NHS GREENWICH CCG ANNUAL REPORT AND ANNUAL ACCOUNTS

2016 – 2017

Contents Section 1: Performance Report 1 Welcome 2 Challenges in Greenwich 4

The Greenwich Health and Wellbeing Strategy 5

Managing Risk 7 Our achievements in 2016/17 8

Medicine Management 8

Primary Care 8

Connect Care 10

Eltham Community Hospital 11

Continuing healthcare 11

Improved Constitutional Standards 12

Performance Analysis: improving quality and performance 13 Challenges addressed 15 Mental health 19 Integrated Working and Better Care Fund 21 Quality, Improvement, Productivity and Prevention (QIPP) 23 Financial overview 24 Sustainable Development 27 Quality and safety 29

Friends and Family Test 31

Patient Safety 31

Quality Issues 32

Safeguarding adults and children 33

Medicines Management Team 35 Medicine’s security 36

Clinical Effectiveness 37 Quality Alert Management system 37

The Provider Assurance Monitoring System 38

Patient and public involvement 39

Clinical Engagement 41

Working together: Our Healthier South East London 42

Have local people been involved? 43

Equality and Diversity 44 Public Sector Equality Duties (PSED) 46

The Equality Delivery System (EDS2) 47

Emergency Preparedness, Resilience and Response 49 Section 2: Accountability Report 51 Member’s report 52

Executive Committee 54

Governing Body 55

Statement on disclosure to auditors 58 Statement of Accountable Officer’s Responsibilities 59 Annual Governance Statement 60 Governance Framework 60

Risk Management Framework 65

Internal Control Framework 69

Information Governance 72

Head of Internal Audit Opinion 75

Remuneration and staff report 81 Remuneration Policy 82

Our staff 87

Section 3: Statement of Financial Position 94

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SECTION 1: PERFORMANCE REPORT

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Welcome Greenwich is a vibrant and fascinating borough with a rich history and diverse population. Like many other areas Greenwich has an ageing population with people living longer but often with one or several long term conditions. I am pleased to say we have an almost complete new permanent senior management team in place with Jo Murfitt as Chief Officer, David Maloney as Chief Finance Officer and Yvonne Leese as Director of Quality and Integrated Governance. The interim Director of Commissioning since June 2016, Liz James, will stay on until we can find a permanent replacement. This is likely to be a joint appointment with Bexley and Lewisham CCGs with whom we share the same main hospital provider – Lewisham and Greenwich NHS Trust. We also have a new third lay member on the Governing Body, Richard Rice, and other permanent staff vacancies are getting filled steadily. All of this is good news and hopefully, will give us a stable management team going forward. 2016/17 has been a particularly challenging year for NHS Greenwich CCG. Despite this we have made some real progress throughout the year and more detail on these areas is highlighted in this report. The most significant being the re-procurement of Musculoskeletal Services - Circle Health will manage and co-ordinate all musculoskeletal services in Greenwich for the next five years. The new service will mean local patients see the right clinician, in the right place, at the right time - a real positive development for Greenwich. We have also replaced the two walk-in centres in Greenwich with GP Access hubs where local GPs can see Greenwich patients outside normal surgery hours but with the benefit of access to their GP records. Unfortunately, we are ending the year with a bigger financial deficit than planned which, in turn, means next year's savings target of around £19 million is even greater than this year's. Our increased financial deficit is due in part to under-performance of some of this year’s savings schemes and also factors outside the CCG’s control, such as payments to support Lewisham and Greenwich NHS Trust and the cost of continuing healthcare payments to individual patients (mainly the cost of nursing care). There are continuing quality concerns at Queen Elizabeth Hospital which concern us and which together with the Trust we are trying to address. Nevertheless we remain optimistic, as we work with local partners in health and social care, including the Royal Borough of Greenwich and Oxleas Foundation Trust, to bring about improvements in healthcare for our local population. As we head into the new financial year with our extremely ambitious savings target, I am very conscious that for any savings scheme to be successful it must be clinically-led. We are looking to our GP membership, as well as CCG GPs and the Local Medical Committee, to advise us on what things will both make general practice more sustainable and reduce demand on secondary care - both things essential and interdependent. We also welcome the opportunities that come with taking on the responsibility for Primary

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Care Commissioning - managing the Personal Medical Service review process, managing primary care, supporting practices and minimising further closures. Finally, the CCG continues to engage with the Sustainable Transformation Plan for South East London, embracing the promise of radical NHS reform, while mindful that we are yet to discover what the final outcome will look like! Dr Ellen Wright Clinical Chair, NHS Greenwich CCG

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Challenges in Greenwich Main areas of poor health In Greenwich, like many other areas nationally, we have a growing and ageing population with growing health and care needs. According to the Joint Strategic Needs Assessment (JSNA) for Greenwich, the major causes of death in Greenwich are cancer and cardiovascular diseases, especially heart attacks and strokes, although overall death rates from these causes are improving, meaning that less people are dying prematurely from these diseases. Respiratory diseases, including Chronic Obstructive Pulmonary Disorder (COPD), are the next biggest cause of preventable deaths in the Borough. The biggest burden on morbidity (poor health) is mental ill health, followed by musculoskeletal health conditions such as back pain, arthritis and other joint conditions. The JSNA priorities include six major conditions, six risk factors and seven underlying determinants of health as below

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With our partners, we have identified the key underlying determinants of health that impact on the health of people in Greenwich. These are shown in the boxes called “causes of the causes” in the diagram above. There is ample evidence that social and environmental factors, including employment, income level and the suitability of housing have a big influence on health. The second main row in the table then shows the “major risk factors for disease” for the conditions listed in the boxes below, called “major conditions” (Greenwich’s avoidable burden of ill health). We describe these conditions as the avoidable burden of ill health, as with the right help and support; for example, to give up smoking or supporting people back into employment, the development of some of the diseases may be prevented. The Greenwich Health and Wellbeing Strategy In response to the major health needs of the population, the Greenwich Health and Wellbeing Board has in place a strategy to improve the health of the population. The strategy is focused on the following priorities:

• Tackling obesity, as a major driver of poor health outcomes including heart disease, cancers and musculoskeletal health problems

• Improving mental health and wellbeing • Enhancing the role of staff across our agencies to ‘make every contact count’ in

improving the health and wellbeing of the population • Promoting and supporting the mental and physical health and wellbeing of employees

across the borough through healthy workplace initiatives

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Summary of status of key health outcomes and their determinants in Greenwich

The diagram on the left provides a summary of some of the main areas in which health is poorest in the Borough and some of the

associated factors, such as poverty and obesity. It shows

where improvements are being seen (for example, in early deaths from cardiovascular diseases), as well as where

outcomes are getting worse (such as in the prevalence of diabetes).

It also shows outcomes where the burden of poor health is

significant but lower and where improvements are being seen (such as TB rates), and where

outcomes are worsening (such as early deaths from liver disease).

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Managing Risk The CCG has assessed its key risks and uncertainties throughout the year using the Governing Body Assurance Framework. The Assurance Framework sets out the principal risks to delivering our strategic objectives and how these risks are managed. There is an established methodology in place to identify, monitor, control and mitigate risks throughout the CCG as part of, and within, the CCG’s Risk Management Strategy and Assurance Framework. The Assurance Framework is presented to the Governing Body at every meeting, so Governing Body members can review the risks and mitigations and receive assurances that the risks are being managed and minimised. The top risks for Greenwich CCG identified in 2016/17: 1. Risk of ability of the Governing Body to fulfill its statutory duties in relation to the financial

position for 2016/17

2. Risk of failure to deliver the £15.45m QIPP (Quality, Innovation, Productivity and Prevention) target for 2016/17

3. Risk of not meeting the NHS Constitution Standards and NHS England priorities and

outcome framework because of challenges regarding:

• Four hour Emergency Department waiting times • Tertiary based referrals to Guys’ and St. Thomas’s NHS Foundation Trust (GSTT) and

Kings College Hospital NHS Foundation Trust for 62 day cancer waits

4. Risk of the demand for hospital care in 2016-17 exceeding available budgeted levels.

As the CCG was unable to meet its full statutory financial duties, the CCG continues to meet monthly with NHS England to provide assurance on the financial recovery plan and the progress to achieve financial balance in 2017/18. As a clinical organisation not managing our money well impacts on the amount of care we can buy for local people and hence our focus on continuing to make sure we manage our difficult financial position as best as we could. Further details on risk are included in the governance statement on page 59.

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Our Achievements in 2016/17 Medicines Management During 2016-17 the Medicines Management Team continued to promote good quality, cost- effective prescribing across the CCG by implementing prescribing work plans. It has been a challenging year for the team; however, the following has been achieved: • Delivery of the national quality premium for the reduction in the total number of antibiotics

prescribed and the percentage of broad spectrum antibiotics prescribed in primary care to below the England average

• has successfully supported practices to implement various National Institute for Health and Care Excellence (NICE) guidelines and implement the NICE Asthma death report via clinical audits, and training and education

• has undertaken extensive engagement events with various stakeholders including patients, GP practices and mental health colleagues regarding the work plan

• has developed a scheme to promote self-care and reduce the prescribing of medicines of low clinical value. The resources from the scheme have been shared with the other CCGs in South East London who are adopting this scheme for 2017-2018

• has collaborated, as a member of the South East London Area Prescribing Committee, to approve 15 new high cost medicines, develop 22 guidelines/pathways/policies, 13 shared care/transfer of care documents, a traffic light system of Red, Amber and Green/Grey list of medicines for use across the sector

• has continued to produce the well-established Prescribing Matters newsletter which updates and educates Clinical and Practice staff

• delivery of the financial QIPP target of £2m set for the year ensuring that resources are used to best effect.

Primary Care Extended Primary Care service is available across the borough. All Greenwich patients now have access to a CCG commissioned scheme which offers additional appointments at Eltham Community Hospital and Thamesmead Medical Centre. These are known as hubs. This means that primary care services are available between 9am and 5pm on a Saturday and 9am to 1pm on a Sunday. Patients may be seen at either of the hubs. A new data sharing agreement means that practices and the 111 service now book appointments via a shared appointment book. Wherever the patient is seen the doctor, with the patient’s consent, has access to their medical records. During 2014/15 all GP Practices in Greenwich came together to work as four geographically-based GP Provider Networks. The aim was to enable general practice to start to build the infrastructure to work together in partnership and offer a wider range of services. In 2016 Greenwich Health Ltd was established as an over-arching GP Federation with representation from each of the four GP Provider Networks on their Board. Greenwich Health Ltd is registered with the Care Quality Commission (CQC) which means they are able to bid and

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provide services to Greenwich Patients.

As part of the agenda to improve technology, Greenwich CCG was chosen as an early adopter site for the installation of Wi-Fi in all GP surgeries and as a result all surgeries will have Wi-Fi available to both staff and patients by the end of May 2017. The CCG has also been working to improve access to GP surgeries by increasing the number of patients who are able to book an appointment and request a prescription online. Nearly 10% of patients are now able to book their appointments online and we are working to increase this further during 2017/18. The Greenwich Community Education Provider Network (CEPN) is a network of local organisations working together to ensure Greenwich has a health and care workforce able to offer the highest quality care to local people. The CEPN has worked to: • Deliver and co-ordinate education and training • Promote multi-professional learning • Improve how workers feel • Improve the quality of care Highlights of achievements in 2015/16 were: • Employment of apprentices in general practice • Development of career pathways in partnership with Greenwich University to help retain

nurses in general practice • Training for general practice staff Greenwich is the seventh highest borough in London for the prevalence of latent Tuberculosis (TB) and is now aiming to eradicate Tuberculosis by 2020. GPs in Greenwich will now identify newly registered patients who have come from a country with high levels of Tuberculosis and have not been tested. These patients are requested to undertake a blood test which is organised by the practice. The scheme will continue into 2017/18 when it will be extended to review patients who are already on the GP practice register.

Greenwich Health Ltd

Meridian Doctors LLP

Eltham Health LLP

Riverview Health LLP

Maritime Doctors LLP

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Where we have allocated the additional funding in 2016/17:

This year Greenwich practices voted to move from being a Level 2 co-commissioner of primary care services with NHS England, to full delegation (level 3). Level 2 is where the CCG (or CCGs) share the decision-making with NHS England. With full delegation from 1 April 2017, Greenwich CCG will take responsibility for the everyday decision making, management and commissioning of Primary Care, with NHS England retaining an overarching view and responsibility. This arrangement applies to General Practice, not Pharmacists, Dentists or Optometrists. There have been some changes in the GP Practices in Greenwich this year. Henley Cross, Alderwood surgery, The Mound and The Slade surgeries have all closed due to the retirement of their GPs. Patients have been able to register with other local practices as there were services within the surrounding areas. Tewson Road Surgery and Plumstead Health Centre, which were both based in the Plumstead Health Centre building, have merged to form one practice. The newly merged surgery is called Plumstead Health Centre and the patient lists have been combined. Connect Care Connect Care enables important patient information to be shared securely so that it can be viewed quickly and safely by staff directly involved in the care of a patient, such as GPs, hospital staff, district nurses, occupational therapists and social workers. It enables them to make more informed decisions about care and treatment. Patients are able to opt out of the system. More information is available on the NHS Greenwich CCG website. In October 2015 we started to roll out Connect Care to GP practices across Greenwich and by March 2017 all practices had access. Connect Care provides health and social care providers with immediate access to up-to-date patient information. During the summer of 2016/17 Oxleas NHS Foundation Trust was also included in the Connect Care programme and access to records is now shared covering a larger catchment area. This is all covered as noted earlier by patient confidentiality data sharing agreements.

Access Hubs,

£778,462

Reslience, £155,643

Patient On-Line, £50,680

Latent TB, £166,000

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As part of the Local Digital Roadmap, Connect Care will be linked with the Local Care Record in Southwark and Lambeth which will enable better sharing of records across the South East London area. This work will continue into 2017/18. Eltham Community Hospital In 2016 Greenwich CCG launched a project to increase the services delivered from Eltham Community Hospital. The CCG created a hub or centre for local musculoskeletal services which will commence in spring 2017 and will increase patient numbers throughout 2017. The primary care services delivered from Eltham Community Hospital has also expanded in 2016 and these are described on page 8. Discussions to open the diagnostic facility of X-ray and ultrasound have continued with Lewisham and Greenwich NHS Trust. It is planned that by summer of 2017, GPs will be able to refer patients to Eltham Community Hospital for X-ray and ultrasound. As part of the financial challenge the CCG faced, the decision was taken to temporarily close one of the two inpatient wards at Eltham Community Hospital. The ward supporting patients requiring further rehabilitation, run by Oxleas Foundation Trust stayed open. In hindsight the decision to close one inpatient ward was optimistic in its expectation that other community based services would be able to support patients at home. As a result the CCG funded additional capacity on the St Mary's Sidcup site throughout the winter and not in Greenwich. As part of a review of urgent care the CCG along with its partners locally is looking at how best to use the empty ward in 2017/18 and ensure that patients do not need to travel out of borough. Continuing Health Care In conjunction with the Royal Borough of Greenwich, the CCG’s Continuing Health Care team has agreed a local protocol around discharge for patients needing long term nursing care. The protocol allows for funding decisions to be made quickly, preventing delayed discharges. As a result what are nationally called Delayed Transfers of care (DToCs) have reduced from twenty-nine in October 2016 to six in February 2017 for Greenwich residents. The rise in October 2016 coincided with about 70 beds in local nursing homes which were not available as a result of decisions by the Care Quality Commission. The section on use of our Better Care Funds gives further details. The National Framework states that CCGs should commission services using models that maximise personalisation and individual control reflecting the individual’s preferences as far as possible. The Personal Health Budget (PHB) Programme was piloted in Greenwich for South East London. From April 2015 everybody meeting the criteria for fully funded NHS health care must have a PHB. We have worked with individuals and families during 2016/17 to equip them to make informed choices and manage their own budget; therefore we have achieved to get all our fully funded patients on PHB.

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Improved Constitutional Standards Greenwich CCG continues to focus on improving performance across all NHS Constitution Standards. However 2016/17 has been a very challenging year and not as much progress has been made as we would have hoped in delivering national standards for local people. The area where we can see some progress is on the two week wait cancer targets although other cancer targets have not been met locally. The CCG is part of the South East London 62 Day Treatment Leadership Group which will continue with the development and performance management of all cancer targets.

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Performance Analysis: improving quality and performance The CCG is measured against a range of targets that reflect what is important to patients. Whether it is waiting times in the Accident & Emergency department or recommending services to others in the Friends and Family test - these things help to reassure patients that we are working hard to deliver the best possible care, in a timely and caring way. Performance is measured by a set of local and national performance measures relating to patient safety, patient experience and the quality of services. These standards help to monitor how well we are performing and allow us to improve the care we provide to our patients. Greenwich CCG has three major reports relating to providing patients and interested parties with information - all of which are reported to our Governing Body and are available on the Greenwich CCG website: 1. Quality Report focuses on patient experience and outcomes 2. Performance Report focuses on NHS constitutional standards (e.g. nationally set waiting

times) and the targets that nationally are required to show we are demonstrating service delivery and improvement

3. Finance Report covers the activity and care we buy from our providers (hospitals, mental health services, voluntary sector etc.) and also gives information on how we have managed resources for local people.

This information is also monitored by NHS England, and our CCG regulator assurance process sets out in the Improvement and Assessment Framework. This replaced the previous CCG assurance framework and performance dashboard. The 2016/17 year-end assessment for Greenwich CCG will be available from July 2017 on: www.nhs.uk/service-search/Performance/Search During 2016/17 the CCG has been working to develop a new integrated Performance Report which includes performance, finance and community activity update. The table on the next page shows NHS Greenwich’s CCG performance against national performance measures for the past 12 months.

Greenwich CCG rolling twelve month performance on national standards

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Challenges Addressed: Accident and Emergency Four Hour Standard The national target is for 95% of patients to be seen and treated and then admitted or discharged within four hours or arriving in the Accident and Emergency department (A&E). The graph below demonstrates that this year was a particularly challenging year for Lewisham and Greenwich NHS Trust as both the national target of 95% and the locally agreed target of 90.1% of patients to be seen and treated within four hours was not delivered.

Greenwich CCG together with the Trust and other partners have been working throughout the year to understand what actions can be delivered to improve performance and improve patient experience and safety. The themes that have arisen reflect the national position and a work programme began through the year to: • Manage demand and provide sufficient capacity • Free up hospital bed capacity Manage demand and provide sufficient capacity. We have worked with our Urgent Care (UCC) provider Greenbrook and the Lewisham and Greenwich NHS Trust to increase front door assessments (streaming) thus providing a faster pathway for the patient to the appropriate clinician. In the last quarter more than 50% of all attendances at the Emergency Department were streamed to Urgent Care Centre. We have also increased the number of patients that can be directly referred to hospital specialties rather than return to A&E. Plans are also agreed to improve the A&E environment and provide more room and confidentially for the streaming process.

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Free up hospital bed capacity. Twenty beds at Queen Mary's Hospital, Sidcup, were opened to provide sufficient community bed capacity over winter. In addition, a joint piece of work was undertaken to review discharge arrangements across the hospital and community beds. The aim has been to enable patients to be discharged quicker and if necessary to be assessed for future care support outside hospital. Significant work continues this coming year to improve our local A&E performance and this will include the opening of an Ambulatory Care Unit that will enable suitable patients to bypass the A&E department if appropriate. London Ambulance Service response times

Targets for ambulance response times at pan-London level were not achieved in 2016/17. The London Ambulance Service has undertaken a series of actions to address performance to ensure they improve performance against targets by meeting agreed monthly trajectories. The Trust continues its tri-partite updates with their lead Commissioner, NHS England and the Trust Development Authority. Referral to treatment times (or waiting times for treatment for surgery) The Referral to Treatment (RTT) requires 92% of patients to be treated in 18 weeks from referral. Achieving RTT access targets, including the 92% standard, has been particularly challenging this year because of underperformance at Kings College Hospital and Guys & St Thomas’. Lewisham and Greenwich NHS Trust met the 92% target in some months in 2016/17 and the CCG is working with them to ensure that they are able to achieve the target consistently in 2017/18. Throughout 2016/17 a small number of Greenwich patients have waited more than 52 weeks from referral to treatment. These have all been at Kings College Hospital and each patient has been reviewed to ensure that no harm to them has resulted from this excessive wait. The CCG continues to work with Kings College Hospital to try to expedite treatment for these patients. Cancer Greenwich CCG measures cancer waiting times performance against eight specific measures and had exceeded national standards for three of these measures in the year to date (2 week wait, 31 day wait to first treatment and 62 day screening). The CCG has, however, been particularly challenged in meeting the 62 day cancer wait at its provider trusts. This standard measures the wait from an urgent GP referral for suspected cancer to first treatment and covers all types of cancer. The target has proved particularly challenging when patients are referred from one Trust, normally Lewisham and Greenwich NHS Trust, to another (known as a tertiary provider). We are working to ensure that patients are referred in a timely fashion in order to improve their experience.

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Diagnostics The diagnostic waiting time standard states that no more than one percent of patients referred for a diagnostic test such as endoscopy, CT scan or plain film x-ray should wait more than five weeks from their date of referral. Ninety-nine percent of Greenwich patients are seen within this timescale, ensuring that they receive a swift diagnosis and can receive their treatment in a timely manner. People with Learning Disabilities and/or Autism Transforming Care is the latest national response to the crises at Winterbourne View and other inpatient units for people with learning disabilities (LD) and/ or autism. The national agenda is being driven by a cross-sector programme and delivered locally across the footprint of the Sustainability and Transformation Plan (STP) through the South East London Transforming Care Partnership (TCP). The programme period is from April 2016 to April 2019. The South East London TCP consists of the 6 CCGs and councils of Bexley, Bromley, Greenwich, Lambeth, Lewisham and Southwark, and NHS England Specialised Commissioning. The Transforming Care initiative is now setting the agenda for all services for people with LD or autism. In the first year of the programme, the SEL TCP was set up, a number of changes were delivered across the patch and we responded to NHS England’s assurance requirements. We went from being a TCP that was not meeting requirements in February 2016 to one of the first in London to be awarded “assured programme” status and one of the first in the country to receive confirmation of programme funding for years two and three. We have worked with people with lived experience in planning our programme and in workshops and events. We have appointed a voluntary sector organization to set up and run a SEL TCP forum for people with lived experience. This forum will ensure that our programme is grounded in people’s real experience. The first change brought about by the Transforming Care agenda was the introduction of Care and Treatment Reviews (CTRs). CTRs are a tool for managing people with LD or autism, who present behavior that challenges and who are in an inpatient unit or at risk of being admitted to one. All LD patients have had a CTR with a clear treatment plan and planned discharge date. The Greenwich CCG Transforming Care Steering Group monitors and actively manages inpatients and those at risk of admission and, since the creation of the South East London TCP, delivers the South East London programme locally. It’s also worth bearing in mind that health and care services for people with LD or autism are commissioned by CCGs and councils and this will continue to the be case.

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Healthcare Acquired Infections (HCAIs)

There are two national targets for infection control: 1. Clostridium difficle (or C.Diff) 2. MRSA (or Methicillin resistant staphylococcus aurens) Both can be acquired in the community or in hospital and MRSA especially is becoming more difficult to treat with antibiotics, hence all NHS staff work hard to prevent its occurrence. The Greenwich C.Diff threshold for 2016/17 remains at 62 and MRSA at zero. From April to December 2016, 28 Greenwich C.Difficile cases were identified, which is below the year to date trajectory of 49. There was one case of MRSA reported in August 2016 (the only one for 2016/17 year to date).

To ensure Greenwich continues to reduce rates of HCAIs in 2016/17, the Health Protection Manager and Clostridium Difficile working group will continue to assess all cases and cascade learning across health care partners in Greenwich. The continued reduction in cases of this bug being identified is reducing across the NHS in England and reflects a sustained effort to deliver those actions which reduce its transmission and therefore risk to patients.

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Mental health Improving Access to Psychological Therapies There are several targets that CCGs are required to achieve in relation to Improving Access to Psychological Therapies (IAPT). The two key standards are the proportion of people entering treatment and the associated Recovery Rate. The service is delivered to Greenwich residents by Oxleas NHS Foundation Trust and the targets were consistently exceeded. Dementia Diagnosis Performance The target for dementia is that 67% of patients with dementia should be identified and given appropriate support. Greenwich CCG has consistently exceeded the target each month. In regard to dementia, the CCG met the 67% minimum diagnosis target and the Community Psychiatric Assessment (CPA) rate in 2016/17. Early Intervention Psychosis The Early Intervention Psychosis (EIP) waiting time standard (designed to identify, diagnose and treat people with their first presentation of psychosis) performed above the target of 50% for the first half of 2016/17 with quarter three performance dipping below the 50% threshold. The CCG is concerned that the rate of new cases of psychosis being served by the EIP service (per 100,000 population) was at 26.5 in the year as opposed to an expected 51.2 for a comparable group of CCGs. Accordingly, the caseload size for the team is also lower than expected. Work to identify the causes of this shortfall in new cases and then address it is already underway. We expect to see an improvement within this service in 2016/17. However the proportion of people being offered and taking up a physical health check was strong at 99 per cent. The CCG’s three-year investment into the Recovery College came to an end in 2016/17. This investment (which was always intended to be time-limited) was to help the college set up and establish its offering, whilst it sought alternative sources that would enable it to run as a social enterprise. To help bridge the gap the CCG found a further £100,000 to help them whilst they continue to put alternate funding sources in place. Perinatal Mental Health During 2016/17 Greenwich CCG developed a perinatal mental health strategy in partnership with our partners Royal Borough of Greenwich and other local service providers. This sets out how to more effectively support women who have just given birth. Once completed the strategy will form the basis for the development of a model of care

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and business case for introducing a service from 2017/18, aligned with Bexley and Bromley, subject to ‘Wave 2’ funding from NHS England. The new service should be in place for 2018/19. Outcomes for Patients During 2016/17 the CCG set up a programme to improve the outcomes for people with mental health needs across Greenwich. These plans will define how we intend to meet the ambitions of the Mental Health Five Year Forward View, including increased targets in 2017/18 in several service areas. One priority that we have already identified is the need to improve the performance of crisis care and mental health liaison services and develop them so that they meet future national standards for 24 hour care. The review also afforded us the opportunity to forge stronger links with the Local Authority towards the end of 2016/17 and we intend to build on this next year, towards developing an increasingly collaborative approach to delivering care. In 2016/17 work has taken place to define and agree a broader range of performance indicators and measures for mental health, which will enable the CCG and main mental health service provider to monitor performance in more detail. As part of this, a number of new local and national indicators that will allow us to track progress towards achieving the ambitions within the Mental Health Five Year Forward View are now being put in place. Child and Adolescent Mental Health Services The Greenwich Local Transformation Plan (LTP) for Children and Young People’s Mental Health and Wellbeing was published in May 2016. It set out the local vision, priorities and plans for transforming care. The ambition is for children and young people to: • grow up with the confidence and resilience to develop and fulfill goals and ambitions • be able to find trustworthy help easily when it is needed • be involved in how mental health services are developed and delivered • receive help that meets their individual needs from people who care

In 2016/17, the LTP development brought together partners across health and care, to build on the base lining and development work undertaken as part of the Child and adolescent mental health services (CAMHS) re-commissioning. The re-commissioning ensured the development of a joined up CCG and Local Authority service that delivers a range to reduce complexity and increase accessibility through ‘no more tiers’. The scope of our Local Transformation plan now covers the full spectrum of service provision and planning to date has focused on understanding local weaknesses and gaps within the themes identified by Future in Mind. This supported development of key priorities and associated activity for 2016/17 which is detailed in the tables below, together with expected outcomes and progress to date. As many of the posts were recruited over the school holiday period and only started to deliver from September 2016, it is not possible to reliably report on the impact at this

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time. However significant activity has taken place to develop the necessary partnerships to embed them as part of the local integrated pathway. Integrated Working and Better Care Fund In 2016/17 Greenwich shared a pooled budget of £20m with the Royal Borough of Greenwich. The central focus of the Better Care Fund programme is to jointly commission health and social care services that enable people access to high quality care in their community. The programme aims to improve the lives of some of the most vulnerable people, placing them at the heart of their care and support, and providing them with ‘wraparound’ fully integrated health and social care, resulting in an improved experience and better quality of life. The Better Care Fund programme schemes are designed to reduce non-elective admissions, admissions to residential care, improve patient satisfaction with services and increase the number of patients living at home after a discharge from hospital. In 2016/17 the Better Care Fund schemes focused on the provision of care packages to people in their own home which then resulted in fewer admissions to residential care, however, unprecedented growth in the number of patients accessing hospital care through emergency resulted in a decline in performance for non-elective admissions in 2016/17. Better Care Fund 2016/17

The Better Care Fund is also targeting Delayed Transfers of Care (DTOC). A DTOC occurs when an adult inpatient in hospital is ready to go home or move to a less acute stage of care but is prevented from doing so. Since 2015 Greenwich has sustained positive performance below the London average and

Q1 Q2 Q3 Q4

Plan 6412 6422 6422 6417

Actual 6333 6926 7083

Plan

Actual

Plan 145.5 145.5 145.5 145.5

Actual^ 163.2 110 106.5

Plan

Actual

Plan

Actual

Admissions to residential care Rate of permanent to residential care per 100,000 population (65+)

Non-Elective Admissions

Measure Definition

Reduction in non-elective admissions

582

Performance 2016/17

Annual total est May 2017

Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into

reablement/rehabilitation services

83.1%

57

Annual collection, release est May 2017

Annual collection, release est May 2017

Reablement (older people still at home 91 days after discharge)

Overall satisfaction of people who use service with care and support

Friends and Family Test question “How likely are you to recommend our GP practice to friends and family if they needed similar care or treatment?” with a focus on the

percentage of patients answering as ‘Unlikely’ or ‘Extremely unlikely’.

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below our neighboring CCG, Lewisham. In June 2016 the rate spiked due to a reduced number of care home places. The issue was quickly resolved through the identification of alternative community placements and the Greenwich DTOC rate is now coming back in line with the London average.

Delayed Transfers of Care 2015-2017

A focus on emergency pathway work and the streamlining discharge pathways for patients moving into nursing and social care facilities is expected to further reduce levels of DTOC in 2017.

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Quality, Improvement, Productivity and Prevention Quality, Improvement, Productivity and Prevention (QIPP) is a programme designed to support clinical teams and NHS organisations to improve the quality of care whilst making efficiency savings that can be reinvested into the NHS. The CCG had a QIPP target of £15.5m for 2016/17 and had validated plans for £11.2m. The QIPP schemes relate to securing better value for money in the services that the CCG were required to commission, this included; • Acute productivity, demand management and access to appropriate healthcare. Providing

accessible services in the community to allow hospitals to be more efficient in treating those requiring attendance or admission.

• Home First Discharge and Length of Stay schemes focused on ensuring patients ready for discharge had access to community and continuing health care services so they may be safely discharged with minimal delay.

• More effective commissioning of Mental Health services by the responsible Commissioner. • Community schemes included the increased utilisation and more flexible use of

intermediate care and nursing home beds. • Primary Care and Prescribing schemes related to increasing access to GPs for Greenwich

registered patients and more efficient primary care prescribing through the use of best practice approaches.

Not all schemes fully delivered, leaving a shortfall of £1.8m against the plan and reserves were committed to partially offset the impact of the shortfall and unidentified QIPP totaling £6.1m. The table below summaries the success of each scheme:

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Financial overview The CCG commissions and provides healthcare services to meet the needs and improve the health of the population of the London Borough of Greenwich. The main NHS providers are Lewisham and Greenwich Healthcare NHS Trust, Guy’s and St. Thomas’ NHS Foundation Trust and Oxleas NHS Foundation Trust. We also co-commissioned with NHS England a number of other services, such as primary care from a range of providers and also meet the prescribing costs of Greenwich GP practices. In 2016/17, expenditure on healthcare and related services compared to plan were as below: Plan Actual Variance £m £ m £m Available Revenue 376.0 376.0 0.0 Expenditure: Acute Services 204.5 206.3 1.9 Mental Health Services 49.5 49.4 (0.1) Community Health Services 25.3 27.6 2.3 Continuing Care 24.6 27.4 2.8 Primary Care 37.8 36.4 (1.4) Other Programme Costs 21.9 23.8 1.9 Total Programme Costs 363.6 370.8 7.2 Running Costs 5.9 5.8 (0.1) Contingency and Earmarked Reserves 4.2 0.0 (4.2) Total Before 1% Reserve 373.7 376.6 2.9 1% Reserve 3.6 0.0 (3.6) Total Expenditure inc 1% Reserve 377.3 376.6 (0.6)

The CCG incurred a deficit of £4.2m in 2016/17, before application of its General Reserve of 1% (£3.6m). The CCG had originally developed a financial plan in which it would have incurred a deficit of £1.3m but this was compounded by a large and unforeseen rise in the costs of funded nursing care and an obligation to make a payment of £1.8m to Lewisham and Greenwich NHS Trust in respect of transitional support following the dissolution of South London Healthcare NHS Trust, which was not in the original plan. In terms of the financial related objectives expected of the CCG are performance was below: Target

(£’000’s) Actual (£000’s)

Achieved

1% Surplus 3,594 -570 Failed Deliver statutory

Operate Under Resource Revenue Limit

376,048 376,618 Failed

financial duties

Not to exceed Running Cost Allowance

5,865 5,770 Achieved

Operate under Capital Resource Limit

0 0 Achieved

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Deliver administrative duty under the better payments practice

95% of NHS creditor payments within 30 days

95% 99.74% Achieved

95% of Non NHS creditor payments within 30 days

95% 99.12% Achieved

Future Years

The CCG has developed a Financial Plan for both 2017/18 and 2018/19 that deliver in-year financial balance in both years. This is consistent with the business rules for Greenwich CCG for both 2017/18 and 2018/19. However the achievement of the plan is dependent upon the delivery of significant QIPP savings (£19.3m in 2017/18 and £13.2m in 2018/19) together with the management of other key financial risks.

The plan submitted for both 2017/18 and 2018/19 represents only the in-year position and therefore does not take into account funding carried forward from previous financial years. The overall resource limit for 2017/18 is £409.3m which includes growth of £8.4m. It also includes funding transferred from NHS England to allow the CCG, in common now with all CCGs, to undertake the co-commissioning of Primary Care. This has increased the budget for which we are responsible to over £400m.

Provision in the 2017/18 financial plan has been made for the following: • A contingency of 0.5% (£2.1m); • A non-recurrent reserve of 1.0% (£3.681m) of which 0.5% is uncommitted; and • Investment to support the delivery of the GP Forward View (£0.4m in 17/18 and £0.4m in

2018/19). In addition, investment in mental health services is in accordance with the Parity of Esteem guidance.

2017/18 2018/19 £ m £ m Available Revenue 409.2 419.8 Expenditure: Acute Services 209.0 214.7 Mental Health Services 51.4 53.2 Community Health Services 29.0 30.0 Continuing Care 18.8 19.1 Primary Care 38.5 39.3 Other Programme Costs 17.1 16.5 Primary Care Co-commissioning 37.2 38.6 Total Programme Costs 401.1 411.5 Running Costs 6.1 6.1 Contingency 2.1 2.1 Total Expenditure 409.2 419.8

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Reserves and Special Payments As set out in the 2016/17, NHS Planning Guidance, CCGs were required to hold a 1% reserve uncommitted from the start of the year, created by setting aside the monies that CCGs were otherwise required to spend non-recurrently. This was intended to be released for investment in Five Year Forward View transformation priorities to the extent that evidence emerged of risks not arising or being effectively mitigated through other means. In the event, the national position across the provider sector has been such that NHS England has been unable to allow CCGs’ 1% non-recurrent monies to be spent. Therefore, to comply with this requirement, NHS Greenwich CCG has released its 1% reserve of £3.6 m to the bottom line, resulting in a reduction of the deficit to £570k from plan. 2016/17 expenditure on hospital services above (services from other NHS Trusts in Note 5 to the Annual Accounts) includes non-recurrent expenditure of £1.75m that was paid by the CCG to Lewisham and Greenwich Trust as part of an NHS system-wide contractual commitment, totaling £10.5m, which was agreed by NHS England in 2013 when the Trust was formed. This contractual commitment refers to 2016/17 and 2017/18 only. For 2017/18 £1.75m is a maximum value and may be reduced through delivery of system wide savings, above those planned for 2017/18. Other matters Remuneration paid to external auditors in relation to audit work was £71K (including non-recoverable VAT). Remuneration for non-audit work was nil. The CCG has complied with HM Treasury’s guidance on setting charges for release of information. Annual Accounts The full annual accounts together with the Statement of Accountable Officer’s responsibilities and Independent Auditors Report are included from page 58.

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Sustainable Development The NHS Carbon Reduction Strategy for England provides a framework which addresses sustainability both in how we operate as an organisation in our own right, and in terms of how we contract for services from providers of healthcare. The plan aims to: 1. drive down direct C02 emissions and energy usage whilst also reducing revenue

expenditure 2. influence commissioned services to reduce their carbon footprint in support of the

10% target reduction 3. ensure that all new buildings and other initiatives are developed with reference to the

plan. In line with the national NHS Carbon Reduction Plan the local plans focus on the same areas. A summary of some of the key actions within the Carbon Reduction Plan are detailed below:

Energy and carbon management: we reduced our own energy and carbon footprint when by moving into The Woolwich Centre, a modern building with many sustainable features (e.g. rainwater used in the toilets, automatic lighting that switches off when no- one is present, etc.) Procurement and food: our main strategy is to influence the carbon footprint of NHS services through the use of our procurement framework, which addresses environmental issues. All contracts for healthcare services include clauses requiring providers to demonstrate their measured progress on climate change adaptation, mitigation and sustainable development, and include performance against carbon reduction management plans. Low carbon travel, transport and access: we have implemented a range of new services, and developed existing services, to bring them closer to the home. In terms of staff and visitor travel, a flat rate is operated for business mileage and also accounts for different modes of transport such as cycling. Cycling has been promoted actively for employees now we have moved to The Woolwich Centre with excellent cycle storage and related facilities.

Water: Efficient use of water is embedded in new capital projects. For example, Eltham Community Hospital and The Woolwich Centre harvest rainwater for use in the building. The Woolwich Centre also has integral filtered watered in all of its kitchens for drinking. Waste: Recyclable waste is appropriately disposed of and we are part of the Royal Borough’s active strategies to reduce waste and promote recycling. We continue to try and reduce our use printing.

Organisational and workforce development: Staff are given opportunities to use low carbon travel options, with walking and cycling encouraged and aligned business mileage

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processes. Audio, video and web conferencing technology and remote working capability are in place, and as far as possible these are promoted so we can avoid having to go into Central London for meetings. We are also promoting online services in GP practices so patients can also reduce their journeys.

Role of partnerships and networks: The Greenwich Core Strategy commits us to working in partnership with stakeholders under Local Strategic Partnerships, in particular the Royal Borough of Greenwich.

Finance: As part of the exercise to calculate the carbon footprint, carbon reduction targets will be set to achieve the NHS target and take advantage of schemes which support investment in energy efficiency initiatives.

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Quality and Safety The focus of the NHS Greenwich CCG Quality Strategy and annual work plan is to address local quality challenges. We provide a quarterly Quality Report to the CCG Governing Body and Quality Committee. The report provides an overview of quality for the CCG and its main service providers. It highlights any good practice that has been identified, but most importantly, ensures that there is a focus on the key quality issues. The report provides assurance to the Governing Body that the CCG is aware of quality issues and that appropriate action is being taken to understand the situation and improve quality and reduce patient safety risks. We hold all of our large providers to account through the work of the CCG Quality Committee and through a Clinical Quality Review Group held monthly with each provider. They focus on patient safety, the clinical effectiveness of services and ensuring a good patient experience. During 2016/7 some of our quality highlights include: Greenwich CCG • NHS Greenwich CCG’s governance leads, along with NHS England colleagues, presented

a pilot of a Quality Risk Profiling Tool at the Good Governance Institute’s ‘Festival of Governance’ on 27 September 2016 at the Royal College of General Practice Conference. This tool aims to provide a systematic shared approach to identifying quality risks in advance of incidents or regulatory actions. Oxleas NHS Foundation Trust worked in partnership with Greenwich CCG and the neighboring CCGs of Bromley and Bexley in the pilot, together with representatives from NHS England and NHS improvement, the regulator of NHS Trusts. The work has been published and is informing NHS England London Regional & National Regional Groups.

• Greenwich CCG has not breached the 2016/7 NHS England trajectory set for C.Difficile infection (30 cases against a trajectory of 62 cases). We have a Health Protection Manager who ensures that the learning from all cases is shared and has effectively managed post infection reviews (PIRs) in the community with local general practices.

• Introduction of Provider Assurance Monitoring System (PAMs): We have been working to develop a web-based quality assurance tool to be used to monitor quality within small providers. Providers started using this tool on 1 May 2016 and it is also being piloted across six ‘early adopter’ nursing homes.

• A Quality Alert Management System between local general practices and providers has been implemented and is in use by local GPs.

• We have maintained good oversight of provider quality, including our small providers, e.g. BMI Blackheath, Out Of Hours GP Services and the Urgent Care Centre.

• We have maintained a programme of provider announced and unannounced site “Quality Visits” of our providers. These are undertaken by our Quality Team through an agreed protocol.

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Oxleas NHS Foundation Trust • The CQC inspection report for Oxleas NHS Foundation Trust was published on 13

September 2016. Fourteen core services were inspected across mental health and community services. Ten out of fourteen services were rated as ‘Good’ with community services for people with a learning disability rated as ‘Outstanding’ under the CQC’s ‘Caring’ category. The overall rating for services was ‘Requires Improvement’, but following a re-inspection in March 2017 this was subsequently upgraded to “good”.

• The Winterbourne View report raised concerns about the widespread off-label use of antipsychotic medication in people with learning disabilities. Oxleas undertook a national Prescribing Observatory for Mental Health (POMH) audit focused on the quality of antipsychotic prescribing for people with learning disabilities. The overall prevalence of antipsychotic prescribing in Oxleas services was lower than in any other Trust nationally, and the clinical indications for such prescribing were consistent with NICE recommendations. Practice in Oxleas was similar to the national average with respect to screening for metabolic side effects and better than the national average with respect to measuring body weight and Body Mass Index (BMI).

• Oxleas is one of the few mental health Trusts to meet the national Commissioning for Quality and Innovation (CQUIN) on mental health (exceeding the national target) and has been commended for this by NHS England.

• Oxleas launched a Quality Scorecard in June 2016. It covers both mental health & community services.

• Oxleas has agreed to provide responses to ‘Enter and View’ reports undertaken by Healthwatch through the Clinical Quality Review Group meetings. This helps all organisations to triangulate important qualitative information and observations.

• Oxleas has established a Safe Staffing Committee which meets quarterly to review safe staffing performance.

• There have been no breaches of mixed sex accommodation.

The statutory Duty of Candour on healthcare providers is a direct response to the recommendation (181) of the Francis Inquiry. It is now a criminal offence to fail to provide notification of a notifiable safety incident and any conviction liable to a fine. Duty of Candour is monitored through the Clinical Quality Review Groups. A clear action plan has been put in place to embed Duty of Candour at Oxleas NHS Foundation Trust. This includes staff information sessions, production of a Duty of Candour video for staff, re-launch of an incident newsletter and audit of serious incidents and Duty of Candour. Lewisham and Greenwich Hospitals NHS Trust • The Patient Reported Outcome Measure (PROM) participation rates at Lewisham and

Greenwich NHS Trust for groin hernia, varicose veins and hip and knee replacement are above trajectory for 2016/17.

• Lewisham and Greenwich Hospitals NHS Trust has been fully compliant with Central Alert System deadlines in the last year to show that they have been responsive to safety alerts.

• There have been no breaches of mixed sex accommodation and this has been maintained consistently throughout this financial year.

• Safe staffing levels have been maintained. While no national tolerances have been set so far, staffing levels between 80% and 106% have been agreed as safe for individual wards.

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Safer staffing levels and workforce (use of agency, locums, staff sickness and turnover) are monitored through the Clinical Quality Review Group.

• The Trust has fully participated in national audits and confidential enquiries. • The statutory duty of candour on healthcare providers is a direct response to the

recommendation (181) of the Francis Inquiry. It is now a criminal offence to fail to provide notification of a notifiable safety incident and any conviction is liable to a fine. Duty of Candour is monitored through the Clinical Quality Review Group. There have been no breaches declared of Duty of Candour at Lewisham and Greenwich NHS Trust.

The CQC revisited the Trust in March 2017 and we are waiting the formal feedback from the review. Friends and Family Test Friends and Family Test has been a requirement of the GP contract since 2014. Greenwich CCG has supported GP practices by purchasing an electronic solution to gain patient feedback. Responses to the Friends and Family Test in Greenwich are high (in December 2016 85% of respondents said they would recommend their practice) and work is ongoing to monitor these responses as part of the GP contract management process. Patient Safety • We have been working to continually improve Pressure Ulcer Management through

Pressure Ulcer Working Groups with both Oxleas NHS Foundation Trust and Lewisham and Greenwich NHS Trust.

• There has been one Never Event reported in the last year at Lewisham and Greenwich NHS Trust (at Queen Elizabeth Hospital). This related to a drug being administered to a patient through the incorrect route.

• Having reviewed the findings from serious incident reports we have classified them as follows: Diagnostic incidents including delays and failure to act on test results Pressure ulcers: Grade 3 and 4. We have seen an improvement in reporting and

are able to ensure that learning takes place which helps to reduce the incidence of ulcers reduce re-occurrence. Grade 3 and 4 are the most serious type of ulcers.

Apparent, actual or suspected self-inflicted harm, e.g. attempted suicide.

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Quality Issues • The Accident and Emergency (A&E) four hour wait target presents a continued

challenge at Lewisham and Greenwich NHS Trust. Performance was particularly challenging through the winter months. Performance is scrutinised via an Emergency Department dashboard.

• The Care Quality Commission Improvement Plan for Lewisham and Greenwich NHS

Trust: Further work has been implemented with the ambulance service, Emergency Care Improvement Systems Team and Greenbrook who run the Urgent Care Centre at Queen Elizabeth Hospital. The Trust is also considering dedicated space for Frailty and the Rapid Access Team, as these are enablers within the Care Quality Commission Improvement Plan.

• Performance on the 62 day standard cancer referral to treatment target remains a quality issue during 2016/7. This is primarily a performance issue but failure to meet targets puts patient outcomes and patient experience at risk. We monitor this through our Clinical Quality Review Group with the Trust and we have also established a Cancer Pathway Clinical Review Group which meets monthly to review all breaches. Lewisham and Greenwich NHS Trust is, however, performing well against the Inter-Trust Transfer target (ITT) and is collaborating with Guy's and St Thomas’ NHS Foundation Trust to facilitate delivery of the 62 day target. The service has significantly improved its performance on median wait times to first treatment across all tumour groups, which is reflected in the overall performance against national cancer targets.

• There have been two areas of concern within maternity services, namely caesarian (C) section rates and stillbirth rates. Lewisham and Greenwich NHS Trust is actively looking at ways it can improve care pathways for women in an attempt to reduce caesarian-sections. New vaginal birth guidelines have been approved which should help staff promote natural birth pathways. The CCG will in the future have the opportunity to consider benchmarking across London providers as a pan-London maternity scorecard is now operational. The Trust presented a comprehensive stillbirth review report which has been co-produced with Public Health and CCGs. The stillbirth review has initiated a long list of recommendations including the establishment of Prevention of pre-term birth and improving women’s experiences (POPIE) - a two year pilot programme funded by Lewisham CCG, which will focus on women with high risk of pre-term births. The expected high risk caseload will be 200 women.

• As a result of a number of peer reviews, Lewisham and Greenwich NHS Trust is reviewing how it can strengthen its clinical leadership because of its importance on the delivery of high quality patient care.

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Safeguarding Adults and Children The CCG has worked closely with the Royal Borough of Greenwich and providers to ensure that effective safeguarding arrangements are in place within all services to safeguard vulnerable adults, children and young people. Children and Young People In 2016/2017 Greenwich CCG gained assurance from all commissioned healthcare providers (through assurance visits, section 11 audits and attendances at provider safeguarding committees) of their commitment to continuous improvement. Although Greenwich CCG was not currently directly responsible in 2016/17 for the commissioning primary medical care (or other primary care services), the CCG has supported improvements in the quality of primary medical care in Greenwich and will continue to work closely with NHS England on this area. In October 2016 The Care Quality Commission undertook a review of Safeguarding and Looked after Children services in Greenwich. This review was conducted under Section 48 of the Health and Social Care Act 2008. The review explored the effectiveness of safeguarding arrangements and health services for Looked after Children. The review also checked whether healthcare organisations were working in accordance with their responsibilities under Section 11 of the Children Act 2004. This includes the statutory guidance ‘Working Together to Safeguard Children 2015’. The review highlighted areas of very good practice across Greenwich and made some recommendations to address identified gaps around the following key themes: • Quality of referrals to children’s services • Timeliness of health assessments for looked after children • Information sharing between primary care and universal children’s health services • Adult mental health professionals to develop a “think family” approach

Safeguarding Adults The further implementation of the Care Act has continued to have implications for adult safeguarding with the widening of the categories of abuse and the subsequent statutory requirements for health organisations and the Safeguarding Adult Board. Equally the ongoing impact of the Supreme Court judgments on the Deprivation of Liberty Safeguards has seen a consistent and significant rise in the number of applications although this has now plateaued, albeit at a level ten times higher than previously.

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0

100

200

300

400

500

600

700

800

14/15 15/16 16/17

Greenwich DoLS activity

Applications

Authorised

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Medicines Management Team Our aim is to ensure we promote safe and effective use of medicines for the benefit of patients treated by Greenwich CCG. This includes minimising any risks associated with the use of medicines for patients and staff. Our Medicines Policy is based upon statutory requirements and guidance issued by the Department of Health and other establishments such as National Institute for Health And Care Excellence and NHS England. This enables the clinical membership to establish the principles that must be adhered to in order to reduce clinical variability and inequalities.

The medicines management team promotes efficient use of NHS resources by developing policies such as:

• Controlled Drugs Policy • Repeat Prescribing Policy • Prescribing Policy for People Intending to Travel Abroad • Greenwich CCG prescribing guidelines and pathways

The team provides an advisory role to GP practices and associated providers in raising awareness of their responsibilities with regard to the care, custody, prescribing and administration of medicines. The team communicates regularly with GP practices and patient/public forums to promote medicines optimisation within Greenwich. We aspire to improve equitable access by adopting the South East London Treatment Access Policy including the Individual Funding Requests by: Transparency in approvals for treatments and procedures for which restricted access

criteria have been agreed Individual Funding Requests are assessed and approved with a clearly defined and

coordinated approach to ensure that the resources are used in an equitable and effective way and that clear, consistent and fair procedures are in place. These are based on the principles of cost effectiveness as stipulated in the Individual Funding Requests policy.

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Medicines Management Security The core function of the CCG’s Medicines Management Team is to ensure there is safe and effective use of medicines for the benefit of patients treated within Greenwich. Our Medicines Policy is an overarching corporate policy that supports us to establish the principles for medicines security. It provides assurance to the organisation by assisting the users to implement the statutory requirements and guidance issued by various official bodies including Department of Health, National Institute for Health and Care Excellence and professional bodies. Patients and clinicians such as GPs, non-medical prescribers and other providers are also supported by a range of other policies, pathways and protocols published by the CCG. These include:

• Controlled Drugs Policy: we monitor controlled drug prescribing, support in incident reviews and policy implementation. It therefore provides confirmation of our compliance with the Misuse of Drugs Act 1971, Schedule one to five.

• Repeat Prescribing Policy: we offer training to clinical and non-clinical staff to prevent errors, to minimise wastage, improve access to medicines and work within the sphere of medico-legal implications of prescribing medicines.

• Prescribing Policy for People Intending to Travel Abroad and Private Patients: we ensure NHS resources are adequately utilised and patient care and the clinician’s role is not compromised.

• Interface Prescribing Policy : we ensure providers adhere to the guidance contained within the following circulars and supporting documents: EL(91)127 ’Responsibility for prescribing between hospitals and GPs’ EL(94)72 ‘ Purchasing and Prescribing’ EL(95)5 ‘ Purchasing high-tech health care for patients at home Development of the “RED list” (hospital only medicine list for South East

London CCGs) Development of transfer of care and shared care documents.

• Excessive and inappropriate prescribing policy: assurance is provided by ensuring

prescribers are following the professional guidance on standards of practice as stipulated in the General Medical Council, Good Medical Practice (2013)

• We also endeavor to uphold medicines security by regular communication via:

Prescribing Newsletters Quarterly prescribing reports Reports on unlicensed medicines CCG Medicines Management website page

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Clinical Effectiveness We have been working hard during 2016/17 to use soft intelligence, to encourage a culture of openness and transparency and ensure shared learning across organisations. The CCG works to ensure soft intelligence is used, together with data from Complaints/MP enquiries/Freedom of Information and Ombudsman Reports. Regular compliance reports are provided to the Quality Committee, Greenwich Executive Group and the Governing Body. We have two key systems, The Quality Alert Management system and The Provider Assurance Monitoring System. Quality Alert Management System The Quality Alert Management System (QAMS) relies on GP practices identifying one or more individuals (usually GPs and practice managers but also administrative staff and healthcare professionals) to log in and raise an alert to the CCG when an issue occurs related to the quality of a service supplied by one of our provider organisations. Traditionally the CCG has relied on receiving intelligence from a small number of high-reporting GP practices. The intention was to get all practices using a simple web form to quickly inform the CCG of any quality concerns. The system uses a short, easy-to-use web form to submit the alert rather than having to download the quality alert template off the intranet and email it to the CCG. QAMS also benefits providers such as Lewisham and Greenwich NHS Trust and Oxleas NHS Foundation Trust who have logins into the system and are able to deal with alerts more quickly. GP practices benefit by being able to have a more comprehensive overview of the alerts they raise and the themes of the alerts raised by their peers. Examples of the benefits of using QAMS: • It has highlighted the problems GPs’ experience in accessing the Primary Care Plus

service for their patients when in mental health crisis. This resulted in the provider agreeing to undertake a deep dive audit into the service with a report and recommendations for implementation.

• GPs have raised issues about Lewisham and Greenwich NHS Trust’s post vasectomy

patients not having follow-up arrangements for semen analysis. Patients are being instructed to consult their GPs for their follow ups. The Trust has been contracted to provide the complete service and so should undertake the follow up. The matter was brought to the attention of the Trust and reinforced with the Urology consultants and their teams to make sure that patients follow the correct pathway.

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The Provider Assurance Monitoring System The development of a Provider Assurance Monitoring System (PAMS) sought to improve quality, safety and safeguarding in nursing homes across Greenwich providing insight into the most vulnerable members of our community. Members of our Quality Team continue to undertake site visits to nursing homes as appropriate to get a first-hand view of the quality of care and gain additional assurance of patient safety. We monitor the quality of care at our local A&E and this is systematically reported through an Emergency Department dashboard at the Clinical Quality Review Group. Our providers develop clinical effectiveness through: • Aligning the three quality domain areas of patient experience, patient safety and

clinical effectiveness to their annual Quality Account Report priorities and linking it to the National Outcomes Framework five domains.

• Linking quality plans and strategies to national and local priorities. • Quality improvement and innovation goals being agreed with commissioners in line

with contracts • Setting out nursing strategies of both Trusts to improve clinical effectiveness and

outcomes • Opportunities for staff to engage in sharing best practice and contribute to the further

development of models of care • Opportunities for staff to participate in research and clinical audit The Clinical Quality Review Groups receives regular reports for clinical audit and assurance of compliance with NICE guidance. These provide assurance to commissioners of the safety and clinical effectiveness of services. Integrated Governance Scorecards have been developed that include clinical effectiveness and key performance indicators linked to this.

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Patient and Public Involvement The CCG recognises the importance of shaping and designing local services with the active involvement of local people and patients. We know that excellent engagement will help us to better understand our communities and how we can best develop and support resilience and better respond to needs. We hold Governing Body meetings in public and before each of these we have a public forum where we extend an open invitation to local people to start a discussion with us on any matter. All Governing Body agendas and papers are published on the CCG website. Our strategic partners, Healthwatch Greenwich, are co-opted members and we have an engagement champion and a lay member on the Governing Body with responsibilities for patient and public involvement. Our Patient Participation Group is a dedicated group established to oversee delivery of our engagement strategy. We also use existing networks, channels and groups as forums for discussion and to advise us on our plans. We have strong links with Healthwatch Greenwich, Greenwich Action for Voluntary Services (GAVS), the Royal Borough of Greenwich and other local groups. We have an established Patient Reference Group made up of members of local Patient Participation Groups to advise the CCG and provide assurance that the CCG has met its statutory obligations pertaining to patient involvement and engagement. Our post engagement activity reports are available on the Greenwich CCG website. We have conducted targeted engagement activities with patients and carers affected by service changes as well as having undertaken events and outreach to the populace of Greenwich to obtain feedback about their local NHS experiences. As commissioners we have ambitious aspirations to put patients, carers and local people of Greenwich at the heart of our commissioning. We recognise that we have fallen short of our aspirations this year especially on some of our work to reduce our expenditure as part of Quality, Innovation, Prevention and Productivity programme, e.g. on decommissioning the Stroke Association and The Source as well as our plans to commission a Musculoskeletal service where our consultation was very limited. We know that we still have a long way to go to improve our patient participation activity. The CCG, however, has committed itself to strengthening its on-going cycle of patient and public engagement. We understand that this is vital to improving standards of local health care and reducing health inequalities in our borough. We recognise that our NHS assessment at ‘Needs Improvement’ was a fair reflection of our year and we are committed to doing much better in 2017/18. Since September 2016 we have held a Public Consultation into changing access to planned surgery and some treatments consulting and engaging residents across the borough as well as online and through social media. We organised two workshops on our Commissioning Intentions with individuals and voluntary sector representatives to ensure that Greenwich CCG’s clinical priorities are influenced by the real life experiences of local residents. We have also launched a series of themed, bi-monthly Patient Forums to enable the CCG to listen to diverse patient and public voices in the community on an on-going basis. We gather information on patient satisfaction from a wide range of sources including national

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and local survey programmes as well as through our quality and complaints monitoring systems. Quality and contract meetings with our providers provide opportunities to discuss issues in detail, identifying trends and assuring ourselves that the experience of our patients is being used to drive quality improvements. We continue to produce regular briefings and reports for MPs, councilors and for the Royal Borough of Greenwich at Healthier Communities and Adult Social Care Panel and the Children and Young People Scrutiny Panel. These Committees examine the planning and delivery of health and social care services and review matters relating to the health and wellbeing of local people. Their remit covers both NHS and council services, including provision at local hospitals and in the community, mental health services, and social care and public health issues. Greenwich CCG works closely with GP members to shape local health care services.

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Clinical Engagement As a GP membership organisation, it is important that we obtain the views of our GP members on commissioning decisions and proposals. We do this in a number of ways, e.g. by inviting members to meetings, responding to feedback on briefings and surveys, meeting regularly with the four GP Syndicate Leads to get feedback from their members and sending regular emails. Feedback from the GP membership has been extremely important during 2016/17 due to the large Quality, Innovation, Productivity and Prevention (QIPP) programme that the CCG has been working on in order to address managing demand on services and reduce our spending to meet our budget. A number of commissioning workshops have been held which our GP Clinical Project Leads and Syndicate Leads have been invited to attend. These workshops have covered planned and urgent care and each of these areas has an assigned GP Clinical Project Lead who works closely with the CCG’s commissioning staff to ensure clinical input into the design and decision making element of Quality, Innovation, Productivity and Prevention. Service Areas covered by GP Clinical Project Leads

• Planned Care • Urgent Care • Primary Care • Children and Maternity • Health and Wellbeing • Local Care Networks • Independent Funding Requests • Long Term Conditions • Cancer and End of Life • Mental Health and Learning Disabilities • Medicine Management • IT & Business Intelligence • Quality The Greenwich-wide Forum meetings, which are held quarterly, provide the opportunity for members to be briefed on a wide range of issues including Quality, Innovation, Productivity and Prevention schemes. The meetings also invite local providers and South East London commissioners to attend. An example of this was the presentation from ‘Our Healthier South East London’ on the consultation on planned orthopedic services in South East London in which our GPs were given the opportunity to raise questions and give clinical support to the proposals.

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Working together: Our Healthier South East London Our Healthier South East London – the Sustainability and Transformation Plan for south east London covers Bexley, Bromley, Greenwich, Lambeth, Lewisham and Southwark, and the NHS providers in the area. In December 2015, NHS organisations in 44 areas of England were asked to work together to produce a five-year plan (up to March 2021) to implement the NHS Five Year Forward View. These plans are called Sustainability and Transformation Plans (STPs). Our STP is called Our Healthier South East London. It has evolved from the commissioner-led strategy, our healthier South East London, which was established in 2013, into a partnership between local commissioners and providers, working with local authorities, patients and the public. The STP is not a blueprint for the next five years but rather is a series of plans for different clinical areas that are at different stages of development but which will all contribute to delivering the plans set out in the 5 Year Forward View. The STP (full version and summary) was published on 4 November 2016 and was one of the first in the country to be made public. The plan aims to address a number of challenges, including: • a growing and ageing population living with long term conditions like diabetes, high blood

pressure and mental illness • quality of care and outcomes of treatment differs depending on when and where people

access services • patient experience differs and some people find it difficult to get an appointment or feel

they do not have enough information about their condition • NHS funding increases in line with inflation but the costs of providing care are rising much

faster – which, at the moment, could mean an overspend for south east London of around £1bn by 2021 if we were to do nothing.

• Our plan is designed to help us avoid spending more than we receive, while making sure services are high quality, more joined up and available closer to home.

What does the plan mean for local people? View the South East London Sustainability and Transformation Plan on the CCG website http://www.greenwichccg.nhs.uk/Get-Involved/Our-Healthier-South-East-London/Pages/default.aspx The South East London Sustainability and Transformation Plan gives a greater detail but a sample of benefits listed here include; • Better community based care including: extra £7.5 million a year to ensure that people in

south east London can book a GP at a time that suits them – including more evening and weekend slots.

• No closures of any A&E and maternity departments – we want to make sure they all meet high standards of care in the future.

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• Better maternity care – dedicated midwives supporting mothers throughout pregnancy, better advice and choice on birth options.

• Developing word-class orthopaedic services – fewer cancelled operations, shorter waiting times and more procedures carried out. Detailed work is underway to refine proposals to develop elective orthopaedic centres, which could mean consolidating planned adult procedures onto two or three sites. More material is being developed to allow the public to consider the pros and cons of both options. A public consultation may then take place in 2017.

• Faster cancer diagnosis – new £160 million purpose built cancer centres at Guy’s Hospital and £30 million centre at Queen Mary’s Sidcup, launch of dedicated oncology support phone line, dedicated clinical nurse specialists for all patients.

• All the different parts of local health and care services working together to use available money and resources in the best way possible - helping us avoid a £1bn overspend by 2021.

Have local people been involved? The models of care developed through Our Healthier South East London are the product of several years of partnership working between clinicians, commissioners, council social care leads, local hospitals, and have been informed by extensive engagement with local communities, patients and the public. Engagement activity to date includes a series of events in each borough, publication of an ‘issues paper’ and ‘emerging thinking’ paper setting out the challenges we face and ideas to tackle them, 2-3 patient and public voices and Healthwatch representatives on each of our clinical work streams and a programme of local engagement in each borough. We have also carried out a series of equalities analysis and created a dedicated Equalities Steering Group to ensure our work takes account of equalities issues. Our approach has been informed and endorsed by The Consultation Institute, who advise on best practice engagement at national level. The engagement programme was also shortlisted for a national award by the Association of Healthcare Communications and Marketing (AHCM). During 2017, we aim to extend the reach of our conversations, inviting more local people and interest groups to find out about our developing plans and contribute their views. A six-month programme of ‘civic engagement’ – a dialogue with the people of south east London – will be launched in March. This will create more opportunities for local people to hear about the plans direct from NHS leaders and tell us what they think. All of south east London engagement activity and information on how we use feedback is routinely published on our website. You can find out how to get involved by visiting www.ourhealthiersel.nhs.uk.

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Equality and Diversity Equality, Diversity & Human Rights Obligations Control measures are in place to ensure that the CCG complies with the required Public Sector Equality Duty as set out in the Equality Act 2010. Through these the CCG aims to: • Improve access and involvement to all services for all public, patients, carers and seldom

heard groups • Develop and implement twenty first century integrated, patient-focused health and care. • Reduce health inequalities through a targeted approach • Achieve better outcomes for all • Understand what constitutes a good patient experience • Continue to develop an inclusive working culture and ensure the CCG values are

incorporated in to all the work we do • Empower, engage and support our staff • Achieve an inclusive leadership at all levels. All Greenwich CCG’s Policies and Procedures include an equality statement and all decisions made by the CCG undergo an equalities impact check list and full equality analysis, where appropriate. This states that Greenwich CCG will have due regard for the need to eliminate unlawful discrimination, promote equality of opportunity, and provide good relations between people of diverse groups, in particular on the grounds of the nine characteristics protected by the Equality Act 2010. The learning from 2016-17 will be taken forward to strengthen the equality impact and analysis to achieve more timely and informed decisions in commissioning health services. Our Communities It is essential that we know our local population in Greenwich well as this allows us to make informed commissioning decisions; they are a major source of evidence for decision-making and ensure that equality and diversity intelligence inform our decisions. Our overarching operational plan has been derived from key strategies. These include a joint health and wellbeing strategy, which identifies three key imperatives: • a focus on prevention as the most cost effective approach to health and wellbeing • the need for new approaches to tackling health inequalities • greater integration in the commissioning and delivery of local services Additionally The Joint Health and Wellbeing Strategy together with the Borough’s Joint Strategic Needs Assessment (JSNA), together forms our integrated plan that sets out our priorities and associated commissioning intentions. These documents have therefore been used as a major source of data when setting and aligning our equality objectives.

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We are committed to engaging with all relevant communities and demonstrate the work carried out to reduce health inequalities thereby improving health outcomes for those from the nine protected characteristics groups. Equality is central to the CCG, both internally and externally, to ensure that all staff are considered in engagement. A Staff Health and Wellbeing Group has been established within the CCG to inform policies and procedures, appraisal and performance, organisational development, and health and wellbeing. The CCG is committed to ensuring that staff are recruited and retained from all diverse backgrounds, provided with a positive and valuing work environment and given training and support to achieve their maximum career development potential. Collection and analysis of workforce statistics by groups of staff with protected characteristics have been an important area of Greenwich CCG’s equalities agenda for 2016-17. The CCG completed its first Workforce Race Equality Standards annual return and produce a detailed Workforce Race Equality Standards Action Plan. As a result Unconscious Bias Training for CCG employees for staff specifically involved in the recruitment of new staff and those responsible for line management has been developed to enable a fairer shortlisting and interview process. The Workforce Learning and Development platform has been introduced which enables a central system to hold data on mandatory and non-mandatory training agreed in personal development plans. The collection of data on the workforce by ethnicity which will cover both workforce data and staff survey data. To enable data analyses on staff employed and regular reports on workforce to Greenwich Executive Group Public Sector Equality Duties The Public Sector Equality Duties consists of both general and specific duties. The broad aim of the general equality duty is to integrate consideration of the advancement of equality into the everyday business of all bodies subject to the duty. The general equality duty is intended to accelerate progress towards equality for all, by placing a responsibility on bodies subject to the duty to consider how they can work to tackle systemic discrimination and disadvantage affecting people with particular protected characteristics. The first aim of the general equality duty is to have due regard to the need to eliminate discrimination, harassment, victimisation and any other conduct prohibited by the Act because of any of these protected characteristics. Race Disability Sex Age Religion or belief Sexual orientation

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Gender reassignment Pregnancy and maternity

The second aim of the duty requires the CCG to have due regard to the need to minimise or remove disadvantages, to take steps to meet the different needs of people with different protected characteristics and to encourage participation in activities by those whose participation is disproportionately low. Meeting the Public Sector Equality Duties in 2016/17 The challenges to make NHS services inclusive and ‘fit for purpose’ for Greenwich’s diverse population cannot be underestimated, particularly within the current financial constraints on health and social care expenditure. In this respect, our focus for 2016/17 was to consolidate our equality, human rights and health inequalities work. Protecting human rights and promoting inclusion are integral to our core business and as such are reflected throughout everything that we do. The Equality Act 2010 provides a legal framework to strengthen and advance equality and human rights. The Act consists of general and specific duties. The general duty requires public bodies to show due regard to: • Eliminate unlawful discrimination • Advance equality of opportunity • Foster good relations We must comply with this general duty when ‘exercising a function’, when formulating policy and to any decisions made in applying policy in individual cases. Compliance with the duty should result in: 1. Better-informed decision-making and policy development 2. Clearer understanding of the needs of service users, resulting in better quality services

which meet varied needs 3. More effective targeting of policy, resources and the use of regulatory powers 4. Better results and greater confidence in, and satisfaction with, public services 5. A more effective use of talent in the workforce 6. A reduction in instances of discrimination. Equality Objectives 2017/21 As part of the Public Sector Equality Duty of the Equality Act 2010, The CCG has reviewed it Equality and Diversity Strategy and have developed new equality objectives for 2017/2021. The purpose of setting objectives is to strengthen our performance against this general equality duty. The CCG will focuses on the things that matter the most for patients, communities and staff, with an emphasis on genuine engagement, transparency and the effective use of evidence. The development of the equality objectives has been aligned to the business of the organisation and aligned with the Equality Delivery System goals and outcomes. To meet our specific duties, we are required to publish relevant proportionate information showing how we meet the Public Sector Equality Duties by 31 January each year, and set specific measurable

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equality objectives by 6 April every four years. The equality objectives, therefore, are not nationally driven, but reflect local equality priorities for the community. They reflect the key equality priorities pertinent at that time. Our most recent equality objectives report can be found on our website: http://www.greenwichccg.nhs.uk/News-Publications/news/Musculoskeletal%20service/Greenwich%20CCG%20Equality%20and%20Diversity%20Strategy%202017-2021.pdf The Equality Delivery System (EDS2) We have also implemented the Equality Delivery System (EDS2), which is the NHS’ equalities reporting framework. This helps us to identify what we are doing well, what we need to improve on, and the equality gaps/risks that we need close or mitigate. It is a comprehensive analysis focusing on four goals (better health outcomes, improved patient access and experience, a representative and supported workforce, and inclusive leadership) measured against eighteen equality and health inequalities outcomes. Like most other CCG’s, we have taken a two-stage approach to implement EDS2. During Stage One, we self-assessed our ‘RAG’ rating on the progress made against EDS2’s four Goals and 18 Outcomes. A draft of our stage one self-assessment report includes what evidence exists to support the RAG rating, equality gaps and actions that may need to be taken to ensure that we are heading in the right direction. Stage two involved working with local organisations, to take critical feedback on our self-assessed RAG rating and have now published an agreed EDS2 RAG rating and action plan. Introducing the EDS2 to our key stakeholders means that we will have in place a partnership approach that will enable a monitoring and evaluating process for our staff and key stakeholder user groups. The EDS2 Scores are based on parameters such as the level of engagement being undertaken across different ‘protected’ groups, whether the issue has been mainstreamed and whether progress plans are in place. This year the CCG has received feedback from its stakeholders on its EDS2 self-assessment and has amended its overall rating from Green (Achieving) to Amber (Developing). This was due to the evidence that was presented in relation to commissioned services did not meet the requirements of EDS2. The evidence should be objective and specific regarding the different protected characteristics. Very little of the evidence the CCG provided made reference to, or identified, any community within the nine protected characteristics. There was no evidence of consideration of varying health needs of different communities or accessibility requirements. Therefore the CCG cannot fully assure itself that the EDS2 outcomes are reported for all protected characteristic groups. Whilst we can reasonably evidence this in regard to our key providers Lewisham and Greenwich NHS Trust and Oxleas NHS Foundation Trust we cannot claim the same for our smaller providers.

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The EDS2 Action Plan for 2017-18 now takes into account these equality gaps and risks identified in the EDS2 summary report and external stakeholder assessment. The NHS Greenwich CCG full Equality Report 2016/17 can be found on the CCG website.

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Emergency Preparedness, Resilience and Response Along with other CCGs, we were required to submit our Emergency Preparedness, Resilience and Response (EPRR) Assurance to NHS England in October 2016. Once reviewed, feedback was given to all of the CCGs in south east London that: • Significant progress has been made over the past twelve months in many

organisations • There is an obvious and significant commitment by the South CCGs to EPRR.

Following this review Greenwich CCG was rated as having ‘substantial compliance’, which provides assurance that the plans and work programme in place appropriately address the core standards for EPRR that we are expected to achieve.

The CCG action plan submitted has two outstanding actions for areas rated amber: Core Standard Outstanding

Action to be taken Timeframe for completion

Lead

Have arrangements in place to manage a fuel shortage

Action plan to be drawn up for 17/18

30 April 2017 EPLO Director of Quality and Integrated Governance

To ensure that the CCG, any providers they commission and any sub-contractors, have robust business continuity planning arrangements in place aligned to ISO22301

Collate evidence that all providers have robust Business Continuity arrangements in place

30 June 2017 EPLO Director of Quality and Integrated Governance

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Exercises and Training Our staff undertook a range of training and exercise initiatives to support EPPR during 2016 as follow: Date Exercise Attended by: 18.03.16 Call Cascade to all staff

Director of Integrated Governance

03.05.16 Call Cascade to all staff

Director of Integrated Governance

29.06.16 Call Cascade to all staff

Director of Integrated Governance

06.12.16 RBG Multi-agency desktop Pandemic Flu exercise

17.02.17 Tube Strike forward planning – to ascertain if there would be enough staff that could get to work on day of strike

EPLO

28.03.17 RBG Multi-agency desktop exercise Major Accident Hazard Pipeline

EPLO

Signed on behalf of the Governing Body Joanne Murfitt Chief Officer

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SECTION 2: ACCOUNTABILITY REPORT

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Members’ Report Our members These are the member practices which form the membership body of the CCG: Blackheath & Charlton Excel (Plumstead and Abbeywood) Blackheath Standard Surgery Abbeywood Surgery Burney Street Practice All Saints Medical Centre Greenwich Peninsula Practice Bannockburn Surgery Manor Brook Medical Centre Basildon Road Surgery Plumbridge Medical Centre Clover Health Centre South St Medical Centre Glyndon Medical Centre The Fairfield Centre Mostafa PMS Vanbrugh Health Centre Plumstead Health Centre Woodland Walk Surgery Tewson Road PMS The Slade Surgery The Waverley Practice Triveni PMS Eltham Network (Woolwich and Thamesmead) Alderwood Surgery Conway PMS Briset Corner Surgery Ferryview Health Centre Dr Baksh The Coldharbour Surgery Gallions Reach Health Centre Dr S Ratneswaren Practice Royal Arsenal PMS Eltham Medical Practice St Marks Medical Centre Eltham Palace Surgery Thamesmead NHS Health Centre Eltham Park Surgery The Trinity Medical Centre Henley Cross Medical Centre New Eltham Medical Practice Sherard Road Medical Centre The Mound Medical Centre Westmount Surgery

Practices are formed in four syndicates: Blackheath and Charlton, Eltham, Excel and Network. Each syndicate covers a geographical area and practices within the syndicate are encouraged to work together through peer review and regular meetings. Each practice has signed the CCG’s Constitution. The CCG’s Constitution states how member practices should be engaged through regular syndicate meetings and with the GP Executive through the Greenwich-wide Forum meetings that take place quarterly. There is a requirement to appointment a GP Syndicate Lead for each of the four syndicates who are voted in by the members of their syndicate. Syndicate Leads act as the conduit between the CCG and its GP membership body to deliver messages and get feedback on commissioning decisions. Syndicate meetings are held bi-monthly in line with the Constitution and the four GP Syndicate Leads meet monthly with the GP Executive. An example of member engagement was the decision by the membership made in October

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2016 for the CCG to apply to take back delegated responsibility from NHS England for managing GP contracts with effect from 1 April 2017. This will enable the CCG to put in place a more local approach on enhanced primary care services that will meet the needs of our population. The table below demonstrates the growth in GP list sizes. This growth is expected to continue to increase as the local re-generation programme that is in place across the Royal Borough of Greenwich progresses. New housing and businesses are being created and this will put more demands on primary care services.

Additional resources are being made available to primary care through funding being released from the General Practice Forward View which was published in April 2016. This document highlighted the challenges for primary care due to growing demand and the need to provide more care in the community. Funding has been targeted at building resilience in general practice through addressing areas around workforce, education and training, increasing the use of technology and addressing estate issues. The four GP syndicates have formed Limited Liability Partnership Groups which will enable the practices to work at scale. Our GP members now have the opportunity to be much more engaged in working in partnership with local health and social care providers in developing Local Care Networks within their geographical boundaries.

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Executive Committee The Executive Committee consists of the GP Executive (elected Governing Body members) and the CCG senior management team and is made up of the following staff: Name Role GP Executive Dr Sylvia Nyame GP elected member Dr Nayan Patel GP elected member Dr Ranil Perera GP elected member Dr Sabah Salman GP elected member Dr Krishna Subbarayan GP elected member Dr Hany Wahba GP elected member Dr Ellen Wright GP elected member and

Chair of the Governing Body Senior Management Team Annabel Burn (until 31.10.17) Chief Officer Ian Fisher (until 3.2.17) Interim Chief Finance Officer Simon Hall (until 3.5.16)

Deputy Chief Officer / Director of Strategy & Performance

Diane Jones (until 10.2.17) Director of Integrated Governance Yvonne Leese (from 13.3.17)

Director of Quality and Integrated Governance

David Maloney (from 20.2.17) Chief Finance Officer Joanne Murfitt (from 1.11.16) Chief Officer Regina Shakespeare (until 31.10.16)

Interim Turnaround Director and interim Director of Delivery & Service Transformation

Samantha Jones (until 8.2.16) Director of Commissioning Liz James (from 20.6.16) Interim Director of Commissioning

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Governing Body The Governing Body oversees the delivery of the CCG’s commissioning plan, sets and leads the strategy for the CCG, and is accountable for the delivery of Greenwich CCG’s functions as a statutory body. It monitors performance against objectives, provides effective financial stewardship and makes sure that high standards of corporate governance are achieved. Having GPs and other clinical members of the Governing Body ensures patients are at the forefront of all decisions. The Governing Body meets on alternate months in public, with extra meetings as necessary; the papers and the minutes of the meetings are published on the CCG website. All meetings have declarations of interests as an agenda item and these are recorded. All members are required to record any interests relevant to their role on the Governing Body. The register of interests is a public document which is open to public scrutiny and published on the CCG website. The composition of the Governing Body in 2016/17 (including advisory and non-executive members) is as follows:

Name Role

Maggie Buckell Registered Nurse on the NHS Greenwich CCG Governing Body Annabel Burn (until 31.10.16)

Chief Officer

Ian Fisher (until 3.2.17)

Interim Chief Financial Officer

Councillor David Gardner

Local Authority Member on the NHS Greenwich CCG Governing Body

Simon Hall (until 3.5.16)

Deputy Chief Officer and Director of Strategy and Performance,

Liz James (from 20.6.16) Interim Director of Commissioning

Diane Jones (until 10.2.17) Director of Integrated Governance

David Maloney (from 20.2.17)

Chief Financial Officer

Joanne Murfitt (from 1.11.16)

Chief Officer

Dr Sylvia Nyame GP Member of the NHS Greenwich CCG Governing Body Dr Nayan Patel GP Member of the NHS Greenwich CCG Governing Body Dr Ranil Perera GP Member of the NHS Greenwich CCG Governing Body Dr Sabah Salman GP Member on the NHS Greenwich CCG Governing Body Regina Shakespeare (until 31.10.16)

Interim Turnaround Director and Acting Director of Commissioning

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Name Role Dr Krishna Subbarayan

GP Member on the NHS Greenwich CCG Governing Body

Dr Greg Ussher Lay Member on the NHS Greenwich CCG Governing Body

Dr Iyngaran Vanniasegarum

Secondary Care doctor on the NHS Greenwich CCG Governing Body

Dr Hany Wahba GP Member of the NHS Greenwich CCG Governing Steve Whiteman Director of Public Health, Royal Borough of

Greenwich Public Health and Wellbeing and Member of the NHS Greenwich CCG Governing

Jim Wintour Lay Member on the NHS Greenwich CCG Governing Body

Dr Ellen Wright Chair and GP member of the NHS Greenwich CCG Governing Body

Richard Rice (from 20 March 2017)

Lay Member and Conflict of Interest Guardian

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Governing Body Members’ Attendance at Governing Body Meetings 2016/17

Standing Order 3.8.1 states that “Members must attend at least 75% of meetings of the Governing Body”. Where this is not possible the Chair must be satisfied as to the reasons. Key: E = Extra Meeting P = Public Meeting, = Not required to attend the meeting

27.4 D

25.5 P

29.6 E

27.7 P

31.8 D

21.9 P

28.9 AGM

26.10 D

30.11 P

21.12 D

25.1 P

22.2 E

% Attendance

Maggie Buckell Y N Y Y N Y Y Y Y Y Y Y 83% Annabel Burn (to 31.10.16)

Y Y Y Y N Y Y N 75%

Ian Fisher (until 3.2.17)

Y Y N Y Y Y Y Y Y Y Y 91%

Councillor David Gardner

Y Y Y Y Y Y Y Y Y N Y N 83%

Liz James (from 20.6.16)

Y Y N Y Y N Y Y Y Y 78%

Diane Jones (until 24.2.17)

Y Y Y Y Y Y Y Y Y Y Y N 92%

David Maloney (from 20.2.17)

Y 100%

Joanne Murfitt (from 1.11.16)

Y N Y Y 75%

Dr Sylvia Nyame

Y Y Y Y Y Y Y Y Y Y Y Y 100%

Dr Nayan Patel Y Y Y Y N Y N N Y Y Y Y 75% Dr Ranil Perera Y Y Y N Y Y Y Y Y N Y Y 83% Dr Sabah Salman

Y Y Y Y Y N N Y Y Y Y Y 83%

Regina Shakespeare (to 2.11.16)

Y Y Y Y Y Y N Y 88%

Dr Krishna Subbarayan

Y Y Y Y N Y N N Y- P2

N Y Y 67%

Dr Greg Ussher Y Y Y Y Y N N Y Y Y Y Y 83% Dr Iyngaran Vanniasegarum

Y Y Y Y N Y Y Y Y Y Y Y 92%

Dr Hany Wahba Y Y Y Y N Y Y Y Y Y Y Y 92% Steve Whiteman

Y Y N Y N Y Y Y Y Y Y Y 83%

Jim Wintour Y Y Y Y Y Y Y Y Y Y Y Y 100% Dr Ellen Wright Y Y Y Y Y N Y Y Y Y Y Y 92% Richard Rice Y 100%

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Statement on disclosure to auditors The Governing Body is not aware of any relevant audit information that has been withheld from the clinical commissioning group’s external auditors, and members of the Governing Body have taken all necessary steps to make themselves aware of relevant information and to ensure that this is passed to the external auditors where appropriate.

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Statement of Accountable Officer’s Responsibilities The National Health Service Act 2006 (as amended) states that each CCG shall have an Accountable Officer and that Officer shall be appointed by the NHS Commissioning Board (NHS England). NHS England has appointed the Chief Officer to be the Accountable Officer of Greenwich CCG. The responsibilities of an Accountable Officer, including responsibilities for the propriety and regularity of the public finances for which the Accountable Officer is answerable, for keeping proper accounting records (which disclose with reasonable accuracy at any time the financial position of the CCG and enable them to ensure that the accounts comply with the requirements of the Accounts Direction) and for safeguarding the CCG’s assets (and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities), are set out in the CCG Accountable Officer Appointment Letter. Under the National Health Service Act 2006 (as amended), 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 Manual for Accounts issued by the Department of Health and in particular to: • Observe the Accounts Direction issued by NHS England, including the relevant accounting and

disclosure requirements, and apply suitable accounting policies on a consistent basis; • Make judgments and estimates on a reasonable basis; • State whether applicable accounting standards as set out in the Manual for Accounts 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 concern basis. To the best of my knowledge and belief, I have properly discharged the responsibilities set out in my CCG Accountable Officer Appointment Letter. I also confirm that:

• as far as I am aware, there is no relevant audit information of which the entity’s auditors are unaware, and that as Accountable Officer, I have taken all the steps that I ought to have taken to make himself or herself aware of any relevant audit information and to establish that the entity’s auditors are aware of that information.

• the annual report and accounts as a whole is fair, balanced and understandable and that I take personal responsibility for the annual report and accounts and the judgments required for determining that it is fair, balanced and understandable

Joanne Murfitt Chief Officer, NHS Greenwich CCG Date: 23 May 2017

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Annual Governance Statement Introduction & Context The CCG was licensed from 1 April 2013 under provisions enacted in the Health & Social Care Act 2012, which amended the National Health Service Act 2006. As at 1 April 2014, the CCG was licensed without conditions. Scope of Responsibility As Accountable Officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of CCG’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 in my CCG Accountable Officer Appointment Letter. I am responsible for ensuring that the CCG is administered prudently and economically and that resources are applied efficiently and effectively, safeguarding financial propriety and regularity. Quality of Leadership Indicator The year-end results for the Quality of Leadership Indicator will be available on MyNHS (Quarter 2 2016/17) from July 2017 at: www.nhs.uk/service-search/scorecard/results/1175 Compliance with the UK Corporate Governance Code We are 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. Governance Framework The National Health Service Act 2006 (as amended), at paragraph 14L (2) (b) states:

The main function of the Governing Body is to ensure that the group has made appropriate arrangements for ensuring that it complies with such generally accepted principles of good governance as are relevant to it.

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Greenwich CCG is responsible for the procurement of services on behalf of the residents of Greenwich. We are responsible for creating suitable arrangements with providers of services that are in the best interests of the service users, and also represent value for money. Considering the complexity and range of services offered it is vital that we have a governance structure with sufficient delegation to ensure that decisions can be made but also sufficient oversight to prevent any deviation from the statutes of the constitution. Greenwich CCG is accountable for exercising its statutory functions. It may delegate authority to act on its behalf to:

• any of its members • the Governing Body • employees • any Committees or sub-committees established by Greenwich CCG for the purpose

of exercising its statutory functions.

The extent of the authority of the respective bodies and individuals depends on the powers delegated to them by Greenwich CCG as expressed through: 1. Its Scheme of Reservation and Delegation ; and 2. for committees, their terms of reference

The Scheme of Reservation and Delegation sets out: 1. Those decisions that are reserved for the membership as a whole 2. Those decisions that are the responsibilities of the Governing Body (and its Committees),

and sub-committees, individual members and employees.

However, Greenwich CCG remains accountable for all of its functions, including those that it has delegated. Greenwich CCG has a robust corporate governance structure with the roles and responsibilities of the members of the Governing Body and supporting Committees clearly set out. Greenwich CCG uses a number of Committees to provide challenge and assurance over specific areas, for example Quality, Improvement, Productivity and Prevention (QIPP) delivery through the Financial Performance and QIPP Committee. All committees have been formed with a membership that provides a sufficient range of skills, including clinical expertise and lay membership, to provide effective management and oversight. The Committees are referenced within the NHS Greenwich CCG Constitution, including new joint arrangements that have been approved by the Governing Body such as Joint Collaborative Arrangements and the Primary Care Commissioning Committee as illustrated below in Table 1.

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Greenwich CCG Governance Framework

The performance of the Governing Body includes development workshops held throughout the year with external facilitation. All GP Governing Body members and the Chief Officer have a review halfway through the year and an appraisal at the end of the year with the CCG Chair. Governing Body Officers, i.e. the Chief Finance Officer and all Directors have an appraisal with the Chief Officer. GP Syndicate Leads and Clinical Project Leads (CPLs) meet with their GP Executive through a formal clinically led meeting to review performance as well as support and guidance outside of the meeting, e.g. to develop and lead on QIPP programmes. The NHS England CCG 360 degree stakeholder survey is undertaken annually. Audit Committee Highlights • Approved an annual internal audit plan with KPMG to provide the Audit Committee and

Governing Body the assurance that Greenwich CCG is operating effectively and productively and monitored any actions arising from the audits.

• Monitored and reviewed financial and other risks and associated controls, corporate governance and financial assurance.

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Quality Committee Highlights • Increased Quality Reporting in year. Monthly Quality Briefing reports to Greenwich

Executive Group and Governing Body; Monthly Integrated Performance Reports; Quarterly Quality Reports to the Governing Body.

• Led the piloting of Quality Risk Profiling Tool with neighboring CCGs, NHS England, Care Quality Commission, NHS Improvement and Oxleas NHS Foundation Trust. This work is now being rolled out nationally. The work was showcased at the Good Governance Institute’s ‘Festival of Governance’ (Sept 2016).

• Maintained a Quality Impact Assessment/Equality Impact Assessment on QIPP business

cases against an ambitious QIPP programme in 2016. • Implemented the Quality Alert Management System and introduced two way reporting (i.e.

from secondary to primary care). • Maintained good oversight of provider quality, including BMI Blackheath Hospital, Out Of

Hours and Urgent Care Centre. • Maintained a programme of site visits by the Quality Team through an agreed protocol for

Quality Monitoring Visits. These have included Queen Elizabeth Hospital Emergency Department, the Urgent Care Centre and Eltham Community Hospital.

• Working with Royal Borough of Greenwich in the monitoring of HCAIs and active work of

the Health Prevention Manager with local practices to ensure effective management of C.Difficile. The CCG has not breached the trajectory set by NHS England for 16/17.

• NHS Greenwich CCG has led the management of the Oxleas NHS Foundation Trust

Clinical Quality Review Group (CGRG); chaired these meetings and developed an annual work programme for the Clinical Quality Review Group across Bexley, Bromley and Greenwich CCGs.

• Addressed Quality Issues and held themed reviews of services with key providers through established Clinical Quality Review Groups. This included for Lewisham and Greenwich NHS Trust: Complaints response rates A&E four hour target challenge cancer referral to treatment performance mortality rates non-compliance with Venous thromboembolism (VTE) standard Friends Family Test response rates Ehlers-Danlos syndrome completion within 24 hours of discharge from hospital Freedom of Information statutory duty

• This included for Oxleas NHS Foundation Trust: Safer staffing levels, reliance on agency

staff and workforce issues, falls and fracture prevention, quality of serious incident

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reporting, management of ‘sleepovers’, quality risks, Healthwatch enter and view reports, management of restraint, sedation and rapid tranquilisation.

• Improved Serious Incident Management and Reporting and lessons learned from serious incidents.

• NHS Greenwich CCG is participating in the ‘Sign Up to Safety’ national initiative as a CCG. This pledges commitment to strengthen patient safety and support key providers in their delivery of Safety Improvement Plans. Oxleas NHS Foundation Trust and NHS Lewisham and Greenwich NHS Trust are part of this initiative.

• Maintained good oversight of adult and child safeguarding and participated in a number of local assessments (e.g. Care Quality Commission conducted a review of child safeguarding and Looked after Children in Greenwich in October 2016).

• Contributed to Quality Summits and agreed action plans from Care Quality Commission assessments with Lewisham and Greenwich NHS Trust, Oxleas NHS Foundation Trust and BMI Blackheath hospital.

Finance, Performance and QIPP (FPQ) Committee

• Provided assurance to the Governing Body that affordable and appropriately budgets

were set. • Effectively monitored the Finance and QIPP Performance throughout 2016/17 and

advised on corrective actions where appropriate. • Maintained the QIPP Planning Delivery & Monitoring Group reporting to the Financial

Recovery Board for QIPP business plans.

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The members of the Governing Body and supporting committees are clearly set out. Our review of committee minutes confirmed that they were operating in accordance with their terms of reference (ToR), with effective review and scrutiny of committee papers and reports. All committees have been formed with a membership that provides a sufficient range of skills, including clinical expertise and lay membership, to provide effective management. The CCG clearly demonstrates its commitment to good governance by including Nolan’s Seven Principles of Public Life within the majority of its committee terms of reference.

Highlighting Areas of Good Practice • The committee structure and individual terms of reference are in line with NHS England

guidance. • The Nolan principles are embedded within the CCGs governance arrangements. • The Risk Register is maintained to a good standard giving adequate details on risks,

controls and action plans in place. • The Governing Body Assurance Framework comprehensively addresses strategic risks

to the organisation. The Risk Management Framework The Risk Management Framework sets out the overarching approach to the management of risk in the organisation. The Governing Body is aware of all significant risks and has sufficient information to enable it to make decisions on the implementation of appropriate controls and the allocation of appropriate resources. The Risk Management Framework outlines definitions, accountabilities and responsibilities of all staff, the risk management process and its governance, including managing risk across organisational boundaries and training.

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All directors and managers are required to identify risks specific to their own activities and circumstances. Risks may be identified from a number of sources, both internal and external. No valid risk will be excluded from the register due to its identification source. Staff are encouraged to be risk aware. The Director of Quality and Integrated Governance maintains a strategic overview of risk. Zero tolerance risks are clearly identified on the CCG’s risk register and in all reporting. The Governing Board Assurance Framework provides the Governing Body with a clear understanding of the principal risks which may affect the achievement of performance objectives for the financial year and therefore informs the Annual Statement of Internal Control declaration. The Governing Board Assurance Framework is formally reviewed at every meeting of the Governing Body and Greenwich Executive Group (monthly basis). Control measures are in place to ensure that obligations under equality, diversity and human rights legislation are complied. The CCG acknowledged feedback from the Greenwich Council Healthier Communities and Adult Social Care Scrutiny Panel that it’s Equality Impact Assessment (EIA) on the decommissioning of the MSK Service in 2016 was not as robust as it could have been. A more detailed Equality Impact Assessment was therefore commissioned The CCG’s Integrated Risk Management Framework sets out the overarching approach to the management of risk in the CCG. The CCG adopted the Risk Management Framework in July 2013. The framework was updated and changes approved by the CCG Governing Body in November 2016. The strategy outlines the CCG’s approach to risk and the manner in which the CCG seeks to prevent, eliminate and control risks and the successful management of the risks that impact most upon the CCG’s objectives. Risk management is embedded within all activities of the CCG. The CCG is able to ensure accountability of risk at all levels of the organisation. The purpose of this framework is to define and document the CCG’s approach to risk and risk management and to: • Enable the Governing Body to have an overview of the risks it faces, taking into

account all aspects of its business • Provide assurance to the Governing Body that action is being taken to mitigate risk to

acceptable levels • Assure the public, patients, practices, partner organisations and staff that the CCG is

managing its risks effectively • Enable the strategic deployment of resources to meet risk, beyond allocations made if

necessary, including financial funding, human resources, capacity and knowledge • Enable constant and consistent improvement of healthcare provision and patient

experience.

Below is the Risk Appetite Statement which was agreed by the Governing Body and is included in the CCG’s Risk Management Framework: NHS Greenwich CCG is working toward a ‘mature’ risk appetite. The CCG has no appetite for financial risk and zero

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tolerance for fraud and regulatory breaches (e.g. safeguarding breaches, poor professional conduct of its staff and information governance [data protection] breaches). Greenwich CCG may take considered risks, where the long term benefits outweigh any short-term losses. The CCG supports well managed risk taking and will ensure that the skills, ability and knowledge are there to support innovation and maximise service improvement. The Governing Body commits to review its risk appetite statement on an annual basis. Zero tolerance risks are clearly identified on the CCG’s Risk Register and in all reporting. All risks are recorded on the Risk Register and clearly identify the responsible director and clinical lead with the levels of risk including actions which should be taken to mitigate the risks. These are reviewed monthly and discussed at appropriate committees. The CCG also identifies and manages risks via internal and external methods such as complaints, claims, serious incidents, audits, patient satisfaction surveys, risk assessments, staff surveys, whistle blowing, new legislation, and review from partnership working. The CCG is responsible for overseeing the commissioning of healthcare and other services from a wide variety of providers. One of the key purposes of the CCG’s risk management process is to ensure that services are commissioned from providers who themselves operate high standards of risk management processes. By ensuring that all staff are aware of their responsibilities in regard to both governance and health and safety, a substantial amount of progress has been made towards ensuring the ownership of risk by staff and the wider membership of each of the sub-committees. The CCG places a 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 that all staff undertake annual information governance training. There are processes in place for incident reporting and investigation of serious incidents. Public Involvement in Managing Risk: We use a variety of patient experience data to understand how different services are performing. Whilst these are individually addressed, a thematic analysis is undertaken on a quarterly basis. The results are presented to the Greenwich Executive Group and the Quality Committee and used to inform our commissioning intentions. There are a number of methods used to ensure our public stakeholders are involved in managing any risks that impact on them: • Quality Alerts raised by GPs and other healthcare professionals on behalf of their

patients. Alongside our ‘Quality Alert’ system, there are many other routes through which the public can make us aware of any concerns. They can raise issues through their GP practice’s Patient Participation Group. All 39 practices have an established patient participation group.

• Lay members sit on the Governing Body and a number of committees. Through their

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attendance they are involved in the review of the Risk Register and challenge/input into the way in which the organisation mitigates those risks.

• The Risk Register that details all identified risks and plans for how they will be addressed is published on our public website.

• Prior to Governing Body meetings held in public there is a question and answer session where any issues can be raised. All questions are answered at the time, where possible, and then taken away to be answered more fully, where necessary. The feedback is then published on our public website and fed back in person at the next Governing Board meeting.

• A Patient Reference Group, that includes representation from Healthwatch, Greenwich Action for Voluntary Service, and Citizen UK, has been established to seek assurance and monitor engagement, and to develop, implement and review progress on our patient and public engagement strategy. This group also provides guidance to our commissioners to ensure involvement is embedded into every stage of the commissioning cycle, including identifying risks and their mitigation.

• Public stakeholders inform service redesign and the issues and concerns they raise are picked up during this process.

• We have built relationships with our local MPs who are able to raise their constituents’ issues with us for us to address and we have a system in place to respond appropriately.

• We attend the Royal Borough of Greenwich Healthier Communities and Adult Social Care Scrutiny Panel. This gives elected Council members and the public the opportunity to question and challenge the CCG. Much of the focus of this committee in 2016 has been on the CCG’s decision to commission Circle Holdings as our prime provider for musculo-skeletal services in Greenwich, given this has raised a high level of concern amongst the public, Lewisham and Greenwich NHS Trust and the Council. In addition the committee has also reviewed our QIPP plan and the resulting decommissioning decisions, e.g. of the Stroke Association, the Recovery College and our plans for consulting on extensions to the current treatment access policy.

Deterrents to Risk Arising: Counter Fraud During 2016/17 the CCG commissioned TIAA, a Local Counter Fraud Specialist to deliver a Counter Fraud Service. The TIAA follows the guidance and standards, set by NHS Protect. The Local Counter Fraud Specialist TIAA provides the CCG with assurance through regular meetings with the Chief Finance Officer to review the Counter Fraud Plan and discuss cases. The Local Counter Fraud Specialist also presented regular reports to the CCG Audit Committee and also provides training regarding Counter Fraud, bribery and corruption to all CCG Staff. Counter fraud policies and services are provided by Internal Audit. Regular updates and alerts are communicated to all staff. We have had had a counter fraud programme in place throughout the year. The counter fraud lead meets with the Chief Finance Officer on a regular basis as well as counter fraud being a permanent agenda item at the Audit Committee.

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The following arrangements are in place:

• Proactive and reactive measures are taken by the Counter Fraud services to deter and identify fraud as well as to encourage staff to report fraud.

• The CCG’s Standing Orders, Standing Financial Instructions and the Scheme of Reservation and Delegation.

• Conflicts of Interests (CoI) are declared at all Governing Body and Committee meetings and subcommittee meetings. The CCG is compliant with CoI guidance and the Governing Body and Senior Management Team participate in development sessions on CoI. To strengthen this and as part of preparing to become a level 3 co-commissioner, the CCG has also recruited a third lay member who will take on the role of CoI lead.

• Management notifies the Local Counter Fraud Service and/or Chief Finance Officer of any concerns of fraud. At the conclusion of an investigation, the Local Counter Fraud Service forwards recommendations to the Chief Finance Officer, which are also reported to the Audit Committee. Internal Audit and the Local Counter Fraud Service hold liaison meetings during the year in order to discuss high risk areas.

• Where management identifies any risk of fraud they are able to introduce appropriate controls to counter the risk.

Risks relating to fraud and bribery will be added to the risk register when they occur and then reviewed by the Governing Body as appropriate. 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. NHS Greenwich CCG’s system of Internal Control is intended to manage risks and not to eliminate risks. To this effect, we have different committees who are responsible for overseeing the process of risk management within the CCG. Overall responsibility for Risk Management rests with the Governing Body. Our system of internal control has been maintained through the monitoring and delivery of its Governing Board Assurance Framework (GBAF) by the Governing Body. Led by the Director of Quality and Integrated Governance, the GBAF provides a structure and process that enables the CCG to focus on those risks that might compromise achieving its most important (principal) annual objectives. It maps out both the key controls that should be in place to manage those objectives and confirms that the Governing Body has gained sufficient assurance about the effectiveness of those controls. The effectiveness of the system of internal control is informed by the work of Internal Auditors,

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External Auditors, Governing Body, Committees, Directors and Clinical Leads within the CCG who have responsibility for the development and maintenance of the internal control framework. The Governing Body Assurance Framework provides the evidence that the effectiveness of controls that manage the risks of the CCG achieving its strategic corporate objectives have been reviewed. The framework has been actively managed and reviewed regularly by the Executive Team, Governing Body and Audit Committee. The Risk Management Framework sets out the overarching approach to the management of risk in the organisation. The Governing Body is aware of all significant risks and has sufficient information to enable it to make decisions on the implementation of appropriate controls and the allocation of appropriate resources. The CCG’s aims and objectives are aligned to the Governing Body Assurance Framework, which is presented at each meeting of the Governing Body in Public. The CCG’s objectives are embedded in the annual objectives of CCG staff at all levels within the organisation and success in the achievement of these are measured through the staff appraisal process. All CCG policies follow a standard operating procedure and adhere to the CCG’s Policy on Policies. The Policy on Policies outlines the appropriate governance route for approval of policies. Conflicts of interest Under the statutory guidelines for the management of conflicts of interest, all CCG are required to undertake an audit of their conflict of interest management as part of their internal audit on an annual basis. The CCG’s auditors reported in April 2017 reaching the overall assessment of “significant assurance with minor improvement opportunities”. The extract from the auditor report sets out their recommendations and the actions the CCG will be taking to address them. Recommendations This section summarises the recommendations that we have identified as a result of this review. We have attached a risk rating to these recommendations as per the following table:

Risk rating for recommendations raised High priority (one): A significant Medium priority (two): Low priority (three):

weakness in the system or process A potentially significant or medium Recommendations which could

which is putting you at serious risk of level weakness in the system or improve the efficiency and/or

not achieving your strategic aims and process which could put you at risk of effectiveness of the system or

objectives. In particular: significant not achieving your strategic aims and process but which are not vital to

adverse impact on reputation; non- objectives. In particular, having the achieving the CCG’s strategic aims

compliance with key statutory potential for adverse impact on the and objectives. These are generally

requirements; or substantially raising CCG’s reputation or for raising the issues of good practice that the

the likelihood that any of the CCG’s likelihood of the CCG's strategic risks auditors consider would achieve

strategic risks will occur. Any occurring. better outcomes.

recommendations in this category

would require immediate attention.

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Management response, officer

No. Risk Recommendation responsible and deadline

1 Registers of Interest, Gifts and Hospitality Agreed

Declarations in the CCG’s Conflicts of Interest (CoI) register and Action to be taken

Register of Gifts, Hospitality and Sponsorship do not adhere to The current register predates the new

the minimum requirements for information to be documented, for

guidance when start and finish dates

example many declarations do not state the dates from which

were not required. The current

the interest related or the type of the interest being declared.

register records interests by the type

Information is currently missing as the last declaration request required in previous guidance.

was sent before the declaration form had been updated to reflect The declaration form has been

the additional mandatory information required.

amended to require this information

Our sample testing of the gifts and hospitality register has and future iterations of the Register

revealed two cases where gifts and hospitality were declared will record this information as it

after the 28 day period set by NHSE for a declaration. becomes available.

Minimum requirements for the information to be kept on the Future iterations of the Register will

registers can be found in the NHSE guidelines - also reclassify interests under the

https://www.england.nhs.uk/commissioning/wp- new headings.

content/uploads/sites/12/2016/06/revsd-coi-guidance-june16.pdf. Director of Quality and Integrated

Governance

Deadline: By 31.7.17.

Management response, officer

No. Risk Recommendation responsible and deadline

2 Conflicts of Interest Guardian Agreed

From review of the CCG website and discussion with staff we Action to be taken

discovered that the CCG is not currently adhering to guidance The third Lay Member and COI

that states the COI Guardian should be named on the website.

Guardian took up their post on

Non-compliance with the guidance could lead to action by

20.3.17.

NHSE. In addition the publication of the COI Guardian’s contact The name of the newly appointed

details provides staff and members of the public with a method of

expressing any perceived conflicts. COI Guardian will be publicised on

the on the CCG website.

We recommend that details of the COI Guardian are published

Director of Quality and Integrated

on the CCG website, and that appointment of a third CoI lay

Governance

member is a key focus as per the requirements of NHSE.

Deadline: By 31.4.17

3 Conflict of Interest Returns Agreed

Although the CCG ensures through quarterly emailing to all staff Action to be taken

that the CoI register of interests is up-to-date there is no Quarterly email to include a voting

requirement to provide a ‘nil return’ where there are no changes

button for recipients to indicate if

to interests.

there has been no change in their

To establish full compliance with NHSE guidance, we

declaration.

recommend the CCG should seek not only to require prompt Director of Quality and Integrated

declarations as part of the current CoI policy, but should also

Governance

implement a system of collecting, ‘nil returns’, if there has been

no change to an individuals conflict of interest circumstance Deadline: By 31.5.17

4 Published Register of Interests Agreed

We identified that there are two versions of the Register of Action to be taken

Interest, one that is the latest cumulative Register of Interests, Remove out dated register from the

but also standalone register available on the CCG website, it is

website.

not the entirely clear to users where to access the register. When

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the user enters the website, if they go to the Conflicts of Interest Director of Quality and Integrated

section under Governance the available Register of Interest at Governance

the time of this report is from May 2014. Deadline: 31.4.17

The CCG should ensure that the correct version of the Register

of Interest is available and clearly signposted on it’s website to

avoid confusion for users.

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 CCG, other organisations and to individuals that personal information is dealt with legally, securely, efficiently and effectively. The Director of Quality and Integrated Governance is the Executive Lead on the Governing Body for Information Governance and also the Senior Information Risk Owner (SIRO). The Caldicott Guardian is a GP and Governing Body member. The Information Governance Steering Group meets bi-monthly. Throughout 2016/17 the CCG has worked to ensure compliance with the Information Governance Toolkit. The CCG has continued to develop all aspects of information governance, improved processes for mapping of information flows of personal data, and understand the risks associated with records, and adopted Information Governance policies and procedures. The current IG pass rate is at 82% which confirms the Accredited Safe Haven status for the CCG. Information Governance Polices have been adopted and approved by the Governing Body and issued to all CCG staff. All staff, including temporary staff, are required to undertake the Information Governance Training on a yearly basis as a mandatory requirement. There are processes in place for incident reporting and investigation of Serious Incidents. The CCG has put in place information risk assessment and management procedures and these have been fully embedded within the CCG. Information Breaches During 2016/17 there were no Serious Incidents relating to information breaches/data security. The CCG has processes for the reporting and investigation of information breaches. This year, there were no reported information breaches. Review of the Effectiveness of Governance, Risk Management & Internal Control As Accounting Officer, I have responsibility for reviewing the effectiveness of the system of internal control within the CCG.

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Capacity to Handle Risk The capacity to handle risk is clearly described within the Risk Management Framework. Leadership is given to the risk management process through the roles and responsibilities set out within the strategy from Chief Officer, Directors, Senior Managers, Lead Managers with specific remits for risk, patient safety and compliance through to all staff. Staff are trained or equipped to manage risk in a way appropriate to their authority and duties. The Datix system is established and utilised across the organisation in risk management. Greenwich CCG Risk Management Framework is available on the CCG intranet under the section of policies. All staff are encouraged to access this and familiarise themselves with the strategy whilst developing an understanding of what is expected of them in line with risk management within the CCG. To enable the Integrated Risk Management Framework to be fully implemented, training sessions and workshops will be set up for managers, staff and clinical professionals. The sessions will include:

• Introduction to and refresher training for risk management and governance as appropriate to the roles and responsibilities within Greenwich CCG and in respective roles in support of the CCG

• As part of the induction process for all new Governing Body members • The provision of appropriate resources to provide Governing Body development on risk

management

Greenwich CCG staff have embedded learning events with providers to ensure shared learning and good practice in regard to serious incidents. The CCG culture is such that it encourages openness and transparency throughout the system about matters of concern. This is in line with the recommendations from the Francis Report (Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry 2013). Where risk is created by deliberate failure to adhere to policy or acting outside professional codes of conduct, action may be taken against individuals under the disciplinary committee. Greenwich CCG fosters a risk aware culture shared by all in the services in putting patients first. To support the culture of listening, learning and responding within the organisation, the CCG will: • Be open and fair • Approach all incidents, complaints and issues fairly and equally • Ensure transparency in the review of incidents and complaints and other issues and

transfer the learning both internally and externally • Ensure all staff are aware of this strategy and processes and all other associated policies

that complement robust risk management and internal control within the CCG. • Support and advise staff with matter relating to risk management

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• Provide relevant training and information resources • Acknowledge reports received and provide feedback on actions and decisions to

demonstrate that the CCG has listened • Ensure there is a framework through which staff can raise concerns, malpractice and

impropriety in a supportive manner • Respond to gaps in policy and processes to improve outcomes, experience and the overall

management of risk Review of Effectiveness My review of the effectiveness of the system of internal control is informed by the work of the internal auditors and the executive managers and clinical leads within the CCG 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 Governing Body Assurance Framework itself provides me with evidence that the effectiveness of controls that manage risks to the CCG achieving its principles objectives have been reviewed. I have been advised on the implications of the result of my review of the effectiveness of the system of internal control by the Governing Body, the Audit Committee and risk/ clinical governance/ Quality Committee, if appropriate and a plan to address weaknesses and ensure continuous improvement of the system is in place. Greenwich CCG recognises that risk management processes are continually evolving and the systems must be reviewed in light of changes in the CCG’s environment, operations, best practice, guidance and legislation. In light of this, the risk management framework is reviewed annually.

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Head of Internal Audit Opinion Basis of opinion for the period 1 April 2016 to 31 March 2017 Our internal audit service has been performed in accordance with KPMG's internal audit methodology which conforms to Public Sector Internal Audit Standards (PSIAS). As a result, our work and deliverables are not designed or intended to comply with the International Auditing and Assurance Standards Board (IAASB), International Framework for Assurance Engagements (IFAE) or International Standard on Assurance Engagements (ISAE) 3000. PSIAS require that we comply with applicable ethical requirements, including independence requirements, and that we plan and perform our work to obtain sufficient, appropriate evidence on which to base our conclusion. Roles and responsibilities The Governing Body is collectively accountable for maintaining a sound system of internal control and is responsible for putting in place arrangements for gaining assurance about the effectiveness of that overall system. The Annual Governance Statement (AGS) is an annual statement by the Accountable Officer, on behalf of the Governing Body, setting out: • how the individual responsibilities of the Accountable Officer are discharged with regard to

maintaining a sound system of internal control that supports the achievement of policies, aims and objectives;

• the purpose of the system of internal control as evidenced by a description of the risk management and review processes, including the Assurance Framework process; and

• the conduct and results of the review of the effectiveness of the system of internal control including any disclosures of significant control failures together with assurances that actions are or will be taken where appropriate to address issues arising.

The Assurance Framework should bring together all of the evidence required to support the AGS. The Head of Internal Audit (HoIA) is required to provide an annual opinion in accordance with PSIAS, based upon and limited to the work performed, on the overall adequacy and effectiveness of the CCG’s risk management, control and governance processes (i.e. the system of internal control). This is achieved through a risk-based programme of work, agreed with Management and approved by the Audit Committee, which can provide assurance, subject to the inherent limitations described below. The purpose of our HoIA Opinion is to contribute to the assurances available to the Accountable Officer and the Governing Body which underpin the Governing Body’s own assessment of the effectiveness of the system of internal control. This Opinion will in turn assist the Governing Body in the completion of its AGS, and may also be taken into account by other regulators to inform their own conclusions. The opinion does not imply that the HoIA has covered all risks and assurances relating to the CCG. The opinion is derived from the conduct of risk-based plans generated from a robust

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and Management-led Assurance Framework. As such it is one component that the Governing Body takes into account in making its AGS. A further component will be the assurances provided on the operation of the systems of internal control the service organisations which provide financial services on behalf of the CCG during 2016-17 as follows: • NHS South East Commissioning Support Unit (Deloitte); • NHS Shared Business Service (Grant Thornton); and • IBM: NHS Electronic Staff Records (PwC).

Assurances on the operation of these systems is provided by ISAE3402 Service Auditor Reports issued by the internal auditors of these organisations. Basis for the opinion The basis for forming our opinion is as follows: An assessment of the design and operation of the underpinning aspects of the risk and assurance framework and supporting processes; and An assessment of the range of individual assurances arising from our risk-based internal audit assignments that have been reported throughout the period. This assessment has taken account of the relative materiality of these areas. Overall opinion Our overall opinion for the period 1 April 2016 to 13 March 2017 is that: ‘Partial assurance with improvements required’ can be given on the overall adequacy and effectiveness of the CCG’s framework of governance, risk management and control. Commentary The commentary below provides the context for our opinion and together with the opinion should be read in its entirety. Our opinion covers the period 1 April 2016 to 13 March 2017 inclusive, and is based on the four audits that we completed in this period which relate to GP Federation Governance, Financial Management and Reporting, Business Continuity, and Better Care Fund. It also takes into account the ISAE3402 assurances received to date. Our final opinion will be updated to include the findings from the ISAE3402 Service Auditor Reports and our remaining 2016-17 reviews. The Design and Operation of the Assurance Framework and Associated Processes The CCG’s Board Assurance Framework does reflect the CCG’s key objectives and risks and is regularly reviewed by the Governing Body. The Executive reviews the Board Assurance Framework on a monthly basis and the Audit Committee provides reviews whether the CCG’s risk management procedures are operating effectively.

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The range of individual opinions arising from risk-based audit assignments, contained within our risk-based plan that have been reported throughout the year We issued no ‘no’ assurance opinions in respect of our 2016-17 assignments. We have issued four ‘partial assurance with improvements required’ opinions on Financial Management and Reporting, Better Care Fund, Business Continuity, and GP Federation Governance. Within each review, areas of good practice have been highlighted to enhance the current arrangements that are in place. KPMG LLP Chartered Accountants London 31 March 2017

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Data Quality: Restrictions on the use of data by commissioners have made it difficult for Greenwich CCG to link and synthesise data; which has also presented problems for the validation of invoices.

The validation process for identifiable data uses information downloaded from Secondary User Services by South East Commissioning Support Unit which is in turn downloaded to the CCG from the South East Commissioning Support Unit data warehouse environment. The CCG uses this data to challenge providers on the usage and cost of Greenwich patients using healthcare services, but is reliant on the quality of this data.

The CCG has retained its Accredited Safe Haven status for 2017-18 and is able to continue accessing identifiable data in this way and through the Health and Social Care Information Centre approved Controlled environment for Finance. Business Critical Models NHS England recognises the importance of quality assurance across the full range of its analytical work. In partnership with analysts in the Department of Health we have developed an approach that is fully consistent with the recommendations in Sir Nicholas Macpherson's review of quality assurance of government models. The framework includes a programme of mandatory workshops for NHS England analysts, which highlights the importance of quality assurance across the full range of analytical work. The Macpherson Report on the review of quality assurance of Government Analytical Models set out the components of best practice in quality assurance making eight key recommendations. For 2016/17, Greenwich CCG has worked with other CCGs and NHS providers in South East London, through the Sustainability and Transformation Plan, to develop the business and financial modeling for the five year strategic plan. The modeling is led through South East London Project Management Office (PMO) and reports back to the South East London Finance Leads Group. The group includes Directors of Finance and Chief Finance Officers from all organisations within the Sustainability and Transformation Plan. The group is chaired by the Chief Finance Officer of Southwark CCG, who acts as the Senior Responsible Officer for the development of the model. The output of the financial modeling is reviewed by a varied number of stakeholders from different disciplines, both internal and external, and underpins the modeling of the impacts of service changes over the next five years. Locally in Greenwich CCG, we have developed a number of business and financial models which underpin the local financial planning, Quality, Improvement, Productivity and Prevention delivery, procurement and service transformation. The identified senior responsible officer is the Chief Finance Officer, who ensures that there are effective processes underpinning the modeling, including appropriate guidance, documentation and training, as well as sharing best practice. This includes ensuring that appropriate assurance processes are in place to ensure the robustness of any modeling.

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Discharge of Statutory Functions

Arrangements put in place by the CCG and explained within the corporate governance framework have been developed with extensive expert external legal input, to ensure compliance with the all relevant legislation. That legal advice also informed the matters reserved for Membership Body and Governing Body decision and the scheme of delegation.

In light of the Harris Review, the CCG has reviewed all of the statutory duties and powers conferred on it by the National Health Service Act 2006 (as amended) and other associated legislative and regulations. As a result, I can confirm that Greenwich CCG is clear about the legislative requirements associated with each of the statutory functions for which it is responsible, including any restrictions on delegation of those functions. Responsibility for each duty and power has been clearly allocated to a lead Director. Directorates have confirmed that their structures provide the necessary capability and capacity to undertake all of the CCG’s statutory duties.

During 2016/17 the CCG undertook an internal audit of CCGs compliance with its statutory duties and powers and evidence to support this. This was presented to the Quality Committee in January 2017. In addition the was a considerable change in the senior management team during 2016/17 with a new Accountable Officer starting in November 2016, a new Chief Financial Officer starting in Mid-February 2017, and a new Director of Quality and Integrated Governance starting in March 2017. In addition the CCG undertook an organisational review of capability and capacity which has resulted in new directorates being created and a number of posts were changed, deleted or created. As a result seven members of staff were made redundant. This re-organisation has meant that the CCG has relied heavily on a number of interims to fill key posts. The CCG is still actively recruiting to these posts. This has resulted in a loss of organisational memory and has been cited as key risk to the CCG. Key relationships with partners and the public has been impacted and contributed to a number of the challenges faced in 2016/17 in terms of performance and delivery. Conclusion

2016/17 has been a very difficult and challenging year for the CCG. Its Executive Team has entirely changed and organisational memory has come through its Clinical and Lay Governing Body membership. The CCG focus in 2016/17 has been on its financial performance which was understandable given the challenge it faced via a very demanding QIPP programme. A lot of rebuilding of the CCG and its relationships has had to take place during this year as well as the rebuilding of internal processes etc. Many of our external assessment e.g. on public and patient involvement where we achieved a rating of ‘needs improvement’ are a fair reflection of the difference between our aspiration and the reality of our performance.

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Despite the challenges the CCG has been successful in a number of areas including our performance on continuing care assessments. Our medicine’s management team has worked hard with our practices to deliver a number of changes to what drugs are prescribed, and our primary care team secured additional funding to support our GP practices. We have also tried to contribute and to deliver the requirements of the national 5 year forward view as set out in the South East London Sustainability Transformation Plan.

Joanne Murfitt Chief Officer, NHS Greenwich CCG Date: 23 May 2017

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Remuneration and Staff Report The Remuneration Committee comprises of four members and has met on occasion during the past year. A full list of the NHS Greenwich CCG members and their roles is below. Name Role Service

Jim Wintour Lay Member / Vice Chair (Audit and COI)

Greg Ussher Lay member (PPI) Dr Iyngarun Vanniasegarum

Secondary Care Doctor

Maggie Buckell Registered Nurse In addition to the members listed above, the following CCG employees provided the committee with advice which was material to the committee’s deliberations.

Name Role Service

Annabel Burn Chief Officer Advice Joanne Murfitt

Chief Officer Advice The following persons who are not employees of the CCG also provided advice to the committee: Name Role Service

Sara Wainwright Human Resource (HR) Business Partner, NHS South East CSU

Advice

The South East London Commissioning Support Unit provides HR advice and support to the CCG in accordance with an agreed Service Level Agreement. This includes advice and support to the Remuneration Committee including agreeing agendas with the Chair of the committee and preparing and presenting papers at committee meetings. The advice given to the Remuneration Committee is based on National Guidance and benchmarking information. The HR Business Partner is appointed by the CSU.

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Remuneration Policy The Committee’s deliberations are carried out within the context of national pay and remuneration guidelines, local comparability and taking account of independent advice regarding pay structures. Business expenses are reimbursed in accordance with the CCG policy based on national guidelines. There are no benefits in kind. Senior Managers’ Performance Related Pay The CCG does not have a policy of performance related pay for senior managers. Senior Managers’ Service Contracts The CCG’s policy concerning senior managers’ contracts is that they are permanent contracts, with a notice period of 6 months. There have been no termination payments in year or any awards to current or former members of the Governing Body, although the CCG has made redundancies in accordance with national NHS Policy for 7 individuals not considered to be persons with “significant financial control”. Should there be termination of contract liabilities in future, these would be in accordance with national NHS policy. Senior managers’ Salaries and Allowances 2016/17 (audited) All members of the Governing Body are deemed to be individuals with significant financial responsibility during the financial year and are therefore regarded as ‘senior managers’. No other CCG senior managers have significant financial responsibility.

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* off-payroll engagements, declared elsewhere in this report, payments include VAT and agency costs. Interim staff receive no holiday or sick pay. The interim staff who were recruited as part of a time-limited turnaround exercise have all either left or been placed on permanent contracts.

Name Title Salary & FeesTaxable Benefits

AnnualPerformance

Related Bonuses

ong termPerformance

Related Bonuses

All PensionRelated Benefits Total Salary & Fees

Taxable Benefits

AnnualPerformance

Related Bonuses

ong termPerformance

Related Bonuses

All PensionRelated Benefits Total

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

Joanne Murfitt Chief Officer from 1 November 2016 45-50 0 0 0 7.5 - 10 55-60

Annabel Burn Chief Officer until 31 October 2016 65-70 0 0 0 -5 - -7.5 60-65 110-115 0 0 0 27.5-30 140-145

David MaloneyChief Financial Officer from 20 February 2017 10-15 0 0 0 30 - 32.5 40-45

Ian FisherInterim Chief Financial Officer From 1st October 2015 to 3 February 2017 285-290 0 0 0 0 285-290 110-115 0 0 0 0 110-115

Chris CostaChief Finance Officer until 30 November 2015 70-75 0 0 0 17.5-20 85-90

Liz JamesInterim Director of Commissioning - From 20 June 20016 225-230 0 0 0 0 225-230

Regina Shakespeare

Interim Turnaround director and Acting Director of Commissioning - From 3 February 2016 to 31 October 2016 280-285 0 0 0 0 280-285 65-70 0 0 0 0 65-70

Simon Hall

Deputy Chief Officer and Director of Strategy and Performance Until 3 May 2016 05-10 0 0 0 -7.5 - -10 0-0 105-110 0 0 0 25-27.5 130-135

Yvonne LeeseDirector of Integrated Commissioning from 6th March 2017 00-05 0 0 0 5 - 7.5 05-10

Diane JonesDirector of Integrated Governance from 24 August 2015 to 28 Feb 2017 85-90 0 0 0 15.0-17.5 95-100 50-55 0 0 0 20-22.5 75-80

Nicola MooreDirector of Integrated Governance until 29 May 2015 40-45 0 0 0 12.5-15 50-55

Sam JonesDirector of Delivery and Service Transformation - Until ?? Feb 2016 85-90 0 0 0 32.5-35 115-120

Dr Ellen WrightChair and GP Member of the NHS Greenwich CCG Governing Body 55-60 0 0 0 0 55-60 60-65 0 0 0 0 60-65

Dr Hany WahbaGP Member of the NHS Greenwich CCG Governing Body 40-45 0 0 0 0 40-45 40-45 0 0 0 0 40-45

Dr Nayan PatelGP Member of the NHS Greenwich CCG Governing Body 40-45 0 0 0 0 40-45 40-45 0 0 0 0 40-45

Dr Sylvia NyameGP Member of the NHS Greenwich CCG Governing Body - From 1 August 2015 40-45 0 0 0 0 40-45 25-30 0 0 0 0 25-30

Dr Ranil PereraGP Member of the NHS Greenwich CCG Governing Body - From 1 May 2014 40-45 0 0 0 0 40-45 40-45 0 0 0 0 40-45

Dr Krishna SubbarayanGP Member of the NHS Greenwich CCG Governing Body - From 1 July 2014 40-45 0 0 0 0 40-45 40-45 0 0 0 0 40-45

Dr Sabah SalmanGP Member of the NHS Greenwich CCG Governing Body - From 1 August 2015 40-45 0 0 0 0 40-45 25-30 0 0 0 0 25-30

Dr Eugenia LeeGP Member of the NHS Greenwich CCG Governing Body Until 1 August 2015 10-15 0 0 0 0 10-15

Dr Rebecca RosenGP Member of the NHS Greenwich CCG Governing Body Until 1 August 2015 10-15 0 0 0 0 10-15

Dr Iyngaran VanniasgarumSecondary Care doctor on the NHS Greenwich CCG Governing Body 15-20 0 0 0 0 15-20 15-20 0 0 0 0 15-20

Maggie Buckell

Registered Nurse on the NHS Greenwich CCG Governing Body - From 8 January 2015 05-10 0 0 0 0 05-10 10-15 0 0 0 0 10-15

Dr Greg UssherLay Member on the NHS Greenwich CCG Governing Body 10-15 0 0 0 0 10-15 10-15 0 0 0 0 10-15

Mr Jim WintourLay Member on the NHS Greenwich CCG Governing Body 10-15 0 0 0 0 10-15 10-15 0 0 0 0 10-15

Mr Richard RiceLay Member on the NHS Greenwich CCG Governing Body 00-05 0 0 0 0 00-05

Councillor David Gardner Local Authority Member 0-0 0 0 0 0 0-0 0-0 0 0 0 0 0-0

Steve Whiteman Director of Public Health 0-0 0 0 0 0 0-0 0-0 0 0 0 0 0-0

Not Applicable

Not Applicable

Financial Year 2016-17 Financial Year 2015-16

Not Applicable

Not Applicable

Not Applicable

Not Applicable

Not Applicable

Not Applicable

Not Applicable

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No Governing Body member, or any other manager, received any performance related pay or bonus, or taxable benefit. The pension benefit figure is based on the HMRC method for calculating the increase in the annual pension entitlement for deferred benefit schemes. It is not the same as the cost to the CCG of its contribution in respect of the individual concerned (the employer’s contribution). NHS organisations are required to disclose the pension benefits for those persons disclosed as senior managers of the organisation, where the clinical commissioning group has made a direct contribution to a pension scheme.

Pension Benefits 2016-17 Name Real Increase in

pension at age 60 (bands of £2500)

Real Increase in pension lump sum at age 60 (bands of £2500)

Total accrued pension at age 60 at 31 March 2017 (bands of

Lump Sum at age 60 related to accrued pension at 31 March 2017 (bands of

Cash equivalent Transfer Value at 31 March 2017

Cash equivalent Transfer Value at 31 March 2016

Real Increase in Cash Equivalent Transfer Value

Employer contribution to stakeholder pension

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

Annabel Burn Chief Officer Until 31 October 2016

0--‐2.5

2.5--‐5

45--‐50

135-140

899

855

-12

--‐

Joanne Murfitt Chief Officer From 1 November 2016

5 - 10

15-20

50-55

155-160

1,090

953

137

Simon Hall Deputy Chief Officer and Director of Strategy and Performance Till 3 May 2016

0--‐2.5

0--‐2.5

35--‐40

105-110

623

605

11

--‐

David Maloney Chief Financial Officer From 20 February 2017

0 - 5

0 -5

35-40

95 -100

591

524

91

--‐ Yvonne Leese Director of Quality & Integrated Governance From 13 March 2017

0-2.5

0 - 5

30 - 35

90 - 95

644

613

24

--‐ Diane Jones Director of Integrated Governance From 24 August 2015 to 10 February 2017

0--‐2.5

0--‐2.5

10--‐15

40-45

231

211

17

--‐

Pay Multiples (Audited) Reporting bodies are required to disclose the relationship between the remuneration of the highest-paid director in their organisation and the median remuneration of the organisation’s workforce. The banded remuneration of the highest paid member of the Governing Body in NHS Greenwich CCG in financial year 2016/17 was £285,000 (2015/16 £112,500). (This year’s figure includes VAT and agency premium). The CCG appointed a Turnaround Director for a

85

period of time, incurring higher costs than the Chief Officer. In calculating the relationship between the highest paid person in the organisation and the median remuneration, the CCG has to remove VAT and an estimate of agency premiums from the payments for all contractors and treat all appointments and employments as if they were full-time and for twelve months. The estimated annual equivalent earnings of the highest paid director in 2016/17 were £327,800. This is 6.95 times higher than the median remuneration of the workforce, which was £47,171 (2015/16 was 2.64 and £42,602). In 2016/17 no employees received remuneration in excess of the highest-paid member of the Governing Body. Remuneration ranged from £18,387 to £327,800 (annualized estimated earnings of highest paid director). Total remuneration includes and pensionable benefits. It does not include severance payments, employer pension contributions and the cash equivalent transfer value of pensions. Off-payroll Engagements Off-payroll engagements existing at 31 March 2017 for more than £220 per day and have lasted longer than six months are as follows: The number that have existed: For less than one year at 31/3/17 2 For between one and two years 1 For between two and three years 0 For between three and four years 1 For four years or more 0 Total number of existing engagements at 31/3/16 6 All existing off-payroll engagements, outlined above, 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 off-payroll engagements in 2016/17 for more than £220 per day and more than 6 months: Number of new engagements, or those that reached six months in duration, between 1/4/16 and 31/3/17

23

Number of the above which include contractual clauses giving the CCG the right to request assurance in relation to Income Tax and National Insurance obligations

23

Number from whom assurance has been requested

0

Of which, from whom assurance has been received

0

And from whom assurance has not been received 0

86

And those that have been terminated where no assurance is received

0

Off-payroll engagement of Governing Body members and senior officials with “significant financial responsibility” between 1 April 2016 and 31 March 2017 Number of off-payroll engagements of Governing Body members, and senior officials with “significant financial responsibility” during the financial year

3

Number of individuals who have been deemed Governing Body members, and senior officials with “significant financial responsibility”, during the financial year (payroll and off-payroll)

9

The tenure of those officials engaged with “off payroll” appointments are 6 months (on-going), 9 months (terminated) and 16 months (terminated) respectively.

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Our Staff Communicating and Engaging There are a number of ways in which the CCG communicates and engages with its staff. These include: • Regular staff briefings, these briefings are shared on the intranet • Each directorate holds monthly staff meetings, and all staff have a regular 1:1

meeting with their line manager • Participation in the national NHS Staff Survey in 2016 – we have an agreed action plan

based on the results of the survey, which is co-ordinated by the Staff Health, Safety and Wellbeing Group

• We will be holding staff events to increase engagement across all staff areas • We held a staff away day in February 2017 and are looking to repeat this later in 2017.

Training and Development All staff are required to complete their Statutory & Mandatory training that has been provided both online via e-learning on the Greenwich CCG Workforce Learning and Development system. Training compliance is reported back to the CCG on a regular basis. All staff have regular 1:1s and we are working towards all staff having appraisals, objectives and Personal Development Plans in place. Employee Consultation Organisational change is managed in accordance with the principles and procedures contained within the CCG's Organisational Change Policy. The CCG also informally communicates and consults with employees via regular staff briefings. Policy on Disabled Employees Disabled employees are protected under the "protected characteristics" of the Equality Act 2010, one of which is disability. The CCG will ensure that the requirements and reasonable adjustments necessary for employees with disabilities are taken into account during their employment and that people with disabilities are not discriminated against on the ground of their disability at any stage of the recruitment process or in their employment with the CCG. The CCG's Sickness Absence Policy confirms that where an employee becomes disabled as a result of sickness, the CCG will make any necessary reasonable adjustments, as required, and in accordance with the Equality Act to enable the employee to return to work. The types of adjustments may include adjustments to work base, working hours, redeploying the employee to another suitable position and providing any necessary equipment to assist the employee to perform their role.

88

Equalities for Staff The CCG promotes a working environment in which all parties and procedures relating to recruitment, selection, training, promotion and employment are free from unfair discrimination, ensuring that no employee or prospective employee is discriminated against, whether directly or indirectly on the grounds of age; disability; gender reassignment; pregnancy and maternity; race including ethnic or national origins, colour or nationality; religion or belief; sex (gender); sexual orientation; marriage and civil partnership; trade union membership; responsibility for dependents or any other condition or requirement which cannot be shown to be justifiable.

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Staff Composition

Gov. Body Clinical Lead Director Employee Grand Total Female Male Female Male Female Male Female Male

4 3 1 5 1 1 43 16 74 Staff Numbers in 2016/17 – Based on Employees and Directors

Average FTE 70.64 Average Headcount 80

Number of Staff by Agenda for Change Band:

Pay Band Total Band 4 6 Band 5 6 Band 6 5 Band 7 11 Band 8A 10 Band 8B 8 Band 8C 9 Band 8D 2 Band 9 2 Local Salary 13 Local VSM 2 Grand Total 74

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The following tables are a profile of the CCG relating to the main protected characteristics of staff as of 31 December 2016. The tables do not include Governing Body membership / Clinical Leads.

91

92

93

Sickness Absence

The CCG sickness absence percentage rate is presented monthly as part of the key performance indicators. The HR Business Partner works closely with managers to ensure that sickness absence cases are being managed appropriately and in accordance with the CCG’s Sickness Absence Policy. An Occupational Health Service is available to provide professional medical advice to the CCG. Staff can access Occupational Health through self-referral and can access the Occupational Health Counseling Service. The CCG also has access to an Employee Assistance Programme which is provided by Right Management, which offers unlimited confidential access to emotional and practical support, 24 hours a day, seven days a week, including legal and financial advice.

Sickness Absence Data 2016/17

I hereby sign off the Remuneration Report element of the NHS Greenwich CCG Annual Report 2016/17. Joanne Murfitt Accountable Officer Date: 23 May 2017

Total Days lost 595 Total Staff Years 72 Average Working days lost 8 Number of persons retiring on ill health grounds 0

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SECTION 3: STATEMENT OF FINANCIAL POSITION

Data entered below will be used throughout the workbook:

Entity name: NHS Greenwich CCGThis year 2016-17Last year 2015-16This year ended 31-March-2017Last year ended 31-March-2016This year commencing: 01-April-2016Last year commencing: 01-April-2015

Annual Accounts - 2

NHS Greenwich CCG - Annual Accounts 2016-17

Page Number

The Primary Statements:

Statement of Comprehensive Net Expenditure for the year ended 31st March 2017 3Statement of Financial Position as at 31st March 2017 4Statement of Changes in Taxpayers' Equity for the year ended 31st March 2017 5Statement of Cash Flows for the year ended 31st March 2017 6

Notes to the AccountsAccounting policies 7Other operating revenue 11Revenue 11Employee benefits and staff numbers 12Operating expenses 15Better payment practice code 16Income generation activities 16Investment revenue 16Other gains and losses 16Finance costs 16Operating leases 16Property, plant and equipment 17Investment property 19Trade and other receivables 19Cash and cash equivalents 20Trade and other payables 21Provisions 21Contingencies 21Financial instruments 22Operating segments 23Pooled budgets 24NHS Lift investments 24Related party transactions 25Events after the end of the reporting period 26Third party assets 26Financial performance targets 26Analysis of charitable reserves 26

CONTENTS

Annual Accounts - 3

NHS Greenwich CCG - Annual Accounts 2016-17

Statement of Comprehensive Net Expenditure for the year ended31 March 2017

2016-17 2015-16Note £'000 £'000

Income from sale of goods and services 2 (7,955) (9,074)Other operating income 2 (2,454) (1,307)Total operating income (10,409) (10,381)

Staff costs 4 6,792 7,291Purchase of goods and services 5 379,534 364,664Depreciation and impairment charges 5 122 337Other Operating Expenditure 5 579 351Total operating expenditure 387,027 372,642

Net Operating Expenditure 376,618 362,262

Finance expense 10 0 0Net expenditure for the year 376,618 362,262Net Gain/(Loss) on Transfer by Absorption 0 0Total Net Expenditure for the year 376,618 362,262

Comprehensive Expenditure for the year ended 31 March 2017 376,618 362,262

Annual Accounts - 4

NHS Greenwich CCG - Annual Accounts 2016-17

Statement of Financial Position as at31 March 2017

2016-17 2015-16

Note £'000 £'000Non-current assets:Property, plant and equipment 12 1,601 2,320Total non-current assets 1,601 2,320

Current assets:Trade and other receivables 14 11,497 6,054Cash and cash equivalents 15 287 119Total current assets 11,784 6,173

Total assets 13,385 8,493

Current liabilitiesTrade and other payables 16 (47,039) (31,829)Provisions 17 0 0Total current liabilities (47,039) (31,829)

Non-Current Assets plus/less Net Current Assets/Liabilities (33,654) (23,337)

Non-current liabilities

Total non-current liabilities 0 0

Assets less Liabilities (33,654) (23,337)

Financed by Taxpayers’ EquityGeneral fund (33,654) (23,337)Total taxpayers' equity: (33,654) (23,337)

The notes on pages 7 to 26 form part of this statement

The financial statements on pages 3 to 6 were approved by the Audit Committee on 26 May 2017 and signed on its behalf by:

Joanne Murfitt

Chief Officer

Annual Accounts - 5

NHS Greenwich CCG - Annual Accounts 2016-17

Statement of Changes In Taxpayers Equity for the year ended31 March 2017

General fundRevaluation

reserveOther

reservesTotal

reserves£'000 £'000 £'000 £'000

Changes in taxpayers’ equity for 2016-17

Balance at 01 April 2016 (23,337) 0 0 (23,337)Transfer between reserves in respect of assets transferred from closed NHS bodies 0 0 0 0Adjusted NHS Clinical Commissioning Group balance at 31 March 2017 (23,337) 0 0 (23,337)

Changes in NHS Clinical Commissioning Group taxpayers’ equity for 2016-17Net operating expenditure for the financial year (376,618) (376,618)

Net Recognised NHS Clinical Commissioning Group Expenditure for the Financial Year (399,955) 0 0 (399,955)

Net funding 366,301 0 0 366,301

Balance at 31 March 2017 (33,654) 0 0 (33,654)

General fundRevaluation

reserveOther

reservesTotal

reserves£'000 £'000 £'000 £'000

Changes in taxpayers’ equity for 2015-16

Balance at 01 April 2015 (22,499) 0 0 (22,499)Transfer of assets and liabilities from closed NHS bodies as a result of the 1 April 2013 transition 0 0 0 0Adjusted NHS Clinical Commissioning Group balance at 31 March 2016 (22,499) 0 0 (22,499)

Changes in NHS Clinical Commissioning Group taxpayers’ equity for 2015-16Net operating costs for the financial year (362,262) (362,262)

Net Recognised NHS Clinical Commissioning Group Expenditure for the Financial Year (384,760) 0 0 (384,760)Net funding 361,424 0 0 361,424

Balance at 31 March 2016 (23,337) 0 0 (23,337)

The notes on pages 7 to 26 form part of this statement

Annual Accounts - 6

NHS Greenwich CCG - Annual Accounts 2016-17

Statement of Cash Flows for the year ended31 March 2017

2016-17 2015-16Note £'000 £'000

Cash Flows from Operating ActivitiesNet operating expenditure for the financial year (376,618) (362,262)Depreciation and amortisation 5 122 337Impairments and reversals 5 0 0(Increase)/decrease in trade & other receivables 14 (5,443) 1,792(Increase)/decrease in other current assets 0 0Increase/(decrease) in trade & other payables 16 15,809 486Increase/(decrease) in other current liabilities 0 0Provisions utilised 17 0 (400)Increase/(decrease) in provisions 0 0Net Cash Inflow (Outflow) from Operating Activities (366,130) (360,046)

Cash Flows from Investing ActivitiesInterest received 0 0(Payments) for property, plant and equipment (3) (1,260)Net Cash Inflow (Outflow) from Investing Activities (3) (1,260)

Net Cash Inflow (Outflow) before Financing (366,133) (361,306)

Cash Flows from Financing ActivitiesGrant in Aid Funding Received 366,301 361,424Other loans received 0 0Other loans repaid 0 0Capital element of payments in respect of finance leases and on Statement of Financial Position PFI and LIFT 0 0Capital grants and other capital receipts 0 0Capital receipts surrendered 0 0Net Cash Inflow (Outflow) from Financing Activities 366,301 361,424

Net Increase (Decrease) in Cash & Cash Equivalents 15 168 118

Cash & Cash Equivalents at the Beginning of the Financial Year 119 1

Effect of exchange rate changes on the balance of cash and cash equivalents held in foreign currencies 0 0

Cash & Cash Equivalents (including bank overdrafts) at the End of the Financial Year 287 119

The notes on pages 7 to 26 form part of this statement

Annual Accounts - 7

NHS Greenwich CCG - Annual Accounts 2016-17

Notes to the financial statements

1.0 Accounting PoliciesNHS England has directed that the financial statements of clinical commissioning groups shall meet the accounting requirements of the Group Accounting Manual issued by the Department of Health. Consequently, the following financial statements have been prepared in accordance with the Group Accounting Manual 2016-17 issued by the Department of Health. The accounting policies contained in the Group Accounting Manual follow International Financial Reporting Standards to the extent that they are meaningful and appropriate to clinical commissioning groups, as determined by HM Treasury, which is advised by the Financial Reporting Advisory Board. Where the Group Accounting Manual permits a choice of accounting policy, the accounting policy which is judged to be most appropriate to the particular circumstances of the clinical commissioning group for the purpose of giving a true and fair view has been selected. The particular policies adopted by the clinical commissioning group are described below. They have been applied consistently in dealing with items considered material in relation to the accounts.

1.1 Going ConcernThese accounts have been prepared on the going concern basis.Public sector bodies are assumed to be going concerns where the continuation of the provision of a service in the future is anticipated, as evidenced by inclusion of financial provision for that service in published documents.Where a clinical commissioning group ceases to exist, it considers whether or not its services will continue to be provided (using the same assets, by another public sector entity) in determining whether to use the concept of going concern for the final set of Financial Statements. If services will continue to be provided the financial statements are prepared on the going concern basis. The CCG has devloped a financial recovery plan, progress against which is reviewed in conjuction with NHS England (London) on a regular basis. The CCG has been allocated funds from NHSE for 2017/08 and and 2018/19. In addition, the CCG has also been notified (December 2015) of indicative allocations from 2019/20 to 2020/21 (4 years further funding in total).

The Governing Body has considered and approved a number of documents that assume that services will be provided on an ongoing basis:- NHS Greenwich CCG's Commissioning Intentions- NHS Greenwich CCG's Operational Plan and Financial Plan- The South East London Sustainability & Transformation Plan

1.2 Accounting ConventionThese accounts have been prepared under the historical cost convention modified to account for the revaluation of property, plant and equipment, intangible assets, inventories and certain financial assets and financial liabilities.

1.3 Charitable FundsUnder the provisions of IAS 27 Consolidated and Separate Financial Statements, those Charitable Funds that fall under common control with NHS bodies are consolidated within the entities' accounts. In accordance with IAS 1 Presentation of Financial Statements, specific disclosure requirements need not be met if the information is not considered to be material to the organisation.The Governing Body does not consider the activities of the NHS Greenwich Charitable Funds to be material to NHS Greenwich CCG. The charitable funds represent approximately 1.0% (2016 – 1.1%) of the revenue resource outturn position of NHS Greenwich CCG. Accordingly, the Governing Body has decided not to consolidate the NHS Greenwich Charitable Funds accounts with that of the CCG.

1.4 Pooled BudgetsWhere the clinical commissioning group has entered into a pooled budget arrangement under Section 75 of the National Health Service Act 2006 the clinical commissioning group accounts for its share of the assets, liabilities, income and expenditure arising from the activities of the pooled budget, identified in accordance with the pooled budget agreement.

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

1.5.1 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 NHS Greenwich CCG’s accounting policies and that have the most significant effect on the amounts recognised in the Financial Statements.The Governing Body does not consider the activities of the NHS Greenwich Charitable Funds to be material to NHS Greenwich CCG. The charitable funds represent approximately 1.0% (2016 – 1.1%) of the revenue resource outturn position of NHS Greenwich CCG. Accordingly, the Governing Body has decided not to consolidate the NHS Greenwich Charitable Funds accounts with that of the CCG.The CCG's arrangements in respect of settling NHS Continuing Healthcare claims are disclosed in note 1.17 to these financial statements.

Annual Accounts - 8

NHS Greenwich CCG - Annual Accounts 2016-17

Notes to the financial statements cont'd.

1.5.2 Key Sources of Estimation UncertaintyThe following are the key estimations that management has made in the process of applying the clinical commissioning group’s accounting policies that have the most significant effect on the amounts recognised in the financial statements:

Management has determined that the value of the Property asset at Eltham Community Hospital, brought into use during the financial year 2015-16, is best estimated at the value of the costs incurred during 2014-15, depreciated on a straight-line basis over the life of the asset, being 25 years. Management has used information from Prescribing Pricing Authority (PPA) and Acute SLAM reports as key sources of estimated outturn expectation for Primary care and acute costs to reduce any uncertainty.The CCG's arrangements in respect of settling NHS Continuing Healthcare claims are disclosed in note 1.17 to these financial statements.

1.6 Revenue

Revenue in respect of services provided is recognised when, and to the extent that, performance occurs, and is measured at the fair value of the consideration receivable. Where income is received for a specific activity that is to be delivered in the following year, that income is deferred. Where the CCG hosts services and recharges other organisations, the recharges are also recognised as operating revenue.

1.7 Employee Benefits1.7.1 Short-term Employee Benefits

Salaries, wages and employment-related payments are recognised in the period in which the service is received from employees.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.

1.7.2 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.

1.8 Other ExpensesOther operating expenses are recognised when, and to the extent that, the goods or services have been received. They are measured at the fair value of the consideration payable.Expenses and liabilities in respect of grants are recognised when the clinical commissioning group has a present legal or constructive obligation, which occurs when all of the conditions attached to the payment have been met.

1.9 Property, Plant & Equipment1.9.1 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,· Collectively, a number of items have a cost of at least £5,000 and individually have a cost of more than £250, where the assets are functionally interdependent, they had broadly simultaneous purchase dates, are anticipated to have simultaneous disposal dates and are under single managerial control; or,· Items form part of the initial equipping and setting-up cost of a new building, ward or unit, irrespective of their individual or collective cost.Where a large asset, for example a building, includes a number of components with significantly different asset lives, the components are treated as separate assets and depreciated over their own useful economic lives.

1.9.2 ValuationAll 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.Land and buildings used for the clinical commissioning group’s services or for administrative purposes are stated in the statement of financial position at their re-valued amounts, being the fair value at the date of revaluation less any impairment.Revaluations are performed with sufficient regularity to ensure that carrying amounts are not materially different from those that would be determined at the end of the reporting period. Fair values are determined as follows:· Land and non-specialised buildings – market value for existing use; and,· Specialised buildings – depreciated replacement cost.HM Treasury has adopted a standard approach to depreciated replacement cost valuations based on modern equivalent assets and, where it would meet the location requirements of the service being provided, an alternative site can be valued.Properties in the course of construction for service or administration purposes are carried at cost, less any impairment loss. Cost includes professional fees but not borrowing costs, which are recognised as expenses immediately, as allowed by IAS 23 for assets held at fair value. Assets are re-valued and depreciation commences when they are brought into use.Fixtures and equipment are carried at depreciated historic cost as this is not considered to be materially different from current value in existing use.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.

Annual Accounts - 9

NHS Greenwich CCG - Annual Accounts 2016-17

Notes to the financial statements cont'd.

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

1.10 Depreciation, Amortisation & ImpairmentsFreehold land, properties under construction, and assets held for sale are not depreciated.Otherwise, depreciation and amortisation are charged to write off the costs or valuation of property, plant and equipment and intangible non-current assets, less any residual value, over their estimated useful lives, in a manner that reflects the consumption of economic benefits or service potential of the assets. The estimated useful life of an asset is the period over which the clinical commissioning group expects to obtain economic benefits or service potential from the asset. This is specific to the clinical commissioning group and may be shorter than the physical life of the asset itself. Estimated useful lives and residual values are reviewed each year end, with the effect of any changes recognised on a prospective basis. Assets held under finance leases are depreciated over their estimated useful lives.

At each reporting period end, the clinical commissioning group checks whether there is any indication that any of its tangible or intangible non-current assets have suffered an impairment loss. If there is indication of an impairment loss, the recoverable amount of the asset is estimated to determine whether there has been a loss and, if so, its amount. Intangible assets not yet available for use are tested for impairment annually.A revaluation decrease that does not result from a loss of economic value or service potential is recognised as an impairment charged to the revaluation reserve to the extent that there is a balance on the reserve for the asset and, thereafter, to expenditure. Impairment losses that arise from a clear consumption of economic benefit are taken to expenditure. Where an impairment loss subsequently reverses, the carrying amount of the asset is increased to the revised estimate of the recoverable amount but capped at the amount that would have been determined had there been no initial impairment loss. The reversal of the impairment loss is credited to expenditure to the extent of the decrease previously charged there and thereafter to the revaluation reserve.

1.11 LeasesLeases are classified as finance leases when substantially all the risks and rewards of ownership are transferred to the lessee. All other leases are classified as operating leases.

1.11.1 The Clinical Commissioning Group as LesseeProperty, plant and equipment held under finance leases are initially recognised, at the inception of the lease, at fair value or, if lower, at the present value of the minimum lease payments, with a matching liability for the lease obligation to the lessor. Lease payments are apportioned between finance charges and reduction of the lease obligation so as to achieve a constant rate on interest on the remaining balance of the liability. Finance charges are recognised in calculating the clinical commissioning group’s surplus/deficit.Operating lease payments are recognised as an expense on a straight-line basis over the lease term. Lease incentives are recognised initially as a liability and subsequently as a reduction of rentals on a straight-line basis over the lease term.Contingent rentals are recognised as an expense in the period in which they are incurred.Where a lease is for land and buildings, the land and building components are separated and individually assessed as to whether they are operating or finance leases.

1.12 Cash & Cash EquivalentsCash is cash in hand and deposits with any financial institution repayable without penalty on notice of not more than 24 hours. Cash equivalents are investments that mature in 3 months or less from the date of acquisition and that are readily convertible to known amounts of cash with insignificant risk of change in value.In the Statement of Cash Flows, cash and cash equivalents are shown net of bank overdrafts that are repayable on demand and that form an integral part of the clinical commissioning group’s cash management.

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

1.14 Non-clinical Risk PoolingThe clinical commissioning group participates in the Property Expenses Scheme and the Liabilities to Third Parties Scheme. Both are risk pooling schemes under which the clinical commissioning group pays an annual contribution to the NHS Litigation Authority 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.

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

1.16 ContingenciesA contingent liability is a possible obligation that arises from past events and whose existence will be confirmed only by the occurrence or non-occurrence of one or more uncertain future events not wholly within the control of the clinical commissioning group, or a present obligation that is not recognised because it is not probable that a payment will be required to settle the obligation or the amount of the obligation cannot be measured sufficiently reliably. A contingent liability is disclosed unless the possibility of a payment is remote.A contingent asset is a possible asset that arises from past events and whose existence will be confirmed by the occurrence or non-occurrence of one or more uncertain future events not wholly within the control of the clinical commissioning group. A contingent asset is disclosed where an inflow of economic benefits is probable.Where the time value of money is material, contingencies are disclosed at their present value.

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

Annual Accounts - 10

NHS Greenwich CCG - Annual Accounts 2016-17

Notes to the financial statements cont'd.

1.17.1 Loans & ReceivablesLoans and receivables are non-derivative financial assets with fixed or determinable payments which are not quoted in an active market. After initial recognition, they are measured at amortised cost using the effective interest method, less any impairment. Interest is recognised using the effective interest method.Fair value is determined by reference to quoted market prices where possible, otherwise by valuation techniques.

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

1.18.1 Other Financial LiabilitiesAfter initial recognition, all other financial liabilities are measured at amortised cost using the effective interest method, except for loans from Department of Health, which are carried at historic cost. The effective interest rate is the rate that exactly discounts estimated future cash payments through the life of the asset, to the net carrying amount of the financial liability. Interest is recognised using the effective interest method.

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

1.20 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).

1.21 Subsidiaries

Material entities over which the clinical commissioning group has the power to exercise control so as to obtain economic or other benefits are classified as subsidiaries and are consolidated. Their income and expenses; gains and losses; assets, liabilities and reserves; and cash flows are consolidated in full into the appropriate financial statement lines. Appropriate adjustments are made on consolidation where the subsidiary’s accounting policies are not aligned with the clinical commissioning group or where the subsidiary’s accounting date is not co-terminus.Subsidiaries that are classified as ‘held for sale’ are measured at the lower of their carrying amount or ‘fair value less costs to sell’.For 2016-17, NHS Greenwich CCG will not consolidate the results of NHS Greenwich Charitable Funds over which it considers it has the power to exercise control in accordance with IAS27 requirements, as the Governing Body does not consider the NHS Greenwich Charitable Funds to be material to NHS Greenwich CCG.

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

1.23 Accounting Standards That Have Been Issued But Have Not Yet Been AdoptedThe Government Financial Reporting Manual does not require the following Standards and Interpretations to be applied in 2016-17, all of which are subject to consultation:· 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)

The application of the Standards as revised would not have a material impact on the accounts for 2016-17, were they applied in that year.

Annual Accounts - 11

NHS Greenwich CCG - Annual Accounts 2016-17

2. Other Operating Revenue2016-17 2016-17 2016-17 2015-16

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

Patient transport services 0 0 0 0Prescription fees and charges 553 0 553 547Education, training and research 108 0 108 465Charitable and other contributions to revenue expenditure: non-NHS 23 0 23 22Non-patient care services to other bodies 7,847 209 7,638 8,609Other revenue 1,878 0 1,878 738Total other operating revenue 10,409 209 10,200 10,381

3. Revenue2016-17 2016-17 2016-17 2015-16

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

From rendering of services 10,409 209 10,200 10,381From sale of goods 0 0 0 0Total 10,409 209 10,200 10,381

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

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

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

Annual Accounts - 12

NHS Greenwich CCG - Annual Accounts 2016-17

4. Employee benefits and staff numbers

4.1.1 Employee benefits 2016-17

TotalPermanent Employees Other Total

Permanent Employees Other Total

Permanent Employees Other

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000Employee BenefitsSalaries and wages 6,056 3,313 2,743 2,715 1,699 1,016 3,341 1,614 1,727Social security costs 351 351 0 184 184 0 167 167 0Employer Contributions to NHS Pension scheme 385 385 0 196 196 0 189 189 0Other pension costs 0 0 0 0 0 0 0 0 0Other post-employment benefits 0 0 0 0 0 0 0 0 0Other employment benefits 0 0 0 0 0 0 0 0 0Termination benefits 0 0 0 0 0 0 0 0 0Gross employee benefits expenditure 6,792 4,049 2,743 3,095 2,079 1,016 3,697 1,970 1,727

Less recoveries in respect of employee benefits (note 4.1.2) 0 0 0 0 0 0 0 0 0Total - Net admin employee benefits including capitalised costs 6,792 4,049 2,743 3,095 2,079 1,016 3,697 1,970 1,727

Less: Employee costs capitalised 0 0 0 0 0 0 0 0 0Net employee benefits excluding capitalised costs 6,792 4,049 2,743 3,095 2,079 1,016 3,697 1,970 1,727

4.1.1 Employee benefits 2015-16

TotalPermanent Employees Other Total

Permanent Employees Other Total

Permanent Employees Other

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000Employee BenefitsSalaries and wages 6,518 3,478 3,040 3,022 1,872 1,150 3,497 1,606 1,890Social security costs 340 340 0 192 192 0 148 148 0Employer Contributions to NHS Pension scheme 433 433 0 235 235 0 198 198 0Other pension costs 0 0 0 0 0 0 0 0 0Other post-employment benefits 0 0 0 0 0 0 0 0 0Other employment benefits 0 0 0 0 0 0 0 0 0Termination benefits 0 0 0 0 0 0 0 0 0Gross employee benefits expenditure 7,291 4,251 3,040 3,449 2,299 1,150 3,843 1,953 1,890

Less recoveries in respect of employee benefits (note 4.1.2) 0 0 0 0 0 0 0 0 0Total - Net admin employee benefits including capitalised costs 7,291 4,251 3,040 3,449 2,299 1,150 3,843 1,953 1,890

Less: Employee costs capitalised 0 0 0 0 0 0 0 0 0Net employee benefits excluding capitalised costs 7,291 4,251 3,040 3,449 2,299 1,150 3,843 1,953 1,890

Total Admin Programme

Total Admin Programme

Annual Accounts - 13

NHS Greenwich CCG - Annual Accounts 2016-17

4.2 Average number of people employed2015-16

TotalPermanently

employed Other TotalNumber Number Number Number

Total 82 64 18 92

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

4.3 Staff sickness absence and ill health retirements2016-17 2015-16Number Number

Total Days Lost 595 447Total Staff Years 72 69Average working Days Lost 8 6

2016-17 2015-16Number Number

Number of persons retired early on ill health grounds 0 0

£'000 £'000Total additional Pensions liabilities accrued in the year 0 0

4.4 Exit packages agreed in the financial year

Number £ Number £ Number £Less than £10,000 1 7,878 0 0 1 7,878£10,001 to £25,000 2 42,253 0 0 2 42,253£25,001 to £50,000 3 103,092 0 0 3 103,092£50,001 to £100,000 0 0 0 0 0 0£100,001 to £150,000 1 100,675 0 0 1 100,675£150,001 to £200,000 0 0 0 0 0 0Over £200,001 0 0 0 0 0 0Total 7 253,898 0 0 7 253,898

Number £ Number £ Number £Less than £10,000 0 0 0 0 0 0£10,001 to £25,000 0 0 0 0 0 0£25,001 to £50,000 0 0 0 0 0 0£50,001 to £100,000 0 0 0 0 0 0£100,001 to £150,000 0 0 0 0 0 0£150,001 to £200,000 0 0 0 0 0 0Over £200,001 0 0 0 0 0 0Total 0 0 0 0 0 0

Number £ Number £Less than £10,000 0 0 0 0£10,001 to £25,000 0 0 0 0£25,001 to £50,000 0 0 0 0£50,001 to £100,000 0 0 0 0£100,001 to £150,000 0 0 0 0£150,001 to £200,000 0 0 0 0Over £200,001 0 0 0 0Total 0 0 0 0

Analysis of Other Agreed Departures

Number £ Number £Voluntary redundancies including early retirement contractual costs 0 0 0 0Mutually agreed resignations (MARS) contractual costs 0 0 0 0Early retirements in the efficiency of the service contractual costs 0 0 0 0Contractual payments in lieu of notice 0 0 0 0Exit payments following Employment Tribunals or court orders 0 0 0 0Non-contractual payments requiring HMT approval* 0 0 0 0Total 0 0 0 0

2016-17Compulsory redundancies Other agreed departures Total

Other agreed departures

2015-16Compulsory redundancies Other agreed departures Total

2016-17 2015-16

2015-16

2016-17

Other agreed departures

Departures where special payments have been made

2015-16 2015-16

Departures where special payments have been made

2016-17

2016-17 2016-17

Annual Accounts - 14

NHS Greenwich CCG - Annual Accounts 2016-17

4.5 Pension costs

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

The Scheme is an unfunded, defined benefit scheme that covers NHS employers, GP 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.

The Scheme is subject to a full actuarial valuation usually every four years (until 2004, every five years) and an accounting valuation every year. An outline of these follows:

4.5.1 Full actuarial (funding) valuation

The purpose of this valuation is to assess the level of liability in respect of the benefits due under the Scheme (taking into account its recent demographic experience), and to recommend the contribution rates to be paid by employers and scheme members. The last such valuation, which determined current contribution rates was undertaken as at 31 March 2012 and covered the period from 1 April 2008 to that date. Details can be found on the pension scheme website at www.nhsbsa.nhs.uk/pensions.

For 2016-17, employers’ contributions of £385,300 were payable to the NHS Pensions Scheme (2015-16: £435,510) at the rate of 14.3%of pensionable pay. The scheme’s actuary reviews employer contributions, usually every four years and now based on HMT ValuationDirections, following a full scheme valuation. The latest review used data from 31 March 2012 and was published on the Governmentwebsite on 9 June 2012. These costs are included in the NHS pension line of note 4.1.1.

Annual Accounts - 15

NHS Greenwich CCG - Annual Accounts 2016-17

5. Operating expenses2016-17 2016-17 2016-17 2015-16

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

Gross employee benefitsEmployee benefits excluding governing body members 6,092 2,395 3,697 6,465Executive governing body members 700 700 0 827Total gross employee benefits 6,792 3,095 3,697 7,292

Other costsServices from other CCGs and NHS England 3,739 1,832 1,907 3,027Services from foundation trusts 128,241 0 128,241 126,466Services from other NHS trusts 151,215 0 151,215 144,437Services from other WGA bodies 143 0 143 80Purchase of healthcare from non-NHS bodies 53,469 0 53,469 51,649Chair and Non Executive Members 477 477 0 468Supplies and services – clinical 1,285 0 1,285 1,388Supplies and services – general 4,782 13 4,769 503Consultancy services 1,675 116 1,559 1,325Establishment 684 304 380 587Transport 7 3 4 17Premises 1,041 170 871 (69)Depreciation 122 0 122 337Audit fees 71 71 0 88Other non statutory audit expenditure· Internal audit services 44 44 0 44· Other services 0 0 0 0Prescribing costs 31,934 0 31,934 32,673Other professional fees excl. audit 381 49 332 334Education and training 171 68 103 418Provisions 0 0 0 0CHC Risk Pool contributions 652 0 652 1,631Other expenditure 102 0 102 (48)Total other costs 380,235 3,147 377,088 365,351

Total operating expenses 387,027 6,242 380,785 372,643

Annual Accounts - 16

NHS Greenwich CCG - Annual Accounts 2016-17

6.1 Better Payment Practice Code

Measure of compliance 2016-17 2016-17 2015-16 2015-16Number £'000 Number £'000

Non-NHS PayablesTotal Non-NHS Trade invoices paid in the Year 6,603 56,849 6,838 56,641 Total Non-NHS Trade Invoices paid within target 6,524 56,346 6,562 51,672 Percentage of Non-NHS Trade invoices paid within target 98.80% 99.12% 95.96% 91.23%

NHS PayablesTotal NHS Trade Invoices Paid in the Year 3,273 280,528 3,194 274,799 Total NHS Trade Invoices Paid within target 3,219 279,790 3,045 270,855 Percentage of NHS Trade Invoices paid within target 98.35% 99.74% 95.34% 98.56%

6.2 The Late Payment of Commercial Debts (Interest) Act 1998 2016-17 2015-16£'000 £'000

Amounts included in finance costs from claims made under this legislation 0 0Compensation paid to cover debt recovery costs under this legislation 0 0Total 0 0

7 Income Generation Activities

8. Investment revenue

There was no investment revenue received by NHS Greenwich CCG in the year.

9. Other gains and losses

There were no other gains and losses recognsed by NHS Greenwich CCG in the year.

10. Finance costs

There were no finance costs incurred by NHS Greenwich CCG in the year.

11. Operating Leases

11.1 As lessee

11.1.1 Payments recognised as an Expense 2016-17 2015-16Land Buildings Other Total Land Buildings Other Total£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Payments recognised as an expenseMinimum lease payments 0 31 18 49 0 73 10 83Contingent rents 0 0 0 0 0 0 0 0Sub-lease payments 0 0 0 0 0 0 0 0Total 0 31 18 49 0 73 10 83

11.1.2 Future minimum lease payments 2016-17 2015-16Land Buildings Other Total Land Buildings Other Total£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Payable:No later than one year 0 133 3 136 0 0 0 0Between one and five years 0 532 6 538 0 0 0 0After five years 0 266 0 266 0 0 0 0Total 0 931 9 940 0 0 0 0

There were no income generation activities whose full cost exceeded £1m or was otherwise material in the year.

NHS Greenwich CCG paid £31k as rent for the Woolwich Centre for a 10 year lease expires in 2025.

Annual Accounts - 17

NHS Greenwich CCG - Annual Accounts 2016-17

12. Property, plant and equipment

2016-17 Land

Buildings excluding dwellings

Assets under construction

and payments on account

Plant & machinery

Information technology

Furniture & fittings Total

£'000 £'000 £'000 £'000 £'000 £'000 £'000Cost or valuation at 01 April 2016 0 1,008 0 207 823 658 2,696

Addition of assets under construction and payments on account 0Additions purchased ₁ 0 0 0 (194) (336) (67) (597)Additions donated 0 0 0 0 0 0 0Additions government granted 0 0 0 0 0 0 0Additions leased 0 0 0 0 0 0 0Reclassifications 0 0 0 0 0 0 0Reclassified as held for sale and reversals 0 0 0 0 0 0 0Disposals other than by sale 0 0 0 0 0 0 0Upward revaluation gains 0 0 0 0 0 0 0Impairments charged 0 0 0 0 0 0 0Reversal of impairments 0 0 0 0 0 0 0Transfer (to)/from other public sector body 0 0 0 0 0 0 0Cumulative depreciation adjustment following revaluation 0 0 0 0 0 0 0Cost/Valuation at 31 March 2017 0 1,008 0 13 487 591 2,099

Depreciation 01 April 2016 0 30 0 41 173 132 376

Reclassifications 0 0 0 0 0 0 0Reclassified as held for sale and reversals 0 0 0 0 0 0 0Disposals other than by sale 0 0 0 0 0 0 0Upward revaluation gains 0 0 0 0 0 0 0Impairments charged 0 0 0 0 0 0 0Reversal of impairments 0 0 0 0 0 0 0Charged during the year 0 41 0 (30) 6 105 122Transfer (to)/from other public sector body 0 0 0 0 0 0 0Cumulative depreciation adjustment following revaluation 0 0 0 0 0 0 0Depreciation at 31 March 2017 0 71 0 11 179 237 498

Net Book Value at 31 March 2017 0 937 0 2 308 354 1,601

Purchased 0 937 0 2 308 354 1,601Donated 0 0 0 0 0 0 0Government Granted 0 0 0 0 0 0 0Total at 31 March 2017 0 937 0 2 308 354 1,601

Asset financing:

Owned 0 937 0 2 308 354 1,601Held on finance lease 0 0 0 0 0 0 0On-SOFP Lift contracts 0 0 0 0 0 0 0PFI residual: interests 0 0 0 0 0 0 0

Total at 31 March 2017 0 937 0 2 308 354 1,601

Revaluation Reserve Balance for Property, Plant & Equipment

Land Buildings

Assets under construction & payments on account

Plant & machinery

Information technology

Furniture & fittings Total

£'000 £'000 £'000 £'000 £'000 £'000 £'000Balance at 01 April 2016 0 0 0 0 0 0 0

Revaluation gains 0 0 0 0 0 0 0Impairments 0 0 0 0 0 0 0Release to general fund 0 0 0 0 0 0 0Other movements 0 0 0 0 0 0 0Balance at 31 March 2017 0 0 0 0 0 0 0

2015-16 Land

Buildings excluding dwellings

Assets under construction

and payments on account

Plant & machinery

Information technology

Furniture & fittings Total

£000 £000 £000 £000 £000 £000 £000Cost or valuation at 01-April-2015 0 0 1,008 207 646 658 2,519

Addition of assets under construction and payments on account 0 0Additions purchased 0 0 0 0 177 0 177Reclassifications 0 1,008 (1,008) 0 0 0 0Cost/Valuation At 31-March-2016 0 1,008 0 207 823 658 2,696

Depreciation 01-April-2015 0 0 0 0 39 0 39

Charged during the year 0 30 0 41 133 132 337Depreciation at 31-March-2016 0 30 0 41 173 132 376

Net Book Value at 31-March-2016 0 978 0 166 650 526 2,320

Purchased 0 978 0 166 650 526 2,320Donated 0 0 0 0 0 0 0Government Granted 0 0 0 0 0 0 0Total at 31-March-2016 0 978 0 166 650 526 2,320

Asset financing:

Owned 0 978 0 166 650 526 2,320Held on finance lease 0 0 0 0 0 0 0

Total at 31-March-2016 0 978 0 166 650 526 2,320

₁The credit in additions reflects the reversal of amounts previously accrued on the understanding that expenditure had occurred and the asset was in use. Information has since come to light that this expenditure was cancelled and the planned replacement expenditure will not go ahead. Therefore these amounts have been removed, as has the related depreciation charged.

Annual Accounts - 18

NHS Greenwich CCG - Annual Accounts 2016-17

12. Property, plant and equipment cont'd

12.1 Additions to assets under construction

There were no additions to assets under construction in the year.

12.2 Compensation from third parties

12.3 Write downs to recoverable amount

12.4 Cost or valuation of fully depreciated assets

The cost or valuation of fully depreciated assets still in use was as follows:2016-17 2015-16

£'000 £'000Land 0 0Buildings excluding dwellings 0 0Dwellings 0 0Plant & machinery 0 0Transport equipment 0 0Information technology 77 0Furniture & fittings 0 0Total 77 0

12.5 Economic lives

Buildings excluding dwellings 23 23Dwellings 0 0Plant & machinery 3 3Transport equipment 0 0Information technology 0 5Furniture & fittings 3 3

There was no compensation from third parties in respect of assets impaired, lost or given up in the year.

Minimum Life (years)

Maximum Life (Years)

There were no write-downs to recoverable amounts in the year.

Annual Accounts - 19

NHS Greenwich CCG - Annual Accounts 2016-17

13. Investment propertyThe CCG has no investment property

14. Trade and other receivables Current Non-current Current Non-current2016-17 2016-17 2015-16 2015-16

£'000 £'000 £'000 £'000

NHS receivables: Revenue 3,261 0 2,050 0NHS prepayments 2,003 0 1,852 0NHS accrued income 1,912 0 229 0Non-NHS and Other WGA receivables: Revenue 4,052 0 1,243 0Non-NHS and Other WGA prepayments 0 0 (151) 0Non-NHS and Other WGA accrued income 236 0 824 0Provision for the impairment of receivables 0 0 0 0VAT 33 0 0 0Other receivables and accruals 0 0 8 0Total Trade & other receivables 11,497 0 6,054 0

Total current and non current 11,497 6,054

Included above:Prepaid pensions contributions 0 0

14.1 Receivables past their due date but not impaired 2016-17 2015-16£'000 £'000

By up to three months 1,333 139By three to six months 207 39By more than six months 856 268Total 2,396 446

£418,692 of the amount above has subsequently been recovered post the statement of financial position date.

Annual Accounts - 20

NHS Greenwich CCG - Annual Accounts 2016-17

15. Cash and cash equivalents

2016-17 2015-16£'000 £'000

Balance at 01 April 2016 119 1Net change in year 168 118Balance at 31 March 2017 287 119

Made up of:Cash with the Government Banking Service 287 119Cash with Commercial banks 0 0Cash in hand 0 0Current investments 0 0Cash and cash equivalents as in statement of financial position 287 119

Bank overdraft: Government Banking Service 0 0Bank overdraft: Commercial banks 0 0Total bank overdrafts 0 0

Balance at 31 March 2017 287 119

Patients’ money held by the clinical commissioning group, not included above 0 0

Annual Accounts - 21

NHS Greenwich CCG - Annual Accounts 2016-17

Current Non-current Current Non-current2016-17 2016-17 2015-16 2015-16

£'000 £'000 £'000 £'000

Interest payable 0 0 0 0NHS payables: revenue 7,515 0 11,405 0NHS accruals 10,237 0 1,869 0Non-NHS and Other WGA payables: Revenue 10,183 0 10,083 0Non-NHS and Other WGA payables: Capital 0 0 599 0Non-NHS and Other WGA accruals 16,807 0 6,272 0Social security costs 47 0 54 0VAT 0 0 56 0Tax 45 0 58 0Other payables and accruals 2,205 0 1,433 0Total Trade & Other Payables 47,039 0 31,829 0

Total current and non-current 47,039 31,829

17. ProvisionsThe CCG has no provisions

18. ContingenciesThe CCG has no contingent liabilites nor assets

Other payables include £53,322 outstanding pension contributions at 31 March 2017

16. Trade and other payables

Annual Accounts - 22

NHS Greenwich CCG - Annual Accounts 2016-17

19. Financial instruments

19.1 Financial risk management

19.1.1 Currency risk

19.1.2 Interest rate risk

19.1.3 Credit risk

19.1.4 Liquidity risk

The Clinical Commissioning Group borrows from government for capital expenditure, subject to affordability as confirmed by NHS England. The borrowings are for 1 to 25 years, in line with the life of the associated assets, and interest is charged at the National Loans Fund rate, fixed for the life of the loan. The clinical commissioning group therefore has low exposure to interest rate fluctuations.

Because the majority of the NHS Clinical Commissioning Group and revenue comes parliamentary funding, NHS Clinical Commissioning Group has low exposure to credit risk. The maximum exposures as at the end of the financial year are in receivables from customers, as disclosed in the trade and other receivables note.

NHS Clinical Commissioning Group is required to operate within revenue and capital resource limits, which are financed from resources voted annually by Parliament. The NHS Clinical Commissioning Group draws down cash to cover expenditure, as the need arises. The NHS Clinical Commissioning Group is not, therefore, exposed to significant liquidity risks.

Financial reporting standard IFRS 7 requires disclosure of the role that financial instruments have had during the period in creating or changing the risks a body faces in undertaking its activities.

Because NHS Clinical Commissioning Group is financed through parliamentary funding, it is not exposed to the degree of financial risk faced by business entities. Also, financial instruments play a much more limited role in creating or changing risk than would be typical of listed companies, to which the financial reporting standards mainly apply. The clinical commissioning group has limited powers to borrow or invest surplus funds and financial assets and liabilities are generated by day-to-day operational activities rather than being held to change the risks facing the clinical commissioning group in undertaking its activities.

Treasury management operations are carried out by the finance department, within parameters defined formally within the NHS Clinical Commissioning Group standing financial instructions and policies agreed by the Governing Body. Treasury activity is subject to review by the NHS Clinical Commissioning Group and internal auditors.

The NHS Clinical Commissioning Group is principally a domestic organisation with the great majority of transactions, assets and liabilities being in the UK and sterling based. The NHS Clinical Commissioning Group has no overseas operations. The NHS Clinical Commissioning Group and therefore has low exposure to currency rate fluctuations.

Annual Accounts - 23

NHS Greenwich CCG - Annual Accounts 2016-17

19. Financial instruments cont'd

19.2 Financial assets

At ‘fair value through profit and

loss’Loans and

ReceivablesAvailable for

Sale Total2016-17 2016-17 2016-17 2016-17

£'000 £'000 £'000 £'000

Embedded derivatives 0 0 0 0Receivables:· NHS 0 5,173 0 5,173· Non-NHS 0 4,288 0 4,288Cash at bank and in hand 0 287 0 287Other financial assets 0 0 0 0Total at 31 March 2017 0 9,748 0 9,748

At ‘fair value through profit and

loss’Loans and

ReceivablesAvailable for

Sale Total2015-16 2015-16 2015-16 2015-16

£'000 £'000 £'000 £'000

Embedded derivatives 0 0 0 0Receivables:· NHS 0 2,279 0 2,279· Non-NHS 0 1,416 0 1,416Cash at bank and in hand 0 119 0 119Other financial assets 0 8 0 8Total at 31 March 2016 0 3,822 0 3,822

19.3 Financial liabilities

At ‘fair value through profit and

loss’ Other Total2016-17 2016-17 2016-17

£'000 £'000 £'000

Embedded derivatives 0 0 0Payables:· NHS 0 17,752 17,752· Non-NHS 0 29,195 29,195Private finance initiative, LIFT and finance lease obligations 0 0 0Other borrowings 0 0 0Other financial liabilities 0 0 0Total at 31 March 2017 0 46,947 46,947

At ‘fair value through profit and

loss’ Other Total2015-16 2015-16 2015-16

£'000 £'000 £'000

Embedded derivatives 0 0 0Payables:· NHS 0 13,274 13,274· Non-NHS 0 18,388 18,388Private finance initiative, LIFT and finance lease obligations 0 0 0Other borrowings 0 0 0Other financial liabilities 0 0 0Total at 31 March 2016 0 31,662 31,662

20. Operating segmentsThe Clinical Commissioning Group and consolidated group consider they have only one segment: commissioning of healthcare services.

Annual Accounts - 24

NHS Greenwich CCG - Annual Accounts 2016-17

21. Pooled budgets

2016-17 2015-16£'000 £'000

Income 18,411 18,010Expenditure 16,153 17,577

£000 £000Budget 2016/17 2015/16Royal Borough of Greenwich 12,430 12,597Greenwich CCG 5,981 5,413Total Budget 18,411 18,010

ExpenditureRoyal Borough of Greenwich 11,953 12,597Greenwich CCG 4,200 4,980Total Expenditure 16,153 17,577

Budget less Expenditure 2,258 433

£000 £000DebtorsGreenwich CCG 4,858 1,050

4,858 1,050CreditorsRoyal Borough of Greenwich 4,858 1,050

4,858 1,050Greenwich CCG

22. NHS LIFT investmentsThe CCG has no NHS LIFT investments

The Greenwich CCG and Royal Borough of Greenwich operate a pooled budget agreement for income and expenditure in the Better Care Fund.

Overall BCF budget underspent by £2,258k. These monies were used to offset expenditure on non-elective admissions, in particular at Lewisham and Greenwich NHS Trust over the winter period.

The NHS Clinical Commissioning Group shares of the income and expenditure handled by the pooled budget in the financial year were:

Under Section 75 of the NHS Act 2006 (as amended), the Secretary of State can make provision for local authorities and National Health Service (NHS) bodies to enter into partnership arrangements in relation to certain functions, where these arrangements are likely to lead to an improvement in the way in which those functions are exercised.

These arrangements are known as pooled budgets but the CCG funds Local Authority expenditure. Hence, the CCG records the total funding and expenditure by both parties in its accounts.The tabulation below identifies the budget and expenditure by both parties for 2016/17.

Annual Accounts - 25

NHS Greenwich CCG - Annual Accounts 2016-17

23. Related party transactions

Details of related parties with GP practices,NHS bodies where individuals are governing body members are as follows:2016-17 2015-16

Payments to Related Party

Receipts from Related Party

Amounts owed to Related

Party

Amounts due from Related

PartyPayments to Related Party

Receipts from

Related Party

Amounts owed to Related Party

Amounts due from Related

Party£'000 £'000 £'000 £'000

NHS Tower Hamlets - Maggie Bucknell(Registered Nurse) 16 (15) 9 7 (14)Burney Street Practice - Dr Sylvia Nyame 1 10St Mark's Medical Centre - Dr Hany Wahba 111 131River View Limited Liability Partnership (LLP) - Dr Hany Wahba 58 114 (14) 29Grabadoc Healthcare Society Ltd Dr Hany Wahba 0 806Thamesmead Medical Associate - Dr Eugenia Lee 0 61Blackheath Standard Surgery - Dr Nayan Patel 15 55Meridian LLP - Dr Nayan Patel 117Vanbrugh Group Practice PMS - Dr Ellen Wright 17 (4) 2 148 (47) (19)Valentine Health Partnership - Dr Rebecca Rosen 0 69Sherard Road Medical centre - Dr Krishna Subbarayan 11 14

346 (19) 9 2 1,415 (75) 29 (19)

The GPs individually named as above are clinical commissioners on the Governing Body. The payments above are not made to the individuals themselves but to their General Practice for clinical services commissioned by the CCG. These payments to the GP Practices exclude funding for prescribing.

• NHS England;• NHS Foundation Trusts;• NHS Litigation Authority; and,• NHS Business Services Authority.The NHS organisations listed below are those where transactions over the year 2015-16 and/or 2016-17 have exceeded £500k:

Barts Health NHS TrustChelsea and Westminster Hospital NHS Foundation TrustDartford and Gravesham NHS TrustGuys St Thmas NHS Foundation TrustKings College Hospital NHS Foundation TrustLewisham And Greenwich NHS TrustLewisham Hospital NHS TrustLondon Ambulance NHS TrustMoorfields Eye Hospital NHS Foundation TrustNHS EnglandNHS Property ServicesNHS South London Commissioning Support UnitNHS Southwark CCGOxleas NHS Foundation TrustSouth London And Maudsley NHS Foundation TrustUniversity College London NHS Foundation TrustNHS Bexley CCGNHS Bromley CCGNHS Lewisham CCG

Royal Borough of Greenwich

Details of related party transactions with individuals are as follows:

In addition, the clinical commissioning group has had a number of material transactions with other government departments and other central and local government bodies. Transactions with other Government Departments over the year 2016/17 which have exceeded £500k:

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. For example:

Annual Accounts - 26

NHS Greenwich CCG - Annual Accounts 2016-17

24. Events after the end of the reporting period

25. Third party assets

The CCG has no third-party assets

26. Financial performance targets

NHS Greenwich Clinical Commissioning Group have a number of financial duties under the NHS Act 2006 (as amended).NHS Greenwich Clinical Commissioning Group performance against those duties was as follows:

2016-17 2016-17 2015-16 2015-16

Target Performance VarianceDuty

Achieved? Target PerformanceExpenditure not to exceed income 386,457 387,027 (570) N 365,911 362,438Capital resource use does not exceed the amount specified in Directions 0 0 0 Y 400 177Revenue resource use does not exceed the amount specified in Directions 376,048 376,618 (570) N 365,511 362,261Capital resource use on specified matter(s) does not exceed the amount specified in Directions 0 0 0 Y 0 0Revenue resource use on specified matter(s) does not exceed the amount specified in Directions 0 0 0 Y 0 0Revenue administration resource use does not exceed the amount specified in Directions 6,067 6,033 34 Y 5,883 5,872

27. Analysis of charitable reserves

NHS England recently announced details of the Clinical Commissioning Groups approved to take on greater delegated responsibility or to jointly commission GP services from 1st April 2017. The new primary care co-commissioning arrangements are part of a series of changes set out in the NHS Five Year Forward View.

NHS Greenwich CCG has been approved under delegated commissioning arrangements which means that the CCG will assume full responsibility for contractual GP performance management, budget management and the design and implementation of local incentive schemes from 1st April 2017.

NHS Greenwich CCG is the Corporate Trustee of the NHS Greenwich Charitable Funds. The Governing Body does not consider the activities of the charity to be material to NHS Greenwich CCG. The charitable funds represent approximately 1.0% (2016 - 1.1%) of the revenue resource outturn position of NHS Greenwich CCG. Accordingly, the Governing Body has decided not to consolidate the NHS Greenwich Charitable Funds accounts with that of the CCG.