supporting residents to manage their own care, thereby avoiding unnecessary use of services and avoiding hospital admission, where appropriate.
Recently, Enfield CCG has worked within the Health and Wellbeing Board to prioritise work for the final two years of the JHWS. Three workstreams were selected, where the Board felt it could add particular value as leaders of the local system. The areas were, giving children the best start in Life; healthy weight, and mental health resilience, and link closely with the goals of the CCG, local providers and Sustainability and Transformation Plan partners.
Health inequalities continues to be an important cross cutting theme in all our work. Enfield is a borough of two divided halves in terms of health outcomes. The major causes of early death are heart disease, stroke and cancer with stark contrasts in the health of our communities across the borough. There are some key modifiable factors in relation to these causes of early death, such as obesity, sedentary lifestyles, smoking, diabetes, atrial fibrillation and hypertension.
Working alongside public health services, such as NHS Health Checks and Stop Smoking services targeted at areas of need in the borough, we are working hard to reduce variation in health across Enfield. A good example of our approach is local work with GP practices to reduce variation in the management and prevention of long-term conditions. We are helping people manage their own health, and strengthening our offer of structured education in diabetes. Alongside this, we are addressing pre-diabetes with a new locally commissioned service and we are proud to play an active part in the National Diabetes Prevention Programme.
In preparation for the refresh of the Joint Health & Wellbeing Strategy in 2018/2019, Enfield CCG is part of the development of a new Joint Strategic Needs Assessment (JSNA). The JSNA is in a process of redesign to improve the currency of information and to make it more accessible. CCG colleagues with their Health & Wellbeing partners have been active in determining the form and content of the new JSNA. The aim is for a more flexible, interactive, web based resource pulling data from across the partnership in Enfield, allowing comparison with neighbours across North Central London Partners.
Key work programmes undertaken in 2017/2018 have included: 1) Falls prevention training: Enfield Public Health commissioned Age UK to
provide falls prevention training for frontline staff in health and social careproviding care for the elderly at risk of falls.
2) Cancer: Enfield Public Health and the CCG jointly organised a publicawareness campaign to improve the uptake of cervical cancer screeningoffered to women in Enfield. The campaign involved wider engagement withGP practices and the GP federation to increase local capacity to managepotential surge in demand for screening.
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3) Infection Control: Enfield CCG in collaboration with North MiddlesexUniversity Hospital, Public Health England and Enfield Public Health teamreviewed community acquired rates of C.difficile infection in the borough.Infection Control training was provided for 116 front line staff working in carehomes, nursing homes and domiciliary care.
4) Improving the rate of undiagnosed blood pressure is a prevention priority forNCL and Enfield. Enfield CCG in collaboration with Enfield Public Health teamapplied for a British Heart Foundation grant, which if successful, will supportdetection of 10,000 cases over a two years’ period.
5) In order to increase high blood pressure detection in the borough, EnfieldPublic Health with support from the CCG clinical lead developed a pharmacybased blood pressure detection pilot programme that will be effective fromApril 2018. The programme will support detection of undiagnosed high bloodpressure in deprived areas and those who may not be registered with a GP.The council has also invested resources to buy two additional health kiosksinstalled at strategic locations to improve self-testing of high blood pressure inthe community setting, without adding pressure to primary care.
6) A Locally Commissioned Service to support primary prevention: Enfielddeveloped this service primarily focused to identify patients at risk of AtrialFibrillation and Diabetes from GP practices. The programme will identifyappropriate patients and offer them diagnosis and those confirmed to be atrisk will be offered anti-coagulant treatment if eligible. The CCG is evaluatingthe effectiveness of this service to identify at risk patients and assess if theprogramme has improved the uptake of anti-coagulation and reduced the rateof hospital admissions or complications for those anti-coagulated who maydevelop stroke. Similarly, this programme is also expected to identify those athigh risk of diabetes (pre-diabetes) and offer them lifestyle interventions.
7) National Diabetes Prevention Programme (NDPP): In collaboration withBarnet Council and Barnet CCG, Enfield Council and the CCG has bid forwave 2 funding to identify those at high risk of diabetes (pre-diabetes) andoffer them lifestyle interventions through nationally commissioned providers.This 24 month prevention programme commenced in May 2017 and hasalready referred 1,122 people at risk of diabetes to participate in theprogramme. NDPP started after Enfield commissioned the LocallyCommissioned Services (LCS) to identify those at high risk of diabetes (pre-diabetes). This identified patients from clinical records review and offeredthem lifestyle advice and guidance. The two programmes were not aligned forLCS to support NDPP by making referral to the programme once identified.We hope with the support of the clinical lead, the LCS and NDPP will align toimprove the overall reduction of the incidence of diabetes.
8) The Council’s Public Health team has continued to support the CCG withevidence review to support the development of the annual commissioningintentions, service re-design and undertaking further evaluation to measureprogress made in 2017/218.
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Helen Pettersen
Accountable Officer
23 May 2018
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ACCOUNTABILITY REPORT
Corporate Governance Report
Members Report Enfield CCG is a membership organisation made up of all 48 GP practices in Enfield. Enfield CCG is accountable to its members and to the residents of Enfield. Our Constitution, supported by all member GP practices, sets out the governance and accountability of our organisation and enables the achievement of our vision, mission and strategic goals. An updated version of the Constitution was published in May 2017, following approval by NHS England.
Information on personal data related incidents where these have been formally reported to the information commissioner’s office is detailed in the Annual Governance Statement.
Member profiles The CCG Governing Body comprises 15 voting members as well as non-voting members that include representatives of the London Borough of Enfield, the London Borough of Enfield Director of Public Health, Healthwatch and the Enfield Patient and Public Participation Group. The 15 voting members include eight elected GP Governing Body locality leads, two lay members, a secondary care doctor, a nurse member, a practice manager representative, the CCG Accountable Officer and the NCL Chief Finance Officer. Full details can be found on the CCG website.
Member practices Enfield CCG has 48 Member Practices which are GP practices in the London Borough of Enfield. The practices are divided into geographical locations - North East, North West, South East and South West localities. A list of CCG member practices can be found here and the composition and governance of our membership body is detailed in our Constitution.
Composition of Governing Body The Chair of Enfield CCG for the year 2017/2018 is Dr Mo Abedi. The Accountable Officer for the period 3 April 2017 to date is Helen Pettersen.
Members of Enfield CCG’s Governing Body during 2017/2018 were: Elected Voting Members: Title Meetings
Attended Dr Mohammed Abedi Chair and GP Governing Body Member 6/6 Dr Fahim Chowdhury Clinical Vice Chair and GP Governing Body
Member 5/6
Dr Jarir Amarin GP Governing Body Member 5/6 Dr Johan Byran GP Governing Body Member (from 1 July 2017) 4/5
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Dr Hetul Shah GP Governing Body Member 5/6 Dr Rebecca Olowookere GP Governing Body Member (from 1 August 2017) 4/4 Dr Elizabeth Babatunde GP Governing Body Member (from 1 August 2017) 3/4 Dr Chitra Sankaran GP Governing Body Member 5/6 Dr Janet High GP Governing Body Member (until 31 July 2017) 2/2
Appointed Voting Members: Ms Angela Dempsey Secondary Care Nurse Representative 5/6 Professor Robert Elkeles Secondary Care Doctor 4/6 Ms Karen Trew Lay Member for Audit and Governance 5/6 Dr Teri Okoro Lay Member for Patient and Public Engagement 5/6 Ms Rathai Thevananth Practice Manager Representative (until February
2018) 5/5
Mr Christopher Curtis Practice Manager Representative (from February 2018)
1/1
Ms Helen Pettersen Accountable Officer for NCL CCGs 5/6 Mr Simon Goodwin Chief Finance Officer for NCL CCGs (from 1 June
2017) 5/5
Non-Voting Members: Public Health Public Health Representative 5/6 Local Authority Local Authority Representative 2/6 Healthwatch Healthwatch Enfield 5/6 Litsa Worrall Enfield Patient Participation Group Representative 4/6
Non-Voting Attendees: Sarah Thompson Chief Officer (until 5 June 2017) 1/1 Noreen Dowd Interim Chief Operating Officer (from 23 May to 21
September 2017) 2/2
John Wardell Chief Operating Officer (from 4 December 2017) 2/2 Deborah McBeal Director of Primary Care Commissioning and
Deputy Chief Officer 3/6
Graham McDougall Director of Commissioning (on secondment from 18 September 2017)
1/2
Rob Whiteford Chief Finance Officer (until 10 April 2017) 0/0 Jane Pike Director of Performance and Corporate Services
(until 30 August 2017) 0/2
Dr Jahan Mahmoodi Medical Director 2/6 Mark Eaton Interim Director of Recovery 3/6 Vince McCabe Director of Commissioning (from 29 August 2017) 4/4 Carole Bruce-Gordon Acting Director of Quality and Integrated
Governance 3/6
Arati Das Deputy Director of Finance 6/6
Further details on Governing Body members can be found here.
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Committee(s), including Audit Committee Information about all Enfield CCG committees including membership, attendance and highlights of work undertaken during the financial year is detailed in our Governance Statement under Governance Arrangements and Effectiveness.
Register of Interests Enfield CCG maintains registers of interest in accordance with NHS England’s Statutory Guidance on Managing Conflicts of Interest and the CCG’s Conflicts of Interest Policy to ensure that decisions made by the CCG will be taken, and seen to be taken, without any possibility of the influence of external or private interests. These registers are published on our website and are reviewed at every Governing Body and Committee meetings.
Personal data related incidents There were no serious incidents relating to data security breaches in 2017/2018 reported to the Information Commissioner.
Statement of Disclosure to Auditors Each individual who is a member of the CCG at the time the Members’ Report is approved confirms:
so far as the member is aware, there is no relevant audit information of whichthe CCG’s auditor is unaware that would be relevant for the purposes of theiraudit report
the member has taken all the steps that they ought to have taken in order tomake him or herself aware of any relevant audit information and to establishthat the CCG’s auditor is aware of it.
Modern Slavery Act Enfield fully supports the Government’s objectives to eradicate modern slavery and human trafficking. Our Slavery and Human Trafficking Statement for the financial year ending 31 March 2017 is published on our website .
Statement of Accountable Officer’s Responsibilities The National Health Service Act 2006 (as amended) (the NHS Act 2006) states that each Clinical Commissioning Group (CCG) shall have an Accountable Officer and that Officer shall be appointed by the NHS Commissioning Board (NHS England). NHS England has appointed Helen Pettersen to be the Accountable Officer of NHS Enfield CCG.
The responsibilities of an Accountable Officer are set out under the NHS Act 2006, Managing Public Money and in the Clinical Commissioning Group Accountable Officer Appointment Letter. They include responsibilities for:
• The propriety and regularity of the public finances for which the AccountableOfficer is answerable;
• Keeping proper accounting records which disclose with reasonable accuracyat any time the financial position of the CCG and enable them to ensure thatthe accounts comply with the requirements of the Accounts Direction;
• Such internal control as they determine is necessary to enable the preparation
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of financial statements that are free from material misstatement, whether due to fraud or error;
• Safeguarding the CCGs assets (and hence for taking reasonable steps for theprevention and detection of fraud and other irregularities);
• The relevant responsibilities of accounting officers under Managing PublicMoney;
• Ensuring the CCG exercises its functions effectively, efficiently andeconomically (in accordance with Section 14Q of the NHS Act 2006 and witha view to securing continuous improvement in the quality of services (inaccordance with Section14R of the NHS Act 2006; and
• Ensuring that the CCG complies with its financial duties under Sections 223Hto 223J of the NHS Act 2006.
Under the NHS Act 2006, NHS England has directed each CCG to prepare for each financial year financial statements in the form and on the basis set out in the Accounts Direction. The financial statements are prepared on an accruals basis and must give a true and fair view of the state of affairs of the CCG and of its net expenditure, changes in taxpayers’ equity and cash flows for the financial year.
In preparing the financial statements, the Accountable Officer is required to comply with the requirements of the Group Accounting Manual issued by the Department of Health and in particular to:
• Observe the Accounts Direction issued by NHS England, including therelevant accounting and disclosure requirements, and apply suitableaccounting policies on a consistent basis;
• Make judgements and estimates on a reasonable basis;• State whether applicable accounting standards as set out in the Group
Accounting Manual issued by the Department of Health have been followed,and disclose and explain any material departures in the financial statements;and,
• Prepare the financial statements on a going basis• Assess the CCGs ability to continue as a going concern, disclosing, as
applicable, matters related to going concern; and• Use the going concern basis of accounting unless they have been informed
by the relevant national body of the intention to dissolve the CCG without thetransfer of its services to another public sector entity.
To the best of my knowledge and belief, and subject to the disclosure set out below, I have properly discharged the responsibilities set out under the NHS Act 2006, Managing Public Money and in my Clinical Commissioning Group Accountable Officer Appointment Letter.
Disclosure: the CCG deficit has been reported by the external auditors under Section 30(b) of The Local Audit and Accountability Act 2014.
I also confirm that:
As far as I am aware, there is no relevant audit information of which theCCG’s auditors are unaware, and that as Accountable Officer, I have taken all
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the steps that I ought to have taken to make myself aware of any relevant audit information and to establish that the CCG’s auditors are aware of that information;
That the annual report and accounts as a whole is fair, balanced andunderstandable and that I take personal responsibility for the annual reportand accounts and the judgments required for determining that it is fair,balanced and understandable.
Helen Pettersen
Accountable Officer
23 May 2018
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Governance Statement
Introduction and context Enfield CCG is a body corporate established by NHS England on 1 April 2013 under the National Health Service Act 2006 (as amended).
The clinical commissioning group’s statutory functions are set out under the National Health Service Act 2006 (as amended). The CCG’s general function is arranging the provision of services for persons for the purposes of the health service in England. The CCG is, in particular, required to arrange for the provision of certain health services to such extent as it considers necessary to meet the reasonable requirements of its local population.
As at 1 April 2017, the clinical commissioning group is subject to any directions from NHS England issued under Section 14Z21 of the National Health Service Act 2006 as follows:
NHS England Legal Directions
On 10 August 2015, the Clinical Commissioning Group was subject to NHS England Legal Directions in relation to its financial position and governance arrangements relating to the associated recovery plan.
The key requirements of the Directions are that: Enfield CCG shall co-operate with the (NHS England) Board regarding the
appointment of any replacement Turnaround Director. Enfield CCG shall produce an Improvement Plan that sets out how it shall
ensure that the capacity, capability and governance of the CCG is made fitfor purpose;
This shall include a Financial Recovery Plan that sets out how NHS EnfieldCCG shall operate within its annual budget for the financial years 2015/16 to2019/20 inclusive. This shall include a schedule for the repayment ofoutstanding debt.
Enfield CCG shall co-operate with the Board regarding the implementation ofthe Financial Recovery Plan and the Improvement Plan, including but notlimited to the prompt provision of information requested by the Board andmaking senior officers available to meet with the Board.
The process to make a permanent appointment to any member of the seniormanagement team at NHS Enfield CCG and the appointment of such officersshall be subject to the Board's approval.
These directions will apply until they are varied or revoked by NHS England. Link for further information on NHS England Directions:
NHS England and NHS Improvement Special Measures
In July 2016, a new intervention regime was introduced by NHS England and NHS Improvement which can be applied to trusts and CCGs who are failing to meet their financial commitments. NHS England and NHS Improvement
published its report on Strengthening Financial Performance & Accountability in 2016/17 to sharpen the direct accountability of trusts and CCGs to live within the public resources made available by Parliament and the Government in 2016/17.
The report concluded that Enfield CCG was one of 26 out of 209 CCGs to be rated overall as inadequate and the CCG was put into ‘special measures’ on 21 July 2016, having failed to meet the financial discipline expected of the CCG and already been subject to NHS England Legal directions’ since 10 August 2015.
Enfield CCG put in place an Improvement and Financial Recovery Plan in response to this.
In August 2017, NHSE removed Enfield CCG from Special Measures.
Scope of responsibility As Accountable Officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of the clinical commissioning group’s policies, aims and objectives, whilst safeguarding the public funds and assets for which I am personally responsible, in accordance with the responsibilities assigned to me in Managing Public Money. I also acknowledge my responsibilities as set out under the National Health Service Act 2006 (as amended) and in my Clinical Commissioning Group Accountable Officer Appointment Letter. I am responsible for ensuring that the clinical commissioning group is administered prudently and economically and that resources are applied efficiently and effectively, safeguarding financial propriety and regularity. I also have responsibility for reviewing the effectiveness of the system of internal control within the clinical commissioning group as set out in this governance statement.
Governance arrangements and effectiveness The main function of the governing body is to ensure that the CCG has made appropriate arrangements for ensuring that it exercises its functions effectively, efficiently and economically and complies with such generally accepted principles of good governance as are relevant to it.
Constitution Enfield CCG’s Constitution sets out the operational arrangements which have been put in place to meet its responsibility as a commissioner of the healthcare services for the population of Enfield. The Constitution confirms the CCG’s membership and accountability, the Governing Body roles and responsibilities and the governance structure and decision-making arrangements.
Governing Body structure The Governing Body comprises 15 voting members, including eight elected posts, two lay members, a registered nurse, a secondary care doctor, a practice manager and two executives.
During the year, elections were successfully run in accordance with our Constitution by the Electoral Reform Service to appoint replacements for GP Governing Body
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members who had come to the end of their terms of office, namely Dr Mo Abedi, Chair of the Governing Body and Locality Lead for North East Locality (who had served one term), Dr Janet High, South West Locality and Dr Alpesh Patel, Clinical Vice-Chair of the CCG, North West Locality, both of whom had completed their second terms as Locality Leads. Dr Janet High completed her term on 31 July 2017, and Alpesh Patel resigned on 31 March 2017 before completion of his term of office.
Dr Mo Abedi was elected for a second term as Chair of the Governing Body and Locality Lead for North East Locality; Dr Elizabeth Babatunde was elected as Locality Lead for South West Locality; Dr Rebecca Olowookere was elected as Locality Lead for North East Locality. Effective start dates for all three appointments was 1 August 2017. Dr Johan Byran was elected as Locality Lead for North West Locality effective 1 July 2017. Dr Byran was interim Locality Lead for North East Locality up to March 2017, following the departure of Dr Ujjal Sarker in November 2016.
Dr Fahim Chowdhury was appointed as Clinical Vice-Chair effective 24 September 2017, having followed due process with the support of the North East London Commissioning Support Unit (NELCSU).
The CCG was also successful in appointing Christopher Curtis effective 1 February 2018, as Practice Manager Representative, replacing Rathai Thevananth, who completed her two terms on 16 February 2017 and was not eligible for re-appointment.
Simon Goodwin was appointed as Chief Finance Officer for NCL CCGs effective 1 June 2017.
Governing Body Committees In line with statutory requirements and guidance, the Governing Body established the following Committees:
Audit Committee Remuneration and Nomination Committee Quality and Safety Committee Finance and Performance Committee Patient and Public Engagement Committee Procurement Committee NCL Joint Commissioning Committee NCL Primary Care Co-Commissioning Committee in Common Executive Committee (until July 2017) Clinical Commissioning Committee (from August 2017)
A summary of the responsibilities of these Committees, their membership and delegated responsibilities can be found in our Constitution and the Terms of Reference of each Committee, which are available on the CCG’s website.
The CCG’s Committee accountability structure, which takes into account the new governance arrangements, is set out below:
Changes to the CCG’s governance arrangements A review of the CCG’s Governance arrangements was undertaken as recommended by the Audit Committee. Following discussions with GP Clinical Leads, Executive Directors and CCG Committee Chairs, proposals to strengthen clinical leadership and governance in the CCG was approved by the Governing Body at its meeting 19 July 2017 as follows:
i. Merging of the Clinical Reference Group with the Executive Committee andestablishing a Clinical Commissioning Committee;
ii. Establishing a Clinical Review Task and Finish Group with GP Clinical Leadmembership to undertake any detailed work on service specifications andquality impact assessments to support service transformation;
iii. The Terms of Reference for the Clinical Commissioning Committee wereapproved by the Governing Body at its meeting on 22 November 2017. Theterms of reference for the Quality and Safety Committee was approved by theCommittee at its meeting in September 2017 and will be approved by theGoverning Body at a future meeting date following further review beingundertaken.
The CCG Constitution will be updated, as part of a wider review of the NCL CCGs’ Constitutions, to reflect the existence of the new Clinical Commissioning Committee, subject to NHS England approval.
The new governance arrangements will enable more efficient and effective utilisation of Enfield CCG’s clinical and management time, improve systems for decision making and support alignment with NCL CCGs.
The effectiveness of the Governing Body and its committees As part of the Audit Committee work plan, all Governing Body Committee Chairs are invited to attend the Audit Committee to report on their Committee’s effectiveness. Committee Chairs also report to each public Governing Body meeting.
In 2017/2018, the Governing Body’s effectiveness was evaluated for the third year using the maturity matrix developed by the Good Governance Institute for supporting board development and improvement.
An effectiveness review was also conducted on all Governing Body Committees and the outcome from most reviews has been the development of an action plan to address the issues raised. Highlights of the work of the committees and a summary
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of their effectiveness can be found below.
Highlights of Governing Body and committee work during 2017/2018
Governing Body The Governing Body met six times in public and six times for informal seminar sessions during the financial year. All meetings in public were quorate in accordance with its terms of reference. Highlights of the year include: Approval of the establishment of the NCL Audit Committee in Common which
will result in a significant time and cost saving whist maintaining therobustness and quality of the current arrangements.
Endorsement of the Procurement Committee’s decision to award the contractfor GP IT Services to the North East London Commissioning Support Unit foran initial period of four years with effect from 1 August 2017.
Approval of the Committees’ terms of reference. Undertook an annual review of its effectiveness. Endorsement of the Patient and Public Engagement Committee’s decision to
approve the CCG Equality Information Report 2016-2017 and the EnfieldCCG Communications and Engagement Strategy 2017-2020;
Approval of the final report of the Adherence to Evidence Based Medicineprogramme.
Approval of the Section 75 Agreement 2017/2018 with London Borough ofEnfield on the recommendation by the Finance and Performance Committee.
Approval of the approach to the development of NCL CCGs’ SystemIntentions for 2018/2019.
Approval to take in-house a range of services currently provided by NELCSUto the five NCL CCGs.
Ratification of Chair’s actions including: Holbrook House lease and contractaward for internal audit and counter-fraud services to RSM Risk AssuranceServices.
Approval of several CCG Policies including the revised Conflicts of InterestPolicy.
Audit Committee The Audit Committee reviews the establishment and maintenance of an effective system of integrated governance, risk management and internal control, across the whole of the organisation’s activities (both clinical and non-clinical), that supports the achievement of the organisation’s objectives. The Committee provides the Governing Body with an independent and objective view of the CCG’s financial systems, financial information and compliance with laws and regulations.
The Committee met five times during the financial year, with an average attendance of 93%. All meetings were quorate in accordance with the Committee’s terms of reference.
Member name Title Meetings attended
Karen Trew Chair and Lay Member for Audit and Governance 4/5
Dr. Jarir Amarin GP Governing Body Member 5/5
Teri Okoro Lay Member for Patient and Public Engagement 4/5 Rathai Thevananth Governing Body Practice Manager Representative
(until February 2018) 4/4
Christopher Curtis Governing Body Practice Manager Representative (from March 2018)
1/1
Adam Sharples External Lay Member - Reciprocal arrangement with Haringey CCG
5/5
The Chief Finance Officer, the Director of Quality and Integrated Governance and internal and external audit representatives are also routinely in attendance. Highlights of the Committee’s work during 2017/2018 include: Approving the 2016/17 Annual Report and Accounts, as delegated by the
Governing Body Reviewing internal and external audit plans and reports, challenging and
seeking assurance that recommended actions were completed and that allissues were managed comprehensively.
Receiving reports on local counter fraud, debtors and waivers. Providing assurance to the Governing Body on areas of governance, risk and
conflicts of interest, including detailed oversight of the Risk Register, as well asdeclarations of interests and gifts and hospitality. The Board AssuranceFramework and Corporate Risk Register were reviewed at every Committeemeeting.
Reviewing the reports on the effectiveness of all the Governing BodyCommittees and the Audit Committee itself.
Remuneration and Nomination Committee Enfield CCG’s Constitution sets out that there should be two lay members on the Remuneration and Nomination Committee and that the Governing Body shall appoint the membership of this Committee in consultation with the Chair of the Committee.
The Committee met six times during the financial year, with an average attendance of 87.5%. All meetings were quorate in accordance with the Committee’s terms of reference.
Member name Title Meetings attended
Teri Okoro Chair and Lay Member for Patient and Public Engagement
6/6
Karen Trew Lay Member for Audit and Governance 6/6 Dr Mohammed Abedi Chair and GP Governing Body Member 4/6 Angela Dempsey Governing Body Nurse Representative 5/6
Quality and Safety Committee The Quality and Safety Committee is responsible for ensuring the quality and safety of all commissioned services and to assure the Governing Body that quality and
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safety is integral to the commissioning function, by providing an overview of quality assurance and clinical governance.
The Committee met six times during the financial year with an average attendance of 83%. All meetings were quorate in accordance with the Committee’s terms of reference.
Member name Title Meetings attended
Angela Dempsey Chair and Governing Body Nurse Representative 4/6 Karen Trew Lay Member for Audit and Governance 5/6
Dr Jarir Amarin Governing Body GP Representative 6/6
Carole Bruce-Gordon Acting Director of Quality and Integrated Governance
3/6
Professor Robert Elkeles Secondary Care Doctor 5/6
Jahan Mahmoodi Medical Director 5/6
Jane Pike Director of Performance and Corporate Services (until August 2017)
2/2
Dr Elizabeth Babatunde Governing Body GP Representative 5/5
Karen Keane Head of Clinical Quality (until July 2017) 2/2
Dr Tha Han Public Health Representative 6/6
Rosalind Murphy CSU Quality and Safety Representative 6/6
Bridget Pratt Assistant Director of Quality & Clinical Governance 6/6 Edmund Nkrumah Head of Performance and Informatics (until
November 2017) 1/4
Stephen Wells Head of Performance and Information (from November 2017)
2/3
Nyasha Mapuranga Head of Clinical Quality (from July 2017) 4/5
Highlights of the Committee’s work during 2017/2018 include: Receiving assurance from the CSU/ CCG Escalation Reports and Quality
Assurance Reports, including System Resilience Planning for 2017/2018,Enfield CCG E.coli action plan
Receiving assurance from the Condensed CSU Integrated Exception Report Receiving quarterly updates from the Enfield Referral Service, Quality Alerts
Medicines Management and CSU Cancer Assurance report Receiving regular updates and the final report on the London Central and
West Unscheduled Care Collaborative (LCW) Investigation relating to a pressarticle involving operating procedures at LCW
Reviewing the terms of reference and workplans and receiving minutes andreports of sub-groups reporting into the Committee
Approved the Committee’s terms of reference following a review of the CCG’sGovernance arrangements
Regularly reviewed Patient Safety & Risk Management, including the Qualityand Safety Risk register, Outcomes of C.difficile review and recommendations
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Received the 2016/17 annual reports for Individual Funding Requests,Complaints and Enquiries and Quality and Governance
Approved the 2017/2018 Quality Strategy and Implementation Plan andpolicies including the amended Incidents and Serious Incident, and Fire SafetyPolicy
Reviewed areas on safeguarding including, Enfield CCG SafeguardingChildren & Adults at Risk Audit of Enfield GP Practices, Safeguarding Adultsand Children Annual Report and Looked After Children Annual report
General Practice Transformation Sub-Group Quality Report Received updates on Information Governance, Emergency Preparedness,
Resilience & Response (EPRR) Annual Report and Workplan, BMI, Kings Oakand Cavel CQC action plan, Optegra CQC action plan
Quality assurance reports including Fairlands ward insight and learning visitreport, Royal Free and Barnet Hospital Maternity Quality Assurance visitreport
Undertook an annual review of the Committee’s effectiveness.
Finance and Performance Committee The Finance and Performance Committee is responsible for overseeing the financial performance of the CCG and the associated financial planning issues and to monitor CCG delivery of the Quality Innovation Productivity and Prevention (QIPP) and Investment Programme.
The Finance and Performance Committee met monthly during the financial year, with an average attendance of 87%. All meetings were quorate in accordance with the Committee’s terms of reference.
Member name Title Meetings attended
Dr. Hetul Shah Chair (from October 2017) and GP Governing Body Member
10/12
Professor Robert Elkeles Secondary Care Representative (Chair until September 2017)
11/12
Sarah Thompson Chief Officer (until 5 June 2017) 2/2Noreen Dowd Interim Chief Officer (from 23 May to 21
September 2017) 3/3
John Wardell Chief Operating Officer (from 4 December 2017) 2/4
Simon Goodwin Chief Finance Officer for NCL CCGs (from June 2017)
9/10
Karen Trew Lay Member for Audit and Governance 12/12
Dr. Jahan Mahmoodi Medical Director 5/11
Arati Das Deputy Director of Finance 10/12
The Director of Performance and Corporate Services or their deputy and the Director of Recovery are non-voting members of the Committee.
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Highlights of the Committee’s work during 2017/2018 include: Receiving monthly Finance and Contracts report, and Integrated Performance
and Quality report Authorisation of business cases Receiving regular reports on the delivery of financial plans and QIPP
programme Approved the 2018/2019 QIPP Plan Received update from the Commissioning and Contracts Operational Group Regularly reviewed the finance and performance risk register Received update on the Development of the Operational Plan for 2018/2019,
the Better Care Fund and the Barnet, Enfield & Haringey Mental Health NHSTrust Pricing Review
Received a report on the Contract Performance Notices – learning and review,following an assessment of the Contract Performance Notices (CPNs)
Received a report on the financial impact of the deep dive data cleanse forContinuing Healthcare
Undertook an annual review of the Committee’s effectiveness.
Patient and Public Engagement Committee The Patient and Public Committee is responsible for ensuring that the Governing Body involves patients and the public in a planned and proactive way, which is integrated with other local partners wherever possible and co-ordinated with staff engagement activities as appropriate, in order to shape services around the needs and preferences of individual users, patients, their families and their carers.
The Patient and Public Engagement Committee met six times during the financial year, with an average attendance of 70%. All but one meeting were quorate. The meeting on 8 March 2018 was inquorate; therefore no decisions were taken at the meeting.
Member name Title Meetings attended
Teri Okoro Chair and Lay Member for Patient and Public Engagement
5/6
Deborah McBeal Director of Primary Care Commissioning and Deputy Chief Officer
5/6
Bridget Pratt Assistant Director of Quality and Clinical Governance
6/6
Rathai Thevananth Practice Manager Representative (until February 2018)
5/5
Christopher Curtis Practice Manager Representative (from February 2018)
1/1
Gail Hawksworth Head of Communications and Engagement 5/6 Litsa Worrall Elected Patient Participation Group Representative 3/6
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Jean Brewer Enfield Patient Participation Group Locality Champion (South West)
4/6
Sonny Khem Chand Enfield Patient Participation Group Locality Champion (South East)
3/6
Lucy Whitman Healthwatch Representative 3/6
Niki Nicolaou London Borough of Enfield
Emdad Haque Equality and Diversity Manager, NELCSU 4/6
Mark Tickner Public Health Representative 5/6
Bridget Pratt Assistant Director of Quality & Clinical Governance 6/6 Voluntary Sector Voluntary Sector Representative 0/6
Highlights of the Committee’s work during 2017/2018 include: Receiving updates from the Patient Participation Group Representatives,
Healthwatch, Medicines Management, Public Health and Equality andDiversity Strategy 2016-2018 Action Plan.
Supported the Adherence to Evidence Based Medicine consultation. Received assurance that BEHMHT was fully compliant with the requirements
of the Accessible Information Standards 2016 and Equality Act 2010. Received regular updates on the STP. Regularly discussed the CCG’s Engagement log and future events. Received minutes of the Voluntary Community Stakeholder Reference Group. Approved Enfield CCG’s Communication & Engagement Strategy 2017-2020. Discussed the 360 Stakeholder Survey results. Approved the appointment of the elected PPG Representative for a second
term and approved the extension of Elected PPG representative term of officefrom 3 years to 6 years, until 5 May 2021, in line with all elected Enfield CCGGoverning Body appointments.
Approved the establishment of a Patient Reference Group. Undertook an annual review of the Committee’s effectiveness.
Clinical Commissioning Committee The Clinical Commissioning Committee was established in August 2017, following a governance review detailed under ‘Changes to the CCG’s Governance Arrangements’. Its purpose is to oversee and monitor the development and implementation of Enfield commissioning strategies and plans, provide clinical leadership and ensure effective multi-professional participation.
The Committee met monthly during the financial year (since August 2017), with an average attendance of 76%. All meetings were quorate in accordance with the Committee’s terms of reference.
Member name Title Meetings attended
Dr Mohammed Abedi Chair and Governing Body GP Member 8/8 Dr Fahim Chowdhury Clinical Vice Chair and Governing Body GP Member 6/8
Dr Jarir Amarin Governing Body GP Member 7/8 Dr Chitra Sankaran Governing Body GP Member 5/8 Angela Dempsey Governing Body Nurse Member 7/8 Karen Trew Lay Member for Audit and Governance 5/6 Noreen Dowd Interim Chief Operating Officer (23 May to 21
September 2017) 1/2
John Wardell Chief Operating Officer (from 4 December 2017) 1/3 Deborah McBeal Director of Primary Care Commissioning and Deputy
Chief Officer 6/8
Carole Bruce-Gordon Acting Director of Quality and Integrated Governance 6/8
Public Health Public Health Representative 7/8 Graham McDougall Director of Commissioning (until 18 September 2017) 1/1 Vince McCabe Director of Commissioning (from 29 August 2017) 5/7Mark Eaton Director of Recovery 7/8Jahan Mahmoodi Medical Director 6/8 Arati Das Deputy Director of Finance 4/8
Highlights of the Committee’s work during 2017/2018 include: Reviewing the Draft 2018/2019 NCL System Intentions including 2018/2019
QIPP Plan Receiving regular updates on the Primary Care Transformation Programme
and being assured of the work being carried out on primary care Reviewing the recommendations from the Clinical Reference Group on the
Adherence to Evidence Based Medicine: Consultation and Recommendations Reviewing and challenging the commissioning strategic risks Receiving updates from the NCL Joint Commissioning Committee Meeting Receiving assurance from the Clinical Review working Group meeting and
approving the group’s terms of reference Receiving regular updates on the NHS England Improvement & Assurance
Framework Receiving regular update on the NCL Individual Funding Requests activity and
performance Receiving progress reports on the NCL Sustainability and Transformation Plan Receiving update from medicines management, including Medicines
Optimisation Locality Scheme 2018/2019 Reviewing winter planning at North Middlesex University Hospital Reviewing Quality Premium.
Procurement Committee The Procurement Committee has been established by the Governing Body to ensure robust and transparent decision making regarding procurement of services and to provide a forum within the CCG governance structure that has responsibility for approving the award of contracts for healthcare services and ensure all decisions are defensible to challenge or scrutiny. There are no GPs on this Committee.
The Committee met 10 times during the financial year with an average attendance for voting members of 86%. All meetings were quorate in accordance with the
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committee’s terms of reference.
Member name (voting members)
Title Meetingsattended
Karen Trew Chair and Lay Member for Audit and Governance 9/9 Teri Okoro Lay Member for Patient and Public Engagement 5/9 Angela Dempsey Governing Body Nurse Member 7/9 Professor Robert Elkeles Secondary Care Doctor 8/9 Sarah Thompson Chief Operating Officer (until 21 June 2017) 1/1 Noreen Dowd Interim Chief Operating Officer (23 May to 21
September 2017) 2/4
John Wardell Chief Operating Officer (from 4 December 2017) 2/2 Deborah McBeal Director of Primary Care Commissioning and
Deputy Chief Officer 2/2
Arati Das Deputy Director of Finance 9/9
Highlights of the Committee’s work during 2017/2018 include: Reviewing the Register of Procurement Decisions and Contracts Register Received update on the In-patient Rehabilitation Services and primary care
hubs Approving the decision of the Evaluation Panel to award the provision of
Gynaecology, Urology & MSK Services to Royal Free London. Furtherapproving the extension of the current Community Gynaecology, CommunityENT and Community Urology service contracts until March 2019.
Approval of the Estates Management and Utilisation Policy Approval of the extension of the contract with Medicare Medical Services
Limited in respect of Edmonton Walk in Centre until 30th September 2017 Received progress update on Enfield Shared Care Record Approval for the CCG to join the new collaborative agreement for 2017/2018
Nursing Homes Any Qualified Provider Approval of the recommendation of the Gateway Panel to award a contract for
the delivery of the Enfield Single Offer from 1st October 2017 to 31st March2019 to Enfield Healthcare Co-Operative Limited subject to certain conditionsbeing met prior to go live
Approval of Deploying Wi-Fi at General Practice, with joint procurementexercise between Barnet and Islington and the programme to be managed byNELCSU and further approval of the recommendation to award the contract toDaisy Communications as the Enfield CCG preferred supplier
Undertook an annual review of the Committee’s effectiveness.
Executive Committee Following the disestablishment of this Committee on 19 July 2017, to form the Clinical Commissioning Committee, no information has been provided for this Committee.
NCL Joint Commissioning Committee The CCG is committed to working in partnership with the CCGs in NCL to jointly commission acute services, integrated urgent care services, learning disability
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services associated with the Transforming Care Programme and specialist services not commissioned by NHS England.
The Committee considered a number of reports including NCL wide acute performance reports, system intentions, Procedures of Limited Clinical Effectiveness, Winter Planning and financial strategies.
The Committee was established in June 2017 and meets bi-monthly. The Committee met 6 times in 2017/2018. All meetings were quorate and in accordance with its terms of reference. Enfield CCG is represented at the Committee by the CCG’s Chair, a lay member, the Accountable Officer and the Chief Finance Officer.
Member name Title Meetingsattended
Dr Mohammed Abedi Chair and Governing Body GP Member 6/6 Karen Trew Lay Member for Audit and Governance 5/6 Angela Dempsey Governing Body Nurse Member 2/6
NCL Primary Care Co-Commissioning Committee in Common In April 2017 the five CCGs in NCL agreed to undertake fully delegated primary care commissioning from NHS England. The CCGs each agreed to establish a primary care commissioning committee to exercise decision making for this delegated function and to hold their Committee meetings together as a Committee in Common.
The committee considered a number of reports and made a number of decisions. These include the outcomes of the Personal Medical Services contracts review and funding for primary care services.
The Committee meets bi-monthly. The committee met 6 in 2017/2018. All meetings were quorate and in accordance with its terms of reference. Enfield CCG’s Committee contains three members who are a lay member, the director responsible for Primary Care and a Governing Body GP representative. Conflicts of interest are managed robustly and in accordance with the NCL Conflicts of Interest Policy.
Member name Title Meetingsattended
Karen Trew Lay Member for Audit and Governance 5/6 GP Representative Medical Director or Clinical Lead for Primary Care 6/6 Deborah McBeal Deputy Chief Officer and Director of Primary Care
Commissioning 2/6
UK Corporate Governance Code Enfield CCG is not required to comply with the UK Corporate Governance Code. However, we have reported on our corporate governance arrangements by drawing upon best practice available, including those aspects of the UK Corporate Governance Code we consider to be relevant to the CCG and best practice.
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This governance statement is intended to demonstrate CCG regard to the principles set out in the Code considered appropriate for clinical commissioning groups for the financial year ended 31 March 2018. Full details of our Corporate Governance arrangements are set out in our Constitution authorised by NHS England.
Discharge of Statutory Functions During establishment, the arrangements put in place by the clinical commissioning group and explained within the Constitution were developed with extensive external expert legal input, to ensure compliance with the all relevant legislation. That legal advice also informed the matters reserved for the Membership Body, Governing Body decision and the scheme of delegation. Enfield CCG has robust arrangements in place for the discharge of its statutory duties as outlined in its constitution.
In light of recommendations of the 1983 Harris Review, the clinical commissioning group has reviewed all of the statutory duties and powers conferred on it by the National Health Service Act 2006 (as amended) and other associated legislative and regulations. As a result, I can confirm that the clinical commissioning group is clear about the legislative requirements associated with each of the statutory functions for which it is responsible, including any restrictions on delegation of those functions. Responsibility for each duty and power has been clearly allocated to a lead Director. Directorates have confirmed that their structures provide the necessary capability and capacity to undertake all of the clinical commissioning group’s statutory duties.
Risk management arrangements and effectiveness Risk Management Strategy Enfield CCG’s Governing Body approved Risk Management Strategy outlines the CCG’s approach to risk management and its vision in relation to assurance systems, including: Identifying committees and groups which have responsibility for risk
management Roles and responsibilities of staff with regards to risk management The process for identification, assessment and management of risk including risk
to data security The process for managing, and Board review of, the Corporate Risk Register
and Board Assurance Framework (BAF) The risk appetite of the organisation which sets out the thresholds for tolerating,
managing and reporting different levels of risk
As part of the approved internal audit plan for 2017/2018, internal auditors were asked to undertake an audit of the CCG’s BAF and risk management arrangements.
Internal audit concluded that: Taking account of the issues identified, the Governing Body can take
reasonable assurance that the controls in place to manage risks are suitablydesigned and consistently applied.
Enfield CCG has a well-developed BAF which has been embedded within therisk management and governance structure of the CCG.
The BAF has progressed to a robust working document which informsdecision making at various levels of the organisation. Risk deep dives are held
routinely and serve an important purpose in obtaining assurance on the risks and hold the responsible executive lead to account.
From an NCL benchmarking perspective, the Enfield CCG BAF comparesfavourably to the other NCL CCGs
Internal audit identified further enhancements to the framework of risk management and internal control to ensure that it remains adequate and effective such as ensuring gaps in assurance and controls are clearly aligned to the actions to address them. The CCG is working with risk leads and owners to implement the recommendations.
Risk identification Risks are identified against strategic, corporate, directorate, programme/project objectives. New risks are identified through directorate risk registers and escalated to the corporate risk register and BAF as appropriate. Methods for identifying risk include:
Internal methods such as: quality alerts information governance breaches equality and quality impact assessments counter fraud audits and incidents complaints, claims and serious incident reporting and identification of trends audits, quality, innovation, productivity and prevention (QIPP) related risks project risks based on the achievement of project objectives, patient satisfaction surveys risk assessments surveys including staff surveys whistle-blowing Contract quality monitoring of commissioned services
External methods include: Media National reports New legislation Reports from assessments and inspections by external bodies Reviews of partnership working. Stakeholders are also involved in the identification of risk which impact on
them through our Patient & Public Engagement Committee with responsibilityfor ensuring equality impact assessments are integrated into core business.
Risk evaluation As part of Enfield CCG’s risk management process, all risks identified are evaluated and given a risk level rating. The higher the risk level, the greater the likelihood an opportunity or threat will occur and the greater its consequence. An acceptable risk may be defined as a potential hazard that is either small enough to have an immaterial effect on the achievement of organisational objectives, or is a significant risk that has been mitigated by the establishment of effective controls to minimise
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the likelihood of the risk occurring, or to minimise the adverse consequences should the risk identified occur.
Control mechanism There are different operational and strategic levels of risk to ensure that the CCG’s internal control mechanism is effective:
Governing Body Audit Committee Finance and Performance Committee Quality and Safety Committee Procurement Committee Clinical Commissioning Committee Patient & Public Engagement Committee Project Steering Groups
The Audit provides scrutiny and assurance of the robustness of risk processes to support the Governing Body.
Prevention of risk In line with best practice, each work-stream, team and directorate will have a forum where risk is discussed, including the risk register, actions, and any required escalation.
One element of pro-active risk management is prevention. Prevention is embedded within the operation of the CCG through: An incident reporting policy which recognises that the vast majority of NHS
patients receive high standards of care but acknowledges that incidents do occurand encourages prompt reporting as a key part of risk management.
The risk evaluation of every decision the Governing Body and its committees areasked to make and the equality and quality impact assessment of all policies,practices, procedures and decisions to ensure equality and diversity compliance.
Horizon scanning identifies positive areas for Enfield CCG to develop itsbusiness and services, taking opportunities where these arise. By implementingformal mechanisms to horizon scan, Enfield CCG is better able to respond tochanges or emerging issues in a planned, structured and coordinated way.Issues identified through horizon scanning link into and inform the businessplanning process. It considers ongoing risks to commissioned services.
Deterrent to risks arising Although internal controls are in place, reliance on external organisations to
perform key functions exposes Enfield CCG to some risk of fraud and bribery.Measures to mitigate these risks are included in the Anti-Fraud and Anti-Bribery Policy and addressed as part of the Local Counter Fraud SpecialistWork Plan.
Corporate/operational risks are recorded and managed through the corporaterisk register or through the BAF if it is deemed that they could impact on theachievement of strategic objectives. The risks in both documents record therisk, its causes and the effects, and are rated according to severity, which iscalculated using weighted values for the likelihood of the risk occurring and the
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consequences if it does occur. Risks are categorised as either low, moderate, high or extreme.
Management of current risks All risks are linked to the CCG’s strategic objectives and assigned a risk
owner (i.e. lead director/senior manager), and a lead committee which hasoversight for the management and mitigation of the risk.
All CCG risks are managed via the Datix risk management system. Datixcaptures risks at all levels within the organisation from operational(directorate) to strategic level, as well as project risks. These risks areprioritised in accordance with the CCG’s Risk Management Strategy,thereby enabling its principal risks to be fed upwards onto the BoardAssurance Framework.
Reporting and monitoring of current risks In 2017/2018, the CCG strengthened its risk reporting arrangements as part of continuous improvement and to reduce duplication in reporting. A risk reporting work plan was approved at the Audit Committee. The work plan outlined Committee risk reporting arrangements including the new Clinical Commissioning Committee with responsibility for reviewing and moderating on commissioning risks.
The risk reporting work plan is aligned to the CCG Risk Management Strategy and provides a schedule on monthly risk updates by directorates, reporting to the relevant CCG Committees ahead of every Governing Body meeting.
Enfield CCG’s risk appetite In 2017/2018, the Governing Body approved Risk Management Strategy defined the CCG’s risk appetite as cautious. The CCG will seek to control all highly probable risks which have the potential to: Cause significant harm to service users, staff, visitors and other stakeholders; Compromise severely the reputation of the organisation; Have financial consequences that could endanger the organisation’s viability; Jeopardise significantly the organisation’s ability to carry out its core purpose; Threaten the organisation’s compliance with law and regulation.
Embedding risk management Our processes for embedding risk management include:
Raising awareness Training to ensure staff have an awareness and understanding of the risks that affect patients, visitors, and staff. Risk identification – line managers will encourage staff to identify risks to ensure
there are no surprises. Staff will not be blamed or seen as being unduly negativefor identifying risks.
Accountability – staff will be identified to own the actions to tackle risks. Communication – there will be active and frequent communication between staff,
stakeholders and partners.
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Competence Staff will be competent at managing risk. Training – staff will have access to comprehensive risk guidance and advice.
Those who are identified as requiring more specialist training to enable them tofulfil their responsibilities relevant to their roles will have this provided internally.
Behaviour and culture – senior management will lead change by example,ensuring risks are identified, assessed and managed. All staff are encouraged toidentify risks.
Management Activities will be controlled using the risk management process and staff are empowered to tackle risks. Risk assessment and management – risks will be assessed and acted upon to
prevent, control, or reduce them to an acceptable level. Staff will have thefreedom and authority within defined parameters, needed to take action to tacklerisks, escalating them where necessary. Contingency plans will be put in placewhere required.
Process – the process for managing risk will be reviewed to continually improve.This will be integrated with our processes for providing assurance, and theprocesses of our stakeholders and any relevant third parties.
Measuring performance – exposure to risk will be measured with the aim ofreducing this over time. The culture of risk management will also be measuredand improved during the lifetime of this strategy.
Public stakeholder engagement Enfield CCG actively promotes patient and public involvement via partnership working and effective external and internal communication, website and intranet. The process for managing risk is reviewed regularly to continually improve. Risks are also reviewed at our Patient & Public Engagement Committee and integrated into our processes for providing assurance, the processes of our stakeholders and any relevant third parties.
Capacity to Handle Risk The Accountable Officer has overall responsibility for risk management and discharges this by:
Continually promoting risk management and demonstrating leadership,involvement and support,
Ensuring an appropriate committee structure is in place and ensuring eachreceives regular risk reports, and
Ensuring that the Governing Body, executive team, clinical directors andsenior managers are appointed with managerial responsibility for riskmanagement.
Responsibility of Directors, Clinical Leads and Heads of Services All risks are assigned a relevant Director Lead, Clinical Lead and Head of Service, who has accountability for overseeing the management of the risk by identifying the most effective means to minimise, transfer or eliminate the risk and ensure the quality of action plans, controls and assurances are robust. A lead Manager is also assigned with management responsibility for delivering the action plan, developing
robust controls and identifying sources of assurance. The Risk Manager provides professional support and training to staff on the risk management process.
Departmental Risk Champions Each CCG department has a trained Risk Champion who:
Proactively engages in the implementation of the monthly risk register reviewand update within their directorate.
Works with Service Leads to ensure risk registers are quality checked withinthe timeframes set out in the risk management strategy.
Input risk register information onto the Risk Module of the Datix database inan accurate and timely manner so that the Risk & Governance Team are ableto supply the Clinical Commissioning Committee, Audit Committee, Finance &Performance Committee, Quality & Safety Committee and other bodies withaccurate and up to date Corporate Risk Registers and AssuranceFrameworks.
Keep up to date with any changes to the database by attending refreshertraining as and when appropriate.
Report any concerns to their Director and advise directors, managers andother staff within their directorate of identified risks requiring attention.
Reporting lines and accountabilities between the Governing Body, its committees and the executive team The Governing Body is responsible for the performance management of the risk management strategy and systems of clinical, financial and organisational control. It oversees the overall system of risk management and assurance to satisfy itself that the CCG is fulfilling its organisational responsibilities and is supported in that function by its committees:
The Audit Committee, in line with the NHS Audit Committee Handbook,ensures the CCG has an effective process in place with regards to riskmanagement and monitors the quality of the assurance framework, referringsignificant issues to the Governing Body.
The Quality & Safety Committee has overarching responsibility for clinical riskmanagement, information governance and health and safety risks.
The Finance and Performance Committee continuously assesses financialand non-financial risks relating to the QIPP plans and ensures the CCG hasmeasures and mitigations in place to manage risk. It also considers risk inrelation to finance and performance.
The Clinical Commissioning Committee monitors commissioning risks toachieving individual corporate objectives including action plans with aparticular focus on risks rated amber and red.
Each Committee reports its findings on risk management to the next Governing Body meeting. In this way, the CCG is assured that risk is effectively controlled and that its governance statement is valid.
Governing Body Oversight The Governing Body Assurance Framework and Corporate Risk Register assess the effectiveness of systems of internal control and provide assurances that risk management processes are effective. The Governing Body Assurance Framework outlines the CCG’s principal objectives, the significant risks (12+) to
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achieving those objectives, key controls and assurances, and gaps in controls and assurances. The Corporate Risk Register contains a mixture of strategic and operational risks (8+) at organisational and directorate level as well as the arrangements in place to mitigate these. The Assurance Framework and Corporate Risk Register is scrutinised at every Audit Committee and reported to every Governing Body Meeting.
Staff training and support A system of trained risk champions has been established in each directorate
responsible for ensuring their department risk registers are managed andupdated.
A list of named departmental risk champions and risk owners has been sharedwith staff. Risk owners are members of the Executive Team and are accountablefor the identification, assessment and management/ mitigation of all risks in theirarea.
All staff receive mandatory training annually in health, fire & safety, including riskassessment and management, via the CCG’s corporate learning anddevelopment programme.
General awareness raising for staff is also undertaken through staff briefings,induction programmes and inclusion of relevant documents on the intranet.
Risk Assessment Risk Assessment in 2017/2018
Using the risk and control framework, risk assessment is conducted in asystematic manner across all aspects of the CCG’s strategic and operationalgoals.
The risks and the controls applied to them are actively scrutinisedthroughout the year by the Governing Body, responsible committees andthe senior management team.
Each risk is assigned a target risk rating and if the Governing Body issatisfied that the level of risk has reduced to that level and is fullymitigated, it may direct that the risk be removed from the BAF.
As part of the NCL Sustainability & Transformation Plan Enfield CCGalso aligned its strategic risk to the NCL Joint Commissioning Committeerisks register.
Throughout 2017/2018, risks were assessed and monitored at the relevant Committees using the process set out in the risk management strategy. Directors reported to the Governing Body and its committees at each meeting ensuring complete oversight of the CCG’s performance. Representatives of the CCG meet regularly with those of other CCGs in North Central London to share best practice and to ensure a collaborative approach across the five CCGs. The CCG met regularly with NHS England throughout the year to ensure that the CCG is complying with the terms of its license. These meetings act as an effective review of the CCG and agreed actions from the meetings are implemented promptly.
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Principal risks to compliance The principal risks to compliance with Enfield CCG’s continued authorisation are identified through a broad range of performance and commissioning priorities: • Are local people getting good quality care?• Are patient rights under the NHS Constitution being promoted?• Are health outcomes improving for local people?• Are CCGs commissioning services within their financial allocations?
The senior management team, responsible committee and the Governing Body regularly receive and scrutinise performance in these areas using the BAF. Further assurance on the effective management of risks to compliance with the CCG’s authorisation is obtained from the NHSE self-assessment process and regular review meetings with NHSE.
Major risks to governance, risk management and internal control in 2017/2018 2017/2018 has been challenging in meeting in-year delivery targets and meeting our statutory financial obligations. In that context, the most significant and enduring risks as of March 2018 are described below.
Identified significant risks (15+) during the financial year and after the year end
Risk Mitigation or closure
1. Failure to maintain long-termfinancial sustainability
The CCG reported a £3.4m YTD deficit against planned budget surplus of £2.1m. This effects CCGs ability to recover its cumulative deficit over the longer term. The cumulative deficit now stands at £40.63m. The immediate impact is an increased QIPP target for 2018/2019
2. Failure to deliver the2017/2018 control total
The risk that the CCG will not deliver its control total has now occurred. There is now a confirmed outturn from £2.1m planned surplus to an adverse variance of £3.39m (£5.49m) movement. This overspend was largely driven by Acute over performance, QIPP under delivery, Significant cost growth in Continuing Healthcare and prescribing cost pressure arising from NCSO (No Cheaper Supply Obtainable) Drugs.
Acute position was also made worse by the lack of year-end agreements with the CCG’s two main acute providers (Royal Free London
and North Middlesex University Hospital.
3. Risks associated with aligningthe STP, Operating Plan, QIPPPlans and Contracts
The CCG continues to work on aligning and delivering QIPP. Concerns remain around a number of QIPP schemes where the STP are responsible and present the CCG with uncertainty and lack of control around delivery. There is also current uncertainty around 2018/2019 QIPP target due to failure to agree QIPP in Acute contracts.
4. Performance & quality riskarising from non-delivery of NHSconstitutional standards arisingfrom provider Cancer & A&Eunderperformance (RFL &NMUH)
RTT Waiting Times performance at RFL continues to be a cause of concern. RFL RTT Steering Group for RFL in place and overseen by NCL SMT Director of Performance. Recovery plan in place and monitored. Cancer 62 day waiting times remains an on-going concern with recovery plans being monitored across NCL CCGs at the NCL Cancer Commissioning Board
5. Failure to ensure a safe andhigh quality service iscommissioned from anddelivered by our providers.(Quality and safety concerns atthe NMUH Emergencydepartment, BEHMHT rated asrequires improvement by theCQC in 2018)
Provider Patient Safety, Patient Experience and Clinical Effectiveness reporting to monthly Clinical Quality Review Group and the CCG Quality & Safety Committee
A programme of Commissioner led Insight & learning Visits in place
Regular NHSE Assurance meetings
CQC Improvement plans monitored at CQRG
Other sources of assurance Internal Control Framework A system of internal control is the set of processes and procedures in place in the CCG to ensure it delivers its policies, aims and objectives. It is designed to identify and prioritise the risks, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically.
The system of internal control allows risk to be managed to a reasonable level rather than eliminating all risk; it can therefore only provide reasonable and not absolute assurance of effectiveness.
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The CCG’s Board Assurance Framework, Standing Orders, Scheme of Reservation and Delegation of Powers, Detailed Financial Policies and Standing Financial Instructions form part of the internal control framework.
Annual audit of conflicts of interest management The revised statutory guidance on managing conflicts of interest for CCGs (published June 2017) requires CCGs to undertake an annual internal audit of conflicts of interest management. To support CCGs to undertake this task, NHS England has published a template audit framework.
In Governing Body and Committee meetings, there is a set agenda item for attendees to declare any conflicts of interest that they may have in relation to the agenda. If there are any conflicts then these will be mitigated appropriately, often by the individuals with interests leaving the room for the agenda item that affects them and in some cases not receiving papers for the agenda item(s). The Register of Interests is circulated at every Governing Body and Committee meetings for members to confirm their entries.
Enfield CCG carried out its annual internal audit of conflicts of interest in 2017/2018. The audit confirmed that the CCG is generally compliant (amber-green rating) with NHS England’s statutory guidance on managing Conflicts of Interest. Internal audit concluded that “Taking account of the issues identified, the Governing Body can take reasonable assurance that the controls in place to manage this risk are suitably designed and consistently applied. However, we have identified issues that need to be addressed in order to ensure that the control framework is effective in managing the identified risk(s).”
The audit assessed compliance with NHS England guidance in each of the five areas below, and assigned a compliance rating for each:
- Governance arrangements (Fully Compliant).- Declaration of Interests and Gifts and Hospitality (Partial Compliance).- Register of Interests, Gifts, Hospitality and Procurement decision (Partial
Compliance).- Decision making processes and contract monitoring (Fully Compliant).- Reporting concerns and identifying and managing breaches/ non-
compliance (Fully Compliant).
Some of the issues identified are already being taken forward.
Breach of Conflicts of Interest (COI) Policy: No breach of the Conflicts of Interest Policy occurred during the financial year. This is due to increased awareness of and robust processes in place on managing conflicts of interest.
Data Quality
The North East London Commissioning Support Unit provides a business intelligence service to the Clinical Commissioning Group which supports the
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management of contract and other data and the production of performance information. This service includes data validation and contract challenges which are then reflected in the reported positions.
Information used by the Governing Body and its Committees enables us to carry out our responsibilities and discharge our statutory functions. Information is operational, financial, or relates to performance, quality and patient experience. The Governing Body and its Committees are engaged in a continuous cycle of improvement with regard to the quality of the information received. The reports received have under gone regular review and improvement.
Information Governance The NHS Information Governance Framework sets the processes and procedures by which the NHS handles information about patients and employees, in particular personal identifiable information. The NHS Information Governance Framework is supported by an information governance toolkit and the annual submission process provides assurances to the clinical commissioning group, other organisations and to individuals that personal information is dealt with legally, securely, efficiently and effectively.
We place high importance on ensuring there are robust information governance systems and processes in place to help protect patient and corporate information. We have established an information governance management framework and have developed information governance processes and procedures in line with the information governance toolkit. We have ensured all staff undertake annual information governance training and have implemented a staff information governance handbook to ensure staff are aware of their information governance roles and responsibilities. There are processes in place for incident reporting and investigation of serious incidents.
The supplier of our information governance function is the NEL Commissioning Support Unit. The process for managing and controlling risks including relating to data security can be found in the risk section above.
Enfield CCG’s Information Governance Framework sets the processes and procedures by which we handle information about patients and employees, in particular personal identifiable information. Our Information Governance Framework and associated policies is supported by an information governance toolkit and the annual submission process provides assurances to the Governing Body, other organisations and to the public that personal information is dealt with legally, securely, efficiently and effectively.
We have submitted a satisfactory level of IG toolkit compliance in 2017/2018 with a score of 89%, a 9% improvement on the previous year. The CCG achieved level 3 in 17 requirements and level 2 in 8 IG Toolkit requirements. In comparison to 2016/2017 IG toolkit, 6 requirements achieved improvement from a level 2 to a level 3 score of the toolkit.
As part of the information governance toolkit, we have undertaken annual data flow mapping, information risk assessment and management procedures and this is
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reported to the relevant committee. There are processes in place for incident reporting and investigation of serious incidents. We have developed information risk assessment and management procedures and a programme has been established to fully embed an information risk culture throughout the organisation. The CCG will continue to monitor information governance via its annual Information Governance Toolkit work plan and implement the new General Data Protection Regulations.
Business Critical Models The key business critical models, on which the Governing Body relies, are in-year financial forecasts, medium term financial planning and financial evaluation and forecasting. These models are the responsibility of the Chief Finance Officer and operated by the Finance and Contracts Team and the Programme Management Office. Operation of these models is delegated from the Governing Body to the Finance and Performance Committee. Quality assurance on these models has been sought, and received, by external expert review and the internal audit programme.
The supplier of our Information and Communication Technology and Business Intelligence functions is the NEL Commissioning Support Unit. Business critical models in use within Information and Communication Technology are subject to a number of quality assurance processes which link into the overall framework and management commitment to quality. There is transparency and management oversight for models and data sources used to make business critical and strategic decisions, with scrutiny within the Clinical Commissioning Committee. Data inputs and outputs are regularly validated, with senior management responsible for an overall ‘sense check’ before decisions are approved.
Third party assurances The CCG uses a range of mechanisms to assess the effectiveness of third party providers including formal customer-supplier performance oversight arrangements and the use of Service Auditor Reports to review control procedures. The CCG monitors the performance of NEL Commissioning Support Unit against the Service Level Agreement through regular performance meetings and outturn reports. The CCG also uses Internal Audit to provide assurances in respect of third party arrangements.
Control Issues Based on the work Internal Audit have undertaken on the CCG’s system on internal control, they do not consider that within these areas there are any issues that need to be flagged as significant control issues within the Annual Governance Statement. Internal Audit concluded that ‘The organisation has an adequate and effective framework for risk management, governance and internal control. However, our work has identified further enhancements to the framework of risk management, governance and internal control to ensure that it remains adequate and effective’
Review of economy, efficiency & effectiveness of the use of resources Processes have been put in place to ensure that resources are used economically, efficiently and effectively. At the beginning of the year budgets are scrutinised to
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ensure they represent an effective use of public funds and are signed off by the Governing Body.
The CCG monitors itself on the “Quality of Leadership” indicator through self-assessment. This assessment is informed by a number of factors including, insights from discussions with NHSE, evidence from IAF, quality of board papers, Annual Report & Accounts, governance statement, Organisation Development plans, staff turnover rates, PPE (Strategy & policy), PDR Completion Rate, up-to-date website information about opportunities for involvement.
The Quality, Innovation, Productivity and Prevention and budget setting processes are reviewed by Internal Audit and reported through the Audit Committee. Best practice is followed in the compilation of business cases to ensure resources are used effectively in the development of new investment ideas.
Detailed monthly finance reports with financial and activity data are received by the Finance and Performance Committee with a summary report going to the Governing Body.
Due to the CCG being financially challenged, significant emphasis is placed on financial planning and in-year performance monitoring with strict controls in place for containing central management costs within caps set by NHSE. Decisions on whether to proceed with QIPP and other projects use the concept of “Best Possible Value” or BPV. The BPV concept aims to balance improvements in outcomes for patients with the need to achieve improved efficiencies.
Delegation of functions The CCG purchases a range of support functions from NEL Commissioning Support Unit, as mentioned above. A Quality Assurance Group is in place to provide assurance to the CCG on activity undertaken on their behalf. The Group received Assurance Reports issued by the internal auditors on information governance, Information Technology, General Controls, Business Continuity/Disaster Recovery, Procurement and Provider Quality Management. No significant concerns were identified. A report on this assurance work is a standing item at Audit Committee meetings.
Counter fraud arrangements ECCG have a contract with RSM to provide the services of an accredited Local Counter Fraud Specialist (LCFS) and have a local nominated LCFS lead who carries out anti-fraud work. This is pre agreed for a set number of agreed days as per the LCFS work plan in order to tackle fraud, bribery and corruption in order to ensure that work is proportionate to identified risks. Reactive work on fraud referrals is also undertaken as and when they arise with support from a senior management team at RSM.
The CCG’s Audit Committee receives a report against the Standards for Commissioners at least annually. There is executive support and direction for a proportionate proactive work plan to address identified risks.
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Head of Internal Audit Opinion Following completion of the planned audit work for the financial year for the clinical commissioning group and the quality assurance work for the CSU the Head of Internal Audit issued an independent and objective opinion on the adequacy and effectiveness of the clinical commissioning group’s system of risk management, governance and internal control.
The Head of Internal Audit concluded that:
“The organisation has an adequate and effective framework for risk management, governance and internal control. However, our work has identified further enhancements to the framework of risk management, governance and internal control to ensure that it remains adequate and effective.”
During the year, Internal Audit issued reasonable assurance opinion in relation to the following reviews Area of Audit Level of Assurance Given Board Assurance Framework Reasonable AssuranceConflicts of Interest Reasonable Assurance Provider Contract Management Reasonable AssuranceFinancial Reporting and Governance Reasonable AssuranceQIPP and Sustainability Reasonable Assurance Primary Care Delegated Commissioning – Part 2 Reasonable Assurance NCL Governance Arrangements Reasonable Assurance
Internal audit also issued partial assurance opinions in relation to the following reviews: Area of Audit Level of Assurance Given Contract Monitoring CSU Partial Assurance Primary Care Delegated Commissioning – Part 1 Partial Assurance
In contract Monitoring CSU, Internal Audit concluded that “there was no alignment and inconsistent performance in the CSU multi-disciplinary teams across the 5 CCGs [Islington CCG, Camden CCG, Haringey CCG, Enfield CCG, Barnet CCG]. We also found an inconsistent approach to the CSU SLA monitoring meetings for the five CCGs. We observed that some of the KPIs were not SMART and there were inconsistencies between the KPIs in the SLA and those in the KPI report which is presented at the SLA Monitoring meeting. Lastly, one of the KPIs in the SLA, relating to human resources had been under-performing since April 2016, but there was no service improvement action plan in place at the time of the review.”
The CCG in collaboration with our colleagues in the other four CCGs have begun steps to bring in-house some of the functions provided by the NELCSU.
NELCSU (North East London Clinical Support Unit) Quality Assurance Plan Internal Audit issued Reasonable Assurance opinion in relation to the following
reviews:
Area of Audit Level of Assurance Given Recruitment Reasonable Assurance Acute and Non-Acute Contracting Reasonable Assurance Provider Quality Management Reasonable Assurance Data Quality and Performance Management Reasonable Assurance
Internal audit also issued partial assurance opinions in relation to the following reviews: Area of Audit Level of Assurance Given Procurement Partial Assurance
Internal Audit also issued the following advisory reports: Cyber Security Follow up and Risk Assessment; and Information Governance Toolkit ( Version 14.1)
Action plans have been agreed and put in place to address any controls issues identified within these reports. The Audit Committee oversees the implementation of these action plans.
Review of the effectiveness of governance, risk management and internal control My review of the effectiveness of the system of internal control is informed by the work of the internal auditors, executive managers and clinical leads within the clinical commissioning group who have responsibility for the development and maintenance of the internal control framework. I have drawn on performance information available to me. My review is also informed by comments made by the external auditors in their annual audit letter and other reports.
Our assurance framework provides me with evidence that the effectiveness of controls that manage risks to the clinical commissioning group achieving its principle objectives have been reviewed.
I have been advised on the implications of the result of this review by: The board The audit committee If relevant, the risk / clinical governance / quality committee Internal audit Other explicit review/assurance mechanisms
Conclusion There have been no significant internal control issues identified during the course of 2017/2018. However I have identified a number of priorities for 2018/2019 to
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continue to develop and strengthen the system of internal controls.
Helen Pettersen Accountable Officer 23 May 2018
Remuneration and Staff Report
Remuneration Report The NHS has adopted the recommendations outlined in the Greenbury Report in respect of the disclosure of senior managers’ remuneration and the manner in which it is determined.
Senior managers are defined as those persons in senior positions having authority or responsibility for directing or controlling major activities within the CCG. This means those who influence the decisions of the CCG as a whole rather than the decisions of individual directorates or departments.
This section of the report outlines how those recommendations have been implemented by the CCG in the year to 31 March 2018.
Remuneration and Terms of Service Committee CCGs are required to have a remuneration committee to oversee the pay, terms and conditions of service of senior managers. The committee’s membership and activities during the year are discussed in the governance statement section of the report.
The main function of the committee is to make recommendations to the Governing Body on the remuneration, allowances and terms of service of other officer members to ensure that they are fairly rewarded for their individual contribution to the CCG, having regard for the organisation’s circumstances and performance, and taking into account national arrangements.
Policy on the remuneration of senior managers The Remuneration Committee sets salaries and terms and conditions of service for all Governing Body Members, including clinical members, lay members and the two executive directors (Chief Officer, Chief Finance Officer) on an annual basis in accordance with the CCG’s constitution. All salaries are set with regard to the guidance laid out in NHS England’s Annex 2: Principles relating to reimbursement and remuneration for governing body members April 2012 and also to local benchmarking provided by NELCSU. The executive directors have their pay and terms and conditions of service set in accordance with the NHS Very Senior Manager (VSM) framework and the NHS London Pay Framework for Very Senior Managers in Strategic and Special Health Authorities, Primary Care Trusts and Ambulance Trusts (June 2013). Pay and terms and conditions for other directors who do not sit on the Governing Body are governed by the national Agenda for Change regulations.”
Remuneration of Very Senior Managers There has been no payment of performance related pay during the year ending 31 March 2018.
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No compensation was payable during the year and no amounts are included that are payable to third parties for the services of senior managers. In the event of redundancy standard NHS packages apply.
Contractual arrangements The Accountable Officer and other directors are on permanent contracts. The Accountable Officer is subject to a three-month notice period and other directors, twelve weeks.
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Senior manager remuneration (including salary and pension entitlements)
The following tables provide the information required. These are subject to audit
Name and Title 2017‐18 Dates served
Salary (bands of £5,000) £000
Taxable Benefits
(rounded to the nearest)
£000
Annual Performance
Related Bonuses (bands of £5000)
£000
Long Term Performance
Related Bonuses (bands of £5000)
£000
All Pension Related Benefits (bands of £2,500) £000
Total Started Ceased
Executive Directors
(1) Ms Helen Pettersen ‐ Accountable Officer 30 ‐ 35 0 0 0 2.5 ‐ 5 30 ‐ 35 03/04/17
Ms Sarah F Thompson ‐ Interim Accountable Officer 25 ‐ 30 0 0 0 32.5 ‐ 35 55 ‐ 60 10/08/15 11/06/17
Ms Deborah Mc Beal ‐ Deputy Chief Officer 105 ‐ 110 0 0 0 32.5 ‐ 35 140 ‐ 145 28/07/15
(1) Mr Simon Goodwin ‐ Chief Financial Officer 20 ‐ 25 0 0 0 2.5 ‐5 25 ‐ 30 01/06/17
Mr Rob Whiteford ‐ Chief Financial Officer 30 ‐ 35 0 0 0 0 30 ‐ 35 18/11/14 07/06/17
Ms Arati Das ‐ Acting Chief Finance Officer (up to 31/5/2017)/ Deputy Director of Finance
90 ‐95 0 0 0 47.5 ‐ 50 135 ‐ 140 01/04/17
(1) Mr NHW Huxter ‐ Director of Strategy 20 ‐ 25 0 0 0 2.5 ‐5 25 ‐ 30 01/06/17
(1) Mr P Sinden ‐ Director of Acute Commissioning & Performance 20 ‐ 25 0 0 0 15 ‐ 17.5 35 ‐ 40 01/04/17
Ms Aimee Fairbairns ‐ Director of Service Quality and IntegratedGovernance. 105 ‐ 110
0 0 0 52.5 ‐ 55 160 ‐165 01/04/13
Ms Carole Bruce‐Gordon‐ Acting Director of Service Quality andIntegrated Governance. 85 ‐ 90
0 0 0 87.5 ‐ 90 175 ‐ 180 01/01/17 30/03/18
Mr Graham MacDougall ‐ Director of Strategy & Partnerships 100 ‐ 105 0 0 0 55 ‐ 57.5 160 ‐165 01/04/13
Ms Jane Pike ‐ Director of Operations 40 ‐ 45 0 0 0 0 40 ‐ 45 02/01/15 30/08/17
Mr Vince McCabe ‐ Director of Strategy & Partnerships 60 ‐ 65 0 0 0 0 60 ‐ 65 29/08/17 30/03/18
Mr John Wardell ‐ Chief Operating Officer 40 ‐ 45 0 0 0 32 ‐ 35 70 ‐ 75 04/12/17
(2) Ms Noreen Dowd ‐ Interim Chief Operating Officer 70 ‐ 75 0 0 0 0 70 ‐ 75 23/05/17 21/09/17
(2& 4)
Mr Mark Eaton ‐ Director of Recovery205 ‐ 210
0 0 0 0 205 ‐ 210 05/09/16 02/04/18
Medical Director
Dr Jahan Mahmoodi ‐ Medical Director (Left on 31/3/2018) 70 ‐ 75 0 0 0 0 70 ‐ 75 20/07/15
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Senior manager remuneration (including salary and pension entitlements) Continues on this page
GP Governing Body Members
(3) Dr Mo Abedi ‐ Chair 80 ‐ 85 0 0 0 0 80 ‐ 85 01/08/14
(3) Dr Janet High ‐ Clinical vice chair / GP Member 10 ‐ 15 0 0 0 0 10 ‐ 15 01/04/13
(3) Dr Fahim Chowdhury ‐ GP Member 25 ‐ 30 0 0 0 0 25 ‐ 30 30/10/13
(3) Dr Rebecca Olowookere ‐ GP Member 30 ‐ 35 0 0 0 0 30 ‐ 35 01/08/17
(3) Dr Hetul Shah ‐ GP Member 25 ‐ 30 0 0 0 0 25 ‐ 30 14/03/17
(3) Dr Chitra Sankaran ‐ GP Member 25 ‐ 30 0 0 0 0 25 ‐ 30 02/09/15
(3) Dr Jarir Amarin ‐ GP Member 20 ‐ 25 0 0 0 0 20 ‐ 25 02/09/15
(3) Dr Lourdrina Thambinayagam ‐ Governing Body Locality Lead 25 ‐ 30 0 0 0 0 25 ‐ 30 11/11/15
(3) Dr Johan Bryan ‐ Acting GP Member SE Locality 30 ‐ 35 0 0 0 0 30 ‐ 35 16/11/16
(3) Dr Elizabeth Babatunde GP Member 20 ‐ 25 0 0 0 0 20 ‐ 25 01/08/17
Other Governing Body Members
Mrs Rathai Thevananth ‐ Practice Manager Member 10 ‐ 15 0 0 0 0 10 ‐ 15 01/04/13 16/02/18
Prof Robert Elkeles ‐ Secondary Care Doctor Member 10 ‐ 15 0 0 0 0 10 ‐ 15 01/04/13
Mrs Angela Dempsey ‐ Nurse Member 10 ‐ 15 0 0 0 0 10 ‐ 15 01/04/13
Mr Christopher Curtis ‐ Practice Manager Representative 0 ‐ 5 0 0 0 0 0 ‐ 5 01/02/18
Lay Members
Ms Karen Trew ‐ Lay Member 20 ‐ 25 0 0 0 0 20 ‐ 25 01/04/13
Dr Teri Okoro ‐ Lay Member 10 ‐ 15 0 0 0 0 10 ‐ 15 01/04/13
(1) North central London shared management team members with salary split equally across Barnet, Camden, Enfield, Haringey and Islington CCGs.(2) Paid to agency not direct to individual.(3) GP members with a contract for services and therefore disclosed under off-payroll engagements.(4) This post was mandated by NHSE legal directions and the CCG satisfied itself that for the specialist skills required, the remuneration was in line with market rates.
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Senior manager remuneration (including salary and pension entitlements) 2016/2017 Name and Title 2016‐17 Dates served
Salary (bands of £5,000) £000
Taxable Benefits (rounded to the
nearest) £000
Annual Performance Related Bonuses (bands of £5000)
£000
Long Term Performance Related Bonuses (bands of £5000)
£000
All Pension Related Benefits
(bands of £2,500) £000
Total Started Ceased
Executive Directors
Mr Paul Jenkins ‐ Chief Officer 35 ‐ 4 0 0 0 0 100 ‐ 102.5 135 ‐ 140 10/08/15 30/04/16
Ms Sarah F Thompson 105 ‐ 110 0 0 0 65 ‐ 67.5 175 ‐ 180 23/05/16
Ms Deborah Mc Beal ‐ Deputy Chief Officer 105 ‐ 110 0 0 0 77.5 ‐ 80 180 ‐ 185 28/07/15
Mr Rob Whiteford ‐ Chief Financial Officer 120 ‐ 125 0 0 0 0 120 ‐ 125 18/11/14
Ms Aimee Fairbairns ‐ Director of Service Quality and Int. Gov. 100 ‐ 105 0 0 0 45 ‐ 47.5 145 ‐ 150 01/04/13
Ms Carole Bruce‐Gordon (NEW) 75 ‐ 80 0 0 0 47.5 ‐ 50 125 ‐ 130 01/01/17
Mr Graham MacDougall ‐ Director of Strategy & Partnerships 95 ‐ 100 0 0 0 32.5 ‐ 35 130 ‐ 135 01/04/13
Ms Jane Pike ‐ Director of Operations 100 ‐ 105 0 0 0 0 100 ‐ 105 02/01/15
(1) Mr Mike Seitz ‐ Director of Recovery 170 ‐175 0 0 0 0 170 ‐ 175 01/05/16 31/08/16
(1) Mr Mark Eaton ‐ Director of Recovery 125 ‐130 0 0 0 0 125 ‐ 130 05/09/16
Medical Director
Dr Jahan Mahmoodi ‐ Medical Director 70 ‐75 0 0 0 0 70 ‐ 75 20/07/15
GP Governing Body Members
Dr Mo Abedi ‐ Chair 80 ‐ 85 0 0 0 0 80 ‐ 85 01/08/14
Dr Alpesh Patel ‐ Chair / Clinical vice chair 40 ‐ 45 0 0 0 0 40 ‐ 45 01/08/14 31/03/17
Dr Janet High ‐ Clinical vice chair / GP Member 25 ‐ 30 0 0 0 0 25 ‐ 30 01/04/13
Dr Fahim Chowdhury ‐ GP Member 25 ‐ 30 0 0 0 0 25 ‐ 30 30/10/13
Dr Ujjal Sarkar ‐ GP Member 15 ‐ 20 0 0 0 0 15 ‐ 20 01/04/13 21/12/16
Dr Hetul Shah ‐ GP Member 5 ‐ 10 0 0 0 0 5 ‐ 10 17/02/16 08/08/16
Dr Chitra Sankaran ‐ GP Member 25 ‐ 30 0 0 0 0 25 ‐ 30 02/09/15
Dr Jarir Amarin ‐ GP Member 20 ‐ 25 0 0 0 0 20 ‐ 25 02/09/15
Dr Lourdrina Thambinayagam ‐ Governing Body Locality Lead 5 ‐ 10 0 0 0 0 5 ‐ 10 11/11/15
Dr Johan Bryan ‐ Acting GP Member SE Locality 5 ‐ 10 0 0 0 0 5 ‐ 10 16/11/16 15/02/17
Other Governing Body Members
Mrs Rathai Thevananth ‐ Practice Manager Member 10 ‐ 15 0 0 0 0 10 ‐ 15 01/04/13
Prof Robert Elkeles ‐ Secondary Care Doctor Member 10 ‐ 15 0 0 0 0 10 ‐ 15 01/04/13
Mrs Angela Dempsey ‐ Nurse Member 10 ‐ 15 0 0 0 0 10 ‐ 15 01/04/13
Lay Members
Ms Karen Trew ‐ Lay Member 20 ‐ 25 0 0 0 0 20 ‐ 25 01/04/13
Dr Teri Okoro ‐ Lay Member 10 ‐ 15 0 0 0 0 10 ‐ 15 01/04/13
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(1) Paid to agency not direct to individual.
Pensions Most staff, including executive senior managers, are eligible to join the NHS pension scheme. The NHS scheme’s employer’s contribution for the year was 14.38% of the individual’s salary as per the NHS Pensions regulations. As in 2015/16 and 2016/17, employee contribution rates for CCG officers and practice staff, and the prior year comparators, were as follows:
Member contribution rates before tax relief (gross) Annual pensionable pay Gross contribution rate
Up to £15,431.99 5.0% £15,432 to £21,477.99 5.6% £21,478 to £26,823.99 7.1% £26,824 to £47,845.99 9.3% £47,846 to £70,630.99 12.5% £70,631 to £111,376.99 13.5% £111,377 and over 14.5%
Scheme benefits are set by NHS Pensions and applicable to all members. Past and present employees are covered by the provisions of the NHS pension scheme.
Cash equivalent transfer values A Cash Equivalent Transfer Value (CETV) is the actuarially assessed capital value of the pension scheme benefits accrued by a member at a particular point in time. The benefits valued are the member’s accrued benefits and any contingent spouse’s (or other allowable beneficiary’s) pension payable from the scheme. CETVs are calculated in accordance with SI 2008 No.1050 Occupational Pension Schemes (Transfer Values) Regulations 2008.
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A CETV is a payment made by a pension scheme or arrangement to secure pension benefits in another pension scheme or arrangement when the member leaves a scheme and chooses to transfer the benefits accrued in their former scheme. The pension figures shown relate to the benefits that the individual has accrued as a consequence of their total membership of the pension scheme, not just their service in a senior capacity to which disclosure applies.
Real increase in CETV This reflects the increase in CETV effectively funded by the employer. It does not include the increase in accrued pension due to inflation, but does include contributions paid by the employee (including the value of any benefits transferred from another scheme or arrangement) and uses common market valuation factors for the start and end of the period.
Benefits shown in the table are the totals for the individuals concerned, irrespective of the shared management arrangements describe in the salaries and allowances of senior managers table, in section 2.2.1.1 of this report.
Salary and pension entitlements of directors and senior managers The following table discloses further information regarding remuneration and pension entitlements. There are no entries in the cases of members with non-pensionable remuneration or GP members with a contract for services.
Pension benefits as at 31 March 2018
Name and Title
Real increase /decrease in pension at
retirement age (bands of £2500)
Real increase /decrease in related lump
sum at retirement age
(bands of £2500)
Total accrued pension at
retirement age at 31 March 2018
(bands of £5000)
Total accrued related lump
sum at retirement age
at 31 March 2018 (bands of
£5000)
Cash Equivalent
Transfer Value (CETV) at 31 March 2018
Cash Equivalent
Transfer Value (CETV) at 31 March 2017
Real increase / decrease in
Cash Equivalent
Transfer Value
Employers Contribution
to Partnership
Pension
£000 £000 £000 £000 £000 £000 £000 £000
Board Members
Ms Helen Pettersen ‐ Accountable officer (1) 0 ‐2.5 2.5 ‐5 45 ‐ 50 140 ‐ 145 1007 964 33
Ms Sarah F Thompson ‐ Interim Accountable Officer 0 ‐ 2.5 0 ‐2.5 40 ‐ 45 120 ‐125 947 863 15
Ms Deborah Mc Beal ‐ Deputy Chief Officer 0 ‐ 2.5 (0‐2.5) 25 ‐ 30 60 ‐ 65 449 400 46
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Mr Simon Goodwin ‐ Chief Financial Officer (1) 0 ‐2.5 (0 ‐2.5) 40 ‐ 45 95 ‐ 100 690 621 52
Ms Arati Das ‐ Deputy Director of Finance 2.5 ‐ 5 2.5 ‐ 5 20 ‐ 25 50 ‐ 55 293 255 36
Ms Aimee Fairbairns ‐ Director of Service Quality and Internal Governance
2.5 ‐ 5 7.5 ‐ 10 25 ‐ 30 85 ‐ 90 620 531 84
Ms Carole Bruce‐Gordon ‐ Acting Director of Quality & Clinical Services
2.5 ‐ 5 10 ‐ 12.5 35 ‐ 40 105 ‐ 110 711 588 117
Mr Graham MacDougall ‐ Director of Strategy & Partnerships
2.5 ‐ 5 7.5 ‐ 10 30 ‐ 35 95 ‐ 100 694 598 89
Mr John Wardell ‐ Chief Operating Officer 0 ‐ 2.5 (0‐2.5) 30 ‐ 35 80 ‐ 85 583 526 17
Mr NHW Huxter ‐ Director of Strategy (1) 0 ‐ 2.5 5 ‐ 7.5 30 ‐35 100 ‐105 711 645 50
Mr P Sinden ‐ Director of Commissioning & Performance (1)
2.5 ‐ 5 5 ‐ 7.5 30 ‐35 70 ‐ 75 516 419 93
Note: 1. Benefits shown in the table are the totals for the individuals concerned, irrespective of the shared management arrangements described above in the salaries
and allowances of senior managers table.
As Lay/Non-Executive members do not receive pensionable remuneration, there will be no entries in respect of pensions for Non-Executive members.
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The Pensions Related Benefits (PRB) figure is calculated using the method set out in the Finance Act 2004(1), and includes using the member's current and prior year pension and lump sum figures. Where there has been only a small increase in pension and lump sum benefits current year compared to last year, this formula can sometimes generate a negative figure. Where this is the case, Department of Health guidance states that a "zero" should be substituted for any negative figures. These benefits are subject to audit.
Pension benefits as at 31 March 2017
Name and Title
Real increase
/decrease in pension
at pension
age (bands of £2500)
Real increase
/decrease in related lump sum at pension
age (bands of £2500)
Total accrued pension
at pension age at
31 March 2017
(bands of
£5000)
Total accrued related
lump sum at pension age at 31
March 2017
(bands of £5000)
Cash Equivalent Transfer
Value (CETV) at 31 March
2017
Cash Equivalent Transfer
Value (CETV) at 31 March
2016
Real increase /
decrease in Cash
Equivalent Transfer
Value
£000 £000 £000 £000 £000 £000 £000
Board Members
Mr Paul Jenkins - Chief Officer 0 - 2.5 0 - 2.5 40 - 45 125 – 130 825 718 9
Ms Sarah F Thompson - Interim Chief Officer 2.5 - 5 7.5 - 10 35 - 40 115 – 120 863 817 39
Ms Deborah McBeal - Deputy Chief Officer 2.5 - 5 12.5 - 15 20 - 25 60 – 65 359 286 73 Ms Aimee Fairbairns - Director of Service Quality & Integrated Governance.
2.5 - 5 7.5 - 10 25 - 30 80 – 85 531 466 65
Ms Carole Bruce-Gordon - Acting Director of Quality & Integrated Governance.
0 - 2.5 0 - 2.5 30 - 35 90 – 95 588 554 8
Mr Graham MacDougall - Director of Commissioning 0 - 2.5 5 - 7.5 30 - 35 90 – 95 598 541 58
Compensation on early retirement of for loss of office One compensation payments for loss of office has been paid in 2017/2018 (None in 2016/2017). Further details are provided in the “Exit packages” note in the Staff Report.
Payments to past members There were no payments to past directors in 2017/2018 (and none in 2016/2017) that has not already been covered above.
Pay multiples Reporting bodies are required to disclose the relationship between the remuneration of the highest-paid director/Member in their organisation and the median remuneration of the organisation’s workforce.
The banded remuneration of the highest paid Director/Member in Enfield CCG in the financial year 2017/2018 was £125k to £130k (2016/2017, £130k to £135k). This was 3.12 times (2016/2017, 3 times) the median remuneration of the workforce, which was £40,105 (2016/2017, £44,182)
In 2017/2018, 0 (2016/2017, 2) employees received remuneration in excess of the highest-paid director/member.
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Remuneration ranged from £0 - 5k to £ 125 - £130k (2016/2017 £0 - £5k to £285 - £290k)
Total remuneration includes salary, non-consolidated performance-related pay, benefits-in-kind, but not severance payments. It does not include employer pension contributions and the cash equivalent transfer value of pensions.
2017/2018 2016/2017
The banded remuneration of the highest paid director / member 125k - 130k 130k - 135k
Median remuneration of the CCG workforce £40,105 £44,182
Ratio of highest paid director / member to median paid employee 3.12 3
No. of employees who were paid more than the highest paid director / member 0 2
Remuneration ranges in the year 0k - 5k
to 125k - 130k
0k - 5k to
285k - 290k
Staff Report
Number of senior managers Gender breakdown of all Senior Managers including managers at Very Senior Manager (VSM) grade There are four male and four female Senior Managers (Directors)/Very Senior Managers at 31 March 2018
Very Senior Manager (VSM) information At 31 March 2018, there are two Senior Managers at the CCG who receive VSM salaries.
Senior Manager Information At 31 March 2018, there are five Senior Managers at the CCG who are on Band 9.
Staff composition, Staff numbers and costs All other employees At 31st March 2018 there were 87 employees at Enfield CCG consisting of 66 female and 21 male staff members. These figures exclude the VSM, Senior Managers (Band 9) and agency/contractor workers.
Pay scale Group Female Male Grand Total
Band 3 11 2 13
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Band 4 8 8 Band 5 7 2 9 Band 6 6 6 Band 7 11 2 13 Band 8 - Range A 6 7 13 Band 8 - Range B 11 3 14 Band 8 - Range C 4 4 8 Band 8 - Range D 2 1 3 Grand Total 66 21 87
Governing Body Members: Gender breakdown of Governing Body members at 31 March 2018.
Category Male Female Elected 5 4Appointed 3 5Non-voting 2 2Total 10 11
Sickness absence data
2017-18 2016-17
Total Days Lost 699 949 Total Staff Years 88.6 87 Average working Days Lost 7.9 10.9 Period covered: January to December 2017
Sickness absence figures are provided by the Department of Health and cover the calendar year.
Average Annual Sick Days per Full Time Equivalent (FTE) has been estimated by dividing the estimated number of FTE-days sick by the average FTE, and multiplying by 225 (the typical number of working days per year).
Staff policies The CCG is committed to equality of opportunity for all employees and is committed to employment practices, policies and procedures which ensure that no employee, or potential employee receives less favourable treatment on the grounds of their protected characteristics as outlined in the Equality Act 2010 and the CCG HR policies reflect the public sector equality duty and the need to show ‘due regard’ to it. The impact of HR policy/organisational change were thoroughly analysed to ensure there would be no unintended negative consequences on staff from protected groups (e.g. disability).
The CCG operates a fair and objective system for recruiting, which places emphasis on individual skills, abilities and experience. This enables a full diversity of people to demonstrate their ability to do a job. The CCG’s Resourcing Policy and Procedure explicitly states that managers will consider and make appropriate reasonable adjustments if an applicant declares themselves as disabled. Reasonable steps are
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taken to ensure all disabled applicants are treated fairly which includes making adjustments in terms of interviewing venue, selection and aptitude tests. Recruitment & selection and unconscious bias training is provided to managers involved in recruitment and selection.
The CCG continues to review how we positively support staff with their health and well-being whilst in employment. The selection criteria contained within the job descriptions and person specifications are regularly reviewed to ensure that they are justifiable and so do not unfairly discriminate directly or indirectly and are essential for the effective performance of the role.
The CCG publishes its Equality Information Report which incorporates the Workforce Race Equality Standard Report (WRES) which is published July. The CCG is also required to seek assurance from providers on their compliance with the WRES –and this is done through the contract monitoring as required by NHS England. Further information about how the CCG is working with its partners is provided in the next section- Health and wellbeing strategy.
Employee consultation The CCG continues to undertake staff engagement as necessary to:
Strengthen and focus the staff establishment and structure Add new roles to the overall establishment Amend current roles to provide a clearer focus on the strategic challenges of the
CCG Move from long-standing, temporary arrangements to more permanent roles and
therefore provide greater certainty and assurance to current members of theCCG about their roles in the organisation
Expenditure on consultancy
In 2017/2018, the CCG spent £2,353 on external consultancy costs.
Off-payroll engagements
For all off-payroll engagements as at 31 March 2018, for more than £220 per day and
that last longer than six months:
Table 1: Off-payroll engagements longer than 6 months Number
Number of existing engagements as of 31 March 2018 12
Of which, the number that have existed:
for less than one year at the time of reporting 3
for between one and two years at the time of reporting 1
for between 2 and 3 years at the time of reporting 0
for between 3 and 4 years at the time of reporting 0
for 4 or more years at the time of reporting 0
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Enfield CCG confirms that all existing off-payroll engagements have at some point been subject to a risk based assessment as to whether assurance is required that the individual is paying the right amount of tax and, where necessary, that assurance has been sought].
For all new off-payroll engagements between 01 April 2017 and 31 March 2018, for
more than £220 per day and that last longer than six months:
Table 2: New off-payroll engagements Number
Number of new engagements, or those that reached six months in duration,
between 1 April 2017 and 31 March 2018 6
Number of new engagements which include contractual clauses giving Enfield
CCG the right to request assurance in relation to income tax and National
Insurance obligations
0
Number for whom assurance has been requested 0
Of which:
assurance has been received 0
assurance has not been received 0
engagements terminated as a result of assurance not being received. 0
Table 3: Off-payroll engagements / senior official engagements
For any off-payroll engagements of Board members and / or senior officials with significant financial responsibility, between 01 April 2017 and 31 March 2018.
Number of off-payroll engagements of board members, and/or senior officers with significant financial responsibility, during the financial year
2
Total no. of individuals on payroll and off-payroll that have been deemed “board members, and/or, senior officials with significant financial responsibility”, during the financial year. This figure should include both on payroll and off-payroll engagements.
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Exit packages, including special (non-contractual) payments Table 1: Exit Packages
Exit package cost band (inc. any special
payment element
Number of compulsory
redundancies
Cost of compulsory
redundancies
Number of other
departures agreed
Cost of other departures
agreed
Total number of
exit packages
Total cost of exit packages
Number of departures
where special payments have been
made
Cost of special payment element
included in exit packages
WHOLENUMBERS
ONLY £s
WHOLE NUMBERS
ONLY £s
WHOLE NUMBERS
ONLY £s
WHOLE NUMBERS
ONLY £sLess than £10,000
0 0 0 0 0 0 0 0
£10,000 - £25,000
0 0 0 0 0 0 0
£25,001 - £50,000
0 0 1 £33,333 0 0 0 0
£50,001 - £100,000
0 0 0 0 0 0 0 0
£100,001 - £150,000
0 0 0 0 0 0 0 0
£150,001 –£200,000
0 0 0 0 0 0 0 0
>£200,000 0 0 0 0 0 0 0 0
TOTALS 0 0 1 £33,333 0 0 0 0
Redundancy and other departure cost have been paid in accordance with the provisions of NHS Scheme. Exit costs in this note are accounted for in full in the year of departure. Where the Enfield CCG has agreed early retirements, the additional costs are met by the Enfield CCG and not by the NHS Pensions Scheme. Ill-health retirement costs are met by the NHS Pensions Scheme and are not included in the table. These are subject to audit
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Table 2: Analysis of Other Departures
Agreements Total Value of agreements
Number £000sVoluntary redundancies including early retirement contractual costs
0 £0
Mutually agreed resignations (MARS) contractual costs
0 £0
Early retirements in the efficiency of the service contractual costs
0 £0
Contractual payments in lieu of notice*
1 £33.3
Exit payments following Employment Tribunals or court orders
0 £0
Non-contractual payments requiring HMT approval**
0 £0
TOTAL 1 £33.3
As a single exit package can be made up of several components each of which will be counted separately in this Note, the total number above will not necessarily match the total numbers in Note 4 which will be the number of individuals. *any non-contractual payments in lieu of notice are disclosed under “non-contracted paymentsrequiring HMT approval” below.**includes any non-contractual severance payment made following judicial mediation, and X (listamounts) relating to non-contractual payments in lieu of notice.
No non-contractual payments were made to individuals where the payment value was more than 12 months’ of their annual salary.
The Remuneration Report includes disclosure of exit packages payable to individuals named in that Report.
Helen Pettersen Accountable Officer 23 May 2018
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Parliamentary Accountability and Audit Report Enfield CCG is not required to produce a Parliamentary Accountability and Audit Report. Disclosures on remote contingent liabilities, losses and special payments, gifts, and fees and charges are included as notes in the Annual Accounts Section of this report. An audit certificate and report is also included in this Annual Report; see following pages.
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INDEPENDENT AUDITOR'S REPORT TO THE MEMBERS OF THE GOVERNING BODY OF NHS ENFIELD CLINICAL COMMISSIONING GROUP
REPORT ON THE AUDIT OF THE FINANCIAL STATEMENTS
Opinion
We have audited the financial statements of NHS Enfield Clinical Commissioning Group ("the CCG") for the year ended 31 March 2018 which comprise the Statement of Comprehensive Net Expenditure, Statement of Financial Position, Statement of Changes in Taxpayers Equity and Statement of Cash Flows, and the related notes, including the accounting policies in note one.
In our opinion the financial statements:
• give a true and fair view of the state of the CCG's affairs as at 31 March 2018 and of itsincome and expenditure for the year then ended; and
• have been properly prepared in accordance with the accounting policies
directed by the NHS Commissioning Board with the consent of the Secretary of State as being relevant to CCGs in England and included in the Department of Health Group Accounting Manual 2017/18.
Basis for opinion
We conducted our audit in accordance with International Standards on Auditing (UK) ("ISAs (UK)") and applicable law. Our responsibilities are described below. We have fulfilled our ethical responsibilities under, and are independent of the CCG in accordance with, UK ethical requirements including the FRC Ethical Standard. We believe that the audit evidence we have obtained is a sufficient and appropriate basis for our opinion.
Going concern
We are required to report to you if we have concluded that the use of the going concern basis of accounting is inappropriate or there is an undisclosed material uncertainty that may cast significant doubt over the use of that basis for a period of at least twelve months from the date of approval of the financial statements. We have nothing to report in these respects.
Other information in the Annual Report
The Accountable Officer is responsible for the other information presented in the Annual Report together with the financial statements. Our opinion on the financial statements does not cover the other information and, accordingly, we do not express an audit opinion or, except as explicitly stated below, any form of assurance conclusion thereon.
Our responsibility is to read the other information and, in doing so, consider whether, based on our financial statements audit work, the information therein is materially misstated or inconsistent with the financial statements or our audit knowledge. Based solely on that work we have not identified material misstatements in the other information. In our opinion the other information included in the
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Annual Report for the financial year is consistent with the financial statements.
Annual Governance Statement
We are required to report to you if the Annual Governance Statement does not comply with guidance issued by the NHS Commissioning Board. We have nothing to report in this respect.
Remuneration and Staff Report In our opinion the parts of the Remuneration and Staff Report subject to audit have been properly prepared in accordance with the Department of Health Group Accounting Manual 2017/18.
Accountable Officer's responsibilities
As explained more fully in the Statement of Accountable Officer's Responsibilities included in the Annual Report, the Accountable Officer is responsible for: the preparation of financial statements that give a true and fair view; such internal control as they determine is necessary to enable the preparation of financial statements that are free from material misstatement, whether due to fraud or error; assessing the CCGs ability to continue as a going concern, disclosing, as applicable, matters related to going concern; and using the going concern basis of accounting unless they have been informed by the relevant national body of the intention to dissolve the CCG without the transfer of its services to another public sector entity.
Auditor's responsibilities Our objectives are to obtain reasonable assurance about whether the financial statements as a whole are free from material misstatement, whether due to fraud or error, and to issue our opinion in an auditor's report. Reasonable assurance is a high level of assurance, but does not guarantee that an audit conducted in accordance with ISAs (UK) will always detect a material misstatement when it exists.
Misstatements can arise from fraud or error and are considered material if, individually or in aggregate, they could reasonably be expected to influence the economic decisions of users taken on the basis of the financial statements.
A fuller description of our responsibilities is provided on the FRC's website at www.frc.org.uk/auditorsresponsibilities
REPORT ON OTHER LEGAL AND REGULATORY MATTERS
Qualified Opinion on regularity
We are required to report on the following matters under Section 25(1) of the Local Audit and Accountability Act 2014.
In our opinion, except for the effects of the matter described below, 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.
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Basis for qualified opinion on regularity
The CCG reported a deficit of £3.392 million in its financial statements for the year ending 31 March 2018, thereby breaching its duty under the National Health Service Act 2006, as amended by paragraph 2231 of Section 27 of the Health and Social Care Act 2012, to ensure that its revenue resource use in a financial year does not exceed the amount specified by NHS England.
Report on the CCG's arrangements for securing economy, efficiency and effectiveness in its use of resources.
Qualified conclusion
Subject to the matters outlined in the basis for qualified conclusion paragraph below we are satisfied that in all significant respects NHS Enfield CCG put in place proper arrangements for securing economy, efficiency and effectiveness in the use of resources for the year ended 31 March 2018.
Basis for qualified conclusion
Subject to the matters outlined in the basis for qualified conclusion paragraph below we are satisfied that in all significant respects NHS Enfield CCG put in place proper arrangements for securing economy, efficiency and effectiveness in the use of resources for the year ended 31 March 2018.
In assessing the arrangements in place to secure the CCG's financial resilience we identified that the CCG reported an in year deficit of £3.392 million. This deficit was reported against an original budget of an in year surplus of £1.9 million, the deficit was driven by acute over performance and slippage in Quality, Innovation, Productivity and Prevention Schemes, As a result the CCG was in breach of its statutory requirement to ensure that revenue resource did not exceed the amount specified in Directions.
The CCG now has a cumulative deficit of £40.633 million and is not planning on reducing this in 2018/19 as it has set a breakeven budget. The CCG has a cumulative underlying deficit of £13.2 million.
Respective responsibilities in respect of our review of arrangements for securing economy, efficiency and effectiveness in the use of resources
As explained more fully in the Statement of Accountable Officer's Responsibilities included in the Annual Report, the Accountable Officer is responsible for ensuring that the CCG exercises its functions effectively, efficiently and economically. We are required under section 21(1)(c) of the Local Audit and Accountability Act 2014 to be satisfied that the CCG has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources. We are not required to consider, nor have we considered, whether all aspects of the CCGs arrangements for securing economy, efficiency and effectiveness in the use of resources are operating effectively.
We have undertaken our review in accordance with the Code of Audit Practice, having regard to the specified criterion issued by the Comptroller and Auditor General (C&AG) in November 2017, as to whether the CCG had proper arrangements to ensure it took properly informed decisions and deployed resources to achieve planned and sustainable outcomes for taxpayers and local people. We planned our work in accordance with the Code of Audit Practice and related guidance. Based on
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our risk assessment, we undertook such work as we considered necessary.
Statutory reporting matters
We are required by Schedule 2 to the Code of Audit Practice issued by the Comptroller and Auditor General ('the Code of Audit Practice') to report to you if:
• we issue a report in the public interest under section 24 of the Local Audit and AccountabilityAct 2014; or
• we make a written recommendation to the CCG under section 24 of the Local Audit andAccountability Act 2014.
We have nothing to report in these respects.
We are required to report to you if we refer a matter to the Secretary of State and the NHS Commissioning Board under section 30 of the Local Audit and Accountability Act 2014 because we have reason to believe that the CCG, or an officer of the CCG, is about to make, or has made, a decision which involves or would involve the body incurring unlawful expenditure, or is about to take, or has begun to take a course of action which, if followed to its conclusion, would be unlawful and likely to cause a loss or deficiency.
On 10 May 2018 we wrote to the Secretary of State in accordance with Section 30(1)(b) of the 2014 Act as a consequence of the CCG's breaching its revenue resource limit. The CCG's financial statements for financial year end 31 March 2018 identified a deficit of £3.392 million in 2017/18 against its revenue resource limit.
THE PURPOSE OF OUR AUDIT WORK AND TO WHOM WE OWE OUR RESPONSIBILITIES
This report is made solely to the Members of the Governing Body of NHS Enfield CCG, as a body, in accordance with Part 5 of the Local Audit and Accountability Act 2014. Our audit work has been undertaken so that we might state to the Members of the Governing Body of the CCG, as a body, those matters we are required to state to them in an auditor's report and for no other purpose. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the Members of the Governing Body, as a body, for our audit work, for this report or for the opinions we have formed.
CERTIFICATE OF COMPLETION OF THE AUDIT
We certify that we have completed the audit of the accounts of NHS Enfield CCG in accordance with the requirements of the Local Audit and Accountability Act 2014 and the Code of Audit Practice.
Joanne Lees for and on behalf of KPMG LLP, Statutory Auditor Chartered Accountants 15 Canada square Canary Wharf London E14 5GL
25 May 2018
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ANNUAL ACCOUNTS
Financial Context Enfield CCG has historically been a financially challenged CCG with a brought forward cumulative deficit of £37.2m. With a growing population, rising demand for services and a financial deficit, we have to evaluate every service we commission.
In December 2013, NHS England confirmed that Enfield CCG was materially underfunded for the needs of its local population. At that time, the level of underfunding was some £26.5m (8.43%) against the actual allocation. This historic funding gap is a key contributory factor to the financial challenges and cumulative deficit faced by Enfield today.
Although, NHS England has since addressed the underfunding through increased allocations bringing Enfield to within 2.2% (£9.1m) of its national target allocation in 2017/2018, it will take a number of years for the required infrastructure to be in place to address historic high cost drivers such Acute overspends. By 2020-21 there will still be a gap of 1.7% or £7.6m as compared to required funding.
Looking ahead, our financial challenge is set to increase in 2018/2019. To achieve financial balance, the CCG will need to make £23.8 million of savings in our commissioning budget (5.2% of total allocation). In everything we do, we will need to prioritise our limited resources to make sure we balance all the health needs of local people to make sure we maximize resources to have maximum impact on the local population.
Financial position in 2017/2018
Financial duties The CCG’s accounts have been prepared under directions issued by NHS England and in accordance with guidance set out in the National Health Service Act 2006. For the financial year 2017/2018, Enfield CCG reported an in-year deficit of £3.4m and an in-year target of £2.1m surplus. Although this is an improvement from last year’s £3.8m, it is still £5.5m adrift from the control target set by NHS England of £2.1 million surplus and takes the CCG’s cumulative deficit to £40.4m.The cost pressure was driven by increases in demand for acute hospital services, drugs costs and adult continuing health care.
In reaching this position, the CCG delivered £15.4m of efficiency savings, against a plan of £22.5m. Of the achieved £15.4m of efficiencies made, £8.4m related to acute contracts and £7m relating to non-acute productivity improvements largely in prescribing services. The reported position also includes two important changes to its bottom line financial position as required by NHSE, namely
o The return to CCGs of the ‘Category M’ drug rebate (the mechanism that controls retainedprofit on drugs purchased by pharmacies).
o The requirement for the CCG to release the 0.5% reserve which, in accordance with2017/2018 national planning guidance, was required to be held uncommitted from the start of
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the financial year. The effect of releasing this reserve served as a contribution to offset the national financial pressures across the provider sector of the NHS.
The CCG’s other financial duties included controlling the amount of spending on the administration resource, this being the spending required by the CCG to fulfil its statutory responsibilities to the public. In 2017/2018 the CCG spent £7.1m in this area in line with budget.
2017/2018 Financial Performance The CCG has continued to experience significant financial challenges in 2017/2018 which were reflected across the healthcare sector as a whole. Rising patient numbers, increasing acuity and rising expectations both locally and nationally have increased pressures on services that were already stretched in recent years. The CCG’s requirement to meet important investment and performance targets have placed greater emphasis on how we operate within our means to best provide safe, efficient and appropriate health care services for our local population.
In 2017/2018, Enfield CCG spent £455.4m on commissioning healthcare for Enfield residents. This comprised:
£251.8m on Acute care £53.5m on Mental Health services £38.3m on Primary Care Prescribing £24.1m on Community Services £23.1m on Continuing Healthcare £39.9m on Primary Care Co-Commissioning £24.7m on Other (including Primary Care)
Actual Expenditure for 2017/2018
2017/2018
£k
Available Resource 414,789
Acute services 251,833
Mental Health Services 53,533 Community Health Services 24,105
Continuing Care Services 23,144
Prescribing 38,300
Primary Care 7,958
Primary Care Co-Commissioning 39,839 Other Programme Services 9,587 Running Costs 7,122
Total Expenditure 455,422
Surplus/ (deficit) (40,633)
Brought forward deficit (37,241)
In year surplus/ (deficit) (3,392)
Our expenditure is shown in the pie chart below:
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The largest area of expenditure, which is also the most difficult to control, is acute care expenditure. Our major providers of acute care are the North Middlesex University Hospital and Royal Free London NHS Foundation Trust. Both were on “Marginal Rate” contracts, which mean we pay for the numbers of patients using the services at a nationally agreed price and any over performance from plan for all agreed areas is only paid at a marginal rate.
Overall the CCG has seen an increase in attendances for outpatients, where both “first” and “follow up” appointments have each increased by about 3.0% compared to 2016/17. Elective (planned) admissions fell by 6.9% and non-elective admissions (unplanned) rose by 4.4% reflecting the increasing demand for these services. The number of attendances at accident and emergency departments rose by 3.0%.
Non-acute services, these being provided outside acute hospital settings such as community, primary care and mental health care, performed marginally better in financial terms. There were however material pressures in Continuing Health Care spending due to increases in patient numbers and rising care package costs to support people receiving nursing care at home or in residential care. The CCG experienced significant pressures within Primary Care Prescribing budgets due to concessions being granted by the Department of Health and Social Care (DHSC) in response to national short stock issues in generic drugs.
The CCG has continued its commitment to ensuring that increases in spending on mental health services are in line with that of physical health services through achievement of the 2017/2018 Mental Health Investment Standard. Non-Acute spending also included the CCG’s £17.4m investment in the Better Care Find. This programme spans both the NHS and Local Authority and seeks to join-up health and care services, so that people can manage their own health and wellbeing, and live independently in their communities for as long as possible.
2017/2018 was the first year of the CCG’s fully delegated control of Primary Care during which Enfield CCG, and the other 4 CCGs across North Central London, took on full responsibility for the
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commissioning of general practice services. Going forward Primary Care will be pivotal for driving transformational change.
Financial Position in 2018/2019The requirement to deliver sustainable finances for 2018/2019 and beyond is extremely challenging. The 2018/2019 financial target for the CCG is to achieve a break even position so expenditure cannot exceed income.
This will be extremely challenging for 2 main reasons:
The CCG will start 2018/2019 with an underlying deficit of £13.6m. This is higher than thereported deficit of £3.4m as 2017/2018 position was improved by net favourable factors whichwill not re-occur in 2018/2019.
In order for this to be achieved the CCG has to deliver an ambitious programme oftransformational changes and improvements of around £23.8m North Central Londoncommissioners and acute providers continue to work collaboratively to develop and implementthe Sustainability and Transformation Plan (STP) assumptions to ensure that the Enfield CCGand the North Central London wide control total is achieved. The contract negotiations withproviders are on-going for 2018/2019.
Enfield CCG submitted its 2018/2019 spending plans to NHS England on the 30th April 2018. These plans set out how the CCG plan to meet financial and performance targets during the year. The plans also included estimates of risk the CCG faces to manage within its means. What is clear from plans is that rising costs and patient numbers have meant that the level of risk is set far higher than in previous years and the CCG faces an extremely year of challenging saving and efficiency targets if it is to deliver a balanced budget in 2018/2019.
What we plan to spend in 2018/2019
In 2018/2019, Enfield CCG is planning a total spend of £462.725m as detailed in the table below.
Planned Expenditure for 2018/2019
2018/2019
£k
Available Resource 422,092
Acute services 251,665
Mental Health Services 52,677 Community Health Services 25,662
Continuing Care Services 25,138
Prescribing 37695
Primary Care Co-Commissioning 42,480 Other Programme Services 11,470
Primary Care 6,502
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Running Costs 7,122
Contingency 2,314
Total Expenditure 462,725
Surplus/ (deficit) (40,633)
Brought forward deficit (40,633)
In year surplus/ (deficit) 0 The pie chart below provides this information as a percentage of total spend.
As in 2017/2018, the CCG will spend the largest proportion of its resources on providing services in acute care. Other material areas of expenditure are Mental Health, Primary Care Co-Commissioning, Prescribing, Community Services and Continuing Care.
Helen Pettersen
Accountable Officer
23 May 2018
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NHS Enfield Clinical Commissioning Group - Annual Accounts 2017-18
CONTENTS Page Number
The Primary Statements:
Statement of Comprehensive Net Expenditure for the year ended 31st March 2018 1 Statement of Financial Position as at 31st March 2018 2 Statement of Changes in Taxpayers' Equity for the year ended 31st March 2018 3 Statement of Cash Flows for the year ended 31st March 2018 4
Notes to the Accounts 1. Accounting policies 5 2. Other operating revenue 8 3. Revenue 8 4. Employee benefits and staff numbers 9 5. Operating expenses 11 6. Better payment practice code 127. Operating leases 12 8. Property, plant and equipment 139. Trade and other receivables 1410. Cash and cash equivalents 1411. Trade and other payables 15 12. Provisions 15 13. Commitments 15 14. Financial instruments 16 15. Pooled budgets 17 16. Related party transactions 18 17. Events after the end of the reporting period 2118. Financial performance targets 21
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NHS Enfield Clinical Commissioning Group - Annual Accounts 2017-18
Statement of Comprehensive Net Expenditure for the year ended 31 March 2018
2017-18 2016-17 Note £'000 £'000
Income from sale of goods and services 2 (4,378) (2,278) Other operating income 2 (460) (90)Total operating income (4,838) (2,368)
Staff costs 4 7,796 6,738 Purchase of goods and services 5 452,071 395,241 Other Operating Expenditure 5 393 382 Total operating expenditure 460,260 402,361
Net operating expenditure & Total Comprehensive net expenditure for the year 455,422 399,993
The notes on pages 5 to 21 form part of this statement
The CCG made an in-year deficit (before allowing for cumulative deficit reflected in the financial performance in note 18) of £3.4m in 2017/18. (2016/17: deficit of £3.8m).
2017-18 2016-17 CCG Cumulative position £'000 £'000
Revenue resource limit 414,789 362,752 Comprehensive expenditure (455,422) (399,993) Surplus (40,633) (37,241)
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NHS Enfield Clinical Commissioning Group ‐ Annual Accounts 2017‐18
Statement of Financial Position as at 31
March 2018
31 March
2018
31 March
2017
Note £'000 £'000
Non-current assets: Property, plant and equipment 8 117 0 Total non-current assets 117 0
Current assets: Trade and other receivables 9 7,757 4,448 Cash and cash equivalents 10 325 284 Total current assets 8,082 4,732
Total assets 8,199 4,732
Current liabilities Trade and other payables 11 (42,352) (36,581) Total current liabilities (42,352) (36,581)
Total Assets less Current Liabilities (34,153) (31,849)
Financed by Taxpayers’ Equity General fund (34,153) (31,849) Total taxpayers' equity: (34,153) (31,849)
The notes on pages 5 to 21 form part of this statement
The financial statements on pages 1 to 21 were approved by the Audit Committee under
delegated authority from the Governing Body on 23rd May 2018 and signed on its behalf
by
Helen Pettersen
Chief Accountable Officer
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NHS Enfield Clinical Commissioning Group - Annual Accounts 2017-18
Statement of Changes In Taxpayers Equity for the year ended 31 March 2018
General fund £'000
Changes in taxpayers’ equity for 2017-18
Balance at 01 April 2017 (31,849)
Net operating expenditure for the financial year (455,422)
Net funding 453,118
Balance at 31 March 2018 (34,153)
General fund £'000
Changes in taxpayers’ equity for 2016-17
Balance at 01 April 2016 (49,268)
Net operating costs for the financial year (399,993)
Net funding 417,412
Balance at 31 March 2017 (31,849)
The notes on pages 5 to 21 form part of this statement
Financial Performance:
During 2017/18 NHS Enfield CCG received Revenue Resource Limit funds of £452,030,000 (£362,752,000 2016/17) and incurred expenditure of £455,422,000 (£399,993,000 2016/17). This resulted in an in year deficit of £3,392,000. The cumulative position being £40,633,000 (£37,241,000 deficit 2016/17).
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NHS Enfield Clinical Commissioning Group - Annual Accounts 2017-18
Statement of Cash Flows for the year ended 31 March 2018
2017-18 2016-17 Note £'000 £'000
Cash Flows from Operating Activities Net operating expenditure for the financial year (455,422) (399,993) (Increase)/decrease in trade & other receivables 8 (3,309) (237) Increase/(decrease) in trade & other payables 10 5,771 (17,178) Net Cash Inflow (Outflow) from Operating Activities (452,960) (417,408)
Cash Flows from Investing Activities (Payments) for property, plant and equipment (117) 0Net Cash Inflow (Outflow) from Investing Activities (117) 0
Net Cash Inflow (Outflow) before Financing (453,077) (417,408)
Cash Flows from Financing Activities Grant in Aid Funding Received 453,118 417,412 Net Cash Inflow (Outflow) from Financing Activities 453,118 417,412
Net Increase (Decrease) in Cash & Cash Equivalents 9 41 4
Cash & Cash Equivalents at the Beginning of the Financial Year 284 280
Cash & Cash Equivalents (including bank overdrafts) at the End of the Financial Year 325 284
The notes on pages 5 to 21 form part of this statement
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Notes to the financial statements
1 Accounting Policies
NHS England has directed that the financial statements of clinical commissioning groups shall meet the accounting requirements of the Group Accounting Manual issued by the Department of Health and Social Care. Consequently, the following financial statements have been prepared in accordance with the Group Accounting Manual 2017-18 issued by the Department of Health and Social Care. The accounting policies contained in the Group Accounting Manual follow International Financial Reporting Standards to the extent that they are meaningful and appropriate to clinical commissioning groups, as determined by HM Treasury, which is advised by the Financial Reporting Advisory Board. Where the Group Accounting Manual permits a choice of accounting policy, the accounting policy which is judged to be most appropriate to the particular circumstances of the clinical commissioning group for the purpose of giving a true and fair view has been selected. The particular policies adopted by the clinical commissioning group are described below. They have been applied consistently in dealing with items considered material in relation to the accounts.
1.1 Going Concern
These accounts have been prepared on the going concern basis despite the issue of a report to the Secretary of State for Health under Section 30 of the Local Audit and Accountability Act 2014. Public sector bodies are assumed to be going concerns where the continuation of the provision of a service in the future is anticipated, as evidenced by inclusion of financial provision for that service in published documents.
Where a clinical commissioning group ceases to exist, it considers whether or not its services will continue to be provided (using the same assets, by another public sector entity) in determining whether to use the concept of going concern for the final set of Financial Statements. If services will continue to be provided the financial statements are prepared on the going concern basis.
1.2 Accounting Convention These accounts have been prepared under the historical cost convention modified to account for the revaluation of property, plant and equipment, intangible assets, inventories and certain financial assets and financial liabilities.
1.3 Pooled Budgets
There is joint working between the CCG and the local authority to agree and monitor the use of the funds. The contracting arrangements in place in practice do not constitute a joint operation under IFRS 11 Joint Arrangements. The CCG is considered to be operating as a single entity in this regard and has therefore correctly accounted for its transactions on a gross basis.
1.4 Critical Accounting Judgements & Key Sources of Estimation Uncertainty
In the application of the clinical commissioning group’s accounting policies, management is required to make judgements, estimates and assumptions about the carrying amounts of assets and liabilities that are not readily apparent from other sources. The estimates and associated assumptions are based on historical experience and other factors that are considered to be relevant. Actual results may differ from those estimates and the estimates and underlying assumptions are continually reviewed. Revisions to accounting estimates are recognised in the period in which the estimate is revised if the revision affects only that period or in the period of the revision and future periods if the revision affects both current and future periods.
1.5.1 Critical Judgements in Applying Accounting Policies
The following are the critical judgements, apart from those involving estimations (see below) that management has made in the process of applying the clinical commissioning group’s accounting policies that have the most significant effect on the amounts recognised in the financial statements:
NHS Property Services/Community Health Partnerships Properties
Under IFRIC 4 the CCG recognises the need to account for payments to NHS Property Services Limited and Community Health Partnerships Limited as a lease arrangement. The indications of a lease include an arrangement comprising a transaction or a series of related transactions, that does not take the legal form of a lease but conveys a right to use an asset in return for a payment or series of payments.
Even though there is no formal contract in place, the transactions involved do convey the right of the CCG to use property assets. As such these transactions are being accounted for as an operating lease in accordance with IAS 17.
1.5.2 Key Sources of Estimation Uncertainty The following are the key estimations that management has made in the process of applying the clinical commissioning group’s accounting policies that have the most significant effect on the amounts recognised in the financial statements:
Partially completed spells
Expenditure relating to patient care spells that are part-completed at the year-end are apportioned across the financial years on the basis of length of stay at the end of the reporting period compared to expected total length of stay OR costs incurred to date compared to total expected costs. The estimated balance at 31st March 2018 is £2,391,192 (£2,824,024 2017).
Accruals
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Notes to the financial statements
For goods and/or services that have been delivered but for which no invoice has been received/sent, the CCG makes an accrual based on the contractual arrangements that are in place and its legal obligation. See trade and other payables Note 11.
Prescribing liabilities NHS England actions monthly cash charges to the CCG for prescribing contracts. These are issued approximately two months in arrears. The CCG uses a forecast based on previous in year charges by the NHS Business Authority to estimate the full year expenditure. The estimated balance at 31st March 2018 is £5,172,490 (£5,812,131 2017).
Maternity pathways Expenditure relating to all antenatal maternity care is made at the start of a pathway. As a result at the year-end part completed pathways at treated as a prepayment. The CCG agrees to use the figures calculated by the local Providers. The estimated balance at 31st March 2018 is £2,095,003.75 (£2,134,124 2017).
1.6 Employee Benefits
1.6.1 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.
1.6.2 Retirement Benefit Costs
Past and present employees are covered by the provisions of the NHS Pensions Scheme. The scheme is an unfunded, defined benefit scheme that covers NHS employers, General Practices and other bodies, allowed under the direction of the Secretary of State, in England and Wales. The scheme is not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities. Therefore, the scheme is accounted for as if it were a defined contribution scheme: the cost to the clinical 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.
1.7 Other Expenses
Other operating expenses are recognised when, and to the extent that, the goods or services have been received. They are measured at the fair value of the consideration payable. Expenses and liabilities in respect of grants are recognised when the clinical commissioning group has a present legal or constructive obligation, which occurs when all of the conditions attached to the payment have been met.
1.8 Property, Plant & Equipment
1.8.1 Recognition Property, plant and equipment is capitalised if: · It is held for use in delivering services or for administrative purposes;
· It is probable that future economic benefits will flow to, or service potential will be supplied to the clinical commissioning group;
· It is expected to be used for more than one financial year; · The cost of the item can be measured reliably; and,· The item has a cost of at least £5,000; or,
· Collectively, a number of items have a cost of at least £5,000 and individually have a cost of more than £250, where the assets are functionally interdependent, they had broadly simultaneous purchase dates, are anticipated to have simultaneous disposal dates and are under single managerial control; or,· Items form part of the initial equipping and setting-up cost of a new building, ward or unit, irrespective of their individual or collective cost.Where a large asset, for example a building, includes a number of components with significantly different asset lives, thecomponents are treated as separate assets and depreciated over their own useful economic lives.
1.8.2 Valuation All property, plant and equipment are measured initially at cost, representing the cost directly attributable to acquiring or constructing the asset and bringing it to the location and condition necessary for it to be capable of operating in the manner intended by management. All assets are measured subsequently at valuation.
Fixtures and equipment are carried at depreciated historic cost as this is not considered to be materially different from current value in existing use.
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Notes to the financial statements
An increase arising on revaluation is taken to the revaluation reserve except when it reverses an impairment for the same asset previously recognised in expenditure, in which case it is credited to expenditure to the extent of the decrease previously charged there. A revaluation decrease that does not result from a loss of economic value or service potential is recognised as an impairment charged to the revaluation reserve to the extent that there is a balance on the reserve for the asset and, thereafter, to expenditure. Impairment losses that arise from a clear consumption of economic benefit are taken to expenditure. Gains and losses recognised in the revaluation reserve are reported as other comprehensive income in the Statement of Comprehensive Net Expenditure.
1.8.3 Subsequent Expenditure Where subsequent expenditure enhances an asset beyond its original specification, the directly attributable cost is capitalised. Where subsequent expenditure restores the asset to its original specification, the expenditure is capitalised and any existing carrying value of the item replaced is written-out and charged to operating expenses.
1.9 Leases
Leases are classified as finance leases when substantially all the risks and rewards of ownership are transferred to the lessee. All other leases are classified as operating leases. Contingent rentals are recognised as an expense in the period in which they are incurred.
1.9.1 The Clinical Commissioning Group as Lessee
Operating lease payments are recognised as an expense on a straight-line basis over the lease term. Contingent rentals are recognised as an expense in the period in which they are incurred.
1.10 Cash & Cash Equivalents
Cash is cash in hand and deposits with any financial institution repayable without penalty on notice of not more than 24 hours. Cash equivalents are investments that mature in 3 months or less from the date of acquisition and that are readily convertible to known amounts of cash with insignificant risk of change in value. In the Statement of Cash Flows, cash and cash equivalents are shown net of bank overdrafts that are repayable on demand and that form an integral part of the clinical commissioning group’s cash management.
1.11 Clinical Negligence Costs
NHS Resolution operates a risk pooling scheme under which the clinical commissioning group pays an annual contribution to NHS Resolution which in return settles all clinical negligence claims. The contribution is charged to expenditure. Although NHS Resolution is administratively responsible for all clinical negligence cases, the legal liability remains with the clinical commissioning group.
1.12 Non-clinical Risk Pooling
The clinical commissioning group participates in the Property Expenses Scheme and the Liabilities to Third Parties Scheme. Both are risk pooling schemes under which the clinical commissioning group pays an annual contribution to NHS Resolution and, in return, receives assistance with the costs of claims arising. The annual membership contributions, and any excesses payable in respect of particular claims are charged to operating expenses as and when they become due.
1.13 Financial Liabilities
Financial liabilities are recognised on the statement of financial position when the clinical commissioning group becomes party to the contractual provisions of the financial instrument or, in the case of trade payables, when the goods or services have been received. Financial liabilities are de-recognised when the liability has been discharged, that is, the liability has been paid or has expired.
1.14 Value Added Tax Most of the activities of the clinical commissioning group are outside the scope of VAT and, in general, output tax does not apply and input tax on purchases is not recoverable. Irrecoverable VAT is charged to the relevant expenditure category or included in the capitalised purchase cost of fixed assets. Where output tax is charged or input VAT is recoverable, the amounts are stated net of VAT.
1.15 Losses & Special Payments Losses and special payments are items that Parliament would not have contemplated when it agreed funds for the health service or passed legislation. By their nature they are items that ideally should not arise. They are therefore subject to special control procedures compared with the generality of payments. They are divided into different categories, which govern the way that individual cases are handled. Losses and special payments are charged to the relevant functional headings in expenditure on an accruals basis, including losses which would have been made good through insurance cover had the clinical commissioning group not been bearing its own risks (with insurance premiums then being included as normal revenue expenditure).
1.16 Joint Operations Joint operations are activities undertaken by the clinical commissioning group in conjunction with one or more other parties, but which are not performed through a separate entity. The clinical commissioning group records its share of the income and expenditure; gains and losses; assets and liabilities; and cash flows.
1.17 Accounting Standards That Have Been Issued But Have Not Yet Been Adopted The DHSC Group accounting manual does not require the following Standards and Interpretations to be applied in 2017-18. These standards are still subject to FREM adoption and early adoption is therefore not 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)
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Notes to the financial statements
· 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 Revenue 2017-18 2017-18 2017-18 2016-17
Total Admin Programme Total
£'000 £'000 £'000 £'000
Recoveries in respect of employee benefits 0 0 0 27Prescription fees and charges 86 0 86 145Education, training and research 638 638 0 689Non-patient care services to other bodies 3,740 734 3,006 1,589Other revenue 374 32 342 (82) Total other operating revenue 4,838 1,404 3,434 2,368
3 Revenue 2017-18 2017-18 2017-18 2016-17
Total Admin Programme Total £'000 £'000 £'000 £'000
From rendering of services 4,838 1,404 3,434 2,368 From sale of goods 0 0 0 0Total 4,838 1,404 3,434 2,368
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4. Employee benefits and staff numbers
4.1.1 Employee benefits 2017-18
Total Permanent Employees Other
£'000 £'000 £'000 Employee Benefits Salaries and wages 6,715 4,794 1,921
Social security costs 498 498 0
Employer Contributions to NHS Pension scheme 541 541 0
Apprenticeship Levy 8 8 0
Termination benefits 33 33 0
Gross employee benefits expenditure 7,795 5,874 1,921
Less recoveries in respect of employee benefits 0 0 0
Total - Net admin employee benefits including capitalised costs 7,795 5,874 1,921
4.1.2 Employee benefits 2016-17
Total Permanent Employees Other
£'000 £'000 £'000 Employee Benefits Salaries and wages 5,721 4,386 1,335
Social security costs 492 492 0
Employer Contributions to NHS Pension scheme 525 525 0
Apprenticeship Levy 0 0 0
Gross employee benefits expenditure 6,738 5,403 1,335
Less recoveries in respect of employee benefits (note 4.1.2) (27) (27) 0
Total - Net admin employee benefits including capitalised costs 6,711 5,376 1,335
Included within the above are termination benefits totaling £25,528.
4.2 Average number of people employed 2017-18 2016-17
Total Permanently
employed Other Total Number Number Number Number
Total 111 92 19 123
Of the above:
Number of whole time equivalent people engaged on capital projects 0 0 0 0
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4.3 Exit packages agreed in the financial year
2017-18 2017-18 2017-18Compulsory redundancies Other agreed departures Total
Number £ Number £ Number £ £25,001 to £50,000 1 33,330 0 0 1 33,330 Total 1 33,330 0 0 1 33,330
2016-17 2016-17 2016-17Compulsory redundancies Other agreed departures Total
Number £ Number £ Number £ £25,001 to £50,000 0 0 1 25,528 1 25,528 Total 0 0 1 25,528 1 25,528
Analysis of Other Agreed Departures 2017-18 2016-17
Other agreed departures Other agreed departures Number £ Number £
Contractual payments in lieu of notice 0 0 1 25,528 Total 0 0 1 25,528
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 2012. The Scheme Regulations allow for the level of contribution rates to be changed by the Secretary of State for Health, with the consent of HM Treasury, and consideration of the advice of the Scheme Actuary and employee and employer representatives as deemed appropriate.
The next actuarial valuation is to be carried out as at 31 March 2016 and is currently being prepared. The direction assumptions are published by HM Treasury which are used to complete the valuation calculations, from which the final valuation report can be signed off by the scheme actuary. This will set the employer contribution rate payable from April 2019 and will consider the cost of the Scheme relative to the employer cost cap. There are provisions in the Public Service Pension Act 2013 to adjust member benefits or contribution rates if the cost of the Scheme changes by more than 2% of pay. Subject to this ‘employer cost cap’ assessment, any required revisions to member benefits or contribution rates will be determined by the Secretary of State for Health after consultation with the relevant stakeholders.
For 2017-18, employers’ contributions of £541,179 were payable to the NHS Pensions Scheme (2016-17: £525,909) were payable to the NHS Pension Scheme at the rate of 14.38% of pensionable pay. The scheme’s actuary reviews employer contributions, usually every four years and now based on HMT Valuation Directions, following a full scheme valuation. The latest review used data from 31 March 2012 and was published on the Government website on 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
Total Admin Programme Total £'000 £'000 £'000 £'000
Gross employee benefits Employee benefits excluding governing body members 6,519 2,441 4,078 5,876 Executive governing body members 1,276 1,068 208 862 Total gross employee benefits 7,795 3,509 4,286 6,738
Other costs Services from other CCGs and NHS England 4,770 2,602 2,168 4,672 Services from foundation trusts 110,207 0 110,207 102,504 Services from other NHS trusts 196,063 0 196,063 185,801 Services from other WGA bodies 0 0 0 (3) Purchase of healthcare from non-NHS bodies 59,880 0 59,880 60,118 Chair and Non Executive Members 393 393 0 382 Supplies and services – clinical 448 0 448 741 Supplies and services – general 131 107 24 310 Consultancy services 146 42 104 33 Establishment 532 547 (15) 399Transport 1 1 0 6 Premises 779 367 413 1,170 Audit fees* 51 51 0 76 Prescribing costs 37,742 0 37,742 38,107 GPMS/APMS and PCTMS 40,305 0 40,305 0 Other professional fees excl. audit 289 209 80 243 Legal fees 121 65 57 0 Education and training 607 642 (34) 831CHC Risk Pool contributions 0 0 0 232 Total other costs 452,465 5,026 447,440 395,622
Total operating expenses 460,260 8,535 451,726 402,360
* The fee to the CCG's external auditors, KPMG, is £42,450 excluding VAT. The figure shown in the note above includesirrecoverable VAT at 20%.
The contract signed on 22nd November 2017 states that the liability of KPMG, its members, partners and staff (whether in contract, negligence or otherwise) shall in no circumstances exceed £500K, aside from where the liability cannot be limited by law. This is in aggregate in respect of all services.
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6. Better Payment Practice Code
Measure of compliance 2017-18 Number £'000
Non-NHS Payables Total Non-NHS Trade invoices paid in the Year 11,353 111,144 Total Non-NHS Trade Invoices paid within target 10,537 105,039 Percentage of Non-NHS Trade invoices paid within target 92.81% 94.51%
NHS Payables Total NHS Trade Invoices Paid in the Year 3206 302152 Total NHS Trade Invoices Paid within target 2967 299877 Percentage of NHS Trade Invoices paid within target 92.55% 99.25%
2016-17 Number £'000
Non-NHS Payables Total Non-NHS Trade invoices paid in the Year 9,990 69,202 Total Non-NHS Trade Invoices paid within target 9,350 61,837 Percentage of Non-NHS Trade invoices paid within target 93.59% 89.36%
NHS Payables Total NHS Trade Invoices Paid in the Year 3,354 311,455 Total NHS Trade Invoices Paid within target 3,129 302,663 Percentage of NHS Trade Invoices paid within target 93.29% 97.18%
7. Operating Leases
7.1 As lessee 7.1.1 Payments recognised as an Expense 2017-18
Buildings Other Total £'000 £'000 £'000
Payments recognised as an expense Minimum lease payments 732 18 750 Total 732 18 750
2016-17 Buildings Other Total
£'000 £'000 £'000 Payments recognised as an expense Minimum lease payments 1,094 19 1,113 Total 1,094 19 1,113
The Clinical Commissioning Group occupies property owned and managed by Community Health Partnerships Ltd and /or NHS Property Services Ltd. For 2016/17, a transitional occupancy rent based on annual property cost allocations was agreed. This is reflected in note 7.1.1 above.
On the 21st December 2017, Enfield CCG signed a new lease with the landlords of Holbrook House (Hermes Property Unit Trust - HPUT). The lease is for 5 years expiring on the 24th December 2022, however it does contain a break clause after 2 years (28th September 2019) at which point the landlord can ask the CCG to vacate the premises, should they wish to resurrect plans to redevelop the site.
The new lease maintains the existing footprint at Holbrook House, while delivering financial savings to the CCG over the length of the lease, including an immediate 3 month rent free period.
The value of the lease in 17/18 is £41k and accounts only for Service Charges incurred, as the lease was subject to a rent free agreement for this period (Hence not included in Note 12a). Moving forward the Rent will cost £295k per annum and Service Charges will be £129k
7.1.2 Future minimum lease payments 2017-18 Buildings Other Total
£'000 £'000 £'000 Payable: No later than one year 424 0 424 Between one and five years 1,696 0 1,696 After five years 0 0 0 Total 2,120 0 2,120
2016-17 Buildings Other Total
£'000 £'000 £'000 No later than one year 0 0 0 Between one and five years 0 0 0 After five years 0 0 0 Total 0 0 0
NHS Enfield Clinical Commissioning Group - Annual Accounts 2017-18
8 Property, plant and equipment
2017-18 Information technology Total
£'000 £'000Cost or valuation at 01 April 2017 0 0
Addition of assets under construction and payments on account 0 Additions purchased 117 117 Cost/Valuation at 31 March 2018 117 117
Depreciation 01 April 2017 0 0
Cumulative depreciation adjustment following revaluation 0 0
Depreciation at 31 March 2018 0 0
Net Book Value at 31 March 2018 117 117
Purchased 117 117
Total at 31 March 2018 117 117
Asset financing:
Owned 117 117
Total at 31 March 2018 117 117
Revaluation Reserve Balance for Property, Plant & Equipment
Information technology Total
£'000 £'000Balance at 01 April 2017 0 0
Balance at 31 March 2018 0 0
8.1 Economic lives
Minimum Life (years)
Maximum Life (years)
Information technology 1 3
107
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NHSEnfieldClinicalCommissioningGroup‐AnnualAccounts2017‐18
9 Trade and other receivables Current Current
2017‐18 2016‐17
£'000 £'000
NHS receivables: Revenue 1,004 1,267 NHS prepayments 2,095 2,134 NHS accrued income 3,884 821 Non-NHS and Other WGA receivables: Revenue 252 96 Non-NHS and Other WGA accrued income 421 98 VAT 90 32Other receivables and accruals 11 0 Total Trade & other receivables 7,757 4,448
Included above: Prepaid pensions contributions 0 0 Prepaid NHS Maternity Pathway Funding * 2,095 2,134
WGA above refers to Whole of Government Accounts
The great majority of trade is with NHS England. As NHS England is funded by Government to provide funding to Clinical
Commissioning Groups to commission services, no credit scoring of them is considered necessary.
9.1 Receivables past their due date but not impaired 2017-18 £'000
2017-18 £'000
2016-17 £'000
DH Group Bodies
Group Bodies
receivables prior years
By up to three months 226 18 495 By three to six months 28 4 119 By more than six months 40 52 68 Total 294 74 682
£66,089 of the amount above has subsequently been recovered post the statement of financial position date.
9.2 Provision for impairment of receivables 2017-18 £'000
DH Group Bodies
2017-18 2016-17 £'000 £'000
Group receivables Bodies prior years
Balance at 01 April 2017 0 0 (2,041)
Amounts written off during the year 0 0 2,041 Balance at 31 March 2018 0 0 0
10 Cash and cash equivalents
Balance at 01 April 2017
2017-18 £'000
284
2016-17 £'000
280 Net change in year 41 4 Balance at 31 March 2018 325 284
Made up of: Cash with the Government Banking Service 325 284
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Current Current 11 Trade and other payables 2017-18 2016-17
£'000 £'000
NHS payables: revenue 21,771 9,784 NHS accruals 156 2,404 Non-NHS and Other WGA payables: Revenue 9,719 13,086 Non-NHS and Other WGA accruals 9,940 10,965 Social security costs 77 72 VAT 0 0 Tax 70 70 Other payables and accruals 619 200 Total Trade & Other Payables 42,352 36,581
Total current and non-current 42,352 36,581
Other payables include £304k outstanding pension contributions at 31 March 2018 (£81k 31 March 2017)
12 Provisions
Under the Accounts Direction issued by NHS England on 12 February 2014, NHS England is responsible for accounting for liabilities relating to NHS Continuing Healthcare claims relating to periods of care before establishment of the clinical commissioning group. However, the legal liability remains with the CCG. The total value of legacy NHS Continuing Healthcare provisions accounted for by NHS England on behalf of this CCG at 31 March 2018 is £0 (£0 at 31st March 2017).
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14 Financial instruments
14.1 Financial risk management
Financial reporting standard IFRS 7 requires disclosure of the role that financial instruments have had during the period in creating or changing the risks a body faces in undertaking its activities.
Because NHS clinical commissioning group is financed through parliamentary funding, it is not exposed to the degree of financial risk faced by business entities. Also, financial instruments play a much more limited role in creating or changing risk than would be typical of listed companies, to which the financial reporting standards mainly apply. The clinical commissioning group has limited powers to borrow or invest surplus funds and financial assets and liabilities are generated by day-to-day operational activities rather than being held to change the risks facing the clinical commissioning group in undertaking its activities.
Treasury management operations are carried out by the finance department, within parameters defined formally within the NHS clinical commissioning group standing financial instructions and policies agreed by the Governing Body. Treasury activity is subject to review by the NHS clinical commissioning group and internal auditors.
14.1.1 Currency risk
The NHS clinical commissioning group is principally a domestic organisation with the great majority of transactions, assets and liabilities being in the UK and sterling based. The NHS clinical commissioning group has no overseas operations. The NHS clinical commissioning group and therefore has low exposure to currency rate fluctuations.
14.1.2 Interest rate risk
The clinical commissioning group borrows from government for capital expenditure, subject to affordability as confirmed by NHS England. The borrowings are for 1 to 25 years, in line with the life of the associated assets, and interest is charged at the National Loans Fund rate, fixed for the life of the loan. The clinical commissioning group therefore has low exposure to interest rate fluctuations.
14.1.3 Credit risk
Because the majority of the NHS clinical commissioning group and revenue comes parliamentary funding, NHS clinical commissioning group has low exposure to credit risk. The maximum exposures as at the end of the financial year are in receivables from customers, as disclosed in the trade and other receivables note.
14.1.3 Liquidity risk
NHS clinical commissioning group is required to operate within revenue and capital resource limits, which are financed from resources voted annually by Parliament. The NHS clinical commissioning group draws down cash to cover expenditure, as the need arises. The NHS clinical commissioning group is not, therefore, exposed to significant liquidity risks.
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14 Financial instruments cont'd
14.2 Financial assets - Loans and Receivables
31 March 2018
31 March 2017
£'000 £'000 Receivables: · NHS 4,888 2,088· Non-NHS 673 194Cash at bank and in hand 325 284Other financial assets 11 0Total at 31 March 2018 5,897 2,566
14.3 Financial liabilities
Other Other 31 March
2018 31 March
2017 £'000 £'000
Payables: · NHS 21,926 12,187· Non-NHS 20,279 24,252 Total at 31 March 2018 42,205 36,439
15 Pooled budgets
The NHS clinical commissioning group shares of the income and
2017-18 2016-17 £'000 £'000
Income 0 0 Expenditure (9,613) (9,151)
There is joint working between the CCG and the local authority to agree and monitor the use of the funds. The contracting arrangements in place in practice do not constitute a joint operation under IFRS 11 Joint Arrangements. The CCG is considered to be operating as a single entity in this regard and has therefore correctly accounted for its transactions on a gross basis.
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16 Related party transactions
16.1 Related party transactions - 2017-18
Employees of NHS Enfield CCG are required to disclose any relevant and material interests they may have in other organisations (related parties). This is recorded in the Register of Interests.
The transactions listed below are payments made to the related parties declared by NHS Enfield CCG's Governing Body members (other than payments to practices, other NHS bodies, and other government departments):
Payments to Related Party
from Related
owed to Related
due from Related
£'000 £'000 £'000 £'000
Medicare Medical Services LLP 1,201 - - -
Barndoc Healthcare Ltd 137 20 2 -2
North East Alliance Ltd 250 - - -
Medicus Health Partners 25 - - -
Enfield Voluntary Action 1 - - -
Greek & Greek Cypriot Community 77 - - -
Enfield One Ltd 1,245 - - -
Top Global Quality Ltd 2 - - -Enfield Healthcare Alliance Ltd 1,027 - 18 -RSM Risk Assurance Services LLP 48 - 3 -
The transactions listed below are payments made to those practices where one of the GPs of that practice is or has been a member of NHS Enfield CCG's Governing Body during 2017-18. These payments include GMS/PMS contract and ad hoc payments, but exclude prescribing payments:
Payments to Related Party
Receipts from
Related Party
Amounts owed to Related
Party
Amounts due from Related Party
£'000 £'000 £'000 £'000
Angel Surgery 533 - 5 - Boundary House Surgery Boakye Cowley Jones 664 - 18 - Brick Lane Surgery 417 - 12 - Carlton House Surgery 1,324 - 53 - East Enfield Medical Practice 359 - 4 - Evergreen PCC 2,319 - 153 - Freezywater Primary Care Centre 1,689 - 94 - Park Lodge Medical Centre 792 - 57 - Winchmore Practice 1,019 - 0 - Woodberry Practice 966 - 16 -
The Department of Health is regarded as a related party. During 2017-18 NHS Enfield CCG has had a significant number of material transactions (expenditure more than £1m) with the Department, and with other entities for which the department is regarded as the parent department, and NHS England the parent entity, including:
NHS Islington CCG NHS NEL CSU Barnet, Enfield & Haringey Mental Health NHS Trust Barts Health NHS Trust London Ambulance Service NHS Trust North Middlesex University Hospital NHS Trust Royal National Orthopaedic Hospital NHS Trust Whittington Health NHS Trust Central & North West London NHS Foundation Trust Guy's & St Thomas' NHS Foundation Trust Homerton University Hospital NHS Foundation Trust Moorfields Eye Hospital NHS Foundation Trust Royal Free London NHS Foundation Trust University College London Hospitals NHS Foundation Trust
In 2017/18, Enfield CCG has made payments to its partner CCGs within the North Central London Sustainability and Transformation Plan (NCL STP), namely Barnet, Camden, Haringey and Islington CCGs. These five CCGs in the NCL STP have shared the same Accountable Officer since the 1st April 2017.
During 2017-18 NHS Enfield CCG has had a number of material transactions with other government departments and other central and local government bodies. The material transactions have been with:
HM Revenue and Customs
National Health Service Pension Scheme
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16.2Relatedpartytransactions‐2016‐17
The transactions listed below are in relation to interests declared, other than those relating to member general practices.
Paymentsto
RelatedParty
Receipts
from
Related
Party
Amounts
owed to
Related
Party
Amounts
due from
Related
Party
£'000 £'000 £'000 £'000
Barndoc Healthcare Ltd 1,695 14 - 2DR Hetul Shah Ltd 8 - - -Enfield Health Partnership Ltd 701 - - -Enfield Healthcare Alliance Ltd 91 - - -Medicare Medical Services LLP 668 - - -
Clinical commissioning groups are clinically led membership organisations made up of general practices. The members of the clinical commissioning group are responsible for determining the governing arrangements for their organisations, which they are required to set out in a constitution.
The members of Enfield Clinical Commissioning Group are contained within Appendix B of the constitution. Where payments have been made to these practices, these are listed below. The majority of the payments are in relation to agreed locally enhanced services and some prescribing costs.
Payments to Related Party
Receipts
from
Related
Party
Amounts
owed to
Related
Party
Amounts
due from
Related
Party
£'000 £'000 £'000 £'000
Abernethy House Surgery 100 - - - Angel Surgery 9 - - - Arnos Grove Medical Centre 5 - - - Bincote Road Surgery 19 - - - Boundary House Surgery Boakye Cowley Jones 17 - - - Bowes Medical Centre 32 - - - Brick Lane Surgery 15 - - - Bush Hill Park Medical Centre 6 - - - Carlton House Surgery 55 - - - Cockfosters Medical Centre 42 - - - Connaught Surgery 19 - - - Curzon Avenue Surgery 9 - 1 - Dean House Surgery 10 - - - Dover House GP Practice 22 - - - Dr H Shah 10 DR ME Silvers Practice 7 - - - Eagle House Surgery Enfield 82 - - - East Enfield Medical Practice 9 - - - Edmonton GP Health centre 454 Enfield Island Surgery 4 - - - Evergreen PCC 86 - - - Forest Group Practice 98 - 7 - Freezywater Primary Care Centre 53 - - - Gillan House Surgery 48 - - -
114
Green Cedars GP Surgery 5 - - - Green Lanes Surgery 121 - 3 - Green Street Surgery 5 - - - Grovelands Road Medical Centre 34 - - - Haverstock Healthcare Ltd 187 - - - Highlands Practice 50 - 3 - Keats Surgery 17 - - - Latymer Road Surgery 15 - - - Lincoln Road Medical Practice 26 - 1 - Moorfield Road Health Centre 8 - - - Morecambe Surgery 20 - - - Nightingale House Surgery 33 - - - Oakwood Medical Centre N14 4AQ 39 - - - Park Lodge Medical Centre 39 - - - Rainbow Practice 20 - - - Riley House Surgery 29 - 1 - Southbury Surgery 18 - - - Southgate Surgery 37 - 6 - The Bounces Road Surgery 86 - 1 - The North London Health Centre 35 - - - Town Surgery 12 - - - Trinity Avenue Surgery 5 - - - White Lodge Medical Practice 51 - 6 -
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Willow House Surgery 20 - - -NHS Enfield Clinical Commissioning Group - Annual Accounts 2017-18
Payments to Related Party
Receipts from
Related Party
Amounts owed to Related Party
Amounts due from Related Party
£'000 £'000 £'000 £'000
Woodberry Practice 81 - 6 -
The Department of Health is regarded as a related party. During the year the clinical commissioning group has had a significant number of material transactions with entities for which the Department is regarded as the parent Department. A minimum limit of £250k has been applied in reporting these figures.
Payments to Related Party
Receipts from
Related Party
Amounts owed to Related
Party
Amounts due from Related Party
£'000 £'000 £'000 £'000
NHS England 233 422 28 744NHS Haringey CCG 108 558 - 376NHS Islington CCG 260 367 3 259NHS North & East London CSU 4,729 55 457 49Barking, Havering & Redbridge University Hospitals NHS Trust 272 - - 137Barnet, Enfield & Haringey Mental Health NHS Trust 56,724 115 1,867 47Barts Health NHS Trust 7,247 - 74 -Central London Community Healthcare NHS Trust 459 - 47 -East & North Hertfordshire NHS Trust 374 - 253 -Hertfordshire Community NHS Trust 64 - 17 -Imperial College Healthcare NHS Trust 1,244 - 486 -London Ambulance Service NHS Trust 11,878 - 451 -London North West Healthcare NHS Trust 735 - 202 -North Middlesex University Hospital NHS Trust 99,122 - 1,482 1,254Royal National Orthopaedic Hospital NHS Trust 1,832 - - 60The Princess Alexandra Hospital NHS Trust 523 - 195 -The Whittington Hospital NHS Trust 4,763 - - 249Camden & Islington NHS Foundation Trust 349 - 4 -Central & North West London NHS Foundation Trust 878 - 24 -Chelsea And Westminster Hospital NHS Foundation Trust 346 - 348 -Chesterfield Royal Hospital NHS Foundation Trust 1 - - -Great Ormond Street Hospital for Children NHS Foundation Trust 966 - 73 -Guy's & St Thomas' NHS Foundation Trust 1,704 - 400 -Homerton University Hospital NHS Foundation Trust 2,298 - 467 -King's College Hospital NHS Foundation Trust 356 - 63 -Moorfields Eye Hospital NHS Foundation Trust 4,252 - 63 -North East London NHS Foundation Trust 191 - 148 -Royal Brompton & Harefield NHS Foundation Trust 313 - - 102Royal Free London NHS Foundation Trust 71,825 - 2,091 677South London & Maudsley NHS Foundation Trust 468 - 36 -The Royal Marsden NHS Foundation Trust 304 - 143 -University College London Hospitals NHS Foundation Trust 16,633 - 1,709 133Health Education England -203 689 - 70NHS Property Services 840 1 85 -
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 Local Authorities or HMRC. A de minimis limit of £250k has been applied in reporting these figures.
Payments to Related Party
Receipts from
Related Party
Amounts owed to Related
Party
Amounts due from Related Party
£'000 £'000 £'000 £'000
HM Revenue and Customs Trust Statement 491 - - -National Health Service Pension Scheme 525 - - -Enfield London Borough Council 14,284 75 9,577 72
116
NHS Enfield Clinical Commissioning Group - Annual Accounts 2017-18
17 Events after the end of the reporting period
No events to report.
18 Financial performance targets
NHS Clinical Commissioning Group have a number of financial duties under the NHS Act 2006 (as amended). NHS Clinical Commissioning Group performance against those duties was as follows:
2017-18 2017-18 2017-18 2017-18Target
Performance Actual
Performance Surplus /
(Deficit) Duty
Achieved £000 £000 £000 Yes/No
Expenditure not to exceed income 456,988 460,377 (3,389) No Capital resource use does not exceed the amount specified in Directions
120 117 3 Yes
Revenue resource use does not exceed the amount specified in Directions 452,030 455,422 (3,392) No
Capital resource use on specified matter(s) does not exceed the amount specified in Directions 0 0 0 Yes
Revenue resource use on specified matter(s) does not exceed the amount specified in Directions 0 0 0 Yes
Revenue administration resource use does not exceed the amount specified in Directions
7125 7,122 3 Yes
As a result of an amended calculation methodology from NHS England, the 2017/18 in year revenue allocation has been calculated on the basis of the total allocation, adjusted for the historic financial outturn of the CCG. In 2016/17 the figure was recorded as just the total in year allocation notified to the CCG.”
2016-17 2016-17 Target
Performance Actual
Performance Surplus /
(Deficit) Duty
Achieved £000 £000 £000 Yes/No
Expenditure not to exceed income 365,120 402,361 (37,241) No
Capital resource use does not exceed the amount specified in Directions
0 0 0 Yes
Revenue resource use does not exceed the amount specified in Directions
362,752 399,993 (37,241) No
Capital resource use on specified matter(s) does not exceed the amount specified in Directions
0 0 0 Yes
Revenue resource use on specified matter(s) does not exceed the amount specified in Directions
0 0 0 Yes
Revenue administration resource use does not exceed the amount specified in Directions
7076 7076 0 Yes