€¦ · developing an integrated team – in north and central aylesbury, and south...

Contents

PERFORMANCE REPORT

Performance overview

Performance analysis

ACCOUNTABILITY REPORT

Corporate governance report

Members report

Statement of Accountable Officer's responsibilities

Governance statement

Remuneration and staff report

Staff report

Parliamentary accountability and audit report

ANNUAL ACCOUNTS

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Chair’s Foreword

I am pleased to introduce the inaugural annual report for NHS Buckinghamshire Clinical

Commissioning Group (BCCG). BCCG was formed upon the merger of NHS Aylesbury

Vale and NHS Chiltern Clinical Commissioning Groups on the 1 April 2018.

It remains a privilege to lead a team of such highly dedicated individuals who are focussed on

ensuring that our NHS resources are best utilised for the maximum benefit to our local

population. I would also like to thank our 50 GP practices who constitute the membership of

our organisation for their continued support.

Over the past year, we have continued on our journey as one of eight, first-wave Integrated

Care Systems (ICSs) in England, seeking to develop shared decision making, improve local

services and manage our limited resources collectively with our partner organisations across

health and social care. As in previous years, the gap between our NHS budget allocation and

the demand for health care in the county has continued to present challenges.

Our commissioning approach over a number of years is reassuringly consistent with the NHS

Long Term Plan which was published in January 2019. This plan seeks to develop community-

based services (out of hospital and closer to home) with resources focussed on evidence-

based health care that is tailored to the specific needs of our local communities.

We also welcome the publication of the five-year framework for general practice to implement

the NHS Long Term Plan. The guidance was published on 3 January 2019 and we are starting

to form networks of GP practices working closely together to develop tailored services with

their local populations.

We recognise the wider social determinants of good health and the health inequalities that

arise when these are not addressed so we continue to listen to and work more closely with our

local communities to better understand their health care needs and their experience of local

services. We have strengthened our clinical focus on health inequalities and hope to empower

the Buckinghamshire population to live a greater proportion of their lives in “good health”.

In summary, Louise Patten (Accountable Officer) and I would like to thank the many individuals

that organise and deliver health and care services in the county. Their skill and dedication is

greatly appreciated and we will work hard to support them during an ongoing period of

transition to towards truly integrated, community-based care in Buckinghamshire.

Dr Raj Bajwa

Clinical Chair, NHS Buckinghamshire CCG

PERFORMANCE REPORT

Principal Activities

The CCG is responsible for commissioning

non-specialist hospital services and both

urgent and planned care. It also

commissions mental health and learning

disability services, GP out-of-hours

services, NHS 111 and ambulance services,

and community rehabilitation and

physiotherapy services. The CCG has also

taken on delegated responsibility for

commissioning General Practice.

Specialist hospital services, dentistry and

optician services are not commissioned by

the CCG – these services are commissioned

by NHS England.

Vision and aims

Activities in 2019/19

Improving Access to Primary Care

Since October 2018, GP practices have been working together to offer patients better access

to appointments across the county. Appointments are now being made available in local

practices up until 8pm from Monday to Friday and on Saturday and Sunday mornings. These

appointments may not be at the patient’s usual practice but will be at a time that is convenient.

Practices in the south Aylesbury area have piloted development of appointments with ‘Q

doctor’ [a skype based service] and a visiting paramedic who works 5 days a week.

Planning for Population Growth

The population growth across the county, and particularly in parts of Wycombe and Aylesbury, will

require a significant investment in general practice infrastructure. The CCG strategy is to

encourage local authorities to be innovative with contributions raised through the developers

under Section 106 or Community Infrastructure Levy, so new investment can support service

transformation. A number of new schemes have been progressed over the last year.

There is particular emphasis from the CCG on delivering healthcare ‘at scale’ and integrating

general practice with acute, community, mental health and social care services to serve the

population increase.

Supporting Rough Sleepers – in Wycombe and central Aylesbury

In 2018, Aylesbury Vale District Council received funding from central government to support

rough sleepers in Aylesbury; 20 people were identified and verified as genuinely sleeping

outdoors in the Aylesbury Vale area. The aim of the funding is to coordinate a multi-agency

approach to help rough sleepers off the streets and support them with housing, health and

benefits needs. A portion of the funding has been set aside for health provision. This will fund

dedicated mental health nursing support and enhanced appointments in primary care. We want

to help these patients to engage better with the whole health and care system.

This approach has also been developed in Wycombe, working with Wycombe

Homeless Connection where a co-ordinator has linked people to support agencies and

generally managed a multi-agency package of care.

Developing an Integrated Team – in north and central Aylesbury, and south

Buckinghamshire localities

Since 2015, GP practices in north and central Aylesbury have been working with a dedicated,

“over 75s” team made up of clinical and non-clinical professionals. The team has focused on

working with multi-agency partners to manage frail and elderly patients with multiple health

conditions in the community and to avoid unplanned admissions to hospital. In 2018, the CCG

confirmed its commitment to supporting the development of these teams as part of the new

community care model and started working with the south Bucks locality to replicate the

Aylesbury model.

GPs in central Aylesbury are now widening their focus to greater support our most complex

patients. This work started by building stronger and robust relationships with community

nursing, mental health, primary care and the voluntary sector. This work includes:

Leg ulcer clubs: These clubs aim to treat leg ulcers and associated conditions in a social

environment, where patients are treated collectively and the emphasis is on social

interaction.

Multi-Disciplinary Team meetings (MDTs): Meetings where different professionals from

a variety of health and care organisations can meet and discuss the care of the most

complex patients

Improving IT connectivity across the locality: All practices are implementing AskNHS, an

app that helps patients explore their symptoms and offers advice or, where appropriate,

access to the GP surgery

North Aylesbury has been focussing on those with age-related conditions, long-term chronic

diseases and recognising the devastating effects that loneliness and isolation can have on

physical and mental wellbeing. The service aims to provide high quality prevention, early

intervention and ongoing care by a range of clinicians and non-clinicians who are trained to

work across a number of health and care needs to utilise their combined resources efficiently,

and practicing within formal and safe guidelines. GPs, community nurses, community

psychiatric nurses, social workers, voluntary organisations and other professionals/

organisations form multi-disciplinary teams and come together to work with the person and

their carer/wider family to agree and deliver a personalised plan of joined up care and support.

This package will be designed to meet their holistic needs (physical health, social care and

mental health) and help them to remain independent for as long as possible. They will be

supported by a care coordinator/keyworker from the team.

South Bucks locality integrated teams include GPs, community nurses, community psychiatric

nurses, social workers, social care assistants and other professionals/organisations in multi-

disciplinary teams. These people come together to develop more patient-centred and efficient

ways of working. This can include developing new healthcare pathways to ensure patients are

seen by the right person at the right time; exploring new technology to facilitate easier working

between the different healthcare providers, and making sure that the full value of the voluntary

sector is utilised wherever possible.

Community Assessment and Treatment Service at Thame and Marlow Hospitals

GP practices have supported increased numbers of referrals into this service during the year

as a pro-active way of addressing many issues facing frail and elderly patients. This has been

particularly significant in the Wooburn Green and South Aylesbury localities. The main benefit

of this service is that it avoids unnecessary admissions into secondary (hospital) care. These

services link closely with those provided by Multi-Disciplinary Day Assessment Service

(MUDAS).

Patient Support Team - North Aylesbury

The service has already made a difference to our older patients. Whether it is through the co-

ordination of care networks, signposting, provision of equipment or improvement in health

outcomes, there has been a positive impact on quality of life and independence for our older

patients. The success of the service made us realise that there are significant numbers of

vulnerable people with long term conditions who are younger than 75, but suffer the same

problems with access, loneliness and isolation, all of which can worsen their medical

problems. Through a working partnership with a charity, it has been possible to try to

address some of the issues around loneliness and isolation.

The project has enhanced the working relationships between the GP practices in the North

Locality. The work of the team was seen as an asset by the Care Quality Commission

when undertaking an inspection and identified as an area of good practice.

There is a suggestion of a downward trend in A&E attendance and unplanned admissions for

patients aged over 75 in the North Locality.

Personalised Care Service (PCS)

The south Bucks locality, building on the work that was already happening in Aylesbury has

piloted a Personalised Care Service (PCS). It is recognised that there are a number of patients

in the system whose needs are not currently being met and as a result end up seeking help

through urgent care health services. The Personalised Care Service uses care co-ordinators to

work with individuals to develop a personalised care plan, focused on the individuals own

goals. The patient is also able to use the local knowledge of the co-ordinator to access

appropriate support, including voluntary and local services.

Collaborative working

Many localities have been exploring ways of collaborative working in smaller geographic

groups and with other healthcare providers, with the support of the CCG and the GP

Federations. This includes exploring commissioning of locality specific services and sharing of

best practice. Recent projects include the re-design of existing discharge pathways from

Wexham Park Hospital, sharing of best practice when using EMIS, the GP clinical system for

making care records, and the creation of a locality-wide locum group. Looking to the future, the

localities introduced a standardised website platform to ensure that all patients have access to

the same high-quality online NHS information no matter where their practice is based.

Working with Frimley – Southern Locality

The Southern Locality has continued to develop a closer relationship with Heatherwood and

Wexham Park hospitals, via the Interim Head of Business Development at Frimley Health NHS

Foundation Trust who acts as the current liaison between Southern Locality and the Trust. This

has been mirrored with a similar relationship with Buckinghamshire Healthcare NHS Trust

through close working with the Director of Strategy and Business Development.

Southern out-of-hours hub

An out-of-hours hub has been proposed for Threeways Practice in Stoke Poges. This enables

patients living across south Buckinghamshire to access the service more locally.

Primary Care Networks (PCNs)

All localities have progressed working with their member Buckinghamshire practices have

been in discussion to form PCNs, which will be in place for July 2019 to become the foundation

of the Integrated Care System and address health inequalities, provide resilience to local

health services and most importantly, ensure improved patient outcomes. It will reduce the

current workload pressures faced by individual practices and improve the working situation for

the primary care team.

NHS Long Term Plan

Practices are working together to support the NHS Long Term Plan covering the three key

areas of life stage, clinical priorities and enablers of improvement, each covering a number of

different areas which we believe will have the greatest potential to deliver improvements to the

way the NHS provides care.

Development of locality packs

During the year, locality and practice packs have been developed which enable practices to

review their achievement levels across the Primary Care Development Scheme, elective and

non-elective care pathways and medicines management. Through a peer review process, best

practice has been shared between surgeries and localities have supported successful delivery

of challenging targets.

Primary Care Development Scheme (PCDS)

This innovative scheme is now finishing its second year and has won accolades from across

the country for its innovation and engagement. Quality of care achievements as part of the

scheme have also fed into the new National Framework.

Training and Practice Development

A comprehensive training programme for clinical and non-clinical staff has seen the

development of care navigators in many practices leading to improved patient support. This

also frees GPs to use their skills for those with more medically demanding needs. A navigator

or a care team assistant is a revolutionary concept in modern medicine. Traditionally, a

physician or nurse's job has been focusing solely on direct patient contact and care. However,

a care navigator provides opportunities that supports good patient care outside of the clinical

environment and alleviates workload of the practice staff.

The Time for Care and Quick Start programmes have improved resilience in general practice

across the county.

Primary Care Commissioning

The Mandeville Practice, Aylesbury

Following a procurement exercise in 2017/18, a new provider, Primary Care Management

Solutions (PCMS) took over the running of The Mandeville Practice on 1 April 2018. The model

PCMS presented as part of its bid for the contract had a number of innovative features

including use of allied health professionals such as clinical pharmacists, paramedics and

physicians assistants to deliver care, improving access by use of a range of consultation

formats and close working with the community especially through the Healthy Living Centre,

which is adjacent to the practice. The practice was also rated as Inadequate by the Care

Quality Commission (CQC) and in Special Measures when PCMS took over in April 2018. The

first year of the contract has seen a marked improvement in the quality and range of services

being provided at The Mandeville Practice. These improvements were reflected in the CQC

overall rating changing from Inadequate to Good upon re-inspection in November 2018. The

CCG is now confident of the sustainability of The Mandeville Practice following a period of

uncertainty.

Chiltern House Medical Centre, High Wycombe

In July 2018, the CCG was notified of dissolution of the partnership that held a contract for the provision of primary medical services at Chiltern House Medical Centre, High Wycombe. A few weeks after this, the branch surgery premises in Holmer Green became unavailable when the lease ended and the landlord did not wish to renew. The CCG secured an interim provider for the practice to ensure the patients continued to receive services whilst information gathering and patient engagement on the future of the practice took place and to allow time for the preferred solution to be implemented. The survey was available online, with paper copies sent to patients over 65. Further copies were available at the practice and local pharmacies. Meetings were held with the Patient Participation Group and staff at the practice, as well as with other practices in the area that cover High Wycombe and Holmer Green. The CCG also worked closely with the PPG to ensure that as many people as possible were able to express their views.

1,124 members of the public took part in a survey. As a result of the feedback from this and other engagement, the CCG has agreed that Option 3 – re-procurement – is taken forward. This means another service provider will be found to run the practice.

This decision supported the preferences of patients who took part in the patient engagement.

The procurement process is now underway (March 2019) and it is hoped a contract award

will be made in May 2019 with the new provider in place ready for 1 September 2019.

Buckinghamshire Special Allocation Service

As part of its responsibility under delegated primary care commissioning, the CCG was

required by NHS England to commission a Special Allocations Service which provides primary

medical services for patients who have been removed from their practice due to violent or

threatening behaviour, in line with the NHS zero tolerance scheme. Using a service

specification based on NHS England guidance, the service was initially offered out to local GP

practices with no interest being received. However a practice in Bedfordshire, who is already

the Special Allocations Service provider for Milton Keynes and Bedfordshire, was interested

in providing the service for Buckinghamshire and took on the service from July 2018. They

are currently providing care for six Buckinghamshire based patients.

Primary Care Transformation

Primary Care Services

The CCG launched the first phase of the new 24/7 primary care service model in April 2018

by introducing a new GP out-of-hours and Urgent Treatment Centre contract. This change in

provider will allow the better integration of existing services to meet patient need, thus

improving patient access and efficiency.

The second phase of improving access was delivered in October 2018, when all practices

began to offer their patients access to a routine bookable appointment 8am to 8pm Monday to

Friday and at selected times over the weekend period. This not only extends access for

patients but reduces pressure on our emergency services.

Primary Care Estates

The CCG published a snapshot of primary care estate in April 2018 which showed the need for

significant capital investment across the county as a result of population growth.

The CCG will be working with Sustainable Transformation Partnership (STP) colleagues so

that a Primary Care Strategy and investment plans can be drawn up across

Buckinghamshire, Oxfordshire and Berkshire.

In the meantime in 2018/19, the CCG has completed two outline business cases for major

new primary care centres in Beaconsfield and Aylesbury. The Beaconsfield scheme will

accommodate Millbarn and Simpson Medical Centre and the scheme in Aylesbury will provide

a new location for both the Berryfields Medical Centre and Meadowcroft Surgery. Both

schemes are due for completion during 2021/22.

In line with our plans to establish health and care centres across the county, the CCG is also

supporting the move of the Wye Valley Surgery from their current premises in High Wycombe

to the Wycombe Hospital site in April 2019. The GP out-of-hours service and Urgent

Treatment Centre are already located on the hospital site and colocation will provide the

opportunity for more joined up care.

Workforce training and development

The STP workforce oversight group was established in 2018. This aims to encourage a joint

approach to training and professional development across the STP. This joint approach has

already proven successful in planning future workforce requirements to ensure workforce

trajectories and training plans are in place and monitored to ensure a robust and sustainable

primary care workforce for the future.

The STP covering Buckinghamshire, Oxfordshire and Berkshire has been awarded significant

funding to establish the GP Workforce Support Programme in support of GP retention. The

programme is based on three areas of work that include the establishment of a bespoke

Locum GP Chambers, a Career Flex mentoring programme, and career coaching / support for

GPs returning to work after a period of absence. This programme will be established and

embedded by the STP training hubs and local GPs should see the benefits in the forthcoming

months.

In July 2018, the CCG hosted a, ‘Time for Care’ showcase which was facilitated by a

team from the NHS England sustainable improvement team. Following on from the

showcase, practices have benefitted from the Bucks Productive General Practice (PGP)

Quickstart Programme and the Fundamentals of Quality Improvement course.

The launch of a care navigation training programme has provided the opportunity for 72

members of practice staff across the county to receive bespoke training by The National

Association of Primary Care (NAPC), with 21 of our primary care navigators also successfully

completing a higher level of training. Primary care navigation means assisting patients and

carers in identifying and accessing the systems and support that are available to them within

health and social care. Further training opportunities will be available in 2019/20.

The CCG has supported practices in upskilling non-clinical staff in the role of workflow

optimisation. Training opportunities will continue throughout 2019/20, however to date, 70

practice staff members have received training. Workflow optimisation allows non-clinical staff

to work using standard protocols developed in-house and refined through continuous

improvement to manage incoming correspondence that does not require clinical oversight

and hence releasing GP’s time to care.

The Bucks Training Hub is now fully established and has its own website and Facebook pages

and co-ordinates all training activities, runs the nurse forums and organises primary care

placements. Around 500 primary care staff have accessed training in 2018.

The first practice manager away day was hosted by the CCG on 1 May 2018, providing an

opportunity for networking, time to discuss the role of practice managers in the transformation

of primary care and practical sessions on a range of topics. A further away day is planned for

this year and the CCG will be working with practice managers to ensure that the agenda meets

their learning requirements.

Bucks Training Hub has worked with our practice to undertake a comprehensive training needs

analysis. The priority for next year will be to ensure training is offered in line with identified

priorities and the emerging Primary Care Network model.

Two primary care professionals from Buckinghamshire have been appointed by Health

Education England (HEE) to join the Thames Valley GP School Fellowship Programme. The

aim is for the successful candidates to work across the BOB STP health and care system, to

develop and deliver high quality care whilst investigating, developing and implementing new

ways of improving local population health interventions.

The CCG is working with STP partners to ensure that Buckinghamshire is prepared to receive

International GPs who, following a robust selection process, have expressed an interest in

working in Buckinghamshire.

Primary Care Lead Nurses

The role of the Primary Care Lead Nurses in Buckinghamshire CCG is:

To promote a culture where improving the local population’s health is at the heart of all

we do.

Their aim is to work with colleagues to ensure the quality and standards of care are the best

they can be across the county.

Some examples of work they have carried out are:

Planned and facilitated educational afternoons for the nurses, health care assistants

and paramedics countywide. By inviting guest speakers to deliver training to the groups

they have increased their skills and knowledge which in turn has improved patient care.

Have a presence on all the key working groups and forums, which include the Clinical and

Care Forum, Care and Support Planning operational group, Long Term Conditions

educational group, Joint Locality Clinical Leads meeting, Bucks Integrated Teams.

Introduced more placement opportunities for student nurses and have

established strong links with local universities.

Reviewed and updated locally commissioned service specifications - notably leg ulcer

care.

Supported the primary care development scheme and the critical role nurses play in

delivering this scheme.

Provided education, support and development of a template for standardising the

recording of wound care in line with colleagues from the Adult Community Healthcare

Teams.

Their priorities for the coming year are to….

Develop an effective and well-supported primary and community care workforce in

accordance with the NHS Long Term Plan.

Provide more placement opportunities so learners choose to start their career in primary

and community care.

Influence and lead new modules of care and new ways of working.

Support networking of the paramedics, health care assistants and phlebotomists in their

own forums.

To continue to embed the General Practice Nurse 10 point plan in everything

we undertake.

Transforming Community Services

During 18/19 the programme of transformation being driven by the CCG with our practices and

health and social care colleagues has been strengthened by working at scale as part of the

Buckinghamshire Integrated Care System (ICS), Buckinghamshire Oxfordshire and Berkshire

STP and developing joint working with Oxfordshire CCG.

As part of Buckinghamshire ICS, we have enabled practices and clinical leaders to be key in

developing the new model of community care as shown below. The implementation of this

model has involved progressing new ways of working across health and social care such as

establishing integrated multidisciplinary teams and introducing shared care records. This work

has kept the patient at the heart of services and in particular benefitted patients with the most

complex care needs. This has only been possible through the strengthening of relationships

between different professionals and teams. In 19/20 the CCG will continue to strengthen the

integration between community and primary care to improve patient outcomes and the

resilience of services.

Learning Disability

Through 2018/19, Buckinghamshire CCG has continued its commitment to deliver improved

services and outcomes for people with a learning disability in line with national best practice

and to meet the expectations of the national Transforming Care Programme.

Buckinghamshire’s Transforming Care Partnership (TCP) continues to provide the opportunity

to work collaboratively to develop and improve services and pathways for people with a

learning disability and/or behaviours that challenge.

Hertfordshire Partnership NHS Foundation Trust (HPFT) is commissioned to deliver

Specialist Adult Learning Disability Services providing proactive community services, with an

intensive support service, and four specialist inpatient beds. Children with a learning disability

are supported through paediatricians and Children’s Community Learning Disability Nurses

provided by NHS Buckinghamshire Healthcare Trust and through the Child and Adolescent

mental health service (CAMHS) provided by Oxford Health NHS Foundation Trust (OHFT).

Work has commenced across children’s and adult services to establish a programme to deliver

training and support in positive behaviour approaches. This work aims to ensure a consistent

approach to challenging behaviour to be applied across ages and agencies. In addition, the

service has developed a Positive Partnerships Team during 2018/19.

Care, (Education) and Treatment Reviews (C (E)TRs) have been more consistently used

through 2018/19 providing a multi-agency approach to minimise admissions to inpatient

services for both children and adults. The process is now more fully embedded within

children’s services although there is still work to do to ensure early recognition of those at risk

of situation breakdown.

Buckinghamshire CCG continues to maintain the nationally required in-patient bed capacity

and promote timely discharge from inpatient stays.

In 2017/18, 56% of patients with Learning Disability had an Annual Health check (exceeding

the local target of 55%). For 2018/19 we have stretched this target to achieving 65%. In

September 2018, Buckinghamshire’s Transforming Care Partnership held an Access all Areas

event to promote annual health checks and support living well and staying well. The event was

aimed at people living in Buckinghamshire aged 14 and over who have a learning disability

and/or autism, and their parents, carers, friends and support workers. It showcased the wide

range of services available for people with Learning Disabilities in Buckinghamshire. This first

event of its kind in Buckinghamshire attracted nearly 250 visitors, and saw 100 people from

organisations across the county come together to help address the health inequalities people

with learning disability or autism can face.

Over 36 health and social care exhibition stands provided advice and support. These included

Nclude, BuDs, Healthy Minds, Bucks Safe Places, Autism Bucks, Audiology and Hearing

Therapy Services (BHT) and Speech and Language Therapy (HPFT). Access All Areas is just

one way that the Transforming Care Partnership is helping to improve the health and

wellbeing of people with a learning disability or autism in Buckinghamshire. As part of this they

want to encourage more people to sign up for Annual Health Checks with their GP.

The Learning from Deaths for people with a Learning Disability (LeDeR) programme has

continued through 2018/19 with multi-agency reviews completed on all relevant cases. These

are being delivered by HPFT who are identifying learning and actions as cases are reviewed

with a bespoke person centred approach to engagement with families/carers. Delivery of the

national STOMP (Stopping over medication of people with a learning disability, autism or both)

action plan has continued with significant positive outcomes for individuals.

Care Homes

The CCG aims to improve the health of care home residents by enhancing the quality and

experience of care they receive. We are also supporting care homes to better plan for end

of life so residents can die where they want to be.

There are a significant number of new care homes being built in Buckinghamshire, which will

increase demand for health and social care services. In order to meet increased demand a

process of transforming primary, community, acute and social care services through

integration has commenced. Without this approach there are risks to the long term

sustainability of health and care services.

In support of these aims we are implementing the Enhanced Health in Care Homes

Framework. One example of this approach is to use video consultations in care homes, which

has begun in Aylesbury and Wycombe. Evaluation of the service demonstrated that it had a

positive impact in reducing the number hospital admissions for residents of care homes using

the service. It also reduces the workload for General Practice so improving GP sustainability.

Therefore, during 2019/20 we will be extending video consultations to those care homes

across the county who will benefit most from the service.

End of Life Care

The CCG supports high quality end of life care and continues with this as one element of the

Primary Care Development Scheme to promote a consistent approach across general practice.

Furthermore, the CCG is continuing to work closely with end of life providers to understand

how increased collaboration across our ICS can address gaps in current service provision

which results in people having fewer hospital admissions in their final months of life and

supports more people dying in their preferred place.

Mental Health – Buckinghamshire overview

Buckinghamshire has continued to work towards achieving the ambitions of the mental health

Five Year Forward View with partners from across the Buckinghamshire Integrated Care

System (ICS). Engagement with people that have lived experience of the condition has been

a key focus over the last 12 months, using their insight to inform the design, commissioning

and delivery of services over the next three to five years; forming the basis for

Buckinghamshire’s all age mental health strategy, due to be published in 2019.

As part of the engagement work people have told us that:

There needs to be a clearer focus on earlier intervention for young people; particularly in

schools, to help raise awareness of mental health as a condition and support young

people proactively; national evidence tells us that 50% of mental health problems are

established by the age of 14.

Mental Health stigma is still a problem for people living with the condition, in particular

those that have not yet sought support; this can act as a barrier for people seeking

and accessing support.

Care needs to be made more easily accessible particularly for people when they are in

crisis; service users and their carers need to know where they can access support

quickly when they need it most.

The physical health needs of those that have a mental health problem need to be

considered in all aspects of care to prevent people that have a severe and enduring

mental illness from dying 20 years earlier (on average) than the rest of the population.

Mental health – community, acute and crisis

Over the past twelve months work has been undertaken locally with the support of statutory

and voluntary care sector partners, patients and carers to better understand what the needs of

the population are with regards to mental health urgent care (MHUC). The following have been

identified as priority areas for the system to focus on:

Better access to MHUC - It is recognised nationally and locally that it can be challenging

to know where to seek support in a crisis particularly during the night. People want one

number they can contact and know they will receive the support they require. This

needs to be delivered from an all age perspective.

Alternatives to the emergency department – people have told us that they would like to

have options available to them other than attending their local emergency department,

some delivered in non-clinical environments.

Crisis Resolution and Home Treatment (CRHTT) – The Five Year Forward View for

mental health sets an expectation for patients to have access to robust CRHTT’s that

have the capacity to provide, as a minimum, three interventions per day. This service

would offer an alternative to admission and would allow treatment for the patient in their

own home.

In light of the above we have reviewed current service provision across the pathway and where

possible, ensure that we are utilising existing resources to offer improved overnight support

away from the emergency department. In line with national best practice, we have also

developed a safe haven service, in partnership with the voluntary sector, delivering support to

people in a non-clinical space outside of normal working hours. Contingent on additional

funding, we will take a phased approach to re-modelling and transforming the urgent care

pathway ensuring that the priorities that have been identified as a result of patient engagement

and national best practice are at the heart of the transformational change.

Physical health of people with mental illness

The importance of physical health in the context of people that have a mental health condition

is significant. National data tells us that for people that have a severe and enduring mental

illness (SMI) their life expectancy is 20 years less than the rest of the general population. In

Buckinghamshire there are approximately 5,000 people living with a SMI. In 2018/19 there has

been a focus locally on supporting patients with either bipolar, schizophrenia or psychosis to

ensure that 60% are receiving an annual health check. This will flag any emerging physical

health concerns and ensure that the most appropriate interventions are provided. We have

worked closely with primary and secondary care colleagues to ensure that we address this

priority. After 6 months, over 20% of checks have been completed, work will continue into

2019/20.

Improving Access to Psychological Services (IAPT)

The national ambition for IAPT services is to increase reach to 25% of the population that have

mild to moderate anxiety and depression by 2020/21. In 2018/19 we are projected to achieve

18% meaning that over 6,000 people have accessed treatment between 2016 and 2018.

Buckinghamshire’s IAPT service remains one of the highest achieving services in the country,

consistently over achieving on the national targets.

The focus this year has been further increasing the reach of psychological support to people

that have a long term condition and identifying the requirements for people that are living

with cancer, recognising that around the time of diagnosis, 50% of people will experience

anxiety and depression severe enough to affect their quality of life.

Dementia

The Five Year Forward view sets out an ambition for a dementia diagnosis rate of 67%. In

Buckinghamshire we have undertaken a significant amount of work and made progress in this

challenging area, our current dementia diagnosis rate is at 65%. We plan to continue to work

towards improving this target in 19/20 by taking learning from national best practice and by

reviewing our local model.

A multi-agency dementia conference was held earlier in the year with the intention of providing

an opportunity for people in Buckinghamshire (particularly those living with the condition and

their carers) to discuss and share their thoughts and ideas regarding current services and gaps

in provision into strategic decision makers. People told us that:

They are not always aware of what services are available for them to access

They do not want to feel as though they have to repeat their story to

different professionals that they come into contact with

That there is a lack of awareness of dementia and that it still has a stigma attached to it

There is not enough training and education on offer for carers of people that have

dementia

People do not always know where to turn when in need of support in a crisis

We will use the feedback from this event to not only inform short term improvements in current

service delivery but to also shape future developments through the all age mental health

strategy.

We have worked to develop a specific delirium pathway in partnership with our existing

providers and primary care utilising national best practice to ensure that the signs and

symptoms of this condition are recognised at an early stage to avoid increased lengths of stay

and subsequent poor patient outcomes.

Children and Young People’s Mental Health

There has been further significant investment in children’s and young people’s mental health

services (CAMHS) in 2018/19. This has allowed the service to increase the numbers of young

people it sees and improve its access times for assessment, ensuring that young people are

seen in a timely manner when requiring specialist services. Increased working with partner

providers has enabled the delivery of interventions via an online platform (Kooth) and work is

ongoing to address the needs of those presenting with challenging behaviour through the

development of positive behaviour support.

The local transformation plan for the county has had a complete refresh to outline how local

services will invest resources to improve children’s and young people’s mental health across

the whole system.

Buckinghamshire was successful with an application to NHS England in November 2018 to

become a first wave trailblazer site for the implementation of mental health support teams

(MHST). These teams will in-reach to schools across the county providing assessment and

treatment for young people that have emerging mental health problems such as mild to

moderate anxiety and depression. Buckinghamshire was one of only a handful of areas from

across the country chosen to deliver this new and exciting preventative service. MHST will be

delivered in partnership with colleagues across health, education, social care and the voluntary

sector. As part of this bid we have also received funding that will enable the delivery of

improved referral to treatment times (4 weeks) for young people requiring support from

CAMHS services.

We have listened to feedback from parents and carers asking for more training in relation to

mental health; specifically raising the awareness of the condition and how to support young

people that have emerging anxiety and depression. In response to this our mental health

provider has developed and run a number of awareness and training sessions that have been

well received and attended. Due to the success, there will be further expansion of this program

in 19/20.

We have also worked with young people to co-produce posters and business cards designed

to steer their peers to the Buckinghamshire CAMHS website for information advice and

guidance about their own mental health if required.

Perinatal Mental Health

At the beginning of 2018/19 Buckinghamshire was successful in a bid to NHS England for

additional funding to deliver an expanded community perinatal mental health service. This

service is now fully operational, staffed with a mix of health, care and voluntary sector

professionals providing assessment and treatment for women experiencing mental health

issues during pregnancy and up to 12 months after giving birth. The service will also deliver

training for other health and care professionals, including GPs, to help raise the profile of the

condition and facilitate the identification of additional women that require support with their

mental health. This will support the national ambition that ‘At least 30,000 more women each

year can access evidence based specialist perinatal mental health care’

Medicines Optimisation

Medicines are the most common intervention in the NHS. 48% of adults have taken a

prescription medicine in the last week. Medicines are the second largest spend in the NHS at

£17.4billion per annum, with a yearly increase in spend of 8%. Wastage on medicines in

primary care is estimated at £300m a year nationally. An aging population with increasing

use of multiple medicines and a global threat of antimicrobial resistance are key drivers for

the improvements in medicines.

Pharmacy and Medicines Optimisation in Buckinghamshire have a long history of joint

collaborative work with a focus on joint decision making for use of medicines and a

wider approach to partnership working to make decisions in the best interest of patients.

In July 2017, as an ICS approach was introduced, stronger links were made to focus efforts to

align with national approaches, reduce duplication and inefficiency, and improve system use of

medicines. In 2018, this was further refined to create a Medicines Optimisation strategy with

three main themes supported by a single joint decision making process.

Value Safety Integration

On a day to day basis, the teams across acute and primary care deliver support to patients

and clinicians for medicines in many ways, such as but not limited to,:

Medicines Information Medicines supply, advice and Medication reviews and support whilst in hospital optimisation in hospital and

advice for clinicians

and at home on discharge

Preparation, supply and

Delivery of Medicines Medication reviews and

support to all acute wards support for patients having

optimisation in Care Homes

and supply of inpatient and chemotherapy

outpatient medicines

Monitoring the use of high Implementation of NICE

Supporting a network of cost drugs used in hospitals medicines optimisation guidelines and technical

that are outside national forums to update clinicians appraisals

tariffs and share learning

A Bucks joint medicines Identifying variation in

formulary to ensure Preparation, supply and

prescribing and supporting consistent use of medicines prescribing of high risk

clinicians to consistently across pathways of care medicines in a way to

make prescribing choices to including continence related minimise risk

improve quality and safety products and wound care

Delivering a dietetic advice

Safe use of medicines service, including monitoring A programme to support the use of nutritional clinicians identify high risk

including antimicrobial

supplements and medicines and support a medicines

appropriate use of baby milk reduction in use

for cow’s milk protein allergy

Delivery of national quality standards e.g antibiotics

In 2018-19 work on integration across medicines governance has developed with significant

improvements.

Achievements in 2018/19 towards supporting the patient in hospital

Development of Anti-Microbial Resistance team – Multi-Disciplinary Team ward

rounds increased leading to a reduction in antibiotic use

Development of ward based technician team to provide more patient contact

including discharge liaison – improved coordination of medicines issued to take home

Pharmacist transcribing introduced

Haematology prescribing pharmacy led clinics

Spinal – Multi-Disciplinary Team working medication error toolkit, improved storage

Medicines Resource Centre development lead recruited

Medicines in acute care, improved team working, development of staff and

improved standards

Review of Governance process and standards, Medicines Optimisation Board Created

Recruitment of Pharmacy Business Manager and Medicines Account

Palliative care pharmacist – Macmillan funded

Opening of Community Pharmacy for Outpatients

Successful in Electronic Prescribing funding from NHS Improvement

ICS Medicines Optimisation Strategy developed, expanding to STP

Delivery of Model Hospital Top Ten Medicines savings, inclusive of biosimilar switches

Achievement in 18/19 towards supporting the patient across primary care

Reducing waste through the redesign of repeat ordering of medication

Delivering value for the NHS by encouraging the purchase of medicines available

over the counter to treat self-limiting and minor illnesses

Delivering value for the NHS by further reducing the use of medicines of low value

Implementation of NHS England’s Medicines Optimisation in Care Homes programme

Improved hydration of the frail elderly in care homes

The introduction of an electronic system to speed up the approval process for

clinicians to use high cost drugs and reduce the resources needed to provide

assurance of NICE TA compliance. Roll out will be completed by 2019

Improving communications of Medicines optimisation messages to a wider audience

including NHS 111, A&E and GP out of hours, the local GP federation, social care

through Buckinghamshire County Council and a stronger link with the locality teams

within the CCG. With the aim to improve implementation and deliver improved

patient outcomes, safety and financial sustainability.

Joint Program of work to support integration and system planning and development of

workforce, medicines value and safety

Bucks Integrated Care Partnership Working

The pharmacy and medicines optimisation teams within Bucks have historically worked closely

together to deliver clinically and cost effective use of medicines seamlessly to the Bucks

population. The development of the Integrated Care System (ICS), has allowed this close

working to develop further, resulting in:

Development of a single Bucks ICS Medicines Optimisation Governance Structure

streamlining the process to assure the safe use of clinically effective medicines

Bucks ICS Medicines Optimisation vision and strategy to set out the goals for the next 5

years

Development of cross-organisational pharmacist posts to break down barriers and

integrate the pharmacy workforce

Agreement for joint Medicines Optimisation Resource Team to support clinicians and

patients in primary and secondary care and maintain the Bucks formulary. This will

prevent duplication of work and provide a single point of medicines support within Bucks

Key Focus for 19/20 is to start to deliver the ambitions set out in the Bucks ICS Medicines

Optimisation strategy which incorporates pharmacy and medicines focused agendas for the

Model Hospital Transformation plan, GP contract and Long Term Plan.

Planned Care

The planned care team continues to think differently and innovative. We hold our providers to

account to ensure we get the best value we can and we aim to ensure patients are at the

centre of all we do.

We have continued to challenge our system to deliver sustainable improvement in key areas.

This has meant programmes of work over the last year have focused on continuation of

significant work programmes from previous years, recognising the time needed to do

undertake whole system change and to sustain this.

Over the last year we have continued working hard on an integrated musculoskeletal service

that rewards the provider for innovation and improved patient outcomes, introducing

multidisciplinary clinics to ensure patients get the most appropriate treatment as soon as

possible, as well as preparing for patients to be able to self-refer and the introduction of First

Contact Practitioners in primary care.

We continue to work with multi-agency partners implementing the cancer strategy

to ensure cancer survival increases to even higher levels. Patients remain central to any

decisions made about their care and we have worked with all service provider to improve

screening and early diagnosis. This has made significant improvement in some pathways in

hospitals, as well as progressing the support for patients living with and beyond cancer.

Management of referrals both from primary to intermediate care and primary/intermediate to

acute care has been a key element of the work since 2016 and something we continue to work

closely with everyone to support. This year has focused on the development of support for GPs

in the form of “Advice and Guidance” from hospital consultants to help with the care of

patients. Pathways are also being reviewed to ensure seamless and effective care for all

patients. This work has ensured that the latest guidelines are being followed and patient

outcomes compare favourably with similar CCGs.

This year has also seen a fundamental shift with contract monitoring continuing but providers

and partners working closely together as an Integrated Care System to improve services and

outcomes for patients across services. This has afforded greater opportunities for

collaboration in transforming care, such as in cancer.

Over the next year we will continue to build on all of these services, pathways and models

of care and utilise opportunities for integration to provide better outcomes for patients and

sustainability for our health system.

Commissioning intentions for 2019/20

Continued emphasis on prevention projects

Development of ophthalmology services

Continued implementation of a new integrated musculoskeletal pathway (iMSK service)

Delivery of cancer strategy

Development of outpatient services

Planned care services have seen unprecedented levels of growth in demand for services this

year, most notably ophthalmology, urology and dermatology. To cope with the demand and

improve patient access to services, the CCG has been working with our providers and

intermediate triage services to monitor and manage pathways – ensuring the pathways are

appropriate and that all patients have the right access to the most appropriate care, as quickly

as possible. This will form part of programme of work over the next year – how we develop a

system that meets demand.

The CCG has also seen and listened to feedback from patients and GPs regarding delays

following referrals to treatment. Investigation by our planned care team identified particular

delays where treatment required individual funding requests (IFR). In response to this, the

CCG has worked with IFR colleagues in the South West and Central Commissioning Support

Unit (CSU) to continually review and improve the process. The traffic light system has proved

to be the most effective model and continues to be embedded further across the Thames

Valley region. The system aims to speed up the approval process and ensure appropriate

treatment is progressed as quickly as possible. This has also identified a high volume of

“Procedures with Limited Clinical Value” being requested. The very nature of these procedures

means they have little or no clinical impact on a patient but add further capacity challenges to

our providers and delay the most important care. The traffic light system in the IFR process

has made these procedures easier to identify and suggests clinical colleagues find suitable

alternative treatments for patients. To complement this, we have also worked with our

providers to introduce advice and guidance between secondary and primary care to offer

effective and appropriate alternative treatments for patients that are likely to be more effective.

A continued area of success for patients in Buckinghamshire is the cancer services from our

providers. With over 4,000 people at any time waiting for cancer treatment, we routinely ensure

they are seen, diagnosed and treated as quickly as possible. This year has seen increasing

numbers of patients being diagnosed and treated within national standards. There are

occasions when the complexity of an individual case means diagnosis is more difficult and

treatment takes a little longer, for example where a patient may have ‘more than once’ tumour.

However, in such instances, it remains crucial that all possibilities are explored and diagnosed,

ensuring treatment will be effective. As part of this the CCG works with providers to understand

each of these cases to ensure the best possible care is in place. The CCG has worked with

local provider and agencies to develop a strategy that aims to improve first year survival,

increased screening and early diagnosis. This has been further enhanced by investment and

support from the Thames Valley Cancer Alliance. Furthermore, the strategic implementation

plan encompasses established lifestyle programmes, to improve prevention through education

and wellbeing. This includes working collaboratively with Public Health, Cancer Research UK

and MacMillan to find new ways to engage with our more diverse communities who are less

likely to access services early. Going forward, we will continue this programme of work that

will see better access to diagnostics; more improvement in pathways; and better support for

patients living with and beyond cancer.

Urgent and Emergency Care

Our aim is to provide integrated urgent and emergency care services to the people of

Buckinghamshire, where patient and staff time is valued.

As patients become unwell, they move between health and social care providers seamlessly,

accessing a responsive service, close to home and tailored to their individual needs. When

hospital level care is provided, this is provided in an ambulatory setting wherever possible, or

in specialty assessment units, with only patients who truly require emergency department input

accessing the service. When patients who stay in hospital are clinically optimised, they return

to their home wherever possible. Assessment for long-term care and support is undertaken out

of hospital, in the most appropriate setting, and at the right time for the person’s needs.

Areas of focus:

Community admission and attendance avoidance – keeping more people at home

A & E admission avoidance – supporting getting people home sooner

Preventing discharge delays – stopping unnecessarily prolonged stays in hospital

In order to deliver this ambitious programme of transformation, all system partners need to

commit to delivery of the vision and the ICS aspirations for Urgent Emergency Care.

Buckinghamshire Healthcare NHS Trust

The Trust continues to see demand increase and remains focused on work streams and

interventions which support system objectives and an improved 4 hour performance

position. Work streams include:

Extending the Emergency Observation Unit (EOU) to facilitate extra capacity

Frailty at front-door Consultant Connect – reduced conveyances & admissions -

maximising the Silverphone

Greater use of the Discharge Lounge

Improved GP Streaming and establish comprehensive model of Same Day

Emergency Care (SDEC) – 12 hours a day, 7 days a week

Executive ward sponsors throughout winter period

Maximising capacity at the Wycombe hospital site for elective pathways

Comprehensive demand and capacity and forecast bed modelling

Planning discharge with patients and families on admission to support patients leaving

the hospital in a timely and dignified fashion

Ensuring a robust community response through a variety of services

Support and wellbeing initiatives for staff

Robust 24/7 on call process with senior management presence on site at the weekends

Cold weather plan for the acute and community services

Recruitment of key members of clinical and support staff

Comprehensive Flu plan

The system also continues to ensure a joined up approach and has resolved to support the

Trust in improving performance. Key areas of work include:

Additional capacity through Discharge to Assess programme of work (Step down

beds, domiciliary care at home, 24/7 nursing care at home)

Maximising community care capacity and flow – a focus on self-funder delays within the

hospital bed base to support improved flow and creation of capacity

Weekly planning processes to be in place using forecast data with focus on the

admission/discharge trigger in the acute.

South Central Ambulance Service

The Ambulance Response Programme (ARP) aims to enhance patient outcomes, improve

patient experience and reduce mortality by prioritising those with the greatest need. The

programme seeks to ensure that all patients receive an appropriate and timely clinical and

transportation response where appropriate. The implementation of ARP resulted in multiple

changes to the Clinical Prioritisation and Ambulance Service Measures including:

A new clinical coding system introduced that allows for better clinical prioritisation based on the

needs of the patient.

Ambulance targets amended to measure median time to patients rather than a percentage of

achievement which could mean those patients that did not meet the target potentially having a

long wait.

Response standards replaced with new categories. New response times as shown below:

As ARP is now established and part of a business as usual model of service delivery,

South Central Ambulance Service (SCAS) continues:

Reviewing the deployment model for Category 1 fleet. SCAS are focusing on how

best to optimise fleet mix to support achieving Category 1 targets

Working towards a 85/15 breakdown between ambulances/cars and ensure efficiency in

process

Working to align fleet changes with roster updates to ensure they are appropriately

staffed with those who can operationalise the fleet

Review of existing plans / procedures including Incident Response Plan

Demand Management Plan REAP (Resource Escalation Action Plan)

The new Integrated Urgent Care Service

NHS 111 plays a significant role within the urgent and emergency care pathway, giving

patients a direct route into triage and care to meet their urgent need. This made the

commissioning of our new Integrated Urgent Care (IUC) service vitally important, to provide

a further enhanced access point for patients.

The Thames Valley IUC service went live in September 2017 and is continuing to develop.

Bucks CCG aligned with Berkshire East and Oxfordshire CCGs to jointly procure South Central

Ambulance Service in providing both IUC and NHS 111 in a single integrated model. The

provider delivers a clinical hub and seamless service with a variety of clinical colleagues and

call handling sites. With significantly enhanced clinical cover, there is an ongoing reduction in

the number of patients being directed by NHS 111 to the Emergency Department, as well as a

reduction in onward referral to any further service. IUC now includes mental health and

pharmacy clinical professionals in the hub. 111 Online is available across Buckinghamshire,

allowing all our public a way to access health advice and signposting quickly.

IUC now books callers directly into our new Wycombe Urgent Care Centre, as well as

supporting the rollout of direct booking into some primary care services.

Seven Day Hospital Services

The Seven Day Hospital Services Programme aims to deliver improvements for patients by

supporting high quality care seven days a week

The Seven Day Hospital Services (7DS) Programme supports providers of acute services to

tackle the variation in outcomes for patients admitted to hospitals in an emergency, at the

weekend across the NHS in England.

This work is built on 10 clinical standards developed by the NHS Services, Seven Days a

Week Forum in 2013.

With the support of the Academy of Medical Royal Colleges, four of these clinical standards

were made priorities for delivery to ensure patients admitted in an emergency receive the

same high quality initial consultant review, access to diagnostics and interventions, and

ongoing consultant-directed review at any time on any day of the week.

A new board assurance process is being introduced in 2019 which will reinforce our

sustainment of these high standards.

High Impact Change Model

The 8 High Impact Change Model was developed by nationally in 2015 to promote a new

approach to system resilience and year around planning for timely discharge. The model

identifies eight system changes which will have the greatest impact of reducing delayed

discharge:

1. Early discharge planning

2. Systems to monitor patient flow

3. Multi-disciplinary/multi-agency discharge teams, including the voluntary and community

sector

4. Home first/discharge to assess

5. Seven-day services

6. Trusted assessors

7. Focus on choice

8. Enhancing health in care homes

Key objectives in Bucks using the 8 High Impact Change Model:

Enable people to take responsibility for managing their own health and wellbeing in the

most appropriate setting for them

Deliver a model of care that ensures people are at the centre of their care, enabling

them to achieve the outcomes that are important to them and promotes a shift in focus

from dependency and ill health to independence and wellbeing

Incentivise effective partnerships, providing care and support in and through the

community

Engage, empower and grow community networks and assets so they are responsive,

timely and flexible to individual needs

Reduce health inequalities and improve health and wellbeing outcomes across the

county

Deliver transformation across the system in order to achieve optimum value for money,

economies of scale and efficiency by leveraging resources and capabilities across the

system

Seasonal pressures, escalation and forward planning

Comprehensive winter planning process in place including an 18/19 review of plans and

their impact and 19/20 system exercise to support planning

System resilience and forward planning as part of business as usual with a weekly look

forward meeting with key system partners. Bucks also feeds into the regional Week

Look Forward Meeting (WOLF)

Roll out demand and capacity model and system capability – this will also mean live

information available in our main hospitals to help identify areas of risk much quicker

Delivering the 7 Urgent and Emergency Care domains

Winter Operating Model

Under the direction of the newly appointed Winter Director, we had a multi-agency

winter team onsite presence at Stoke Mandeville, supporting as required to other health

and care services across systems and borders.

The model operated within a command and control methodology during times of

significant system challenge

The Winter Director liaised with NHSE/I winter rooms and when required the

WOLF (Winter Operating Look Forward ) calls

How we have progressed from last year:

System Winter Director in Post (December)

Implemented a comprehensive Winter Plan (Started 1 November)

Implementation of NHS 111 Online Service and 100% of population have access

System Demand and Capacity Tool

Children’s Urgent Care (Clinically led multi-agency sub-group established)

Non-Elective Demand Management Efficiencies Dashboard developed and

comprehensive programme in place to act on the intelligence

Sustainable Discharge to Assess model

Working within the BOB STP footprint to deliver the Urgent and Emergency Care (UEC)

Strategy locally (BOB UEC committee stood-up)

Primary Care resilience - Improved Access to General Practice went live in Oct 18 and

we increased fill in GP Out of Hours shifts

Mental Health Urgent Care pathways (safe havens were in place for winter and

Psychiatric Liaison personnel were on site at our local hospitals)

South Central Ambulance Service implemented full Ambulance Response Programme

Enhanced NHS 111 offer – in Bucks we consistently report that over 50% of people

calling the service receive clinical assessment

Fully established Urgent Treatment Centre (UTC) at Wycombe General Hospital which

was successfully identified as a wave 1 site UTC site. UTC offer includes the option of

booking through NHS 111

The UTC has been recognised by NHSE as an exemplar in the region (UTC

consistently reports over 99% against the 4 hour standard)

Established GP streaming as part of BAU at the front door of Stoke Mandeville Hospital

(approx. 15-20% are seen in the GP streaming service)

Established a key working group to focus on driving down delays for long stay patients

(BHT have reduced the number of patients in a bed for over 21 days)

Significant reductions in Hospital Handover delays at BHT sites (BHT have been

identified as an exemplar in Thames Valley)

Prevention, Self-Care and Long Term Conditions

Prevention is a key priority in our vision of moving care out of hospital and closer to home. It

encompasses primary, secondary and tertiary prevention throughout the lifetime of our

population.

The ICS recognises the continued need to take action on obesity, smoking, alcohol, physical

activity and social isolation to reduce the risk to individuals, communities and the

subsequent NHS challenge of managing diseases such as diabetes, cardiovascular and

respiratory disease.

We work closely with Public Health, hospitals, local authorities and other key partners to

prevent ill health and ensure seamless provision of services is available, so when people

require health services, they are delivered locally through an Integrated Care System.

Our vision is an inspired, informed and confident population who are motivated to make life

choices that have positive impacts on their health and wellbeing, reducing the incidence and

prevalence of Long Term Conditions (LTCs), and for those who develop LTCs, to help

manage the impact of living with them.

Our Objectives:

For prevention to be recognised as a priority for investment for the Integrated Care

System (ICS)

People have the inspiration, knowledge and confidence to best manage their health &

wellbeing

Those at risk are identified early and supported to best manage their lives on a daily

basis

Support for people with Long Term Conditions is holistic, integrated, person centred,

best practice and in line with the "as close to home" philosophy

Buckinghamshire’s ICS workforce is supported, inspired, motivated and committed to

prevention

Innovate, try things, learn from them, and share with others across the system

Resources are deployed to maximise impact on health & social outcomes

Our approach to prevention is based on the continued implementation and support of key

activities across the ICS in the areas below:

Increasing High quality

Promoting Case patient education clinical care

healthy finding and supported

lifestyles self-care

Care closer Social Employee prescribing to home wellbeing

Co- Integrated

morbidity care

The nine activities below provide examples of the areas of focus for the coming year:

Live Well Stay Well

Live Well Stay Well is one of the fundamental enablers needed to prevent the rise in long term

conditions. The Integrated Lifestyle Service Live Well Stay Well (LWSW) was re-commissioned

with colleagues in Public Health in April 2018.

Since its original launch two and half years ago there have been over 16,000 referrals

50% of these have multiple lifestyle risk factors

13% of referrals are from BME population

Over 1000 patients referred to IAPT for help with the psychological issues

Over 3500 people referred to Tier 2 weight management programme

Over 1000 people referred to Stop Smoking

Over 300 referrals to exercise referral programmes since launch

The service has expanded to provide an online assessment and more services. It is our priority

to embed the service throughout our clinical pathways and to raise awareness to the general

public for self-referral as well as amongst health and social care professionals.

Diabetes and Diabetes Prevention

By identifying more of those with, or at risk of developing type 2 diabetes, and encouraging

their attendance at education and disease management courses, potential sufferers can be

encouraged to take proactive steps to change their lifestyle and lower their future life risks.

Over 800 diabetics have accessed education support

Over 1200 pre-diabetic patients accessed prevention education, including 200 using

digital training packages

Alongside education, we aim to increase the number of patients that receive the eight

recommended care processes for their disease and meet the three clinical targets for their

care to reduce clinical variation across Buckinghamshire.

8 Care Processes - 37 Practices improved their performance (Jan 19)

Triple Target – 25 Practices have increased performance (Jan 19)

Primary Care Development Scheme (PCDS)

The Primary Care Development Scheme supports and encourages practices to identify

and engage with patients to prevent and/or better manage Long Term Conditions. It

replaced certain elements of the national Quality Outcomes Framework and enables us

to develop a foundation across general practice to standardise approaches to care with

improved outcomes and reduction in variation. The PCDS has helped improve the

prevention, diagnosis and management of LTCs across Bucks.

Professional clinical training and awareness raising

We have developed a programme of education for diabetes management for Primary

Care and others in the multi-disciplinary team

420 Health Care Professionals across 46 practices have received a broad curriculum of

training. We have also provided diabetes education to 19 prison staff and 20 inmates

We have delivered three community engagement activities, providing more than

80 individuals with specific information regarding Diabetes & Ramadan

Social Prescribing

Social prescribing is a way of linking patients and residents with sources of support within the

community. It provides a non-medical option to help improve health and wellbeing.

Buckinghamshire Social Prescribing Steering Group was established this year involving a

range of organisations from the voluntary sector so as to make our social prescribing services

more accessible to the population and to raise its profile amongst professionals and the public.

Key enablers such as Care Navigators within Primary Care, an online countywide directory of

services and the development of an integrated approach amongst services providers has put

us in a strong position going forward, and excitingly the NHS has recently announced funding

for Primary Care Networks to recruit Social Prescriber Link Workers.

80 Care Navigators trained from 20 practices

Conference planned for May 2019 to celebrate the success of those practices

Directory of Services has been created and will continue to be enhanced.

Care and Support Planning (CSP)

Care and Support Planning (CSP) has been shown to increase patient and carer confidence in

their ability to self-care and manage their illnesses. CSP involves patients and their carers in

deciding what is important to them, then setting individualised goals and action plans that

encourage effective self-care with support.

We have established a joint team across Buckinghamshire & Oxfordshire to lead on this

training

CSP: 170 practice staff from 45 practices and 15 non-practice staff trained

Nearly 12,000 people with diabetes now have a Care Support Plan, an increase of

3000 from last year

Make Every Contact Count (MECC) & Motivational Interviewing

Make Every Contact Count (MECC) supports organisations and their staff to maximise on the

opportunity they have when meeting with the public to promote health and enable them to

make changes to improve their health and wellbeing. Telling people what to do is not the

most effective way to help them change. MECC is about altering how we interact with people

through having Healthy Conversations and delivering ‘very brief’ or ‘brief’ evidence-based

interventions encouraging lifestyle and behavioural change.

Make Every Contact Count: 72 practice staff from 17 practices and 73 non-practice staff

Behaviour Change and Motivational Interviewing: 216 practice staff from 42 practices

and 73 non-practice staff

£289k Diabetes Treatment & Care Programme delivered

National Diabetes Prevention Programme: Face-to-Face £31,500 launched and in

delivery

National Diabetes Prevention Programme: Digital version £18,500 launched and in

delivery

Care and Support Planning joint team launched across Bucks and Oxford

Service Transformation

850 patients with long term conditions repatriated from Outpatients back into GP care

Multi-disciplinary virtual clinics established across the county

Training Network and Coordination Hub established involving CCG and ICS partners

Obesity Pathway developed and commissioning of Digital Tier 3 service commenced

Children’s Services

The Integrated Children’s Therapies Service was jointly commissioned with Buckinghamshire

County Council in April 2017 and is now in its second year of operation. This has resulted in

physiotherapists, speech and language therapists and occupational therapists working

together to support children, their families and school staff through one referral route. The

service is provided by Buckinghamshire Healthcare NHS Trust which is supporting an average

of 2,700 children and young people at any one time.

This year the service has reviewed demand and capacity and the learning from this review is

being used to inform service developments. There has been a particular focus on reviewing

referral pathways and exploring how the service might work differently with education to

manage lower level speech and language needs.

Children’s Urgent Care:

The Children’s Urgent Care Advisory Group brings together CCG colleagues and consultant

paediatricians from across Buckinghamshire and parts of Berkshire to develop initiatives that

aim to help prevent children and young people seeing their GP or needing to go to their

Accident & Emergency Department unnecessarily. This has included;

Organising an “Asthma Education Bus” which visited a number of secondary schools

across Buckinghamshire providing guidance on asthma management to over 150

young people

Working with the Children’s Outpatient team at Stoke Mandeville Hospital to offer the flu

vaccine to children who may have not have had the opportunity to receive this at school

or through their GP

Promotion of leaflets explaining how to manage common children’s illnesses which

have been made available for parents/carers and development of a local Facebook

page “NHSChildHeathBucks”

Community Paediatrics:

Buckinghamshire Healthcare NHS Trust is the commissioned provider of the Community

Paediatrics service in Buckinghamshire. They provide a wide range of high quality medical

services enabling children and their families to lead independent lives. This includes a

specialised medical service for children and young people with moderate and severe

neurodevelopmental disorders or complex disabilities.

There is currently a structured programme in place to support the Community Paediatric

Service to reduce waiting times. The Designated Clinical Officer is also working with the

Community Paediatric Service to support their input into the Education, Health and Care

Plan process.

Looked After Children:

Looked After Children (LAC) are statutorily entitled to a health assessment within 20 working

days of becoming looked after. Review health assessments are then carried out on an annual

or six monthly basis. Buckinghamshire Healthcare NHS Trust is commissioned to provide

these health assessments in Buckinghamshire. This year there has been a strong focus on

collaborative working between BHT and Children’s Social Care to ensure that children are

seen in a timely manner and to support other improvements to the health assessment process.

Joint Neuro-developmental pathway for children and young people aged 5-17:

During 2018, Paediatrics and CAMHS began to work together in the diagnosis of

Neurodevelopmental conditions for children and young people. Joint working across CAMHS,

Paediatrics and the CCG has continued, and at the end of January 2019 a fully integrated

Neurodevelopmental Pathway was launched. This will help improve the quality and timeliness

of diagnosis for autism and attention deficit disorders, and streamline post-diagnostic support.

Under 5s will still be seen by the Paediatric service.

Special Educational Needs and Disability (SEND) reforms: The Designated Clinical Officer

(DCO) for SEND has supported work in a number of areas including:

The quality and timeliness of the Education Health and Care Plan process

The health content of the Local Offer for SEND, which provides families with

information.

Supporting the role out of the ‘Ready, Steady, Go’ programme. This is designed to

support young people with health conditions as they transfer into adult health services.

Ensuring the voices of children, young people and their families are heard in support

of service developments.

The launch of the Autism Toolbox in October 2018. This is an online resource which

provides advice, information and links for families and professionals to support children

and young people with Autism Spectrum Disorder regardless of whether there has been

a diagnosis.

Maternity What are we trying to achieve?

Personalised care delivery to 100% of Women by 2020

Continuity of carer delivery of first phase of programme by April 2019

Develop community hubs to enable women access to a range of services for

antenatal and postnatal care

Where are we now?

Specialist antenatal clinics and pre-term birth clinic implemented 2018

https://www.bucksfamilyinfo.org/kb5/buckinghamshire/fsd/localoffer.page

https://www.bucksfamilyinfo.org/kb5/buckinghamshire/fsd/advice.page?id=L_mxUn9WDWs

Saving babies lives and Each Baby Counts recommendations fully implemented

10% below national average for perinatal mortality compared to previous year, this

remains an ongoing area of focus as part of our Local Maternity System plan.

Maternity safety training funding utilised to resource neonatal life support and human

factors training

Women now have access to a professional midwifery advocate

Success stories so far:

Successfully recruited to the system resource to implement the delivery plan

Well-developed relationships with the Maternity Voices Partnership

Digital transformation across the ICS and in Primary Care

Building on the progress made, we set out a vision in 2017/18 to deliver the following

capabilities to support the transformation of care using shared care records:

Personal Held Record (data in our patients hands)

Population Health Management (data about groups)

Processes across organisations

Care Home bed/chair availability (as a precursor to discharge automation)

Extending to hospices (and with a view to improving end of life care)

CareFlow for secure communications and alerts across whole ICS (available now)

EMIS Clinical Services (EMIS CS) enables new services like integrated teams and the

new diabetes service

Patient Apps like “Ask NHS” empower our population and make it easier for us to

deliver services.

In 2019/20, the programme aims to deliver the following:

Record Sharing (My Care Record)

Communication, Engagement and Patient

Empowerment

Primary and Community Care

Thames Valley & Surrey Local Health

and Care Record Exemplar Partnership

My Care Record: Shared Care Record for Buckinghamshire ICS

CareCentric (Record sharing)

Shared Record for all care settings across Buckinghamshire ICS

o Procured and licensed on an unlimited basis

o GP data already available. Acute data partially loaded, Community and

Social Care (Adults and Children's) being loaded

Already in use by Social Workers to access NHS Data

Allows a care professional access to all data about a person (subject to appropriate

protections and controls)

Fully integrated with Population Health / Business Intelligence

Best used for care pathways across organisations

2019 Plan:

Load all remaining care settings data

Mental Health records to be added (OHFT) in early 2019

Acute and Community rollout by end of 2019

Integrate with Thames Valley and Surrey Local Health and Care Record

CareFlow (Secure Messaging)

Secure real time messaging and alerting between care professionals

Works across organisations, licensed for whole of ICS

In pilot in BHT and a number of GP practices

2019 Plan:

Will be integrated into shared record within 2019

BHT go-live integrated with Medway PAS and eObservations

Shared care records

Personal Held record: Goals and long term conditions

Quick view of personalised goals

Actions to achieve the goal can also be entered

At a glance view of the active goals and state of the goals

A digital process to underpin supported self-care

EMIS Clinical Services and remote consultations are supporting clinicians to work more

seamlessly together to deliver care across traditional organisational boundaries, providing:

Direct EMIS to EMIS referrals from:

o GP to Clinical Service o Clinical Service to Clinical Service

Instant access to patient primary care /community shared information

Mobile access via iPad for home visits

Reduces administration and clinical time spent on information gathering and contacting

other organisation

Enables more responsive service for patients

Plans for 2019/20:

Extend use of EMIS Clinical Services, Remote Consultations and Federated

Appointments to support Integrated Teams, Improved Access in Primary Care, the

development of Primary Care Networks and other priority service transformations

Further work on benefits realisation planned in 19/20

Developing a Digital First approach in Primary Care with online consultations

Digital transformation projects

A significant element of the GPIT & Digital Transformation programme is carried out by South

Central and West Commissioning Support Unit which supports Primary Care and the wider

community with IT provision and transformation services to enable new and improved ways of

working.

South Central and West Commissioning Support Unit has built on the work from last year and

continued its delivery of a number of programmes and projects to further develop IT in primary

care and the wider community to support new and improved ways of working.

The replacement of the NHS N3 network to the Health and Social Care Network (HSCN) for all

GP Practice sites in Buckinghamshire is progressing. This work underpins key national

initiatives regarding the integration of health and social care services.

Further mobile devices have been deployed to GP practices which provide greater flexibility

for accessing clinical records during consultations away from GP Practice sites such as in

patients’ homes and Care Homes. Work has commenced on upgrading the current document

management system used in most practices to the newest version. This will allow greater

flexibility in accessing documents via mobile devices.

Work continues on moving to paperless working and supporting organisations to send

documents via electronic means, using national systems where appropriate.

Uptake on the use of Electronic Prescriptions and Patient Online Services has increased.

The CSU has worked with Patient Participation Groups at practices and Buckinghamshire

County Council to set up training sessions for using the Patient Online application.

Ongoing project management, technical and training support has been provided for GP

Practice mergers, clinical system changes and site changes and an ongoing programme of

computer replacements has been carried out. To support the wider care community, a project

has commenced to enable Care Homes with electronic messaging via NHS email.

Commissioning for quality and safety

Over the last year, the CCG with its ICS partners has been developing its quality framework.

We conducted a series of workshops focused on values, outcomes and joint priorities.

During 19/20 we will further transition our quality framework to focus on further integration

and accounting for community models of care.

Quality in Primary Care

The CCG continues to embed the Quality Assurance Framework for Primary Care to meet

their responsibility for the commissioning and monitoring of safe and high quality care. The

Quality Team meets regularly with the CQC Inspectorate to review Primary Care across

Buckinghamshire. Additionally a rolling programme of supportive Quality Assurance visits

which complement the latest CQC inspection framework will be implemented in 2019

throughout the county.

Staff satisfaction

We use nationally reported staff surveys to focus effort and engagement with our providers

of commissioned services.

Patient Experience

A multi-agency dementia conference was held earlier in the year with the intention of providing

an opportunity for people in Buckinghamshire (particularly those living with the condition and

their carers) to discuss and share their thoughts and ideas regarding current services and gaps

in provision into strategic decision makers.

The ICS has implemented a single service improvement programme, quality, service

improvement and redesign (QSIR) within the principles there is focus on using patient

feedback and co-design for service improvements. Examples include, Living with and Beyond

Cancer and Diabetes.

Through the review of a number of complaints during 2018/19 this has identified areas

for improvement and as a result the CCG, with Providers, reviewed pathways of care and

implemented changed based on patient feedback.

For LeDeR (Learning Disabilities Mortality Review Programme) the CCG in partnership with

other agencies has taken an individualised approach to engaging families / carers in the review

process. To recognise the sensitivity of the programme we have agreed bespoke methods of

feedback and engagement from people engaged with the programme. As a result of feedback

we are focussing on improvement activities for 2019/20 around sepsis, access to community

equipment, training and education and end of life care planning.

Patient safety

There are agreed processes in place to oversee the quality agenda across provider services

supported by the contractual Clinical Quality Review Meetings (CQRMs) between the CCG

and each provider and the CCG Quality & Performance Committee. During 2019/20 the

CCG/ICS quality leads will participate further in internal provider peer review and accreditation

programmes as part of the assurance role of the ICS.

The CCG has been working with our main acute provider to further improve the approach to

management of post infection reviews for C.difficile. The CCG recommended for one of our

providers to complete a thematic analysis of Venous Thromboembolism harms (VTE). We will

be working with the provider to implement the improvement plan during 2019/20.

The CCG is undertaking a thematic analysis of all serious incidents to identify improvement

activities to be completed during 2019/20.

The CCG, working with partners during 2018/19 has taken a preventative approach to

early engagement with Care Homes where safeguarding or quality issues have been

identified through patient feedback, CQC, infection control information and collaborative

sharing of information.

Perinatal Mental Health

At the beginning of 2018/19 Buckinghamshire was successful in a bid to NHS England for

additional funding to deliver an expanded community perinatal mental health service. This

service is now fully operational, staffed with a mix of health, care and voluntary sector

professionals providing assessment and treatment for women experiencing mental health

issues during pregnancy and up to 12 months after giving birth. The service will also deliver

training for other health and care professionals, including GPs, to help raise the profile of the

condition and facilitate the identification of additional women that require support with their

mental health. This will support the national ambition that ‘At least 30,000 more women each

year can access evidence based specialist perinatal mental health care’

Furthermore, the CCG, working with our lead providers, has successfully bid for further funding

for an additional perinatal mental health midwife to support continuity of carer and

improvement in safety. The programme is being developed for implementation beyond

2019/20.

Seven day services

We continue to assure ourselves that our providers continue to provide arrangements for

safe seven day services.

Access to primary care services outside of regular day time hours was made simpler and more

accessible from April 2018. In October 2018, a new improved service to access GP

appointments was launched, this service involved local GP practices working together to offer

better patient access to planned appointments until 8pm and at weekends.

Performance Overview

Our contracts with providers have been constructed to ensure that all NHS Constitution

standards are met.

There are currently specific performance challenges in relation to a number of pathways that

are highlighted at contract meetings to understand the causes and actions being taken.

Performance against a number of the Constitutional standards and locally agreed trajectories

has improved during 2018/19. The CCG remains committed to maintaining and improving

performance against these core standards, utilising transformation of services to achieve this.

The construction of our provider contracts ensures that we improve our position on

NHS Constitution standards.

Processes to improve the achievement of the standards have been implemented and

significant progress has been made and will continue against the following standards:

A&E 4 Hour

Ambulance

Cancer RTT Response Wait

Performance Performance Times Performance Performance

There are currently specific performance challenges in relation to:

The ICS remains committed to maintain and improve performance against these

core standards utilising transformation of services to achieve this.

How the CCG measures performance:

Performance Reporting

The CCG Quality & Performance report provides a concise and succinct report of

performance for the National Standards by exception; highlighting recommendations

for action and areas of risk.

The CCG regularly monitors the progress against the Integrated Assurance

Framework Indicators, also monitored by NHS England, and develops recovery plans

as appropriate.

Holding providers to account

We work with all our providers to encourage the development of smart outcomes based

dashboards to illustrate the performance of their services and inform patient choice.

We expect all providers to develop clear clinical quality standards for their services and

measure their performance against these.

Discharge of Function:

The CCG performance framework utilises the NHS Commissioning Improvement &

Assessment Framework (IAF) to provide assurance to NHS England that all indicators

are fully embedded in the organisation plans and are monitored on a regular basis.

Performance against national and local standards is reported through the monthly

Quality & Performance Report overseen by the CCG Board and the Quality &

Performance Committee.

The CCG works closely with system partnership organisations to monitor individual

provider performance through a range of internal and system meetings and reports.

Performance Summary

2018-19 National Bucks CCG Report Report Period

Operational

Standard Month Actual INDICATOR Plan

A&E 4 Hour Wait Provider

Buckinghamshire Healthcare Trust 95.02% 87.17% Category A Ambulance Calls CCG

Category 1 - Life-threatening injuries and illness ( MEAN) 7 Minutes 0:08:09

Category 1 - Life-threatening injuries and illness ( 90th PERCENTILE ) 15 Minutes 0:15:09

Category 2 - Emergency calls e.g. Stroke patients ( MEAN ) 18 Minutes Feb

0:19:12

Category 2 - Emergency calls e.g. Stroke patients ( 90th PERCENTILE ) 40 Minutes

0:37:28

Category 3 - Urgent calls ( 90th PERCENTILE ) 120 Minutes 2:35:20

Category 4 - Less Urgent calls ( 90th PERCENTILE ) 180 Minutes 3:38:27 Referral to Treatment CCG

RTT Incomplete % within 18 weeks 92% 90.70% 88.43%

RTT Incomplete 52+ week waits 0 1 4 Diagnostic test waiting times CCG

Diagnostics % waiting over 6 weeks 1% 1% Feb 1.07% Cancer patients CCG

Cancer - 2 week wait 93% 93.0% 95.1%

Cancer - Breast symptoms 2 week wait 93% 93.6% 95.5%

Cancer - 31 day first definitive treatment 96% 96.5% 94.7%

Cancer - 31 day subsequent treatment - surgery 94% 96.3% Feb

95.7%

Cancer - 31 day subsequent treatment - drug 98% 98.6% 98.8%

Cancer - 31 day subsequent treatment - radiotherapy 94% 94.3% 98.5%

Cancer - 62 day - Urgent GP Referral to 1st Definitive Treatment 85% 85.9% 75.2%

Cancer - 62 day - Screening 90% 95.2% 63.6% Mental Health CCG

CPA - Followed -up within 7 days of discharge (Qtrly) 95% Q3 18/19 98.2% Mental Health - Improving Access to Psychological Therapy (IAPT) CCG Access: The proportion of people with depression/anxiety that have entered psychological

19.5% Revised to

19.32% therapies. 18% by Q4

Recovery: Proportion of people with depression/anxiety completing treatment and moving to 53%

Mar 60%

recovery

People that wait 6 weeks or less from referral to entering IAPT 75% 99%

People that wait 18 weeks or less from referral to entering IAPT 95% 100% Mental Health CCG

Early Intervention in Psychosis - Psychosis treated with a NICE approved care package within two 53% 77% Feb 80%

weeks of referral

Waiting Times for Routine Referrals to CYP Eating Disorder Services - Within 1 week (Urgent). 95% 100% Q3 18/19 50.0%

Waiting Times for Routine Referrals to CYP Eating Disorder Services - Within 4 weeks (Routine). 95% 73.7% Q3 18/19 88.9%

Learning Disability Health Checks Proportion of people on the GP Learning Disability Register that have received an annual health

75% by 2020 65% Jan 29.3% check during the year

Dementia Diagnosis

Dementia Diagnosis Rate 66.7% 66.0% Feb 64.10% Delayed Transfer of Care CCG

Rate of Days Delayed Transfers of Care per 100,000 856.6 Q3 18/19 879.5 Continuing Healthcare CCG

Percentage of CHC assessments within 28 days 80% Mar 55% Reduction in CHC assessments in Acute hospitals <15% Feb 18% Mixed Sex Accommodation CCG

Breaches of Mixed sex accommodation 0 Feb 20 Infection Control CCG

Incidence of healthcare associated infection - MRSA 0 (Year) 0 Mar

0

Incidence of healthcare associated infection - C.Difficile 108 (Year) 9 10

Electronic Referral System (ERS) CCG NHS e-Referral Service (eRS) for all consultant led first outpatient referrals. Dec 81%

VTE (Venous Throboembolism) Provider

Buckinghamshire Healthcare Trust 95% Q3 18/19 94.6% Please note: RAG rating for all Monthly standards will be against CCG Operational Plan if included

Improvement & Assessment Framework (IAF) Indicators

Improvement & Assessment Framework Indicators - Position as at Q3 2018-19 (published 19th January 2019)

Buckinghamshire CCG

Domain Area Ref Indicator Period England

Target Achievement Direction of Rank (out of 195 except

Value

Travel as stated)

Annual Assessment 999a Annual Assessment 2017-18 Not reported No data N/A

Child Obesity 102a Percentage of children aged 10-11 2014/15 to 2016/17 33.9% 27.5% 11 classified overweight or obese

Personalisation & Choice 105b Personal Health Budgets 18-19 Q3 60 10 159

Inequality in unplanned

Health Inequalities 106a hospitalisation for chronic ambulatory 18-19 Q2 2109 2094 83 care sensitive and urgent care sensitive

Better Health conditions

Antimicrobial resistance: appropriate

107a prescribing of antibiotics in primary 2018 12 0.977 0.965 0.984 88

Antimicrobial Resistance

care

Antimicrobial resistance: appropriate

107b prescribing of broad spectrum 2018 12 8.71% 10% 8.81% 101

antibiotics in primary care

Proportion of carers with a long term

Carers 108a condition who feel supported to 2018 0.59 0.56 No data 153

manage their condition

Buckinghamshire CCG



Value

Travel as stated)

Financial Sustainability 141b In-year financial position 2019 02 2.30% Amber + N/A

Utilisation of the NHS e-referral service

Paper-free at the point of care 144a to enable choice at first elective 2018 02 99.6% 98.7% No data 172

Sustainability referral

Demand Management 145a Expenditure in areas with identified 18-19 Q3

Not reported

No data N/A scope for improvement

Probity & Corporate 162a Probity & corporate governance 18-19 Q3

Not reported

No data N/A

Governance

163a Staff engagement index 2017 3.78 Not reported No data N/A

Workforce Engagement 163b Progress against the Workforce Race 2017 0.13

Not reported

No data N/A

Equality Standard

Leadership CCGs Local Relationships 164a Effectiveness of working relationships 2017-18 Not reported No data N/A in the local system

Quality of Leadership 165a Quality of CCG leadership 18-19 Q3 Not reported No data N/A

Patient & Community

166a

CCG compliance with standards of

2017

Not reported

No data N/A Engagement public and patient participation

Page 55

Buckinghamshire CCG



Value

Travel as stated)

103a Diabetes patients who achieved NICE 2017-18 38.7% 39.8% 86 targets

Diabetes People with diabetes diagnosed less

103b than a year who attend a structured 2017-18 (2016 cohort) 8.54% 10.8% 65

education course

Falls 104a Injuries from falls in people 65yrs + 18-19 Q3 2051 2038 102

Percentage of deaths with three or more

End of Life Care 105c emergency admissions in the last three 2017 5.37% 5.51% 92

months of life

121a Provision of high quality care: Hospital 18-19 Q3 66 No data 15

Provision of High Quality Care 121b Provision of high quality care: Primary 18-19 Q3 67 No data 52 medical services

121c Provision of high quality care: Adult 18-19 Q3 63 No data 63 social care

122a Cancers diagnosed at early stage 2017 53.52% No data N/A

People with urgent GP referral having

Cancer

122b first definitive treatment for cancer 18-19 Q3 79.5% 85% 80.70% 91 within 62 days of referral

122c One-year survival from all cancers 2016 72.8% 73.90% No data 40

122d Cancer patient experience 2017 8.8 113

Better Care 123a

Improving Access to Psychological 18-19 Q3 51.8% 50% 57.5%

20 Therapies: Recovery

123b Improving Access to Psychological 18-19 Q3 4.48% 5.22% 36 Therapies: Access

People with first episode of psychosis

123c starting treatment with a NICE- 2019 02 75.9% 87.7% 42 recommended package of care treated

Mental Health within 2 weeks of referral

123e Mental Health: crisis team provision 2017-18 43.8% No data 68/180

123f Mental Health: out of area placements 18-19 Q3 123 133.0 136

123i Delivery of Mental Health Standard 18-19 Q3 Green + N/A

Ensuring the quality of mental health

123j data submitted to NHS Digital is robust 18-19 Q2 NULL 0.85 No data 101

(DQMI)

Reliance on specialist inpatient care

124a for people with a learning disability 18-19 Q3 38 24

and/or autism

Learning Disability

Proportion of people with a learning

124b disability on the GP register receiving 2017-18 51.4%

55.1%

71

an annual health check

124c Completeness of the GP learning 2017-18 0.5% 0.39% 153 disability register

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Buckinghamshire CCG



Value

Travel as stated)

125a Neonatal mortality and stillbirths 2016 NULL 4.4 91

Maternity

125b Women's experience of maternity 2018 82.7 81.7 116 services

125c Choices in maternity services 2018 60.4 58.4 135

125d Maternal smoking at delivery 18-19 Q3 10.5% 6.88% 47

126a Estimated diagnosis rate for people 2019 02 67.9% 64.1% 148

Dementia with dementia

126b Dementia care planning & post- 2017-18 77.5%

Not reported

N/A diagnostic support

127b Emergency admissions for urgent care 18-19 Q2 2409 2,073 49 sensitive conditions

Percentage of patients admitted,

127c transferred or discharged from A&E 2019 03 86.6% 95% 86.7% 79

Urgent & Emergency Care within 4 hours

127e Delayed transfers of care per 100,000 2019 02 10.3 10.6 112 population

127f Population use of hospital beds 18-19 02 499 531 136 following emergency admission

128b Patient experiences of GP services 2018 83.8% 83.6% No data 105

Better Care Primary Care Access: proportion of 128c population benefitting from extended 2019 02

100%

No data 1/191

access services

Primary Care 128d Primary care workforce 2018 09 1.05 1.07 + 66

Count of total investment in primary

care transformation made by the CCGs

128e compared with the £3head commitment 18-19 Q3 Green No data

made in the General Practice Forward

View

Elective Access 129a Patients waiting 18 weeks or less from 2019 02 87% 92% 88.5% 90 referral to hospital treatment

7 Day Services 130a Achievement of clinical standards in 2016-17 4 No data 1 the delivery of 7 day services

NHS Continuing Healthcare 131a Percentage of NHS CHC assessments 18-19 Q3 9.23% 24.1% 173 taking place in acute hospital setting

Evidence that sepsis awareness raising Patient Safety 132a amongst healthcare professionals has 2017 Not reported No data N/A

been prioritised by the CCG

Diagnostics 133a Percentage of patients waiting 6 weeks 2019 02 2.30% 1.07% 99 or more for a diagnostic test

Page 57

Performance analysis

How the CCG Measures Performance

The CCG Operating Plan outlines the National and local targets to be achieved during

the year. These are monitored and reported each month through the Quality &

Performance Report which is scrutinised by the CCG Board, Quality & Performance

Committee. The report is shared with NHS England to provide assurance against all the

CCG targets. The report includes risks and mitigating actions as well as future

developments to enhance performance.

The CCG measures performance in line with the Improvement & Assessment

Framework (IAF) indicators, which are reported to the CCG Executives and

Governing body. Performance against these indicators influences the CCG clinical

priorities and focus of transformation of system pathways

Where appropriate the CCG utilises the NHS Standard Contract to enforce performance

requirements and achievement

The wider NHS, Our local health economy and the CCG has all encountered a challenging

year during 2018-19. Continued strategic and financial investment combined with a stronger

relationship with Buckinghamshire Healthcare NHS Trust (BHT) for robust performance

management has ensured that the CCG has achieved to maximum potential in this difficult and

changing environment.

Currently specific challenges are in relation to:

Cancer

Referral to Treatment

GP Referrals

A&E 4 Hour waits

Delayed Transfers of Care

Ambulance Response

Continuing Health Care

Dementia Diagnosis Rate

Eating Disorders

Learning Disability Health Checks

Mixed Sex Accommodation

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The details of actions being taken to address these issues can be found in the Quality &

Performance reports, with an overview of each area summarised below:

Cancer

Performance against all standards improved towards the end of the year, achieved

through the implementation of new processes to review long waiting patients and

introducing alternative pathways to ensure a faster flow of patients. A few areas of

concern remain, but are being addressed across the system. Delays due to Patient

choice remain a concern.

Referral to Treatment

Performance as a whole has been consistent despite capacity issues due to the high

level of non-elective activity across the system. A number of specialties have a high

number of long waiting patients which are management on a weekly basis to prevent

breaches. Buckinghamshire Health care NHS Trust (BHT) continues to report zero 52+

week waits.

A&E 4 hour Wait

Whilst the service remains challenged with high number of attendances, BHT

performance is above the national and regional average. The implementation of the

Rapid Assessment & Treatment Unit (RAT) is seen as an exemplar within the region

Delayed Transfers of Care (DToC)

The number of patients remains higher than the nationals standard. A number of

actions have been implemented to reduce the number of stranded and super stranded

patients waiting over 21days, with patients being transferred to more appropriate care

where possible. Measures are also aimed at reducing the number of over 7 day

waiters.

Ambulance Response

South Central Ambulance Service (SCAS) have worked with partnership organisations

to improve performance against all targets throughout the year. There have been a

number of restricting factors, which have impacted on the performance achieved.

Handover delays at BHT have greatly reduced due to the implementation of the RAT at

the Stoke Mandeville site

Continuing Health Care (CHC)

Performance against both the 28 day assessment and assessment within an acute

hospital targets has seen significant improvement towards the end of the year following

the implementation of an agreed recovery plan.

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Eating Disorders

Performance has improved towards the latter part of the year, but due to small numbers

of referrals to the service is it not possible to achieve complete recovery for the 4 week

target

Learning Disability Health Checks

In previous years the performance of this indicator greatly improves in the last quarter of

the year, however as the baseline of the number of people on the register is increasing

the prediction is that this indicator will be under achieved in 2019.

Mixed Sex Accommodation

Breaches occur across the system, but mainly at Frimley Health due to the nature of

the layout of several departments. Breaches will continue to occur until the completion

of building works due early 2019.

Principal risks:

The purpose of the Governing Body Assurance Framework is to report that the principal risks

to the organisation are effectively and appropriately mitigated.

The Framework demonstrates controls (methods) and assurances (evidence that methods are

working) in place. It also details further actions required to mitigate any identified gaps in

control and/or assurance.

The Framework is a standing item on the agenda for each meeting held in public.

During 2018/2019, the Framework was re-designed to:

Reflect current best practice

Link directly to both 5 year strategic objectives (2016-2021) and in-year corporate

objectives

Better Health for Bucks – to commission high quality services that are safe, accessible to all and

achieve good patient outcomes for all

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Organisational and workforce development

The Integrated Care System’s (ICS) Organisational Development & Workforce Steering and

Working Groups have been meeting monthly over the last year and during this time have been

successful in gaining funding from Thames Valley Health Education England (TVHEE), the ICS

Transformation Funds and Thames Valley and Wessex Leadership Academy (TVWLA) to

support the organisational development (OD) required as we form an Integrated Care System

(ICS). We have developed an OD and Workforce strategy with three key elements:

Having reviewed the OD and workforce teams put in other integrated care systems, we

decided to build our own infrastructure so we can make rapid progress on the three elements

for all staff, while we research and consider the specific requirements for the development of

our locality networks in the community. Recruitment to three roles is underway. In the

meantime, we have reviewed the content of the Buckinghamshire Healthcare Trust’s

leadership course and changed it to reflect the ICS way of working. The course has been

opened out to staff from all partners so that cross organisational working becomes the norm

and so far take up across the ICS has been positive.

The OD and Workforce Working Group learned of a new NHSE workforce-modelling tool and

invited the designer to explain how it works so we can explore its functionality and application.

We will use either this or the Local Action Workforce Board (LWAB) model when working with

our new Primary Care Networks to guide the important conversations about what skills will be

needed to provide the new services of the future, how many workers we will need and how we

get them recruited or trained. We also provided guidance, HR frameworks and documents to

support secondments and staff movements between partner’s organisations.

Organisation development and workforce deliverables

The Working Group also explored a number of change and service improvement models so

that one can be taught and used across the system. There is consensus that the NHS Change

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Model and the associated quality, service improvement and redesign (QSIR) tools are most

suitable for our needs and should be consistently applied across the ICS (and this has

been discussed with Bucks County Council as a possible approach for the Unitary change

management too).

Discussions have been had with provider organisations about the kind of offer they might make

to support the ICS with Primary Care Network development. Now that the Long Term Plan has

been published and the changes to the general practice contract made clear, the Working

Party needs to review the ambition of each of the Primary Care Networks with them and

establish how best we can use the resource identified in our various business cases to support

the change required.

The ICS has also developed a plan for a coaching pool across all partners.

At the CCG work has begun to establish the key commissioning functions and statutory duties

which will remain at county level in ‘place’ and which are more strategic and will be

undertaken in the future at the larger footprint of the Buckinghamshire, Oxfordshire and

Berkshire Sustainability and Transformation Partnership (STP) level.

At STP level the Local Action Workforce Board (LWAB) has developed a draft STP wide

workforce strategy, Our People Strategy: Building a Great Place to Work, and a plan for taking

it forward in 19/20. This document complements and aligns well with the strategy developed

at ICS level and the Local Authority’s complementary ‘Great Place to Work’ people

framework. We also continued to support the STP work on GP workforce as part of the Five

Year Forward View.

The recently published NHS Long Term Plan indicates the need for recruitment of significant

numbers of staff to support general practice over the next three years in the fields of social

prescribing, clinical pharmacy, physiotherapy, physician’s associates and community

paramedics. This, and establishing Primary Care Networks, will require first call on the OD

support in early 2019/20.

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Engaging people and communities

Communication and engagement

The focus of our communications and engagement plan is to ensure that all stakeholders are

well informed and have the opportunity to be involved in shaping healthcare services through

the most appropriate channels to meet their specific needs.

Public

Involvement of Buckinghamshire residents in shaping the services we plan,

commission and deliver

Understanding of all our audiences and how to reach all groups including those in our

diverse communities

Improved patient and service user experience for those receiving NHS and/or

social care services

Improved understanding of the system and how to navigate it, ensuring single points

of access and seamless service delivery

Staff

Greater understanding of the ICS and what the changes in each organisation mean for

each other

Involvement of staff in identifying opportunities for better integration

Increased knowledge of other roles and how they contribute to residents health

and wellbeing

Improved understanding of health and care as one system

Spreading good practice across the system

Using real examples and demonstrating the strengths in our system to support our

recruitment and retention drives promoting Buckinghamshire as a “good place to work”

Deliverables in 2018/19

Developing the ICS story including frequently asked questions to ensure a

consistent message across all organisations

Understand knowledge of the ICS and each organisations preferred channels to

help inform our plan

Through blogs and tweets, share our journey to greater integration

Continue to develop cross organisation communications networks

Maximise opportunities to share our messages both locally and nationally

Work directly with communities to reduce health inequalities

We have several mechanisms for engagement which are supported by the 2018 - 2020

Communications and Engagement Strategy. These include:

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https://www.buckinghamshireccg.nhs.uk/wp-content/uploads/2019/01/CCG-Engagement-Strategy-2018-2020-FINAL.pdf

An online engagement platform www.letstalkhealthbucks. We use this to

host discussions, online forums and surveys

Social media platforms, including Twitter and Facebook, plus the support of partners

channels such as Healthwatch Bucks, and ICS communication channels Regular newsletter to engage and inform member practices of updates from the

CCG and the wider NHS Regular newsletter to involve and update staff who work across the ICS Patient Participation Groups (PPGs) in every practice A PPG network meeting that meets bi-annually

A co-production group consisting of volunteer members of the public who offer advice

on how healthcare services are managed in our community. Patient Representatives that sit on various groups and committees

An Engagement Steering Group consisting of representatives from PPGs to advise

the CCGs on engagement opportunities. A Health and Social Care communications group that consists of representatives of the

wider health and social care community

An Equality, Diversity and Inequalities Steering Group. This group helps us to widen our

reach within the community An Inequalities Advisory Group which is an independent forum composed of

community leaders with reach into our more diverse communities.

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Over the last twelve months, we have undertaken extensive engagement and consultation

with the local community, some of the activity is summarised below:

ICS Engagement Roadshows (changes to community healthcare services)

Primary Care Improved Access (Survey with over 1000 responses on what is important

to our residents)

Primary Care Improved Access – campaign to launch the new service and ongoing

promotion to public thereafter. An advertising campaign was launched in March to last

for 6 weeks over the Easter period

Primary Care Improved Access – targeted campaign to reach groups identified in

Equality Impact Assessment, including working with community groups to promote

Inequalities Advisory Group – to reach diverse, potentially excluded and disadvantaged

groups to reduce health inequalities.

Production of Equality Annual Report and Equality and Diversity Objectives for 2019-

2023

Adult Social Care Better Lives Strategy launch

Outcomes Framework Engagement

Campaign to address health inequalities for people with a learning disability or autism

by ensuring patients were on their GPs learning disability register and having an Annual

Health Check

Co-production of large event (Access All Areas – 13 September) for young people with

a learning disability/autism

Launch of Live Well Stay Well service and website

Annual General Meeting held jointly with the hospital trust promoting the work of

the NHS and ICS

Fortnightly GP Members’ Bulletin

Launch of Getting Buckinghamshire involved steering group (ICS user engagement and

co-production group including)

Workshop on 24 September for development of Thame community hub

GP out-of-hours service in south Buckinghamshire - public engagement

Chiltern House Medical Centre - closure of branch practice and procurement of

provider– public engagement, high profile reassurance. Over 1200 responses to survey

and ongoing work with community

Wye Valley Practice – support and advice on relocation of practice to Wycombe

Hospital

Falls Prevention campaign

Prevention at scale campaign

Launch of Community Asset tool and ongoing campaign

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https://www.buckinghamshireccg.nhs.uk/wp-content/uploads/2015/11/Equality-Annual-Report-draft-30-Jan.pdf

Engagement toolkit for localities

More information about our communication and engagement activities can be found here

https://www.buckinghamshireccg.nhs.uk/public/getting-involved/public-engagement-updates/

Key activities for 2019/20 will be:

Working with partners

Healthwatch

The CCG continued to work with and develop relationships with our local Healthwatch which

had representation on a number of our programme boards and project groups. Healthwatch

also continue to support the CCG with the development of Patient Participation Groups (PPGs)

in General Practice and share their deep dive reports with the CCG.

Integrated Care System Partnership Board

The Integrated Care System (ICS) consists of health and care partners from across Bucks,

namely Buckinghamshire Healthcare NHS Trust, South Central Ambulance NHS Foundation

Trust, Oxford Health NHS Foundation Trust, FedBucks and Buckinghamshire County

Council. Over the last year, the ICS has established its governance arrangements and set out

its operating plan. Louise Patten, CCG Accountable Officer, is the ICS Lead and many

members of the CCG’s team have supported its programmes of work.

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https://www.buckinghamshireccg.nhs.uk/public/getting-involved/public-engagement-updates/

Sustainability and Transformation Partnership (STP)

Buckinghamshire CCG is part of the Buckinghamshire, Oxfordshire and Berkshire West (BOB)

STP footprint along with the associated CCGs, Local Authorities and providers. The BOB STP

comprises three local health and care economies which include two first wave Integrated Care

Systems (ICS). The approach being taken across the STP is to do things at the footprint that

make sense to local stakeholders and local populations. The STP focus is on strategic

collaboration and shared learning when more can be achieved by working together on a larger

scale. Programmes being led by the STP include cancer, prevention, population health

management, digital technology, estates and workforce.

Health and Wellbeing Board

Buckinghamshire’s Health and Wellbeing Board (HWB) is a statutory body that brings together

key leaders from our local health and social care system to improve the health and wellbeing of

our local population and reduce health inequalities. The board is the owner of the county’s joint

strategic needs assessment and its health and wellbeing strategy. The CCG is represented on

the board alongside County and District Council representatives, Public Health, Healthwatch

and NHS England.

As members of the HWB, the CCG has been supportive of the Board’s ongoing wish to

improve how it engages and consults with our local population.

How the CCG contributes to the delivery of a joint health and wellbeing strategy:

The CCG is a partner of the Buckinghamshire Health and Wellbeing board. The Joint Health

and Wellbeing Strategy (JHWS), including its vision, forms the overarching strategy for the

ICS and part of the CCG (plans for 2018/19. During the year the contribution has been

reviewed regularly by the Health and Wellbeing Board through a number of ways including:-

(a) A systematic review into the performance dashboard against the Health and Wellbeing strategy of which CCG performance indicators feature.

(b) A number of deep dives including into Children’s Services, Mental Health and the Winter plan which was developed across the ICS

(c) A number of development sessions including the Health and Wellbeing role in the Long Term plan

(d) Specific responses to recommendations to the DPH annual report setting out the actions the CCG will take

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How the CCG has consulted each relevant Health and Wellbeing Board (HWB) in

preparing the review of their contribution to the delivery of any joint health and

wellbeing strategy?

The CCG does not consult separately with the HWB as it is an integral part of our

system working and the overall strategy of the ICS.

Buckinghamshire HWB provides leadership and vision for health, care and wellbeing, and has

strategic oversight of progress, key deliverables and system-wide projects in the ICS.

Partners in Buckinghamshire have a history of joint working and relationships are strong.

Elected Members sit on the ICS Partnership Board and the council’s chief executive chairs the

System Implementation Board; over time there may be potential for greater alignment between

the partnership board and the HWB.

Elected Members are keen that reforms do not result in a host of new acronyms and that

developments are reflected in plain language. Buckinghamshire has a strong sense of place,

and wherever possible partners intend to build on and support developments that are already

underway rather than setting up new structures and mechanisms.

Some key developments include the following:

Buckinghamshire has an integrated commissioning structure covering all age groups managed

through a joint commissioning team. It operates pooled budgets in mental health, children’s

services and learning disabilities and has a transparent approach to other budgets, such as

continuing healthcare. Commissioning intentions are set out in market position statements, and

in future more responsibility for achieving outcomes will be delegated to provider partnerships.

Buckinghamshire is developing a tailored population health management approach to

support both system-wide commissioning and locality working through detailed local data

packs. As a newly unitary council, Buckinghamshire is working to establish local community

boards which will develop a neighbourhood vision and strategy. It will explore how primary

care networks, community health and care delivery, and the voluntary and community sector

could work together in neighbourhoods.

The ICS has ambitious plans for an integrated information technology system across the

council, the CCG and an NHS trust. Part of this programme will be to develop a single portal

for professionals from all sectors to access and add to data, and for the public to access their

own cross-service data.

The JHWS was refreshed in 2017 to put a stronger emphasis on place, reducing inequalities

and children’s and adults’ mental health. This was accompanied by a comprehensive

dashboard to monitor progress.

Buckinghamshire’s population is predicted to grow by 16 per cent by 2039, a faster rate than

the South East. This will have a significant impact on services and infrastructure and the HWB

has agreed that collaboration on the growth agenda is a priority. Another priority, within the

shared approach to prevention, is to tackle social isolation which is among the highest in the

country for people over 65 in some areas of Buckinghamshire.

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GP Federations

Buckinghamshire has two GP Federations – FedBucks and Medicas, working as general

practice provider organisations and representing almost all practices in Bucks. The CCG

continued to work with both organisations to support change in localities that enables the new

community care model to be introduced.

Sustainable Development

Promoting sustainability

We are legally obliged to meet Government targets on cutting carbon emissions by 35% by

2020 against a background of climate change and scarcer natural resources. The NHS is the

largest public sector emitter of carbon emissions.

Within our own organisation, we:

Are proactively using technology for our staff to reduce the use of cars between our

office sites for internal meetings

Have introduced digital travel expense claims

Have considerably cut our use of paper resources over the last two years

through issuing more laptops and tablets

Have a continued focus on promoting a culture of everyday recycling and healthy living

Have encouraged staff to undertake activities to improve their fitness and wellness

We commission to:

Focus on reducing waste of medicines by ensuring prescribing accurately meets patient

needs

Encourage our providers in primary and secondary care to design their services to the

needs of local population clusters that minimises travel time for both appointments and

extended stays in healthcare settings

Encourage our providers to cut their paper use, especially in managing records archives

and sharing electronic care records Actively promote use of electronic referrals and hospital discharges

Work collaboratively with patients and communities to seek their feedback about

environmental impact of our purchasing decisions

All these measures aim for appropriate efficiency, resilience and integration within our

operations and patient pathways to avoid unnecessary waste and duplication.

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Improve quality

What are we trying to achieve?

Establish a robust and effective system of assurance for the quality, safety

and experience of care across the ICS;

Provide a collaborative focus for common challenges; and

Provide strategic leadership and accountability to facilitate improvement of outcomes

and experience for the whole population of Buckinghamshire.

Where are we now?

Finalised responsibilities, roles and systems of accountability to support

good governance and management

Over the previous 12 months, the CCG has met its statutory obligations for Quality

(Safety, Clinical Effectiveness, and Patient Experience)

Over the previous 12 months there was a focus on rapid development of

assurance systems around 6 key priority areas:

o Learning from deaths (LeDeR) o Safeguarding o Serious incidents

o Children, young people, and families

o Maternal health o Infection prevention and control

Increasing leadership capacity and capability in quality improvement is underpinned by

a shared agreement to use a single Quality Service Improvement and Redesign

programme across ICS providers

Success stories so far

The quality of reviews for LeDeR (Learning From Deaths for people with a

Learning Disability)

Development of relationships across ICS

Inaugural ICS Quality Forum meeting was held in September 2018

Collaborative preventative work to avoid/reduce likelihood of a Large Scale Enquiry

Reducing health inequality

Every year we write an annual report explaining how we have met our commitments to

equality, diversity and health inequalities. This year we worked on the areas shown below and

more can be found out about these initiatives by seeing our on our website.

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During the year we agreed four new Equality and Diversity Objectives for 2019 – 2023. A

clinically led working group has been set up to ensure that the objectives are embedded in our

work going forward.

The Inequalities Advisory Group is also reviewing the objectives so that the members

can influence, support and promote the work plan as it emerges.

The newly published NHS Long Term Plan also places significant importance on addressing

health inequalities. This requires the Integrated Care System to set out how it will reduce

inequalities by 2023/24 with the new Primary Care Networks (PCNs) playing their part.

Population health data from the Joint Strategic Needs Assessment will inform the emerging

PCNs in developing strategies and services to address inequalities. Click here to read our

Equality Annual Report.

Our four new Equality and Diversity Objectives for 2019 – 2023

We will provide targeted support to identify and treat those people with high blood

pressure who are black or from ethnic minority communities. Also those who live in

our most deprived areas. As a result, we will increase the numbers of people

diagnosed and improve the percentage of people with high blood pressure whose

treatment is successful by 2022.

We aim to promote good mental health for all and improve access to mental health

services when these are needed, with a special focus on children and young people.

So we aim to increase the number of Mental Health Support Teams in schools in

catchment areas with the highest levels of deprivation, and increase the numbers of

children from these schools accessing mental health services in 19/20 compared to

18/19.

We will reduce the gap in experience of Care and Support Planning for people who

have long-term conditions (including mental health) between those who are white

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British patients and those of black or minority ethnic origin. To do this we will need to

improve the recording of ethnicity in the Primary Care record from the 2018 position.

We will reduce the numbers of people smoking generally and aim to achieve the

greatest reduction in smokers registered at GP practices in the most deprived

areas of our county.

Health and wellbeing strategy

The Health and Wellbeing Board aims to create the best conditions in Buckinghamshire for

people to live healthy, happy and fulfilling lives and achieve their full potential. It does this

through the collaboration of local councillors, local GPs, senior managers in the local authority

and NHS, and a representative of local people through Healthwatch Buckinghamshire.

The Health and Wellbeing Board has a five year strategy describing the vision, aims and

priorities for health and wellbeing and this was last refreshed in 2017. It is due to be in

place until 2021.

The key priorities from this strategy have been worked into the CCG’s operating plan each

year and over the last year, have been worked into the Integrated Care System’s operating

plan. These priorities also align well to the newly published NHS Long Term Plan.

The Health and Wellbeing Board produces a performance dashboard to show the impact that

the Board and its partners, which include the CCG, have made over the year to improving the

county’s health and wellbeing.

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Innovation, Education and Research

The NHS Long Term Plan has given a no holds barred opportunity to

1. Improve outcomes

2. Provide unparalleled streamlined pathways

3. Deliver efficient patient experiences

4. Commission value added healthcare

5. Reduce the inequality gap

In light of this, there is no question the CCG needs to build on its achievements, such as in

cardiovascular medicine and cancer care. It will deliver its biggest and most radical

overhaul yet, and that needs to be enabled by innovative approaches and thinking, by

cutting edge technology and with trialing novel ideas and the forefront of medical research.

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EPPR Emergency, Planning, Preparedness and Response)

The NHS needs to plan for, and respond to, a wide range of incidents and emergencies that

could affect health or patient care. These could be anything from extreme weather conditions

to an outbreak of an infectious disease or a major transport accident. The Civil

Contingencies Act (2004) requires NHS organisations and providers of NHS funded care to

show that they can deal with such incidents while maintaining services by putting in place

incident response plans, including reviewing and testing our major incident plans, which are

fully compliant with NHS England’s latest guidance on emergency preparedness.

The accountable emergency officer is responsible for making sure these standards are met. As

part of the national EPRR assurance process the CCG is required to assess itself against

these core standards and we were able to declare compliance in 2018/19.

We certify that the CCG has incident response plans in place which are fully compliant with the

NHSE Emergency Preparedness Guidance of 2015. The CCG regularly reviews and makes

improvements to its business continuity and system resilience escalation plans and has a

programme for regularly testing these.

Signed:

Louise Patten

Chief Officer and Accountable Officer

23rd May 2019

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ACCOUNTABILITY

REPORT

Corporate Governance Report

Members Report

The purpose of the corporate governance report is to explain the composition and

organisation of the CCG’s governance structures and how they support the achievement

of the CCG’s strategic objectives.

Member profiles

GOVERNING BODY (voting members)

Dr Raj Bajwa, Clinical Chair

Dr Bajwa is the Clinical Chair for NHS Buckinghamshire

CCG, re-elected in November 2018. He was previously

Clinical Chair for NHS Chiltern CCG from July 2016,

and prior to that the Clinical Commissioning Director

responsible for Long Term Conditions, Medicines

Management and End of Life Care.

Raj is a GP and senior partner and trainer at Little Chalfont

Surgery having trained in the Vocational Training Scheme

within the Oxford Deanery. He initially qualified as a

pharmacist at Kings College, London before studying

medicine at Southampton. He is married with 3 children.

Robert Parkes, Lay Vice Chair and Chair of the

Audit Committee

Robert, a retired chartered accountant, was Executive

Director, Finance of the URENCO Group until the end of

2015. Robert worked for URENCO for more than 20 years

and during this time, was responsible for the group’s

finance functions as well as Procurement and IT. Prior to

joining URENCO, Robert was UK Finance Director of

Schering.

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Robert is married with two children and five grandchildren.

He lives in Chearsley and outside of work his main

interests are gardening, travel and languages.

Dr Graham Jackson, Member GP and Clinical Lead

for the Integrated Care System

A GP Partner in Aylesbury since 1991; he founded

AYDDOC (an Out of Hours GP co-operative) in

1993, acting as Medical Manager until 2004.

Graham was Clinical Chair at Aylesbury Vale CCG

between 2012-2018.

Graham spent 10 years as a Hospital Practitioner in

Psychiatry and has previously been Managing Director

of Bucks Urgent Care, a chair of Vale Health (a GP led

provider company), a former Vice Chair of

Buckinghamshire Health and Wellbeing Board and a

member of Thames Valley Priorities Committee.

He has been a member of Bucks Local Medical

Committee (LMC) member since 1995 and is currently

Chair of the Primary and Secondary Care Interface

National Working Group, a member of the GP

Forward View oversight group and a member of the

Board of Trustees of the NHS Confederation.

Dr Karen West, Clinical Director Integrated

Care/Caldicott Guardian

Karen is a GP partner at Haddenham Medical Centre.

She is the Clinical Lead for Integrated Care, chairs the

Quality and Performance Committee, and is appointed to

the statutory role of Caldicott Guardian.

An enthusiastic member of the team, she is committed to

ensuring the NHS, especially General Practice, remains a

service we can be proud of, centred around patient care.

As a GP she believes we can, and will, be able to provide

a better service to our patients, going forward.

Dr Rebecca Mallard-Smith, Clinical

Director Unplanned Community Care

Dr Mallard-Smith is Clinical Director responsible for

unplanned community care and specialises in the

transformation of Primary care for the CCG. She qualified

at the Royal Free Medical School in London in 1992 and

then trained as a GP on the Oxford vocational training

scheme.

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She started as a partner at the John Hampden surgery in

1997. She is now the senior partner in this surgery and is

proud to continue to develop a surgery with a local village

approach to General Practice. Rebecca is also a clinical

appraiser for General Practitioners in the Thames Valley

area.

Anthony Dixon, Lay Member and Chair of the

Finance Committee

An accountant by background and Director of Finance

in local government during his working career, he is also

a director of Windsor Theatre Ltd, a non-profit making

company limited by guarantee.

Tony has been involved in various NHS roles since

2002, including lay memberships of primary care trusts

which preceded clinical commissioning groups.

Tony joined Chiltern CCG as a lay member of the Audit

Committee in 2013 and became Audit Chair in January

2015. His lay member role has continued with Bucks CCG

from April 2018.

Colin Seaton, Lay Member, Patient and Public

Engagement

After retiring from his post as the Wycombe District

Deputy Police Area Commander, Colin founded

CSMentoring, a youth mentoring organisation that

focuses on improving the lives of young people.

Prior to his retirement, Colin was the district lead officer for

Neighbourhood Policing, Community Engagement and

Partnership. During his service he held various posts

within Buckinghamshire, Berkshire and Oxfordshire

including Detective Chief Inspector responsible for

investigating major crimes within the three counties.

Colin has two commendations for leadership and

investigation and was awarded the lifetime achievement

award for his service to the community. Colin has been

involved with NHS Aylesbury Vale CCG for a number of

years as a lay member. This has continued into the new

Bucks CCG where he chairs the Inequalities Advisory

Group and set up the Inequalities Advisory Group.

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Graham Smith, Lay Member and Chair of Primary

Care Commissioning Committee (PCCC)

Graham is a barrister who was called to the bar by Middle

Temple in 2009. He is an experienced advocate who has

appeared in Courts throughout the country and has used

his legal experience to lecture Law to students studying

degree courses as well as helping more mature students

return to education after a period in work. He is also a

governor at Halton Combined School near Wendover.

He lives locally in Buckinghamshire and is a father of

three. Graham has been involved with NHS Aylesbury

Vale CCG for a number of years as a lay member. He has

continued this role into the new Bucks CCG following

merger with NHS Chiltern CCG. He is Chair of the

Primary Care Commissioning Committee and the

Individual Funding Requests Case Review Panel.

Dr Crystal Oldman, Registered Nurse

Dr Crystal Oldman joined NHS Aylesbury Vale CCG as

nurse member of the Governing Body in January 2013, a

role continuing through federation with NHS Chiltern CCG

and now as the newly merged Bucks CCG.

She is the Chief Executive of the Queen’s Nursing

Institute (QNI). Crystal trained as a nurse and worked in

the NHS for 16 years, in the acute setting of burns,

plastics, oncology and intensive care nursing. She later

moved into community nursing and public health, working

with some of the most deprived communities in London.

She joined Buckinghamshire New University as a senior

lecturer and later as Dean of Enterprise and Business

Management in the Faculty of Society & Health where her

role included the development of partnerships with

external agencies to promote research and assist in

workforce development.

Crystal’s longstanding interest in leadership and

management has inspired her doctoral studies into the

knowledge, skills and attributes of middle managers which

she completed in 2014. Crystal was awarded a CBE in

2017 for services to community nursing and leadership of

the Queen’s Nursing Institute.

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Dr Robin Woolfson, Secondary Care Doctor

Robin qualified from Cambridge University and St

Thomas’ Hospital Medical School in 1983. Following

specialty training in kidney medicine, he was appointed

as a Consultant Nephrologist in 1997 to UCH and the

Whittington Hospital, transferring to the Royal Free

Hospital in 2006.

Robin is committed to improving patient experience,

outcomes and value through service improvement with a

strong focus on clinical leadership, education and

academic development. As Divisional Director for

Transplantation & Specialist Service (2009 - 2017), Robin

gained significant experience from managing the

successful mergers of the Renal (2006), Liver/

Hepatobiliary and pancreatic (HPB) (2011) and Malignant

Haematology (2015) services in North Central London,

as well as the recent development of the UCLP-based

Hepatitis and Renal Cancer networks.

Robin was involved in the acquisition of Barnet & Chase

Farm Hospitals Trust and subsequent development of

the Royal Free London Group Model in 2017. Robin was

appointed Medical Director of the Royal Free Hospital in

2017.

External roles include Chair of the North London Deanery

Renal Specialty Training Committee from 2005–12 and

Chair of the Strategic Partnership Board for Camden’s

Diabetes Integrated Practice Unit (2014-17). He was first

appointed to membership of Chiltern CCG’s Governing

Body in March 2016, with his role continuing to the

Governing Body of Bucks CCG.

Louise Patten, Chief Officer and Accountable Officer

Louise Patten has been Chief Officer of Aylesbury Vale

and Chiltern CCG since June 2016, having previously

been Chief Officer at Aylesbury Vale CCG since

2013. She successfully led the federation of the two

Buckinghamshire CCGs and then the successful bid for

Buckinghamshire to become one of the first eight

Integrated Care Systems (ICS). In January 2018 she also

became the Chief Officer for Oxfordshire CCG, with

Aylesbury Vale and Chiltern CCGs then merging to

become Bucks CCG in April 2018.

During this time she has developed high performing

CCGs with strong system leadership and a national

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reputation for clinical leadership and innovation. A

registered nurse, Lou has developed a patient focused

approach to system wide change across

Buckinghamshire, working in partnership with other

health and care organisations. She brings these skills to

Oxfordshire with the specific aim of developing and

supporting integrated system working in order to

enhance the BOB STP development.

Lou trained as a registered nurse at Southampton

University Hospital and later took her diploma in district

nursing, degree in health science and an MBA. She has

board level experience within Provider and Commissioner

organisations, worked for a commercial healthcare

company, set up her own consultancy and held a Director

post at Watford Football Club's Community Trust.

Lou maintains her nursing registration and has a

strong patient- focused approach to commissioning

services, recognising the importance of sustainable

primary & community health and care to support out of

hospital transformation.

Gary Heneage, Chief Finance Officer

With an accountancy background and training, Gary

Heneage joined Bucks CCG as Chief Finance Officer in

April 2018. He was previously Head of Finance for NHS

England South Central region and as a statutory

appointment automatically becomes a voting member

of the CCG Governing Body. Prior to joining NHS

England six years ago, Gary spent a decade as a Chief

Finance Officer in the private sector.

Robert Majilton, Deputy Chief Officer

Robert is Deputy Chief Officer of the CCG and in addition

oversees Corporate Governance, the Digital

Transformation programme, Strategy and Planning and

programme delivery through the Programme Management

Office.

He has previously led both the urgent care and planned

care portfolios for Aylesbury Vale CCG as well as

helping to establish the Integrated Care System in

Buckinghamshire through co-chairing the first system

transformation delivery group.

Previous to this Robert held many finance roles within the

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NHS including Chief Financial Officer for both

Aylesbury Vale and Chiltern CCGs, Director of Finance

for Community Health Services in Oxfordshire and

senior finance roles across commissioning and provider

organisations.

Debbie Richards, Director of Commissioning

and Delivery

Debbie has been Director of Commissioning and Delivery

since October 2016, and became a voting member of the

Governing Bodies in common for both NHS Aylesbury

Vale and NHS Chiltern CCG in February 2017. This role

continues for the newly merged Bucks CCG.

Debbie trained as a social worker at Oxford University

and specialised in mental health social work. She

progressed through social work team management into

NHS general management, working at a senior level in

several mental health and acute hospital Trusts.

Debbie has maintained her registration with the Health

and Care Professions Council (HCPC) and has a

particular interest in improving jointly commissioned

services for children and young people, mental health and

learning disabilities.

Debbie is also the CCG Accountable Emergency Officer

which involves contingency planning in the event of

major incidents, and is also a nominated governor of

Oxford Health NHS Foundation Trust.

Nicola Lester, Director of Transformation

The Director of Transformation is co-opted as an

additional voting member only in circumstances of

conflict of interest material to member GPs/Chair which

requires them not to count for quorum purposes.

Nicola has been committed to the NHS since undertaking

general nurse training in the 1980’s. Having specialised in

the field of intensive care nursing, she built her career via

the nurse management route, culminating in a matron

role.

The challenge of major changes in the remit of critical care

in the early 2000’s sparked an interest in the role of

clinicians as general managers and so after 20 years

directly caring for patients, she became a Divisional

Manager in an acute Foundation Trust.

Seeking a more strategic role and experience outside of

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the hospital setting, Nicola began working in

commissioning in 2009 and became a CCG Director in

Buckinghamshire in 2012.

EXECUTIVE COMMITTEE (additional voting members who are not also

voting members of the Governing Body)

Dr Malcolm Jones, Locality Clinical

Director, Aylesbury Vale South

Malcolm graduated from Cambridge University in 1996

and spent several years in hospital medicine, much of it

specialising in paediatric medicine.

Although he enjoyed working as a specialist, he

appreciated the need for more holistic practice and

decided to change tack by becoming a GP. He qualified

as a GP in 2006, gaining merit in his MRCGP diploma.

His entire GP career has been in Buckinghamshire.

Dr Toby Gillman, Locality Clinical Director, Aylesbury

Vale Central

Dr Gillman is a partner at Meadowcroft Surgery in

Aylesbury and became Lead for the NHS Aylesbury Vale

CCG Central Locality in autumn 2017, a role which

continues for Bucks CCG following merger with NHS

Chiltern CCG from April 2018. Prior to this he worked with

the Individual Funding Request panel. He also works as

the Clinical Lead for Digital Transformation and has been

involved in the rollout of a number of IT projects including

AskNHS and Graphnet shared care records.

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Dr Juliet Sutton, Clinical Director for Children’s

Following training at the Middlesex and UCH hospitals in

London, Dr Sutton undertook a number of junior and

senior house officer roles at Hemel Hempstead and St.

Albans hospitals. She later enrolled in the GP Training

scheme at Hemel Hempstead Hospital, eventually joining

Popular Grove practice in Aylesbury as a partner in 1993.

Dr Sutton became involved in clinical commissioning from

2014, initially as clinical lead for Children, Young People

and Maternity for NHS Aylesbury Vale CCG. Following the

Federation of NHS Aylesbury Vale and NHS Chiltern CCG

in July 2016, Dr Sutton focused her role on children’s

commissioning and was later appointed as an additional

voting member of the joint Executive Committee from

September 2017. This role has continued with the merger

of the CCG’s from 1 April 2018.

In addition to her CCG role, Dr Sutton is a visiting partner

at a local nursing home, and supports external training

for learning GP Registers. She is married with two

children, and outside of work particularly enjoys travelling

and walking.

Dr Dal Sahota, Clinical Director for Urgent Care

Dr Sahota is Clinical Commissioning Director for Urgent

Care, having previously been the Clinical Director for

Maternity, Newborn’s and Children. She qualified at

University College London in 2001. She then completed

her Vocation Training Scheme (VTS) within the Oxford

Deanery based at The Royal Berkshire Hospital,

Reading. Thereafter she worked as a partner in Berkshire

for 5 years.

Following the births of her two children, Dal now lives and

works in Buckinghamshire. She is a portfolio GP, so as

well as being a family doctor, has a special interest in

dermatology and skin surgery and is also a GP appraiser

in Buckinghamshire. In 2017 she became clinical director

for urgent care across Aylesbury Vale and Chiltern

CCGs, a role which continues with the two CCGs

merging as of 1 April 2018.

Dr Sian Roberts, Clinical Director for Mental Health

& Learning Disabilities

After qualifying at St Bartholomew’s Hospital Medical

School in 1992, Sian served in the RAF on a Short

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Service Commission where she completed her GP

training. Following her military service, she worked abroad

in China and in Singapore and then returned to the UK

and the NHS in 2003.

Sian has been actively involved in health commissioning

since 2011, initially as the Locality Lead for Amersham

and Chesham practices, and since 2016, as the Clinical

Director for Mental

Health, Learning Disabilities and Dementia.

Sian recognises that many of her patients presenting in

General Practice have mental health illness. She is

passionate about reducing the health inequalities in

those with poor mental health and /or learning disabilities

and she sees Primary Care as having a pivotal role in

addressing these inequalities.

Sian is also Thames Valley Strategic Clinical Network

Clinical Lead for Dementia and has been instrumental in

supporting the Dementia Friendly Practice initiative across

Buckinghamshire and the Thames Valley.

Member practices

Buckinghamshire CCG is a group of 50 member GP practices and their associated

branches across the entire county, serving a population of over 560,000. The names and

details of the member practices are contained within Appendix C of the CCG’s

Constitution.

Composition of Governing Body

The Governing Body of the CCG comprises the following members:

1. The Clinical Chair – GP from a Member Practice

Dr Raj Bajwa

2. Three Member GPs – clinical directors appointed by the Governing Body

Dr Karen West

Dr Graham Jackson

Dr Rebecca Mallard-Smith

3. Four Lay Members – one to act as the Lay Vice Chair. The Lay Members will

between them have a role in chairing the Audit Committee and Remuneration

Committee; act as conflicts of interest guardian; lead on primary care

commissioning; lead on corporate governance; and lead on patient championship,

with separation of duties as required;

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Anthony Dixon

Robert Parkes

Colin Seaton

Graham Smith

4. One Registered Nurse;

Dr Crystal Oldman

5. A registered secondary care specialist doctor;

Dr Robin Woolfson

6. The Accountable Officer;

Louise Patten

7. The Chief Finance Officer;

Gary Heneage

8. Two other management directors

Robert Majilton (Deputy Chief Officer)

Debbie Richards (Director of Commissioning and Delivery)

To be quorate and to transact decisions it must have the following members present:

Clinical GP Chair (or Lay Vice Chair)

Accountable Officer or Deputy Accountable Officer or Chief Finance Officer

Two clinicians (one of which must be a Registered Nurse or specialist

hospital doctor)

Two Lay Members

One other management director

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Committee(s), including Audit Committee

The structure of the CCG and the accountable sub-committees of the Governing

Body are as follows:

Membership of Buckinghamshire CCG

Council of Members

Governing Body

Executive Finance Audit Remuneratio Quality and Primary Care

Committe Committe Committe n Committee Performance Commissioning

Committee

Committee

Further details of membership of and attendance to the above is described within

the Annual Governance Statement

Register of Interests

Our Register of Interests, policy and self-assessments against NHS England guidance

are all published here:

https://www.buckinghamshireccg.nhs.uk/public/about-us/how-we-

make-decisions/registers-of-interests/

Personal data related incidents

The CCG had during 2018/19 one personal data related incident formally reported to

the information commissioner’s office.

Statement of Disclosure to Auditors

Each individual who is a member of the CCG at the time the Members’ Report

is approved confirms:

so far as the member is aware, there is no relevant audit information of

which the CCG’s auditor is unaware that would be relevant for the purposes

of their audit report

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https://www.buckinghamshireccg.nhs.uk/public/about-us/how-we-make-decisions/registers-of-interests/



The member has taken all the steps that they ought to have taken in order

to make him or herself aware of any relevant audit information and to

establish that the CCG’s auditor is aware of it.

Modern Slavery Act

NHS Buckinghamshire CCG fully supports the Government’s objectives to eradicate

modern slavery and human trafficking. Our Slavery and Human Trafficking Statement

for the financial year ending 31 March 2019 is published on our website at

https://www.buckinghamshireccg.nhs.uk/wp-content/uploads/2015/11/Modern-slavery-

statement-2018-FINAL.pdf

Annual Governance Statement

NHS Buckinghamshire Clinical Commissioning Group (“the CCG”) was formed from 1

April 2018 as a result of the merger of two Clinical Commissioning Groups being NHS

Aylesbury Vale Clinical Commissioning Group and NHS Chiltern Clinical

Commissioning Group (who have previously been working collaboratively in 2017/18).

Both Clinical Commissioning Groups were licenced from 1 April 2013 under provisions

enacted in the Health & Social Care Act 2012, which amended the National Health

Service Act 2006. Both the Clinical Commissioning Groups commenced their

responsibilities from 1 April 2013, following a period of time to allow for the completion of

the licencing process and the establishment of function, systems and processes.

Former NHS Aylesbury Vale Clinical Commissioning Group and NHS Chiltern

Clinical Commissioning Group were licenced without conditions.

Introduction & Context

The CCG is a clinically-led membership organisation comprising over c250 General

Practitioners (GPs) working across the 50 GP practices covering Buckinghamshire,

serving a population of over 561,000. The CCG had a total budget for 2018/19 of circa

£700m.

The membership practices of the CCG are responsible for determining its governing

arrangements.

Scope of Responsibility

As Accountable Officer, I have responsibility for maintaining a sound system of internal

control that supports the achievement of the 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 Clinical Commissioning Group’s

Accountable Officer Appointment Letter.

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https://www.buckinghamshireccg.nhs.uk/wp-content/uploads/2015/11/Modern-slavery-statement-2018-FINAL.pdf



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.

Compliance with the UK Corporate Governance Code

Whilst the detailed provisions of the UK Corporate Governance Code are not mandatory

for public sector bodies, compliance with relevant principles of the Code is considered to

be good practice. This Governance Statement is intended to demonstrate how the

Clinical Commissioning Group had regard to the principles set out in the Code

considered appropriate for Clinical Commissioning Groups for the financial year ended

31 March 2019.

The Clinical Commissioning Group 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.

The Constitution sets out the responsibility for commissioning and how the group works

with and on behalf of the Member Practices to enhance the health and wellbeing of the

local population, and how it fulfils its statutory duties.

Standing orders have been drawn up to regulate the proceedings of the CCG so that the

CCG can fulfil its obligations as set out in the Health and Social Care Act 2012 (“HSCA”).

The standing orders, together with the CCG’s scheme of reservation and delegation (set

out at Appendix F of the Constitution) and the CCG’s prime financial policies (set out at

Appendix G), provide the procedural framework within which the CCG discharges its

business.

The CCG has a governing body and which fulfils the statutory responsibilities under the

HSCA and such other functions as are delegated to the CCG by the group’s membership,

which shall include the powers and authority to lead the CCG and to set its strategic

direction in line with the views set by the Member Practices.

The principal function of the CCG’s Governing Body is to ensure that the group has

appropriate arrangements in place to exercise its functions effectively, efficiently and

economically and in accordance with any generally accepted principles of good

governance that are relevant to it; and to assure itself that the Executive Committee is

delivering accordingly.

In accordance with Part I, Section 6.4.1 of the CCG Constitution, the CCG has the

following statutory committees:

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The Audit Committee The Remuneration Committee The Primary Care Commissioning Committee

And has established delegated committees of the Governing Body as shown in Appendix

D of the CCG constitution:

Executive Committee Finance Committee Quality & Performance Committee Remuneration Committee

The terms of reference for each of these committees have been ratified by the

Governing Body and the minutes are publicly available along with those of the Governing

Body meeting papers (with the exception of the remuneration committee).

The Governing Body includes two GPs as representatives from member practices, one

of which is also a member of the Executive Committee. The member practices aim to

meet at least once a year to influence strategy and key organisational decisions. In

2018/19 there were six protected learning time events along with four joint CCG

education sessions. Further meetings may be requested by member practices. Member

practices are able to influence strategy and key decisions such as expressing confidence

(or otherwise) in the governing body or executive team, voting for the Clinical Chair, and

use of additional resources allocated by NHS England.

The CCG has, through named staff, established a number of system wide (Integrated

Care System - ICS) programme boards for Integration, Access Care and Efficiency

(ACE), and Joint Commissioning along with an Accident & Emergency Delivery Board. In

addition, the Integrated Commissioning Executive Team (ICET) is co-chaired by the CCG

and accountable to the Local Authority and Wellbeing Board, and jointly manages and

monitors shared issues and oversees strategy and performance.

Governing Body

The Governing Body uses national guidance and ‘generally accepted principles of good

governance’ to set out the way it conducts its business. Members abide by the Standards

for Members of NHS Boards and Clinical Commissioning Group governing bodies in

England (Nov 2012). The responsibilities of the CCG are detailed within section 5 of the

Constitution (functions and general duties), and the roles and responsibilities of members

of the Governing Body are in section 7. The standing orders, the prime financial policies

and the scheme of reservation and delegation are contained within sections 8 and 10, as

well as Appendices C and D.

The Governing Body had 12 meetings in 2018/19 of which 8 were in public and 4

were workshop meetings.

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Governing Body Members As at 31 March 2019

GP Executive Member Dr

Registered Nurse

GP Executive Member Secondary Care Doctor

Dr Rebecca Mallard-

Karen West

Dr Crystal Oldman

Dr Robin Woolfson

Smith

Chief Officer Chief Finance Officer Clinical Chair Deputy Chief Officer

Louise Patten Gary Heneage Dr Raj Bajwa Robert Majilton

Lay Member - Finance

Lay Member - Audit

Lay Member - Primary Director of

Care Commissioning

Commissioning & Committee Chair

Chair & GB Vice Chair

Committee Chair

Delivery

Anthony Dixon

Robert Parkes

Graham Smith

Debbie Richards

Lay Member - Patient & Public Engagement

Colin Seaton

Clinical

Managerial

Lay

In addition to statutory standing items on quality, finance, contracting and performance;

review of the Quality, Innovation, Productivity and Prevention (QIPP) plans; and review

of the Governing Body Assurance Framework; the Governing Body agenda for the CCG

in 2018/19 included reporting on:

Commissioning Intentions Planning and budget setting

Emergency Preparedness Resilience and Response (EPRR) and winter

preparedness

Better Care Fund and Strategic and operational planning

Issues where decisions at Executive Committee and Primary Care Commissioning

Committee were subject to conflicts of interest

Safeguarding

Communications and engagement activity

Joint Health and Wellbeing Strategy

Development of Integrated Care Systems and related governance documents

Ratification of policies and procedures on conflicts of interest, bribery and staff

code of conduct

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Portfolio presentations were received from a number of clinical leads covering urgent

care, learning disabilities, mental health, children and young people and medicines

management. The purpose of the presentations was to both brief the Governing Body

on the wider agenda of the portfolio and to allow the Governing Body to seek assurance

on the effectiveness of the executive functions around the risks and actions taking place.

The Governing Body also reviewed its own governance arrangements and the Terms of

Reference of its sub-committees, as well as reviewing the CCG’s constitution and the

Scheme of Reservation and Delegation. The registers of interests and gifts and

hospitality were both reviewed and all members made an annual public declaration of

their commitment to the NHS Standards for Members of CCG Governing Bodies.

Conflict of interest

The CCG recognises the potential for interests of members to conflict with the business

of the CCG; consequently the CCG has embedded in its governance documents, a

number of policies, protocols and processes to ensure that conflicts are recognised and

managed, and that decisions are made only by those who do not have a vested interest.

The document: “Managing Conflicts of Interest: Revised statutory guidance for CCGs”

published 28 June 2016 and updated July 2017, refers to a “requirement for CCGs to

include an annual audit of conflicts of interest management within their internal audit

plans and to include the findings of this audit within their annual end-of-year governance

statement”

Accordingly the assessment of annual internal audit is reported as follows:

Internal Audit have not issued any ‘no assurance’ (red) opinions to the CCG during

the year or indicated any issues that need to be incorporated into this report.

Executive Committee

The Executive Committee is responsible for the overall management and delivery of the

operational plan and its associated work programmes and has the responsibility for day

to day management of the CCG and certain functions as delegated by the Governing

Body. Some of the delivery of these functions is delegated to sub-committees of the

Executive Committee such as the Programme Boards.

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Executive Committee Members

As at 31 March 2019

Clinical Director - Unplanned Acute Care

Dr Dal Sahota

Clinical Director - Locality Lead-South Dr Malcolm Jones

Clinical Director - Clinical Director - Clinical Director -

Chief Officer

Locality Lead -

Mental Health &

Children's Louise Patten

Wycombe

Learning Disabilities

Dr Juliet Sutton Dr Rashmi Sawhney

Dr Sian Roberts

Director of

Clinical Director -

Clinical Director - Director of

Commissioning & Transformation Locality Lead - Central Integration

Delivery Nicola Lester Dr Toby Gillman Dr Karen West

Debbie Richards

Chief Finance Officer Deputy Chief Officer Gary Heneage Robert Majilton

Clinical

Managerial

The CCG also works across the Health and Social Care system on Urgent Care through

the A & E Delivery Board. This includes representatives of key providers and

commissioners of Urgent Care Services. Through the year key areas of focus have been:

To provide better support for self-care.

To help people with urgent care needs get the right advice in the right place,

first time.

To provide highly responsive urgent care services outside of hospital, so people

no longer choose to queue in A&E.

To ensure that those people with serious or life-threatening emergency care

needs receive treatment in centres with the right facilities and expertise, to

maximise chances of survival and a good recovery.

To connect all urgent and emergency care services together, so the

overall system becomes more than just the sum of its parts.

The Executive Committee held 11 meetings in 2018/19.

Certain matters are considered at most meetings as part of a standing agenda including

the Chief Officer’s Report, Chief Finance Officer’s Report, and Performance and Quality

Reports. In addition to the standing items, there have been further topics discussed

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including: updates from projects such as – Musculo-skeletal (MSK) Redesign,

Buckinghamshire Diabetes Transformation Project, new models of care, resilience and

quality within primary care, out of hours procurement, care & support planning, redesign

of the Direct Awards for 19/20, as well as Locality and Clinical Directors feeding back

during these meetings. Any items where there are specific items of Conflict of Interest

are sent to the Governing Body or Primary Care Commissioning Committee for decision.

While the Executive Committee does not meet in public, its minutes are available to

the public within the Governing Body papers.

Audit Committee

The overall purpose of the Audit Committee is to provide assurance and advice to the

Governing Bodies and Accountable Officer on the proper stewardship of resources and

assets, financial reporting, the effectiveness of audit arrangements (internal and external)

risk management, control and corporate governance arrangements as detailed in its

approved terms of reference.

The Audit Committee met 5 times in 2018/19.

The CCG had extraordinary Audit Committee meetings in April and May 2018 to approve

the submission of the draft and final Statutory Accounts and Annual Reports for the

previous CCGs.

The Committees receive regular reports from:

the Chief Finance Officer

Internal Audit and External Audit – including reports on the outcome of

reviews together with recommendations on any necessary actions

the Local Counter Fraud Specialist has presented reports as necessary

The Chief Finance Officer in respect of the risk registers and the Governing

Body Assurance Framework

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Audit Committee Members

As at 31 March 2019

External Audit Internal Audit Local Counter Fraud

Representative

Representative

Director of

Chief Officer Chief Finance Officer Commissioning &

Louise Patten Gary Heneage Delivery

Debbie Richards


Lay Member - Audit

Lay Member - Primary

Commissioning Committee Chair Chair & GB Vice Chair

Committee Chair Anthony Dixon Rorbert Parkes

Graham Smith

Member

Attendee - Non Voting

The Audit Committee also received updates on the year-end closedown process,

specific issues regarding information governance, the Commissioning Support

Unit governance and the service auditor approach interim audit report

The Committees have continued their cyclical review of financial and

information governance policies during the year

The Committees also considered the output from the Risk Management

workshop and commended to the Executive Committee a Risk Appetite Approach

and also reviewed the needs of the Pensions Charter

The Audit Committee reviewed the CCG’s accounts prior to submission for

added assurance

Finance Committee

The Finance Committee undertakes objective scrutiny of the financial plans and

decisions on behalf of the Governing Body. The Committee reviews the CCG’s monthly

financial performance and identifies the key issues and risks requiring discussion or

decision by the CCG’s Executive Committee. It also gives an opinion on the stewardship

of CCG’s financial resources and the going concern status. Additionally, the Governing

Body may request that the Committee to review specific aspects of financial

performance where it requires additional scrutiny and assurance.

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Finance Committee Members

As at 31 March 2019

Deputy Chief Finance

Deputy Chief Finance Director of

Commissioning & Officer Officer

Delivery Kate Holmes Alan Cadman

Debbie Richards

Chief Officer Deputy Chief Officer Chief Finance Officer

Louise Patten Robert Majilton Gary Heneage


Lay Member - Audit Lay Member - Primary

Commissioning Committee Chair Chair & GB Vice Chair

Committee Chair Anthony Dixon Robert Parkes

Graham Smith

Lay Member

Managerial

The committee considers issues relating to:

the development of the CCG’s annual financial plan and medium term

financial strategy, including underlying assumptions and methodology used,

ahead of review and approval by the CCG’s Governing Body.

Reviewing the CCG’s monthly financial performance (together with performance

against savings programmes, including QIPP) and identify the key issues and

risks requiring discussion or decision by the CCG’s Governing Body, recognising

that the primary ownership and accountability for the CCG’s financial performance

rests with the full Governing Body.

To scrutinise QIPP programme performance and the development of monitoring

and mitigation schemes.

Action requests from the Governing Body on specific aspects of financial

performance where the Governing Body requires additional scrutiny and

assurance and has the right of access to obtain all the information and

explanations it considers necessary to fulfil its remit.

Evaluate, scrutinise and quality assure the financial validity of the

investment, disinvestment and business case framework.

Maintain an overview of the value for money provided by the CCG’s

support arrangements (for example, the contract provided by the CSU).

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Advise the Governing Body on relevant reports by NHS England, regulators and

other national bodies, and, where appropriate, management’s response to these.

Quality and Performance Committee

The Committee is accountable to the CCG’s Governing Body, and provides assurance on the

quality and performance of services commissioned and promotes a culture of continuous

improvement and innovation with respect to safety of services, clinical effectiveness,

outcomes and patient experience. This includes a responsibility to promote research and the

use of research and monitor reports made to the National Reporting and Learning System.

The Committee makes recommendations on areas such as access and service

improvements needed, and is responsible for advising on new developments for

implementation such as NICE. The Governing Body approves and keeps under review the

terms of reference for the quality and performance committee, which includes information on

the membership of the quality and performance committee.

Quality and Performance Committee Members

As at 31 March 2019

GP Clinical Director - Associate Director of

Secondary Care Doctor

Quality and Integrated Care Dr

Dr Robin Woolfson

Safeguarding

Karen West

David Williams

Director of

Commissioning &

Delivery

Debbie Richards

Clinical

Managerial

The Committee will:

Provide the Governing Body with assurance that the quality and performance of all

commissioned services is systematically monitored

Provide assurance that risks are identified, escalated and appropriately managed

Support collaborative working and decision making that improves health and

social care outcomes in Buckinghamshire

Support effective partnerships working between health, local authority and wider

partnership organisations in Buckinghamshire

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Ensure consistency in implementation of relevant policies in an evidence-based,

cost effective and safe manner, and support wider CCG commissioning intentions.

The Quality and Performance Committee will also:

1. Assure the Governing Body of appropriate arrangements, for both the CCG and

providers of the quality of commissioned services, in respect of safeguarding,

infection control, incident management, complaints, workforce data, staff surveys,

reporting of quality accounts, or any other area of quality. This will be undertaken

through a series of reports from providers, the Commissioning Support Unit (CSU)

and from Buckinghamshire CCG. 2. Assure the Governing Body of appropriate arrangements for both the CCG and

providers of the performance of commissioned services against the constitutional

standards e.g. stroke services, cancer waiting times and A & E performance etc. 3. Receive assurance on performance and quality risks, including clinical risks,

ensuring risks are reviewed and appropriate action is taken to mitigate and / or

close. 4. Receive assurance of the quality of clinical portfolios from portfolio holders to

ensure that all commissioned services are operating together in such a way as to

deliver maximum benefit and a good patient experience and compliance with

NICE Quality Standards. 5. Receive assurance on QIPPS through Quality Impact Assessments (QIAs), to

assess any impact on quality and performance, in order to provide challenge

where necessary. 6. Ensure that there is a continuing structured process for leadership, accountability

and working arrangements for quality and performance within the CCG.

The Committee, under the Governing Body Scheme of delegation has the delegated

responsibilities for assuring the following:

Contract performance

Clinical risk management

Quality, clinical effectiveness and health improvement

Patient safety and experience

Serious Incidents (SIs), complaints and PALS

Infection Control

Safeguarding

The Committee also has the delegated responsibility for the:

Approval and ratification of policies relating to quality and patient safety

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Ratify the Terms of Reference for reporting groups into the committee and

approve their work programmes

Primary Care Commissioning Committee

The Committee has been established in accordance with the statutory provisions to

enable the members to make collective decisions on the review, planning and

procurement of primary care services in Buckinghamshire under delegated authority from

NHS England.

Primary Care Commissioning Committee Body Members

As at 31 March 2019

Lay Member - Finance Lay Member - Primary

Lay Member - Patient Commissioning

Committee Chair

& Public Engagement Committee Chair

Anthony Dixon

Colin Seaton Graham Smith

Lay Member - Audit NHS England

Health and Well Being

Chair & GB Vice Chair

Representatives

Board Representatives

Robert Parkes

GP Executive Member Clinical Chair Local Medical Council

Dr Karen West Dr Raj Bajwa Representatives

Chief Officer Deputy Chief Officer Chief Finance Officer

Louise Patten Robert Majilton Gary Heneage

Director of Transformation

Nicola Lester

Clinical

Managerial

Lay & Invited parties

The CCG Clinical Chair and GP Executive Member are not voting members.

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The Committee undertakes the following activities:

Review and monitor GMS, PMS and APMS contracts (including the design of

PMS and APMS contracts, taking contractual action such as issuing

breach/remedial notices, and removing a contract) and enhanced services (“Local

Commissioned Services” and “Directed Enhanced Services”);

Design of local incentive schemes as an alternative to the Quality

Outcomes Framework (QOF);

Decision making on whether to establish new GP practices in an area and to

approve practice mergers and making decisions on ‘discretionary’ payments.

To plan, including needs assessment, primary care services in

Buckinghamshire and undertake and deliver a primary care estates strategy

across the Buckinghamshire area.

To undertake reviews and manage the budget for commissioning of primary care

services in Buckinghamshire and to co-ordinate a common approach to the

commissioning of primary care services generally.

To assist and support NHS England in discharging its duty under section13E of

the NHS Act 2006 (as amended by the Health and Social Care Act2012) so far as

relating to securing continuous improvement in the quality of primary medical

services.

Integrated Commissioning Executive Team

The joint committee with Buckinghamshire County Council (BCC) is responsible for the

integration of commissioning and extending integrated commissioning across health and

social care demonstrating qualitative and efficiency improvements for both health and

social care.

To oversee discrete areas of collaborative commissioning activity such as the

implementation of the older people's commissioning strategy, out of hospital services,

Integrated Community Equipment Services (ICES) and S117 arrangements, further

integration of learning disabilities services and responsibility for the Better Care Fund

(BCF).

The Integrated Commissioning Executive Team is accountable to the Health and

Wellbeing board.

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Integrated Commissioning Executive Team Members

As at 31 March 2019

Managing Director CHAS

Director of Joint

Head of Strategic Integrated

Commissioner and

- Co Chair

Commissioning

Commissioning Adults

Pooled Budget Manager

Chief Officer - Co Chair Clinical Commissioning Head of Joint care

Deputy Chief Officer Director

Commissioning

Consultant in Public Director of

Finance Lead

Commissioning &

Health

Delivery

County Council Representatives CCG Representatives

The Committee oversees the following:

To agree an annual programme of work to be delivered to achieve the

proposed milestones

Within the framework of the Section 75 and in line with the agreed delegated

functions, to provide a robust governance framework, overseeing the delivery of

the collaborative commissioning agenda between the CCG and

Buckinghamshire County Council.

To oversee the delivery, including deployment of resources, for agreed

programmes of work, within the context of the S75 agreement through Lead

Commissioning arrangements, agreeing which services will be funded through

Pooled Budgets, and monitor.

An Annual Performance reporting framework for the BCF and receive regular

updates from the Integrated Commissioning and Pooled Budget Manager

To maintain a joint and active register of risks escalating significant risks to the

partner organisations as required.

Remuneration Committee

The overall purpose of this committee is to assure the Governing Bodies that the duty to

act effectively, efficiently and economically has been met, and that use of resources for

remuneration does not exceed any amount specified.

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Renumeration Committee Members

As at 31 March 2019

Chief Officer Human Resources

Louise Patten Represtative

Lay Member - Finance Lay Member - Audit Lay Member - Patient

Committee Chair Chair & GB Vice Chair & Public Engagement

Anthony Dixon Robert Parkes Colin Seaton

Managerial

Lay

Where the subject under discussion is such that members have conflicts of

interest, an additional independent member is co-opted.

The committee considered specific remuneration issues and recommendations

received from the Executive Committee.

Due to the nature of the meetings, the minutes of this Committee are not available

to the public through Governing Body papers.

Membership of the Remuneration Committee is drawn from the Governing Body and only

the lay members can be members with the Chief Officer and Human Resources being

standing invitees. No member is present for matters involving their personal

remuneration.

The committee met 5 times in 2018/19.

As part of the normal business process of the Executive Committee and Governing

Body, a post meeting performance review is undertaken which it is considered has

helped these committees to continue to develop throughout the year.

It is the intention of the CCG to continue to undertake assessments of the

performance and effectiveness of key committees and to use different tools to ensure

that assessments are as rounded as possible.

Governing Bodies and Sub- Committees

Attendance at the scheduled meetings of the Governing Bodies and their committees in

2018/19 Financial Year is shown in the following table:

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Gove

rnin

gBod

y

Exec

utive

Com

mitt

ee

Audi

tCom

mitt

ee

Finan

ceCo

mm

ittee

Qual

ity

&Per

form

ance

Com

mitt

ee

Prim

ary

Care

Com

miss

ioni

ngCo

mm

ittee

Inte

grat

edCo

mm

issio

ning

Exec

utive

Team

Rem

uner

atio

nCom

mitt

ee

Anthony Dixon 4/8 5/5 11/12 3/5 4/5

Dr Crystal Oldman 6/8

Colin Seaton 6/8 2/5

Debbie Richards 5/8 10/11 10/12 4/6 10/10

Dr Dal Sahota 6/11

Dr Graham Jackson 4/8

Graham Smith 6/8 4/5 5/5 4/5

Dr Juliet Sutton 9/11

Dr Karen West 6/8 6/11 5/6 7/10

David Williams 4/11 4/6 3/5

Louise Patten 5/8 3/11 0/5 2/5 0/10 2/5

Dr Malcolm Jones 8/11

Nicola Lester 6/8 9/11 4/5 2/5

Gary Heneage 8/8 8/11 5/5 12/12 1/5 2/5

Dr Raj Bajwa 8/8 2/5 1/5

Robert Majilton 6/8 6/11 2/5 9/12 2/5 7/10 2/5

Dr Rebecca Mallard-Smith 4/8 1/5

Robert Parkes 7/8 5/5 9/12 1/5 3/5

Dr Rashmi Sawhney 8/11

Dr Robin Woolfson 7/8 5/6

Dr Sian Roberts 8/11

Dr Toby Gilham 7/11

The Clinical Commissioning Group Risk Management Framework

The risk management framework and strategy is approved by the Governing Body and

outlines the CCG’s appetite for risk and how those risks will be managed. The CCG has

invested in a Project Management tool called Verto which enables the CCG to manage

and report transformational projects and programme risks effectively. It also outlines the

CCG’s commitment to a culture of safety, quality and openness, where members of staff

can feel able to report openly an incident/near miss or conduct which is unacceptable.

The CCG response is to ensure the commissioning of services is designed to reduce risk

to patients, staff and the public; it is not one of blame, but rather one of support and

learning.

The risk framework/strategy:

Outlines the CCG’s strategic aims, objectives and commissioning intentions;

Describes the accountability framework and reporting structure;

Describes the principal processes for managing risk, and the tools to be used;

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Provides guidance on the escalation and acceptability of risk at different levels of

the organisation;

Includes/lists related policies and procedures dealing with specific aspects of risk

management, e.g. risk management and evaluation (using recognised risk-rating

matrices), whistleblowing, and complaints, among others;

Outlines risk management responsibilities at all levels of the CCG, and the support

and training available within the organisation.

During 2018/19 the assurance framework has been discussed at meetings of the

Governing Bodies and Audit Committees; the Audit Committees are also attended by the

internal auditor, external auditor, and the Local Counter Fraud Specialist. The Executive

Committee has also considered the assurance framework during the financial year.

At the meetings of the Information Governance Steering Group risks surrounding data

security are reviewed. The steering group in turn reports to the CCG’s Audit Committee,

thus allowing the reporting and escalation of risk, where appropriate.

Each sub-committee to the Governing Bodies and Executive Committee maintains a

risk register with mitigation plans. Risks with scores of 12 or above (out of a maximum

25) are escalated to the Corporate Risk Register; the CCG ensures that plans are put in

place to lower the levels of risk whenever risks are 15 and above.

Internal Audit undertook reviews of our risk management and assurance framework

during the year which provided positive assurance. Further developments are being

considered as a result of these reviews.

The Clinical Commissioning Group Internal Control Framework

A system of internal control is the set of processes and procedures in place to ensure the

CCG delivers its policies, aims and objectives. It is designed to identify and prioritise the

risks, to evaluate the likelihood of those risks being realised, 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.

Through the Audit Committee, the CCG has reviewed those operational policies where

update has been required either due to the policy reaching its review date or through the

need to update and reflect new legislation and guidance; this includes the scheme of

reservation and delegation and its inter-operation with key staff within the Commissioning

Support Unit to whom the CCG has contracted our main financial, quality and

governance functions. During the year our internal auditors have assessed the operation

of these controls in so much as they operate within the CCG’s sphere of direct control.

During the year, our auditors have issued one partial assurance opinion in respect of

Primary Care Co Commissioning – Contract and Performance Management which the

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CCG was aware of and correct action taken; this indicates that assurance processes are

operating appropriately.

The control framework, as it operates within the Commissioning Support Unit, is subject

to separate internal audit process under the service audit approach. Our contract

requires of them to be assessed under the Type II approach which assesses both the

design and operational effectiveness of system controls.

Our Internal Audit plan for 2018/19 again retains the same number of audit days and

continues to reflect the CCG’s concerns in this area.

The CCG has a set of policies that are reviewed on a rolling cycle; this includes policies

covering Fraud and Corruption, Whistleblowing, Conflicts of Interest and Standards of

Business Conduct.

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 Framework is supported by an information governance

toolkit and the annual submission process provides assurance to the CCG, other

organisations and to individuals that personal information is dealt with legally, securely,

efficiently and effectively.

The CCG place high importance on ensuring robust information governance systems and

processes are in place to help protect patient and corporate information. The CCG has

established an information governance framework and are developing information

governance processes and procedures in line with the toolkit. The CCG have ensured all

staff undertakes annual information governance training at the level required for their

role.

There are processes in place for incident reporting and investigation of serious incidents.

The CCG are developing information risk assessment and management procedures and

a programme will be established to fully embed an information risk culture throughout the

organisation.

Internal Audit undertook an in-year audit in respect to compliance with the General Data

Protection Regulation (GDPR). This has identified a number of actions which are now

being addressed. Meanwhile, the CCG has assured its Audit Committee that it has

achieved a ‘GOOD’ self-assessment standard against all the assertions within the Data

Security and Protection Toolkit (SSPT) submitted to NHS Digital by 31 March 2019.

Pension Obligations

As an employer with staff entitled to membership of the NHS Pension Scheme, control

measures are in place to ensure all employer obligations contained within the scheme

regulations are complied with. This includes ensuring that deductions from salary,

employer’s contributions and payments into the scheme are in accordance with the

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scheme rules, and that member pension scheme records are accurately updated in

accordance with the timescales detailed in the regulations.

Equality, Diversity & Human Rights Obligations

The CCG has established an Equality, Diversity and Inequalities Working Party to ensure

that it complies with the Public Sector Equality Duty set out in the Equality Act 2010.

An annual report detailing examples of actions to demonstrate compliance with the

Public Sector Equality Duty was published as required in January 2019.

Public Sector Equality Duty (PSED) final report 18-19

Sustainable Development Obligations

The CCG is required to report progress in delivering against sustainable development

indicators. A section on our latest position is presented within the annual report.

Risk Assessment in Relation to Governance, Risk Management & Internal Control

The CCG recognise that risk management is an integral part of good management

practice. As such, risk management is integrated into all aspects of the CCG work at all

levels, as part of ‘business as usual’.

Structured risk management and assessment processes include:

Portfolio Teams and Programme Boards: regular reviews of the risk registers to

ensure that risk management is a fundamental part of the total approach to

governance and quality; Executive Committee: on-going review of the Corporate Risk Register with

updates provided by Directors from discussions and reviews at their respective

Team meetings; Governing Body Assurance Framework (GBAF) is a standing item on the agenda of

Governing Body meetings and has been discussed at audit committee meetings

where again it is a recurring agenda item. The Governing Body also undertook an

extensive deep-dive review of the GBAF and the associated Corporate Risk

registers during the year;

Key risks to delivering the CCG’s strategic objectives have been identified through

a number of risks on the GBAF, including:

If alternative care pathways are unable to have an impact on demand, then activity

at healthcare providers may increase causing both financial and capacity issues; If the CCG is unable to maintain its optimum staffing levels at any time, then this

may impact capacity or capability to discharge its commissioning functions;

If the CCG is unable to meet commitments of the Five Year Forward View for New

Models of Care, Primary Care and Mental Health, or its commitments to developing

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the Integrated Care System, then outcomes and improvement in patient

services may be compromised.

These risks were reported and managed throughout 2018/19, and were scrutinised

during the Internal Audit reviews. No new major risks have been identified for 2019/20,

and the existing risks continue to apply to the CCG delivering its key targets.

Additionally, following the Internal Audit report on our governance processes, the CCG

has undertaken a further review of our GBAF and identified more areas for development

in 2019/20.

Review of Economy, Efficiency & Effectiveness of the Use of Resources

The CCG seeks to assure itself that they are using resources in an appropriate way to

deliver economy, efficiency and effectiveness through the assurance framework and

committee structure. Our external auditors have provided an unqualified value for money

conclusion of the CCG; the finance including the Quality Improvement Productivity

Prevention (QIPP) and performance reports are all considered and challenged by the

relevant committees at each meeting. Specific actions that the CCG undertook include:

The CCG has continued to work with partners to secure best value during

2018/19, and have progressed a number of projects –

o Continue to establish Community Networks to supply services to patients.

Have piloted Buckinghamshire Integrated Teams (BITS) in 3 localities

covering population of approx.100, 000. Piloted Community Assessment

and Treatment Service in two localities covering a population of approx.

70,000. Have established 13 GP clusters , developed 24/7 primary care

service and working together to transform reablement and social care

services to help more people to live independently at home for longer.

o Implementation of MSK prime provider model from October 2017, Delivery

of cancer strategy; review and development of Long Term Conditions inked

to the model of outpatient services to ensure care is provided close to

home with a shared care record, Live Well Stay Well programme re-

commissioned, Diabetes service transformation with over 1000 Type 2

patients now being managed in primary care.

o Implementation of GP streaming in October 2017, Launch of Thames

Valley 111 integrated service from September 2017, Multidisciplinary

integrated 24/7 urgent care provision from 2018, Links to GP Improved

Access and Integrated teams, Improved Directory of Services and

increased clinical triage through NHS 111.

o Pilot changes in ASD pathway and access with focus on CYP, progressed

a new delirium pathway, expanded IAPT programme to LTC patients

Contract Management – the CCG has ensured that best value is obtained through

robustly applying the terms of our contracts with providers. Commissioners are

working with Commissioning Support Unit (CSU) colleagues and others to ensure

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that evidence and contract clause-based monitoring is in place to deliver this and

acknowledge that further work is required in developing this strand of our

assurance process.

The CCG’s Standing Orders and Procurement Policy are also designed to ensure

that best value is obtained through appropriate tendering and procurement

practice.

Governing Bodies and Finance Committees review QIPP performance as part of

their standing agenda (contained in the Finance Report). Internal Audit undertook

a review of our QIPP programme management and was rated reasonable.

The Right Care Programme Board has carried out a full systematic review of

opportunities that has been built into the Operational Plan.

Review of the Effectiveness of Governance, Risk Management & Internal Control

As Accountable Officer I have responsibility for reviewing the effectiveness of the system

of internal control within the clinical commissioning group.

Capacity to Handle Risk

The Governing Body is responsible collectively for the system of internal controls and

management, and for agreeing the annual governance statement. The Governing Body

needs to gain assurance that appropriate strategies and policies are in place and that

risk management systems are functioning effectively.

The Governing Body recognises that effective risk management is an essential element

of good management practice, and this is promoted widely throughout the CCG. The

CCG are committed to ensuring that risk management forms an integral part of the

CCG’s ethos and that responsibility for the identification, assessment, evaluation,

treatment and mitigation of risk is accepted at all levels throughout the organisations. The

Governing Body recognises that appropriate induction, awareness-raising and/or training,

at all levels is central to effective risk management.

The Audit Committee have approved the CCG’s Risk Management Framework on behalf

of the Governing Body. The framework strategy, and other related policies and

procedures define the responsibilities across the group, providing the tools to enable

staff to identify, evaluate, document and treat risks enabling review by the Governing

Body, and subcommittees.

Work has been undertaken to embed further risk management within the CCG processes

and also with the CSU in terms of supporting the CCG; the Executive Committee has

approved investment in additional resource to further strengthen capacity in this area. As

part of the CCG’s review of policies and procedures, staff has been reminded of the

approved processes and undertaken appropriate mandatory training.

The CCG has reviewed the current Risk Management Framework and continues to discuss

its ongoing tolerance to risk; and as a result, the CCG’s risk appetite statement.

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Review of Effectiveness

My review of the effectiveness of the system of internal control is informed by the work of

the internal auditors, the executive managers and clinical leads within the groups 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 audit results report, the

Head of Internal Audit opinion and other reports.

The Governing Body Assurance Framework (GBAF) provides me with evidence that the

effectiveness of controls that manage risks to the CCG’s ability to achieve its principal

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 and the Audit Committee, and a

plan to address weaknesses and ensure continuous improvement of the system is in

place.

As part of the management responses to the Internal Audit reviews of our governance,

risk management and assurance processes, action plans have been agreed that will

enhance our effectiveness.

The Governing Body has received reports at each meeting covering quality,

performance and finance; they also received the minutes of all of its sub-

committees, excepting the remuneration committee, each month together with

those of the Executive Committee. It meets on a monthly basis with meetings being

held in public on a quarterly basis as a minimum. These public meetings include

dedicated sections where members of the public are encouraged to interact with the

Governing Body, asking questions or making comment and observation about the

subject matter in hand. The Audit Committees have reviewed and agreed all policies during the year and

received reports each meeting from the Chief Finance Officer, internal auditors,

external auditors and other parties as required. At each meeting time is set aside for

a private meeting between the lay members of the Audit Committee and our

auditors. The minutes of the Audit Committee are received by the Governing Body

and, in addition, a briefing paper covering key issues considered by the committees

and progress against the internal audit plan has been developed to support

Governing Body assurance. The Quality and Performance Committee has considered reports from the

Associate Director of Quality and Safeguarding, Safeguarding Lead, Infection

Control Lead Nurse and other individuals covering key issues including complaints

and risk management, provider quality assurance and safeguarding. The minutes

of this committee are considered by the Governing Body and complement the

quality and performance reports. The Accountable Officer and the Associate Director of Quality and Safeguarding

Lead have seats on, and attend, the risk summits and associated forums linked to

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main provider Trusts. It is through this presence that the CCG gains assurance as

to the progress that the providers are making in delivering the requirements of their

plans, including rectification plans arising from external review by, for example, the

Care Quality Commission or NHS England/NHS Improvement.

The Health and Adult Social Care Select Committee discharges the health scrutiny

function on behalf of the County Council. It reviews and scrutinises the planning,

provision and operation of health services and adult social care, with a focus on

improvement. It voices the views of local residents and holds commissioners and

providers of health and social care services to account. It provides an early warning

system through which quality issues can be identified and addressed. This process

of oversight supports our own assurance process. Internal Audit agreed a work plan with the Chief Finance Officer and the Audit

Committee. During the year ten assurance and one advisory audits have been

undertaken with all reports indicating positive assurance; our internal auditors also

ran an audit follow-up programme. The reports highlight recommendations for

further improvement and actions have been agreed against these; the reviews show

that the CCG has made good progress against the plans with all actions either

completed or in progress. The Head of Internal Audit, or their nominated deputy,

attends all meetings of the Audit Committee and apprises the Committee as to

management response to reports as well as wider risks experienced across his

client portfolio; The Finance Committee has been further embedded over the last year, providing

greater focus on efficiencies and financial performance and will continue to operate

into 2019/20. The Local Counter Fraud Specialist attends meetings of the Audit Committee as

required and produces interim briefings in respect to fraudulent activities

experienced in the public sector more widely. To date no fraud within the CCG

control environment has been detected or reported which in itself provides a level

of assurance to me. The NHS England undertook quarterly checkpoint reviews of the CCG and monthly

assurance meetings. These produced positive assurance of the CCG progress in

their development. Additionally the NHS England South Central Director of Finance

holds monthly reviews of the financial position with the Chief Finance Officer, the

outcome of which feeds into the wider NHS England South Central assurance

process.

I do not consider there to be any significant gaps in control.

Following completion of the planned audit work for the financial year for the CCG, the

Head of Internal Audit issued an independent and objective opinion on the adequacy and

effectiveness of the clinical commissioning group’s systems of risk management,

governance and internal control. The Head of Internal Audit concluded that:

The purpose of the annual Head of Internal Audit Opinion is to contribute to the

assurances available to me as Accountable Officer and the Governing Body which

underpin the Governing Bodies’ own assessment of the effectiveness of the

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organisations’ system of internal control. Based upon the work undertaken during

2018/19 the opinion of our Head of Internal Audit was:

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

Area of Audit Level of Assurance Given

Continuing Healthcare Reasonable Assurance

Primary Care Co Commissioning – Substantial Assurance

governance

Primary Care Co Commissioning – Partial Assurance

contract performance & management

Contract Management and Performance Reasonable Assurance

Key Financial Controls Substantial Assurance

Risk Management and Assurance Substantial Assurance

Framework

QIPP – Financial Delivery Governance Reasonable Assurance

Arrangements

Data Quality

The various sub-committees have the required data available to help them discharge

their duties. However, there remain concerns regarding the underlying data quality

produced by some providers; these issues are being addressed through the normal

contract monitoring routes, data challenges and Data Quality Improvement Plans being

agreed with providers. The CCG continues to work with CSU and other colleagues to

ensure that data is robustly scrutinised and quality issues raised with providers within the

prescribed timescales.

Business Critical Models

The Macpherson report, Review of Quality Assurance of Government Analytical Models,

was published in March 2013 and included 8 headline recommendations. The report

covers models with certain uses some of which could apply to the CCG specifically those

pertaining to forecasting, financial evaluation, planning and allocations.

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The CCG uses a financial ledger provided to it by NHS England and likewise its financial

planning templates were also developed centrally on our behalf.

I do not believe that the CCG has any business critical models, within the definition of the

report, that require declaration to the Analytical Oversight Committee.

Data Security

The CCG has assured its Audit Committee that it has achieved a ‘GOOD’ self-

assessment standard against all the assertions within the Data Security and Protection

Toolkit (DSPT) submitted to NHS Digital by 31 March 2019.

During the financial year the CCG made 1 security breach declaration to the Information

Commissioner’s Office (ICO).

Discharge of Statutory Functions

In light of recommendations of the 1983 Harris Review, the clinical commissioning group

has reviewed all of the statutory duties and powers conferred on it by the National Health

Service Act 2006 (as amended) and other associated legislative and regulations.

As a result, I can confirm that the clinical commissioning group is clear about the

legislative requirements associated with each of the statutory functions for which it is

responsible, including any restrictions on delegation of those functions.

Responsibility for each duty and power has been clearly allocated to a lead Director.

Directorates have confirmed that their structures provide the necessary capability and

capacity to undertake all of the clinical commissioning group’s statutory duties.

Constitutional Targets

Although not all constitution targets have been met, the CCG will continue to work

with our partners and has developed action plans to address those omissions.

Table of performance of Constitutional Targets

Page 111

2018-19 National Bucks CCG Report Report Period

Operational

Standard Month Actual INDICATOR Plan

A&E 4 Hour Wait Provider

Buckinghamshire Healthcare Trust 95.02% 87.17% Category A Ambulance Calls CCG

Category 1 - Life-threatening injuries and illness ( MEAN) 7 Minutes 0:08:09

Category 1 - Life-threatening injuries and illness ( 90th PERCENTILE ) 15 Minutes 0:15:09

Category 2 - Emergency calls e.g. Stroke patients ( MEAN ) 18 Minutes Feb

0:19:12

Category 2 - Emergency calls e.g. Stroke patients ( 90th PERCENTILE ) 40 Minutes

0:37:28

Category 3 - Urgent calls ( 90th PERCENTILE ) 120 Minutes 2:35:20

Category 4 - Less Urgent calls ( 90th PERCENTILE ) 180 Minutes 3:38:27 Referral to Treatment CCG

RTT Incomplete % within 18 weeks 92% 90.70% 88.43%

RTT Incomplete 52+ week waits 0 1 4 Diagnostic test waiting times CCG

Diagnostics % waiting over 6 weeks 1% 1% Feb 1.07% Cancer patients CCG

Cancer - 2 week wait 93% 93.0% 95.1%

Cancer - Breast symptoms 2 week wait 93% 93.6% 95.5%

Cancer - 31 day first definitive treatment 96% 96.5% 94.7%

Cancer - 31 day subsequent treatment - surgery 94% 96.3% Feb

95.7%

Cancer - 31 day subsequent treatment - drug 98% 98.6% 98.8%

Cancer - 31 day subsequent treatment - radiotherapy 94% 94.3% 98.5%

Cancer - 62 day - Urgent GP Referral to 1st Definitive Treatment 85% 85.9% 75.2%

Cancer - 62 day - Screening 90% 95.2% 63.6% Mental Health CCG

CPA - Followed -up within 7 days of discharge (Qtrly) 95% Q3 18/19 98.2% Mental Health - Improving Access to Psychological Therapy (IAPT) CCG Access: The proportion of people with depression/anxiety that have entered psychological

19.5% Revised to

19.32% therapies. 18% by Q4

Recovery: Proportion of people with depression/anxiety completing treatment and moving to 53%

Mar 60%

recovery

People that wait 6 weeks or less from referral to entering IAPT 75% 99%

People that wait 18 weeks or less from referral to entering IAPT 95% 100% Mental Health CCG

Early Intervention in Psychosis - Psychosis treated with a NICE approved care package within two 53% 77% Feb 80%

weeks of referral

Waiting Times for Routine Referrals to CYP Eating Disorder Services - Within 1 week (Urgent). 95% 100% Q3 18/19 50.0%

Waiting Times for Routine Referrals to CYP Eating Disorder Services - Within 4 weeks (Routine). 95% 73.7% Q3 18/19 88.9%

Learning Disability Health Checks Proportion of people on the GP Learning Disability Register that have received an annual health

75% by 2020 65% Jan 29.3% check during the year

Dementia Diagnosis

Dementia Diagnosis Rate 66.7% 66.0% Feb 64.10%

Delayed Transfer of Care CCG

Rate of Days Delayed Transfers of Care per 100,000 856.6 Q3 18/19 879.5 Continuing Healthcare CCG

Percentage of CHC assessments within 28 days 80% Mar 55%

Reduction in CHC assessments in Acute hospitals <15% Feb 18% Mixed Sex Accommodation CCG

Breaches of Mixed sex accommodation 0 Feb 20 Infection Control CCG

Incidence of healthcare associated infection - MRSA 0 (Year) 0 Mar

0

Incidence of healthcare associated infection - C.Difficile 108 (Year) 9 10

Electronic Referral System (ERS) CCG

NHS e-Referral Service (eRS) for all consultant led first outpatient referrals. Dec 81%

VTE (Venous Throboembolism) Provider

Buckinghamshire Healthcare Trust 95% Q3 18/19 94.6% Please note: RAG rating for all Monthly standards will be against CCG Operational Plan if included

Conclusion

The Audit Committee has confirmed that there were no significant control issues for the

financial year ending 31 March 2019.

Louise Patten


23rd May 2019

Statement of Accountable

Officer’s Responsibilities

The National Health Service Act 2006 (as amended) states that each Clinical

Commissioning Group shall have an Accountable Officer and that Officer shall be

appointed by the NHS Commissioning Board (NHS England). NHS England has

appointed the Louise Patten to be the Accountable Officer of NHS Buckinghamshire

Clinical Commissioning Group.

The responsibilities of an Accountable Officer are set out under the National

Health Service Act 2006 (as amended), Managing Public Money and in the Clinical

Commissioning Group Accountable Officer Appointment Letter. They include

responsibilities for:

The propriety and regularity of the public finances for which the

Accountable Officer is answerable,

For keeping proper accounting records (which disclose with reasonable accuracy

at any time the financial position of the Clinical Commissioning Group and enable

them to ensure that the accounts comply with the requirements of the Accounts

Direction),

For safeguarding the Clinical Commissioning Group’s assets (and hence for taking

reasonable steps for the prevention and detection of fraud and other irregularities).

The relevant responsibilities of accounting officers under Managing Public Money,

Ensuring the CCG exercises its functions effectively, efficiently and economically

(in accordance with Section 14Q of the National Health Service Act 2006 (as

amended)) and with a view to securing continuous improvement in the quality of

services (in accordance with Section14R of the National Health Service Act 2006

(as amended)),

Ensuring that the CCG complies with its financial duties under Sections 223H

to 223J of the National Health Service Act 2006 (as amended).

Under the National Health Service Act 2006 (as amended), NHS England has directed

each Clinical Commissioning Group to prepare for each financial year a statement of

accounts in the form and on the basis set out in the Accounts Direction. The accounts

are prepared on an accruals basis and must give a true and fair view of the state of

affairs of the Clinical Commissioning Group and of its income and expenditure,

Statement of Financial Position and cash flows for the financial year.

In preparing the accounts, the Accounting Officer is required to comply with the

requirements of the Government Financial Reporting Manual and in particular to:

Observe the Accounts Direction issued by NHS England, including

the relevant accounting and disclosure requirements, and apply

suitable accounting policies on a consistent basis; Make judgements and estimates on a reasonable basis;

Page 113

State whether applicable accounting standards as set out in the Government

Financial Reporting Manual have been followed, and disclose and explain

any material departures in the accounts; and, Prepare the accounts on a going concern basis; and Confirm that the Annual Report and Accounts as a whole is fair, balanced

and understandable and take personal responsibility for the Annual Report

and Accounts and the judgements required for determining that it is fair,

balanced and understandable.

NHS Commissioning Board (NHS England) has appointed Louise Patten as

Accounting Officer of NHS Buckinghamshire Clinical Commissioning Group.

The responsibilities of an Accounting Officer, including responsibility for the propriety and

regularity of the public finances for which the Accounting Officer is answerable, for

keeping proper records and for safeguarding Buckinghamshire CCG’s assets, are set

out in Managing Public Money published by the HM Treasury.

As the Accounting Officer, I have taken all the steps that I ought to have taken to make

myself aware of any relevant audit information and to establish that NHS

Buckinghamshire Clinical Commissioning Group auditors are aware of that information.

So far as I am aware, there is no relevant audit information of which the auditors are

unaware.

I also confirm that:

as far as I am aware, there is no relevant audit information of which the

CCG’s auditors are unaware, and that as Accountable Officer, I have taken all

the steps that I ought to have taken to make myself aware of any relevant

audit information and to establish that the CCG’s auditors are aware of that

information.

Louise Patten


23rd May 2019

Page 114

Remuneration and staff report

Remuneration policy

The CCGs use Agenda for Change terms and conditions for all employees except those

classified as Very Senior Managers (VSMs). The Remuneration Committee has a

standing agreement that VSM pay and expenses are up lifted in accordance with Agenda

for Change awards as made by the national Pay Review Body. This agreement is

reviewed at each Agenda for Change award to ensure that it remains an appropriate

strategy.

Senior managers’ remuneration is set through a process that is based on a

consistent framework and independent decision-making based on accurate

assessments of the content of the roles and individuals’ performance in them. This

ensures a fair, independent and transparent process for setting the pay of the senior

managers. No individual is involved in deciding his or her own remuneration.

Executive senior managers are on permanent NHS contracts. The length of contract,

notice period and compensation for early termination are set out in the Agenda for

Change, NHS terms and conditions of service handbook.

Remuneration Committee

The overall purpose of this committee is to assure the Governing Bodies that the duty to

act effectively, efficiently and economically has been met, and that use of resources for

remuneration does not exceed any amount specified.

Membership of the Remuneration Committee is drawn from the Governing Bodies. The

Chief Finance Officer and Chief Officer would normally attend in addition a

representative from Human Resources. No member is present for matters involving their

personal remuneration. Additional lay members can be co-opted to ensure relevant

experience is available. The committee met 5 times in 2018/19.

(The following tables are subject to audit).

Page 115

The Senior Managers in post to 31/3/19 were:

The Remuneration package does not include any performance related bonuses and no

remuneration has been paid in relation to this.

All appointments to the Governing Bodies, other than those described as "officers"

are substantive employees of the CCGs.

Those who are officers have fixed term contracts with their specific arrangements

described in the table below:

Provision for

Governing Body Officers Role on Governing Body Date of Contract Unexpired Term Notice Period compensation for early

termination

Dr Raj Bajwa Clinical Chair 01/11/2018 136 weeks 12 weeks Nil

Dr Graham Jackson (1) ICS Clinical Lead 01/04/2016 0 Weeks 12 weeks Nil

Dr Karen West Joint Commissioning & Partnership Working 01/04/2016 52 weeks 12 weeks Nil

Robert Parkes Lay Member & Audit Committee Chair -

Vice Chair 04/01/2019 144 weeks 12 weeks Nil

Graham Smith Lay Member - Primary Care Joint Committee Chair 01/08/2018 72 weeks 12 weeks Nil

Colin Seaton Lay Member - Patient & Public

Engagement 01/04/2018 104 weeks 12 weeks Nil

Crystal Oldman (2) Registered Nurse Specialist 17/01/2013 92 weeks 12 weeks Nil

Lay Member & Finance Committee

Anthony Dixon (2) Chair 01/04/2018 88 weeks 12 weeks Nil

Robin Woolfson (2) Secondary Specialist Doctor 01/03/2016 192 weeks 12 weeks Nil

1) Resigned 19/3/2019 2) Term extended for a further 2 years from 10/1/19 3) Term renewed for a futher 3 years from 10/1/19

Page 116

The following is the remuneration of the Governing Bodies, Executive and Non-Executive members for 2018/19.

Page 117

The following is the remuneration of the Governing Bodies, Executive and Non-Executive members. This is a combined report covering

Aylesbury Vale CCG and Chiltern CCG who federated from 1/7/16.

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NHS Buckinghamshire CCG - Pension Benefits – Greenbury Disclosure 2018/19

Total

Lump sum at

Real increase pension age

Real

Real increase accrued Cash Cash in pension at in pension pension at related to Equivalent increase Equivalent

lump sum at accrued in Cash Notes pension age pension age Transfer Transfer

pension age pension at Equivalent Name Title

(bands of at 31 March Value at 1st Value at 31

(bands of 31 March Transfer

£2,500) 2019 (bands April 2018 March 2019 £2,500) 2019 (bands Value of £5,000) of £5,000)

£'000 £'000 £'000 £'000 £'000 £'000 £'000

Louise Patten Accountable Officer 7.5-10 10-12.5 30-35 45-50 479 108 601

Gary Heneage (2) Chief Finance Officer 5-7.5 0-2.5 10-15 0-5 64 70 136

Debbie Richards Director of Commissioning and Delivery 0-2.5 0-2.5 25-30 85-90 592 78 688

Robert Majilton Deputy Accountable Officer 0-2.5 0-2.5 40-45 55-60 434 92 540

Dr Graham Jackson (3)* Member GP 0-2.5 0-2.5 10-15 30-35 204 43 255

Dr Karen West* Clinical Director for Integrated Care & Quality Lead 0-2.5 0-2.5 10-15 25-30 153 30 188

Dr Rodger Dickson Locality Lead GP for the North Locality 0-2.5 0-2.5 0-5 0-5 151 0 0

Dr Malcolm Jones Clinical Director - Southern Locality 0-2.5 0-2.5 0-5 0-5 189 0 0

Dr Juliet Sutton Clinical Director - Children 0-2.5 0-2.5 5-10 25-30 177 20 203

Lisa Beaumont (1) Associate Director of Quality & Safeguarding 0-2.5 0-2.5 30-35 75-80 475 6 638

Nicola Lester Director of Transformation 0-2.5 0-2.5 40-45 120-125 798 92 914

Dr Rebecca Mallard-Smith* Clinical Commissioning Director 0-2.5 0-2.5 10-15 20-25 175 25 205

Dr Dal Sahota Clinical Director - Unplanned Care 0-2.5 0-2.5 10-15 20-25 127 34 165

Dr Raj Thakkar Clinical Commissioning Director 0-2.5 0-2.5 0-5 0-5 139 0 0

Dr Peter Newman Clinical Locality Lead 0-2.5 0-2.5 5-10 25-30 193 0 0

Dr Rashmi Sawhney Clinical Director - Wycombe Locality 0-2.5 0-2.5 5-10 25-30 210 18 234

Dr Sian Roberts Clinical Director - Mental Health & Learning Disabilities 0-2.5 0-2.5 0-5 0-5 46 14 62

Dr Toby Gillman Clinical Director - Central Locality 0-2.5 0-2.5 10-15 25-30 128 26 158

Dr Stephen Burr* Locality Director/Lead 0-2.5 0-2.5 5-10 0-5 58 23 83

Dr Shona Lockie Clinical Director 0-2.5 0-2.5 10-15 35-40 231 32 270 (1) Lisa Beaumont is on secondment to NHS England from 15/4/18 (2) Gary Heneage was on secondment from NHSE from 1st April 2018 and was appointed substantively from 1st February 2019 as Chief Finance Officer (3) Dr Graham Jackson left in March 2019 * Change in CETV: The opening balances on some of the Cash Equivalent Transfer Vlaues (CETV) have changed from the prior year audited accounts. The reason for the change is that some of the factors used in the calculation of

the closing 2017/18 position have been updated and this has resulted in a change specifically for members in the 2015 scheme

McCloud - The calculations above do not take account of the recent McCloud ruling (This is a legal case concerning age discrimination over the manner in which UK public service pensions schemes introduced a CARE benefit design in

2015 for all but the eldest members who retained a Final Salary design). We believe this to be appropriate given the considerable uncertainty on teh implications of any future ruling in this matter.

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Cash Equivalent Transfer Values

A Cash Equivalent Transfer Value (CETV) is the actuarially assessed capital value of

the pension scheme benefits accrued by a member at a particular point in time. The

benefits valued are the member’s accrued benefits and any contingent spouse’s

pension payable from the scheme. A CETV is a payment made by a pension

scheme or arrangement to secure pension benefits in another pension scheme or

arrangement when the member leaves a scheme and chooses to transfer the

benefits accrued in their former scheme. The pension figures shown relate to the

benefits that the individual has accrued as a consequence of their total membership

of the pension scheme, not just their service in a senior capacity to which disclosure

applies. The CETV figures and the other pension details include the value of any

pension benefits in another scheme or arrangement which the individual has

transferred to the NHS pension scheme. They also include any additional pension

benefit accrued to the member as a result of their purchasing additional years of

pension service in the scheme at their own cost. CETVs are calculated within the

guidelines and framework prescribed by the Institute and Faculty of Actuaries.

Real Increase in CETV

This reflects the increase in CETV effectively funded by the employer. It takes

account of the increase in accrued pension due to inflation, contributions paid by the

employee (including the value of any benefits transferred from another scheme or

arrangement) and uses common market valuation factors for the start and end of

the period.

Exit packages

The clinical commissioning group had no exit packages in this financial year or

the preceding year for the previous organisations.

Workforce Remuneration

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 the

CCG in the financial year 2018-19 was £140k-£145k (2017/18 was £175k to £180k)

on an annualised basis. This was 2.9 times (2017/18 - 3.5 times) the median

remuneration of the workforce, which was £49,969 (2017/18 £50,972). The reduction

in 18/19 is attributable to the premium pay rate for the Interim Chief Finance Officer

employed in 17/18.

In 2018/19, no employees (2017/18 no employees) received remuneration in excess

of the highest paid member of the governing body. Remuneration ranged from

£5,000 to £145,000 (2017/18 £5,000 to £178,000).

Total remuneration includes salary, non-consolidated performance-related pay and

Page 120

benefits-in-kind. It does not include severance payments, employer pension

contributions and the cash equivalent transfer value of pensions.

Off-payroll Engagements

For all off-payroll engagements as of 31 March 2019, for more than £245 per day

and that last longer than six months:

Number Number of existing engagements as of 31 March 2019 0 Of which, the number that have existed:

for less than one year at the time of reporting 0

Confirmation that all existing off-payroll engagements have at some point

been subject to a risk based assessment as to whether assurance is required

that the individual is paying the right amount of tax and, where necessary, that

assurance has been sought.

For all new off-payroll engagements between 1 April 2018 and 31 March 2019,

for more than £245 per day and that last longer than six months:

Number

Number of new engagements, or those that reached six months 0

in duration, between 1 April 2018 and 31 March 2019

Number of new engagements which include contractual clauses 0

giving the Buckinghamshire CCG the right to request assurance in

relation to income tax and National Insurance obligations (IR35)

Number for whom assurance has been requested 0

Of which:

assurance has been received 0

assurance has not been received 0

engagements terminated as a result of assurance not being received 0

Number of off-payroll engagements of board members, and/or senior 0

officers with significant financial responsibility, during the year

Number of individuals that have been deemed “board members, and/or 0

senior officers with significant financial responsibility” during the financial

year. This figure includes both off-payroll and on-payroll engagements

Louise Patten


23rd May 2019

Page 121

Our Staff

Our staff remains our most valuable asset. We therefore continue to ensure that

the team is suitably skilled, competent, happy and healthy at work. As at 31st

March 2019, Buckinghamshire CCG employed a workforce of 104 people from a

wide variety of professional backgrounds.

We recognise and value the importance of maintaining positive working relationships

with our staff and their representatives. Due to our relatively small size and inclusive

culture, local arrangements for formal consultation are determined on an ad hoc

basis as required in accordance with our established policies to ensure appropriate

and effective consultation arrangements are in place.

This includes inviting staff representatives to provide feedback and suggestions

on the development of new HR policies and the review process for existing

policies through the Staff Partnership Forum prior to ratification by the CCGs’

Executive Committee.

The CCG recognises all of the trade unions outlined in the national Agenda for

Change terms and conditions handbook who have members employed within the

organisation.

The Clinical Commissioning Group has a contract with a fraud specialist

organisation which attends the Audit Committee. All staff are made aware of the

fraud policy which details actions to be taken if a fraud is suspected. The fraud

specialist will investigate and report on any occurrence. The CCG also has a

‘Raising Concerns in the NHS’ whistleblowing policy. This was refreshed in 2016

and is compliant with the latest guidance.

We have continued to actively encourage open and transparent communication and

the senior leadership team operates an open door policy enabling anyone to raise

concerns or issues. In addition to this, we hold fortnightly Team Briefs at both sites

to share information and listen to staff concerns. We have also had a whole team

event over the last year, to build on working relationships. There is a lot of change

afoot for the team and staff morale has been low. It is expected that the new plans

for the ICS will give the vision and assurance of an exciting future for

commissioners, providers and the patients of Buckinghamshire.

In addition to annual appraisal and arising personal development plans, all staff are

required to undertake statutory and mandatory training via an on-line portal.

Compliance is monitored on a quarterly basis and individuals are not able to

undertake personal development until this has been completed.

Sickness Absence

We are proud of our high levels of staff attendance for the CCG and believe this is

an indicator of a culture where staff are engaged and valued for their contribution.

Page 122

Sickness absence is managed in a supportive and effective manner by CCG

managers, with professional advice and targeted support from Human Resources,

Occupational Health and Staff Support services which are appropriate and

responsive to the needs of our workforce. The CCGs’ approach to managing

sickness absence is governed by a clear HR policy and this is further reinforced

by the provision of HR support and training sessions for all line managers on the

effective management of sickness absence.

We also proactively promote the health and wellbeing of staff through the provision

of annual flu jabs and initiatives including eyecare plans, monthly webinars on

different themes through the Employee Assist Programme and an annual Health and

Wellbeing month of taster sessions to promote physical and mental wellbeing. This

year we have also trained two people as mental health first aiders with another four

keen to undertake the course once places are available.

The process of sickness reporting is embedded within teams and sickness absence

is actively monitored and reported to the CCG on a quarterly basis as part of the

workforce reporting process.

The sickness absence rate for 2018/19 is shown in the table below:

2018/19 Number 2017/18 Number

Total Days Lost 37 43

Total Staff Years 82 72

Average Working Days 3 4

Lost

Employees with disabilities

The CCG has developed an integrated approach to delivering workforce equality so

do not have a separate policy for disabled employees or for any other protected

characteristics.

Equalities issues are incorporated in policies covering all aspects of the employee

lifecycle ranging from recruitment to performance. Our aim is to provide an

environment in which all staff are engaged, supported and developed throughout

their employment and to operate in ways which do not discriminate our potential or

current employees by virtue of any of the protected characteristics specified in the

Equality Act 2010. We are also committed to supporting our employees to maximise

their performance including making any reasonable adjustments that may be

required on a case by case basis.

Page 123

We have started to regrade the outcomes developed for staff in the NHS

Equality Delivery System.

The annual staff survey includes a number of questions so that we can monitor our

performance on the Workforce Race Equality Standards (WRES) which were

introduced to the NHS in April 2015. The WRES metrics in 2018 for the CCG are

below.

NHS Buckinghamshire CCG

NHS Workforce Race Equality Standard: Workforce Indicators

Please enter the following data:

Total staff in the workforce 105

Total number of staff whose 87

ethnic origin is known

Total number of BME staff 14

Total number of White Staff 73

"Not Stated" 18

Indicator Indicator CCG Baseline Data

Percentage of staff in each of the AfC Descriptor Indicator

Bands 1-9 or medical and dental Number BME staff in Bands 8 to 9 and VSM 9

Total number of staff Bands 8 to 9 and VSM

58 subgroups and VSM (including executive

% BME staff Bands 8 to 9 and VSM 15.5%

board members) compared with the

Number of BME staff in clinical roles 8

percentage of staff in the overall workforce

1 Number of BME staff in non-clinical roles 6

disaggregated by: a) Non-clinical staff, b) % BME staff in Bands 1-4 in Clinical roles

100.0%

Clinical staff, of which - i) Non-medical

% BME staff in Bands 1-4 in non-Clinical roles 25.0% % BME staff in Bands 5-7 in Clinical roles 0.0%

staff - ii) Medical and dental staff. Note:

% BME staff in Bands 5-7 in non-Clinical roles 13.0%

definitions for these categories are based

% BME staff in Bands 8-9 and VSM in Clinical roles 29.2%

on Electronic Staff Record occupation % BME staff in Bands 8-9 and VSM in non-Clinical roles 5.9% codes with the exception of medical and Number BME staff in overall workforce 14

Total number of staff in overall workforce whose ethnic origin 87

dental staff, which are based upon grade % BME staff in overall workforce 16.1%

codes.


Relative likelihood of staff being appointed Descriptor White BME

2 from shortlisting across all posts. Note: Number shortlisted applicants 77 47

this refers to both external and internal Number appointed from shortlisting 20 2 posts. Ratio shortlisting/appointed 26.0% 4.3% Relative likelihood of White staff being

6.10

appointed from shortlisting compared to BME

staff is times greater

Indicator Indicator CCG Baseline Data Relative likelihood of staff entering the Descriptor White BME

formal disciplinary process, as measured Number in workforce 87 14

3 by entry into a formal disciplinary Number of staff entering formal disciplinary 0 0

investigation. This indicator will be based Likelihood of White staff entering formal 0

on data from a two year rolling average of Likelihood of BME staff entering formal 0

the current year and the previous year. The relative likelihood of BME staff entering 0.00


Relative likelihood of staff accessing non-

Descriptor White BME

Number of staff in workforce 87 14

4 mandatory training and CPD.

Number of staff accessing non mandatory

36 4

training and CPD Likelihood of White staff accessing non- 0.414

mandatory training and CPD

Likelihood of BME staff accessing non- 0.286

mandatory training and CPD

Relative likelihood of White staff accessing non- 1.448

mandatory training and CPD compared to BME

staff

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Indicator Indicator CCG Baseline Data KF25. Percentage of staff experiencing Descriptor White BME

5 harassment, bullying or abuse from Not in the last 12 months 77% 89%

patients, relatives or the public in last 12

1 to 2 15% 0%

months.

3 to 5 4% 11%

6 to 10 2% 0%

More than 10 2% 0%


6 KF26. Percentage of staff experiencing Descriptor White BME

harassment, bullying or abuse from staff Not in the last 12 months 90% 78%

in last 12 months.

Yes 10% 22%


KF 21. Percentage believing that trust Descriptor White BME

7 provides equal opportunities for career Yes 75% 11%

progression or promotion. No 2% 22%

Don’t Know 23% 67%


8 Q17. In the last 12 months have you Descriptor White BME

personally experienced discrimination at

work from any of the following?b) Yes 4% 12.5%

Manager/team leader or other No 96% 87.5%

Indicator Indicator CCG Baseline

Percentage difference between the Descriptor White BME Not Stated 9 organisations’ board voting membership Board Representation

66.67%

8.33%

25.00%

and its overall workforce disaggregated:

CCG Staff

69.89%

13.98%

16.13%

- By voting membership of the board -

By executive membership of the board.

Percentage difference -3.22% -5.65% 8.87%

Our team composition as at 31 March 2019 was:

Bucks CCG Female Male Total

Governing Body 6 3 9

Very Senior 5 9 14

Managers

All other 55 26 81

Employees

Total employees 66 38 104

Health and Safety

With working arrangements changing for many staff as a result of our relocation of

one office to Amersham Hospital, our Health and Safety Policy and its associated

local procedures have been reviewed in 2017 by the Staff Partnership Forum. Our

‘competent person’ has also undertaken an audit of health and safety arrangements

on both sites. A small number of minor rectifications were required, all of which have

been completed.

Page 125

Modern Slavery Act

Buckinghamshire CCG fully supports the Government’s objectives to eradicate

modern slavery and human trafficking but does not meet the requirements for

producing an annual Slavery and Human Trafficking Statement as set out in

the Modern Slavery Act 2015.

Parliamentary Accountability and Audit Report

Buckinghamshire CCG is not required to produce a Parliamentary Accountability

and Audit Report. Disclosures on remote contingent liabilities, losses and special

payments, gifts, and fees and charges are included as notes in the Financial

Statements of this report at Note 2. An audit certificate and report is also included in

this Annual Report

Page 126

ANNUAL ACCOUNTS

From 1st

April 2018 the NHS Aylesbury Vale and NHS Chiltern CCGs merged

to become NHS Buckinghamshire CCG.

Financial review:

At the end of the financial year, NHS Buckinghamshire CCG has a deficit of

(£3,230k) compared to its planned deficit of (£3,325k). This is represented by:

In year position Surplus £ 95 k

Historic Brought Deficit (£3,325k) Forward

Reported Position Deficit (£3,230k)

As set out in the 2018/9 NHS Planning Guidance, CCGs were required to hold a

0.5% reserve uncommitted from the start of the year, created by setting aside the

monies that CCGs were otherwise required to spend non-recurrently. This reserve

of £3.5m has been fully utilised in the year supporting activity pressures in the

Acute, Mental Health and Continuing Healthcare sectors.

As above there have been significant pressures in year in the planned and urgent

care sector largely due to expenditure on acute services rising more than

planned. These expenses relate to increased activity in elective, outpatients, non-

elective admissions, critical care and A&E.

There were also increases in expenditure in the area of Continuing Healthcare

placements with additional impact due to the aging population. An increase in

numbers requiring placements and the complexity of their needs resulted in higher

costs of care packages.

Prescribing costs have reduced against plan as a result of the planned growth not

coming to fruition and the delivery of efficiencies. NCSO (No Cheaper Stock

Obtainable) continued to be a pressure which has partly been mitigated by extra

funding from NHS England.

The CCGs again worked on mitigation of financial pressures through the year

e.g. use of non-recurrent gains, to achieve its planned position and receive

Commissioner Sustainability Funding (CSF) to the level of the planned deficit of

£15.5m resulting in an in year surplus of £95k.

The following table compares 2018/19 actual spend to planned spend by service

group:

Page 127

Area Annual Plan Spend Under/Over

2018/19 2018/19 Spend

£000's £000's £000's

Hospitals 355,609 361,753 (6,144)

Community 52,300 52,336 (36)

Mental Health 61,050 62,918 (1,868)

Continuing Healthcare 60,175 62,937 (2,762)

Prescribing 68,429 65,535 2,894

Primary Care Commissioning 67,994 68,443 (449)

Other Primary Care 15,912 14,808 1,104

Running Costs 11,693 10,553 1,140

Other 24,196 17,981 6,215

In Year surplus 0 0 0

Historic B/fwd (3,325) (3,325)

Totals 714,033 717,264 (3,231)

Within the overall position, hospital care overspent by £6,144k (1.7%) which was

largely with the acute hospitals and includes planned, non-planned and emergency

services. Continuing Healthcare Services was overspent by £2,762k (4.6%) as a

result of the aging population requiring more placements and the complexity of

need for those individuals.

Page 128

The CCG complied with the Mental Health Investment Standard (MHIS) for

2018/19, (investment should be greater than programme growth). Programme

growth was 3.1% and actual spend in all Mental Health areas was 4.0%.

The clinical commissioning groups follow the Better Practice Payment Code in

aiming to pay 95% of its creditors within 30 days of receipt of a valid invoice.

For Non NHS suppliers the clinical commissioning groups achieved 91% in

number terms and 87% in value terms, as shown on page 149.

The clinical commissioning group has not signed up to the Better Payments Code.

In 2018/19, the CCGs had a single combined Quality, Innovation, Prevention and

Productivity (QIPP) challenge of £21,435k.

Risks to project delivery were faced due to a range of factors intrinsic to many of

the QIPP schemes. Those dealing with pathway changes and service redesign are

often complex pieces of work, crossing multiple organisational boundaries,

involving a range of stakeholders. Many of the schemes affect contracts which are

activity based – i.e. if the activity keeps flowing in the same way as in the past, and

then the costs will keep being incurred. Monitoring of activity, finance and a range

of quality and efficiency metrics through the year enables us to measure delivery

from month to month, and allow for corrective and mitigating actions to be taken in

year.

The actual performance in 2018/19 was 100% achievement of the £21,435k

QIPP target.

Future Financial Planning:

The financial plans for 2019/20 have been produced, at organisation, ICS and STP

system levels in accordance with the NHS Operational Planning and Contracting

Guidance 2019/20 issued in January 2019 and submitted in accordance with

associated deadlines.

As part of this guidance there is a further requirement to submit 5 year system plans

by the autumn of 2019 and this joint plan is being produced in collaboration with

system partners.

The plans reflect latest NHS England national business rules, population growth,

inflation and strategic changes such as access standards for A&E, Mental Health

and Dementia, sustainability & quality of GP services, reduction in waiting times

and alignment with Sustainability & Transformation Partnerships (STP) plans.

Service Level Agreements have been agreed with local providers which reflect

current working practices and we will work with local partners to control the volume

and type of activity undertaken to reflect the strategic transformation changes such

as care closer to home and a number of community schemes initiatives focussed

on reducing Urgent Care activity.

Page 129

A full set of financial accounts are included within the Annual Report. The Annual

accounts financial tables also include details of:

Assets: NHS Buckinghamshire CCG has £1,386K of tangible or intangible

assets relating to the interoperability and integration project across

Buckinghamshire.

Creditors: Creditor Payments performance where the aim is to pay 95% of

non NHS creditors within 30 days of an agreed invoice. To this end we

achieved a rate of 91% on the number of invoices paid and 87% of the value

of invoices paid.

Cash: the closing cash balance was £10k which compared favourably to

the target of a maximum cash balance of £695k.

Debtors: The CCG has applied the new IFRS standard, IFRS 9, and as the

CCG has minimal Non NHS Debtors there is a small bad debt provision.

Provisions: we have one relating to Continuing Health Care, the estimation

techniques used have been developed on experience and have been agreed

as appropriate with our external auditors. The other relates to restructuring

of outsourced services.

Page 130

FINANCIAL ACCOUNTS

FOR THE PERIOD ENDED 31 MARCH 2019

NHS BUCKINGHAMSHIRE COMMISSIONING GROUP

Financial Information - Accounts Year Ended 31 March 2019

These accounts for the year ended 31st

March 2019 have been prepared by

Buckinghamshire Clinical Commissioning Group under a Direction issued by

the NHS Commissioning Board, now known as NHS England under the National

Health Service Act 2006.

Buckinghamshire Clinical Commissioning Group management have assessed

the entity’s ability to continue as a going concern. The management are not

aware of any material uncertainties related to events or conditions that may cast

significant doubt on the entity’s ability to continue as a going concern.

131

NHS Buckinghamshire Clinical Commissioning Group - Annual Accounts 2018-19

CONTENTS Page Number

The Primary Statements:

Statement of Comprehensive Net Expenditure for the year ended 31st March 2019 136

Statement of Financial Position as at 31st March 2019 137

Statement of Changes in Taxpayers' Equity for the year ended 31st March 2019 138

Statement of Cash Flows for the year ended 31st March 2019 139

Notes to the Accounts Accounting policies Note 1 140

Other operating revenue Note 2 145

Revenue Note 3 145

Employee benefits and staff numbers Note 4 146

Operating expenses Note 5 148

Better payment practice code Note 6 149

Operating leases Note 7 150

Property, plant and equipment Note 8 151

Intangible non-current assets Note 9 152

Inventories Note 10 152

Trade and other receivables Note 11 153

Cash and cash equivalents Note 12 153

Trade and other payables Note 13 154

Provisions Note 14 154

Financial instruments Note 15 155

Operating segments Note 16 157

Joint arrangements - interests in joint operations Note 17 157

Related party transactions Note 18 159

Events after the end of the reporting period Note 19 162

Financial performance targets Note 20 162

Impact of IFRS Note 21 162

132

INDEPENDENT AUDITOR’S REPORT TO THE MEMBERS OF THE GOVERNING BODY OF NHS BUCKINGHAMSHIRE

CLINICAL COMMISSIONING GROUP

Opinion

We have audited the financial statements of NHS Buckinghamshire Clinical Commissioning Group for the year ended 31 March 2019

under the Local Audit and Accountability Act 2014. The financial statements comprise the Statement of Comprehensive Net

Expenditure, the Statement of Financial Position, the Statement of Changes in Taxpayers’ Equity, the Statement of Cash Flows and the

related notes 1 to 21. The financial reporting framework that has been applied in their preparation is applicable law and International

Financial Reporting Standards (IFRSs) as adopted by the European Union, and as interpreted and adapted by the 2018-19 HM

Treasury’s Financial Reporting Manual (the 2018-19 FReM) as contained in the Department of Health and Social Care Group Accounting

Manual 2018/19 and the Accounts Direction issued by the NHS Commissioning Board with the approval of the Secretary of State as

relevant to the National Health Service in England (the Accounts Direction).

In our opinion, the financial statements:

· give a true and fair view of the financial position of NHS Buckinghamshire Clinical Commissioning Group as at 31 March 2019 and of its net operating costs for the year then ended; and · have been properly prepared in accordance with the Health and Social Care Act 2012 and the Accounts Directions issued thereunder.

Basis for opinion

We conducted our audit in accordance with International Standards on Auditing (UK) (ISAs (UK)) and applicable law. Our

responsibilities under those standards are further described in the Auditor’s responsibilities for the audit of the financial statements

section of our report below. We are independent of the clinical commissioning group (CCG) in accordance with the ethical requirements

that are relevant to our audit of the financial statements in the UK, including the FRC’s Ethical Standard and the Comptroller and

Auditor General’s (C&AG) AGN01, and we have fulfilled our other ethical responsibilities in accordance with these requirements.

We believe that the audit evidence we have obtained is sufficient and appropriate to provide a basis for our opinion.

Conclusions relating to going concern

We have nothing to report in respect of the following matters in relation to which the ISAs (UK) require us to report to you where:

· the Accountable Officer’s use of the going concern basis of accounting in the preparation of the financial statements is not appropriate; or · the Accountable Officer has not disclosed in the financial statements any identified material uncertainties that may cast

significant doubt about the Clinical Commissioning Group’s ability to continue to adopt the going concern basis of accounting for a period of at least twelve months from the date when the financial statements are authorised for issue.

Other information

The other information comprises the information included in the annual report set out on pages 1-130, other than the financial statements and our auditor’s report thereon. The Accountable Officer is responsible for the other information.

Our opinion on the financial statements does not cover the other information and, except to the extent otherwise explicitly stated in this report, we do not express any form of assurance conclusion thereon.

In connection with our audit of the financial statements, our responsibility is to read the other information and, in doing so,

consider whether the other information is materially inconsistent with the financial statements or our knowledge obtained in

the audit or otherwise appears to be materially misstated. If we identify such material inconsistencies or apparent material

misstatements, we are required to determine whether there is a material misstatement in the financial statements or a

material misstatement of the other information. If, based on the work we have performed, we conclude that there is a material

misstatement of the other information, we are required to report that fact.

We have nothing to report in this regard.

Opinion on other matters prescribed by the Health and Social Care Act 2012

In our opinion the part of the Remuneration and Staff Report to be audited has been properly prepared in accordance with the Health and Social Care Act 2012 and the Accounts Directions issued thereunder.

133

Matters on which we are required to report by exception

We are required to report to you if:

· in our opinion the governance statement does not comply with the guidance issued by the NHS Commissioning Board; or

·we refer a matter to the Secretary of State under section 30 of the Local Audit and Accountability Act 2014 because we have

reason to believe that the CCG, or an officer of the CCG, is about to make, or has made, a decision which involves or would

involve the body incurring unlawful expenditure, or is about to take, or has begun to take a course of action which, if

followed to its conclusion , would be unlawful and likely to cause a loss or deficiency; or we issue a report in the public

interest under section 24 of the Local Audit and Accountability Act 2014; or · we make a written recommendation to the CCG under section 24 of the Local Audit and Accountability Act 2014; or we are not satisfied that the CCG has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources for the year ended 31 March 2019.

We have nothing to report in these respects.

Responsibilities of the Accountable Officer

As explained more fully in the Statement of Accountable Officer’s Responsibilities set out on page 113, the Accountable Officer is responsible for the preparation of the financial statements and for being satisfied that they give a true and fair view

and is also responsible for ensuring the regularity of expenditure and income.

In preparing the financial statements, the Accountable Officer is responsible for assessing the Clinical Commissioning Group’s ability

to continue as a going concern, disclosing, as applicable, matters related to going concern and using the going concern basis of

accounting unless the Accountable Officer either intends to cease operations, or have no realistic alternative but to do so.

As explained in the Annual Governance Statement the Accountable officer is responsible for the arrangements to secure

economy, efficiency and effectiveness in the use of the CCG's resources. We are required under Section 21(1)(c) of the Local

Audit and Accountability Act 2014 to be satisfied that the CCG has made proper arrangements for securing economy,

efficiency and effectiveness in its use of resources. Section 21(5)(b) of the Local Audit and Accountability Act 2014 requires

that our report must not contain our opinion if we are satisfied that proper arrangements are in place.

Auditor’s responsibilities for the audit of the financial statements

Our objectives are to obtain reasonable assurance about whether the financial statements as a whole are free from material

misstatement, whether due to fraud or error, and to issue an auditor’s report that includes our opinion. Reasonable assurance is a high

level of assurance, but is not a guarantee that an audit conducted in accordance with ISAs (UK) will always detect a material

misstatement when it exists. Misstatements can arise from fraud or error and are considered material if, individually or in the aggregate,

they could reasonably be expected to influence the economic decisions of users taken on the basis of these financial statements.

A further description of our responsibilities for the audit of the financial statements is located on the Financial Reporting Council’s website at https://www.frc.org.uk/auditorsresponsibilities. This description forms part of our auditor’s report.

Scope of the review of arrangements for securing economy, efficiency and effectiveness in the use of resources

We have undertaken our review in accordance with the Code of Audit Practice, having regard to the guidance on the

specified criterion issued by the Comptroller and Auditor General in November 2017, as to whether the CCG had proper

arrangements to ensure it took properly informed decisions and deployed resources to achieve planned and sustainable

outcomes for taxpayers and local people. The Comptroller and Auditor General determined this criterion as that necessary

for us to consider under the Code of Audit Practice in satisfying ourselves whether the CCG put in place proper

arrangements for securing economy, efficiency and effectiveness in its use of resources for the year ended 31 March 2019.

We planned our work in accordance with the Code of Audit Practice. Based on our risk assessment, we undertook such

work as we considered necessary to form a view on whether, in all significant respects, the CCG had put in place proper

arrangements to secure economy, efficiency and effectiveness in its use of resources.

We are required under Section 21(1)(c) of the Local Audit and Accountability Act 2014 to be satisfied that the CCG has made proper

arrangements for securing economy, efficiency and effectiveness in its use of resources. Section 21(5)(b) of the Local Audit and

Accountability Act 2014 requires that our report must not contain our opinion if we are satisfied that proper arrangements are in place.

We are not required to consider, nor have we considered, whether all aspects of the CCG’s arrangements for securing economy, efficiency and effectiveness in its use of resources are operating effectively.

134

Report on Other Legal and Regulatory Requirements

Regularity opinion

We are responsible for giving an opinion on the regularity of expenditure and income in accordance with the Code of Audit Practice prepared by

the Comptroller and Auditor General as required by the Local Audit and Accountability Act 2014 (the "Code of Audit Practice").

We are required to obtain evidence sufficient to give reasonable assurance that the expenditure and income recorded in

the financial statements have been applied to the purposes intended by Parliament and the financial transactions conform to the authorities which govern them.

In our opinion, in all material respects the expenditure and income reflected in the financial statements have been applied to the purposes intended by Parliament and the financial transactions conform to the authorities which govern them.

Certificate

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

Janet Dawson (Key Audit Partner) Ernst & Young LLP (Local Auditor) Reading 24 May 2019

The maintenance and integrity of the NHS Buckinghamshire Clinical Commissioning Group web site is the responsibility of the members; the

work carried out by the auditors does not involve consideration of these matters and, accordingly, the auditors accept no responsibility for any

changes that may have occurred to the financial statements since they were initially presented on the web site. Legislation in the United

Kingdom governing the preparation and dissemination of financial statements may differ from legislation in other jurisdictions.

135


Statement of Comprehensive Net Expenditure for the year ended 31 March 2019

2018-19 2017-18

Note £'000 £'000

Income from sale of goods and services 2 (494) (50)

Other operating income 2 (3,467) (2,964)

Total operating income (3,961) (3,014)

Staff costs 4 5,891 5,326

Purchase of goods and services 5 714,150 696,793

Depreciation and impairment charges 5 524 411

Provision expense 5 257 (112)

Other Operating Expenditure 5 402 212

Total operating expenditure 721,224 702,630

Net Operating Expenditure 717,263 699,616

Total Net Expenditure for the Financial Year 717,263 699,616

Comprehensive Expenditure for the year 717,263 699,616

The notes on pages 140 to 162 form part of this statement Throughout these Financial Statements and Notes the 2017-18 comparables relate to the sum of the preceding

organisations in Buckinghamshire - NHS Aylesbury Vale and NHS Chiltern Clinical Commissioning Groups who merged

from 1st April 2018 to form NHS Buckinghamshire Clinical Commissioning Group.

136


Statement of Financial Position as at 31 March 2019

2018-19 2017-18

Note £'000 £'000

Non-current assets:

Property, plant and equipment 8 1,139 1,425

Intangible assets 9 248 381

Total non-current assets 1,387 1,806

Current assets: Inventories 10 927 0

Trade and other receivables 11 7,547 27,041

Cash and cash equivalents 12 10 20

Total current assets 8,484 27,061

Total current assets 8,484 27,061

Total assets 9,871 28,867

Current liabilities Trade and other payables 13 (53,073) (73,219)

Provisions 14 (551) (293)

Total current liabilities (53,624) (73,512)

Non-Current Assets plus/less Net Current Assets/Liabilities (43,753) (44,645)

Non-current liabilities Provisions 14 (67) (67)

Total non-current liabilities (67) (67)

Assets less Liabilities (43,820) (44,712)

Financed by Taxpayers’ Equity General fund (43,820) (44,712)

Total taxpayers' equity: (43,820) (44,712) The notes on pages 140 to 162 form part of this statement

The financial statements on pages 136 to 139 were approved by the Governing Body on 22nd May 2019 and signed on its behalf by: Louise Patten Gary Heneage Chief Officer and Accountable Officer Chief Finance Officer

137

31 March 2019

Total

General fund reserves

£'000 £'000

Changes in taxpayers’ equity for 2018-19

Balance at 01 April 2018 (44,712) (44,712)

Adjusted NHS Clinical Commissioning Group balance at 31 March 2018 (44,712) (44,712)

Changes in NHS Clinical Commissioning Group taxpayers’ equity for 2018-19 Net operating expenditure for the financial year (717,263) (717,263)

Net funding 718,155 718,155

Balance at 31 March 2019 (43,820) (43,820)

Total

General fund reserves

£'000 £'000

Changes in taxpayers’ equity for 2017-18

Balance at 01 April 2017 (34,426) (34,426)

Adjusted NHS Clinical Commissioning Group balance at 31 March 2018 (34,426) (34,426)

Changes in NHS Clinical Commissioning Group taxpayers’ equity for 2017-18 Net operating costs for the financial year (699,616) (699,616)

Net funding 689,330 689,330

Balance at 31 March 2018 (44,712) (44,712)

The notes on pages 140 to 162 form part of this statement

138


Statement of Cash Flows for the year ended 31 March 2019

2018-19 2017-18

Note £'000 £'000

Cash Flows from Operating Activities

Net operating expenditure for the financial year (717,263) (699,616)

Depreciation and amortisation 5 524 409

(Increase)/decrease in inventories 10 (927) 0

(Increase)/decrease in trade & other receivables 11 19,494 (14,780)

Increase/(decrease) in trade & other payables 13 (20,218) 25,550

Increase/(decrease) in provisions 14 258 (112)

Net Cash Inflow (Outflow) from Operating Activities (718,132) (688,549)

Cash Flows from Investing Activities (Payments) for property, plant and equipment (14) (794)

(Payments) for intangible assets (19) 0

Net Cash Inflow (Outflow) from Investing Activities (33) (794)

Net Cash Inflow (Outflow) before Financing (718,165) (689,343)

Cash Flows from Financing Activities Grant in Aid Funding Received 718,155 689,330

Net Cash Inflow (Outflow) from Financing Activities 718,155 689,330

Net Increase (Decrease) in Cash & Cash Equivalents 12 (10) (13)

Cash & Cash Equivalents at the Beginning of the Financial Year 20 33

Cash & Cash Equivalents (including bank overdrafts) at the End of the Financial Year 10 20

The notes on pages 140 to 162 form part of this statement

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Notes to the financial statements

1 Accounting Policies

NHS England has directed that the financial statements of Clinical Commissioning Groups shall meet the accounting requirements of the Group

Accounting Manual issued by the Department of Health and Social Care. Consequently, the following financial statements have been prepared in

accordance with the Group Accounting Manual 2018-19 issued by the Department of Health and Social Care. The accounting policies contained in the

Group Accounting Manual follow International Financial Reporting Standards to the extent that they are meaningful and appropriate to Clinical

Commissioning Groups, as determined by HM Treasury, which is advised by the Financial Reporting Advisory Board. Where the Group Accounting

Manual permits a choice of accounting policy, the accounting policy which is judged to be most appropriate to the particular circumstances of the

Clinical Commissioning Group for the purpose of giving a true and fair view has been selected. The particular policies adopted by the Clinical

Commissioning Group are described below. They have been applied consistently in dealing with items considered material in relation to the accounts.

1.1 Going Concern

These accounts have been prepared on a going concern basis.

Public sector bodies are assumed to be going concerns where the continuation of the provision of a service in the future is anticipated, as

evidenced by inclusion of financial provision for that service in published documents.

Where a Clinical Commissioning Group ceases to exist, it considers whether or not its services will continue to be provided (using the

same assets, by another public sector entity) in determining whether to use the concept of going concern for the final set of financial

statements. If services will continue to be provided the financial statements are prepared on the going concern basis.

1.2 Accounting Convention

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

1.3 Movement of Assets within the Department of Health and Social Care Group

Transfers as part of reorganisation fall to be accounted for by use of absorption accounting in line with the Government Financial Reporting Manual, issued by HM

Treasury. The Government Financial Reporting Manual does not require retrospective adoption, so prior year transactions (which have been accounted for under

merger accounting) have not been restated. Absorption accounting requires that entities account for their transactions in the period in which they took place, with

no restatement of performance required when functions transfer within the public sector. Where assets and liabilities transfer, the gain or loss resulting is

recognised in the Statement of Comprehensive Net Expenditure, and is disclosed separately from operating costs.

Other transfers of assets and liabilities within the Department of Health and Social Care Group are accounted for in line with IAS 20 and similarly give rise to income and expenditure entries.

1.4 Pooled Budgets

The Clinical Commissioning Group has entered into a pooled budget arrangements with Buckinghamshire County Council in accordance

with section 75 of the NHS Act 2006. Under the arrangement, funds are pooled for the provision of health and social care services and Note

17 provides details of the income and expenditure.

· The assets the Clinical Commissioning Group controls;

· The liabilities the Clinical Commissioning Group incurs;

· The expenses the Clinical Commissioning Group incurs; and, · The Clinical Commissioning Group’s share of the income from the pooled budget activities.

The pools are hosted by Buckinghamshire County Council. The Clinical Commissioning Group accounts for its share of income and

expenditure arising from the activities of the pooled budget, identified in accordance with the pooled budget agreement.

1.5 Revenue

The transition to IFRS 15 has been completed in accordance with paragraph C3 (b) of the Standard, applying the Standard retrospectively

recognising the cumulative effects at the date of initial application.

In the adoption of IFRS 15 a number of practical expedients offered in the Standard have been employed. These are as follows:

• As per paragraph 121 of the Standard the Clinical Commissioning Group will not disclose information regarding performance

obligations part of a contract that has an original expected duration of one year or less,

• The Clinical Commissioning Group is to similarly not disclose information where revenue is recognised in line with the practical expedient

offered in paragraph B16 of the Standard where the right to consideration corresponds directly with value of the performance completed to date.

• The FReM has mandated the exercise of the practical expedient offered in C7(a) of the Standard that requires the Clinical

Commissioning Group to reflect the aggregate effect of all contracts modified before the date of initial application.

Payment terms are standard reflecting cross government principles. There are no significant terms agreed.

The value of the benefit received when the Clinical Commissioning Group accesses funds from the Government’s apprenticeship service are

recognised as income in accordance with IAS 20, Accounting for Government Grants. Where these funds are paid directly to an accredited training

provider, non-cash income and a corresponding non-cash training expense are recognised, both equal to the cost of the training funded.

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1.6 Employee Benefits

1.6.1 Short-term Employee Benefits

Salaries, wages and employment-related payments, including payments arising from the apprenticeship levy, are recognised in the period in which the service is received from employees, including bonuses earned but not yet taken.

The cost of leave earned but not taken by employees at the end of the period is recognised in the financial statements to the extent that employees are permitted to carry forward leave into the following period.

1.6.2 Retirement Benefit Costs

Past and present employees are covered by the provisions of the NHS Pensions Schemes. These schemes are unfunded, defined benefit

schemes that cover NHS employers, General Practices and other bodies allowed under the direction of the Secretary of State in England and

Wales. The schemes are not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme

assets and liabilities. Therefore, the schemes are accounted for as though they were defined contribution schemes: the cost to the Clinical

Commissioning Group of participating in a scheme is taken as equal to the contributions payable to the scheme for the accounting period.

For early retirements other than those due to ill health the additional pension liabilities are not funded by the scheme. The full amount of the

liability for the additional costs is charged to expenditure at the time the Clinical Commissioning Group commits itself to the retirement,

regardless of the method of payment.

1.7 Other Expenses

Other operating expenses are recognised when, and to the extent that, the goods or services have been received. They are measured at the fair value of the consideration payable.

1.8 Equipment

1.8.1 Recognition

Equipment is capitalised if:

· It is held for use in delivering services or for administrative purposes;

· It is probable that future economic benefits will flow to, or service potential will be supplied to the Clinical Commissioning Group;

· It is expected to be used for more than one financial year; · The cost of the item can be measured reliably; and,

· The item has a cost of at least £5,000; or, · Collectively, a number of items have a cost of at least £5,000 and individually have a cost of more than £250, where the assets are

functionally interdependent, they had broadly simultaneous purchase dates, are anticipated to have simultaneous disposal dates and are

under single managerial control; or, · Items form part of the initial equipping and setting-up cost of a new building, ward or unit, irrespective of their individual or collective cost.

1.8.2 Measurement

All equipment is measured initially at cost, representing the cost directly attributable to acquiring or constructing the asset and bringing it

to the location and condition necessary for it to be capable of operating in the manner intended by management.

Assets that are held for their service potential and are in use are measured subsequently at their current value in existing use. Assets that

were most recently held for their service potential but are surplus are measured at fair value where there are no restrictions preventing

access to the market at the reporting date

IT equipment, transport equipment, furniture and fittings, and plant and machinery that are held for operational use are valued at

depreciated historic cost where these assets have short useful economic lives or low values or both, as this is not considered to be

materially different from current value in existing use.

1.8.3 Subsequent Expenditure

Where subsequent expenditure enhances an asset beyond its original specification, the directly attributable cost is capitalised. Where

subsequent expenditure restores the asset to its original specification, the expenditure is capitalised and any existing carrying value of the

item replaced is written-out and charged to operating expenses.

1.9 Intangible Assets

1.9.1 Recognition

Intangible assets are non-monetary assets without physical substance, which are capable of sale separately from the rest of the Clinical Commissioning Group’s business or which arise from contractual or other legal rights. They are recognised only: · When it is probable that future economic benefits will flow to, or service potential be provided to, the Clinical Commissioning Group;

· Where the cost of the asset can be measured reliably; and,

· Where the cost is at least £5,000. Intangible assets acquired separately are initially recognised at fair value. Software that is integral to the operating of hardware, for example

an operating system, is capitalised as part of the relevant item of equipment. Software that is not integral to the operation of hardware, for

example application software, is capitalised as an intangible asset. Expenditure on research is not capitalised but is recognised as an

operating expense in the period in which it is incurred.

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1.9.2 Measurement

Intangible assets acquired separately are intially recognised at cost. The amount initially recognised for internally-generated intangible

assets is the sum of the expenditure incurred from the date when the criteria above are initially met. Where no internally-generated

intangible asset can be recognised, the expenditure is recognised in the period in which it is incurred.

Following initial recognition, intangible assets are carried at current value in existing use by reference to an active market, or, where no

active market exists, at the lower of amortised replacement cost or the value in use where the asset is income generating .

1.9.3 Depreciation, Amortisation & Impairments

Depreciation and amortisation are charged to write off the costs of 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.

At each reporting period end, the Clinical Commissioning Group checks whether there is any indication that any of its equipment assets 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.

1.10 Leases

Leases are classified as finance leases when substantially all the risks and rewards of ownership are transferred to the lessee. All other leases are classified as operating leases. The Clinical Commissioning Group has no finance leases.

1.11 Inventories

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

1.12 Cash & Cash Equivalents

Cash is cash in hand and deposits with any financial institution repayable without penalty on notice of not more than 24 hours. Cash

equivalents are investments that mature in 3 months or less from the date of acquisition and that are readily convertible to known amounts

of cash with insignificant risk of change in value.

In the Statement of Cash Flows, cash and cash equivalents are shown net of bank overdrafts that are repayable on demand and that form an integral part of the Clinical Commissioning Group’s cash management.

1.13 Provisions

Provisions are recognised when the Clinical Commissioning Group has a present legal or constructive obligation as a result of a past event,

it is probable that the Clinical Commissioning Group will be required to settle the obligation, and a reliable estimate can be made of the

amount of the obligation. The amount recognised as a provision is the best estimate of the expenditure required to settle the obligation at

the end of the reporting period, taking into account the risks and uncertainties. Where a provision is measured using the cash flows

estimated to settle the obligation, its carrying amount is the present value of those cash flows using HM Treasury’s discount rate as follows:

• A nominal short-term rate of 0.76% (2017-18: negative 2.42% in real terms) for inflation adjusted expected cash flows up to and including 5 years from Statement of Financial Position date. • A nominal medium-term rate of 1.14% (2017-18: negative 1.85% in real terms) for inflation adjusted expected cash flows over 5 years up to and including 10 years from the Statement of Financial Position date. • A nominal long-term rate of 1.99% (2017-18: negative 1.56% in real terms) for inflation adjusted expected cash flows over 10 years and up to and including 40 years from the Statement of Financial Position date. • A nominal very long-term rate of 1.99% (2017-18: negative 1.56% in real terms) for inflation adjusted expected cash flows exceeding 40 years from the Statement of Financial Position date.

All 2018-19 percentages are expressed in nominal terms with 2017-18 being the last financial year that HM Treasury provided real general provision discount rates.

When some or all of the economic benefits required to settle a provision are expected to be recovered from a third party, the receivable is recognised

as an asset if it is virtually certain that reimbursements will be received and the amount of the receivable can be measured reliably.

A restructuring provision is recognised when the Clinical Commissioning Group has developed a detailed formal plan for the restructuring and has

raised a valid expectation in those affected that it will carry out the restructuring by starting to implement the plan or announcing its main features to

those affected by it. The measurement of a restructuring provision includes only the direct expenditures arising from the restructuring, which are

those amounts that are both necessarily entailed by the restructuring and not associated with on-going activities of the entity.

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1.14 Clinical Negligence Costs

NHS Resolution operates a risk pooling scheme under which the Clinical Commissioning Group pays an annual contribution to NHS

Resolution, which in return settles all clinical negligence claims. The contribution is charged to expenditure. Although NHS Resolution is

administratively responsible for all clinical negligence cases, the legal liability remains with Clinical Commissioning Group.

1.15 Non-clinical Risk Pooling

The Clinical Commissioning Group participates in the Property Expenses Scheme and the Liabilities to Third Parties Scheme. Both are risk

pooling schemes under which the Clinical Commissioning Group pays an annual contribution to the NHS Resolution and, in return,

receives assistance with the costs of claims arising. The annual membership contributions, and any excesses payable in respect of

particular claims are charged to operating expenses as and when they become due.

1.16 Financial Assets

Financial assets are recognised when the Clinical Commissioning Group becomes party to the financial instrument contract or, in the

case of trade receivables, when the goods or 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 amortised cost;

The classification is determined by the cash flow and business model characteristics of the financial assets, as set out in IFRS 9, and is determined at the time of initial recognition.

1.17 Financial Liabilities

Financial liabilities are recognised on the statement of financial position when the Clinical Commissioning Group becomes party to the

contractual provisions of the financial instrument or, in the case of trade payables, when the goods or services have been received. Financial

liabilities are de-recognised when the liability has been discharged, that is, the liability has been paid or has expired.

1.17.1 Financial Liabilities at Fair Value Through Profit and Loss

Embedded derivatives that have different risks and characteristics to their host contracts, and contracts with embedded derivatives whose separate

value cannot be ascertained, are treated as financial liabilities at fair value through profit and loss. They are held at fair value, with any resultant gain or

loss recognised in the Clinical Commissioning Group’s surplus/deficit. The net gain or loss incorporates any interest payable on the financial liability.

1.17.2 Other Financial Liabilities

After initial recognition, all other financial liabilities are measured at amortised cost using the effective interest method, except for loans from Department of Health

and Social Care, which are carried at historic cost. The effective interest rate is the rate that exactly discounts estimated future cash payments through the life of

the asset, to the net carrying amount of the financial liability. Interest is recognised using the effective interest method.

1.18 Value Added Tax

Most of the activities of the Clinical Commissioning Group are outside the scope of VAT and, in general, output tax does not apply and

input tax on purchases is not recoverable. Irrecoverable VAT is charged to the relevant expenditure category or included in the

capitalised purchase cost of fixed assets. Where output tax is charged or input VAT is recoverable, the amounts are stated net of VAT.

1.19 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).

1.20 Critical accounting judgements and key sources of estimation uncertainty

In the application of the Clinical Commissioning Group’s accounting policies, management is required to make judgements, estimates and assumptions about the

carrying amounts of assets and liabilities that are not readily apparent from other sources. The estimates and associated assumptions are based on historical

experience and other factors that are considered to be relevant. Actual results may differ from those estimates and the estimates and underlying assumptions are

continually reviewed. Revisions to accounting estimates are recognised in the period in which the estimate is revised if the revision affects only that period or in

the period of the revision and future periods if the revision affects both current and future periods.

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1.20.1 Critical accounting judgements in applying accounting policies

The following are the critical judgements, apart from those involving estimations (see below) that management has made in the process of applying the Clinical Commissioning Group’s accounting policies that have the most significant effect on the amounts recognised in the financial statements: · The Clinical Commissioning Group generates provisions to cover future liabilities of more than one year. These provisions are estimated by management based on knowledge of the business, assumptions of probability and are reviewed on an annual basis. · The Provision relates to Continuing Healthcare claims that have to be assessed. There is a potential uncertainty in respect of

the number of successful claims resulting in financial cost. Actual claims settled may differ from those calculated.

1.20.2 Sources of estimation uncertainty

The following are the key estimations that management has made in the process of applying the Clinical Commissioning Group’s accounting policies that have the most significant effect on the amounts recognised in the financial statements: · Accruals are calculated utilising management knowledge, market intelligence and contractual arrangements. These accruals cover

areas such as prescribing and contracts for healthcare including partially completed spells, maternity pathway elements and non healthcare

services. Actual results may differ from those calculated.

1.21 Accounting Standards That Have Been Issued But Have Not Yet Been Adopted

The DHSC GAM does not require the following IFRS Standards and Interpretations to be applied in 2018-19. These Standards are still

subject to HM Treasury FReM adoption, with IFRS 16 being for implementation in 2019-20, and the government implementation date for

IFRS 17 still subject to HM Treasury consideration. ● IFRS 16 Leases – Application required for accounting periods has been deferred and not yet adopted by the FReM: early adoption is not therefore permitted. ● IFRS 17 Insurance Contracts – Application required for accounting periods beginning on or after 1 January 2021, but not yet adopted by the FReM: early adoption is not therefore permitted. ● IFRIC 23 Uncertainty over Income Tax Treatments – Application required for accounting periods beginning on or after 1 January 2019.

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2 Other Operating Revenue 2018-19 2017-18

Total Total

£'000 £'000

Income from sale of goods and services (contracts) Non-patient care services to other bodies 494 50

Total Income from sale of goods and services 494 50

Other operating income Other non contract revenue 3,467 2,964

Total Other operating income 3,467 2,964

Total Operating Income 3,961 3,014

Revenue in this note does not include cash received from NHS England which is drawn down directly

into the bank account of the Clinical Commissioning Group and credited to the General Fund.

The Clinical Commissioning Group has no other revenue from that of the supply of services.

3.1 Disaggregation of Income - Income from sale of good and services (contracts)

Non-patient

care services to

other bodies

£'000

Source of Revenue

Non NHS 494

Total 494

Non-patient

care services to

other bodies

£'000

Timing of Revenue

Point in time 494

Over time 0

Total 494

3.2 Transaction price to remaining contract performance obligations

The Clinical commissioning Group has no Contract revenue expected to be

recognised in the future periods related to contract performance

obligations not yet completed at the reporting date

145


4. Employee benefits and staff numbers

4.1.1 Employee benefits Total 2018-19

Permanent Employees Other Total

£'000 £'000 £'000

Employee Benefits

Salaries and wages 4,768 73 4,841

Social security costs 504 0 504

Employer Contributions to NHS Pension scheme 539 0 539

Apprenticeship Levy 7 0 7

Gross employee benefits expenditure 5,818 73 5,891

Total - Net admin employee benefits including capitalised costs 5,818 73 5,891

Less: Employee costs capitalised 0 0 0

Net employee benefits excluding capitalised costs 5,818 73 5,891

4.1.1 Employee benefits Total 2017-18

Permanent Employees Other Total

£'000 £'000 £'000

Employee Benefits

Salaries and wages 3,998 307 4,305

Social security costs 470 0 470

Employer Contributions to NHS Pension scheme 545 0 545

Apprenticeship Levy 6 0 6

Gross employee benefits expenditure 5,019 307 5,326

Less recoveries in respect of employee benefits (note 4.1.2) 0 0 0

Total - Net admin employee benefits including capitalised costs 5,019 307 5,326

Less: Employee costs capitalised 0 0 0

Net employee benefits excluding capitalised costs 5,019 307 5,326 Note:

Employee Benefits is shown net of recharges covering: 1) Recharge of a proportion of the Chief Officers employee benefits to NHS Oxfordshire Clinical Commissioning Group 2) Recharge of staff member on secondment to NHS England 3) Recharge of staff members to NHS Oxfordshire Clinical Group who host the Buckinghamshire,

Oxfordshire and Berkshire West Sustainability and Transformation Partnership (STP)

146


4.2 Average number of people employed

2018-19 2017-18 Permanently Permanently

employed Other Total employed Other Total Number Number Number Number Number Number

Total 79.10 1.42 80.52 79.89 2.39 82.28

The Clinical Commissioning Group has no whole time equivalent people engaged on capital projects in 2018-19

The Clinical Commissioning Group has not had any Exit packages in 2018-19 nor in 2017-18.

4.3 Pension costs

Past and present employees are covered by the provisions of the two NHS Pension Schemes. Details of the benefits payable and rules of the Schemes can be

found on the NHS Pensions website at www.nhsbsa.nhs.uk/pensions. Both are unfunded defined benefit schemes that cover NHS employers, GP practices and

other bodies, allowed under the direction of the Secretary of State for Health in England and Wales. They are not designed to be run in a way that would enable

NHS bodies to identify their share of the underlying scheme assets and liabilities. Therefore, each scheme is accounted for as if it were a defined contribution

scheme: the cost to the NHS body of participating in each scheme is taken as equal to the contributions payable to that scheme for the accounting period.

In order that the defined benefit obligations recognised in the financial statements do not differ materially from those that would be determined at the reporting

date by a formal actuarial valuation, the FReM requires that “the period between formal valuations shall be four years, with approximate assessments in

intervening years”. An outline of these follows:

4.3.1 Accounting valuation

A valuation of scheme liability is carried out annually by the scheme actuary (currently the Government Actuary’s Department) as at the end of the reporting

period. This utilises an actuarial assessment for the previous accounting period in conjunction with updated membership and financial data for the current

reporting period, and is accepted as providing suitably robust figures for financial reporting purposes. The valuation of the scheme liability as at 31 March 2019,

is based on valuation data as 31 March 2018, updated to 31 March 2019 with summary global member and accounting data. In undertaking this actuarial

assessment, the methodology prescribed in IAS 19, relevant FReM interpretations, and the discount rate prescribed by HM Treasury have also been used.

The latest assessment of the liabilities of the scheme is contained in the report of the scheme actuary, which forms part of the annual NHS Pension Scheme

Accounts. These accounts can be viewed on the NHS Pensions website and are published annually. Copies can also be obtained from The Stationery Office.

4.3.2 Full actuarial (funding) valuation

The purpose of this valuation is to assess the level of liability in respect of the benefits due under the schemes (taking into account recent demographic

experience), and to recommend contribution rates payable by employees and employers.

The latest actuarial valuation undertaken for the NHS Pension Scheme was completed as at 31 March 2016. The results of this valuation set the employer

contribution rate payable from April 2019. The Department of Health and Social Care have recently laid Scheme Regulations confirming that the employer

contribution rate will increase to 20.6% of pensionable pay from this date.

The 2016 funding valuation was also expected to test the cost of the Scheme relative to the employer cost cap set following the 2012 valuation. Following a judgment from the

Court of Appeal in December 2018 Government announced a pause to that part of the valuation process pending conclusion of the continuing legal process.

For 2018-19, employers’ contributions of £539k were payable to the NHS Pensions Scheme (2017-18: £545k) were payable to the NHS Pension Scheme at the rate

of 14.38% of pensionable pay. The scheme’s actuary reviews employer contributions, usually every four years and now based on HMT Valuation Directions,

following a full scheme valuation. The latest review used data from 31 March 2012 and was published on the Government website on 9 June 2012.

147


5. Operating expenses 2018-19 2017-18

Total Total

£'000 £'000

Purchase of goods and services Services from other CCGs and NHS England 5,552 7,918

Services from foundation trusts 183,386 171,711

Services from other NHS trusts 270,240 258,796

Services from Other WGA bodies - 1

Purchase of healthcare from non-NHS bodies 113,306 121,219

Prescribing costs 64,346 63,976

General Ophthalmic services 33 32

GPMS/APMS and PCTMS 74,233 69,666

Supplies and services – clinical 38 98

Supplies and services – general 926 1,351

Consultancy services 500 583

Establishment 445 503

Transport 3 1

Premises 309 347

Audit fees 102 114

Other non statutory audit expenditure

· Internal audit services 49 49

· Other services 30 6

Other professional fees 473 53

Legal fees 162 307

Education, training and conferences 17 62

Total Purchase of goods and services 714,150 696,793

Depreciation and impairment charges Depreciation 372 296

Amortisation 152 115

Total Depreciation and impairment charges 524 411

Provision expense Provisions 257 (112)

Total Provision expense 257 (112)

Other Operating Expenditure Chair and Non Executive Members 247 202

Other expenditure 155 10

Total Other Operating Expenditure 402 212

Total operating expenditure 715,333 697,304

148


6 Better Payment Practice Code

Measure of compliance 2018-19 2018-19 2017-18 2017-18

Number £'000 Number £'000

Non-NHS Payables

Total Non-NHS Trade invoices paid in the Year 10,856 108,051 12,944 124,402

Total Non-NHS Trade Invoices paid within target 9,880 93,723 11,992 117,978

Percentage of Non-NHS Trade invoices paid within target 91.01% 86.74% 92.65% 94.84%

NHS Payables Total NHS Trade Invoices Paid in the Year 4,061 441,150 5,409 392,312

Total NHS Trade Invoices Paid within target 3,951 437,166 5,200 388,460

Percentage of NHS Trade Invoices paid within target 97.29% 99.10% 96.14% 99.02%

The Better Payment Practice Code requires the Clinical Commissioning Group to aim to pay 95% of all valid invoices by the due date or

within 30 days of receipt of an invoice, whichever is later.

149


7. Operating Leases

7.1 As lessee 7.1.1 Payments recognised as an Expense 2018-19 2017-18

Buildings Other Total Buildings Other Total

£'000 £'000 £'000 £'000 £'000 £'000

Payments recognised as an expense

Minimum lease payments 219 5 224 282 1 283

Total 219 5 224 282 1 283 The Clinical Commissioning Group occupies and pays rent on offices located at Amersham Hospital and at Aylesbury Vale District Council. The

rent is paid to Buckinghamshire Healthcare Trust and NHS Property Services limited respectively. Under paragraph 9 of IFRIC4 these arrangements

are a lease and as such accounted for in accordance with IAS17. Payments is respect of these arrangements for 2018-19 are disclosed above. At

present the CCG hasn't a signed contract for Amersham Hospital and in the absence of a formal contract it is not possible to quantify the future

lease payments. With regard to the lease with NHS Property Services this ends in January 2020.

7.1.2 Future minimum lease payments 2018-19 2017-18

Buildings Other Total Buildings Other Total

£'000 £'000 £'000 £'000 £'000 £'000

Payable:

No later than one year 75 - 75 52 - 52

Between one and five years - - - 43 - 43

After five years - - - - - -

Total 75 - 75 95 - 95

150


8 Property, plant and equipment

Information Furniture &

2018-19 technology fittings Total

£'000 £'000 £'000

Cost or valuation at 01 April 2018 1,986 46 2,032

Additions purchased 86 - 86

Cost/Valuation at 31 March 2019 2,072 46 2,118

Depreciation 01 April 2018 604 3 607

Charged during the year 370 2 372

Depreciation at 31 March 2019 974 5 979

Net Book Value at 31 March 2019 1,098 40 1,139

Purchased 1,099 40 1,139

Total at 31 March 2019 1,099 40 1,139

Asset financing:

Owned 1,099 40 1,139

Total at 31 March 2019 1,099 40 1,139

The IT assets relate to the following projects:

The Clinical Commissioning Group has purchased Tangible IT assets required by the Interoperability and Integration project including Digital Life Sciences

and Airedale projects which is a Buckinghamshire wide project to enable IT to

8.1 Economic lives Minimum Life Maximum Life

(years) (Years)

Information technology 2 5

Furniture & fittings 5 10

151


9 Intangible non-current assets

Computer Software:

2018-19 Purchased Total

£'000 £'000

Cost or valuation at 01 April 2018 627 627

Additions purchased 19 19

Cost / Valuation At 31 March 2019 646 646

Amortisation 01 April 2018 246 246

Charged during the year 152 152

Amortisation At 31 March 2019 398 398

Net Book Value at 31 March 2019 248 248

Purchased 248 248

Total at 31 March 2019 248 248 The Clinical Commissioning Group has purchased Tangible IT assets required by the Interoperability and Integration

project including Digital Life Sciences and Airdale projects which is a Buckinghamshire wide project to enable IT to

9.1 Economic lives Minimum Life Maximum Life

(years) (Years)

2 5

Computer software: purchased

10 Inventories

Consumables Total £'000 £'000

Balance at 01 April 2018 0 0

Additions 927 927

Balance at 31 March 2019 927 927

Inventories relate to equipment that is out in the Community being used by the patients to aid recovery

from illness or to improve their lives.

The stock value will be reassessed each financial year.

152


11.1 Trade and other receivables Current Non-current Current Non-current

2018-19 2018-19 2017-18 2017-18

£'000 £'000 £'000 £'000

NHS receivables: Revenue 1,734 0 4,223 0

NHS prepayments 1,526 0 1,580 0

NHS accrued income 1,314 0 8,726 0

NHS Non Contract trade receivable (i.e pass through funding) 1,364 0 0 0

Non-NHS and Other WGA receivables: Revenue 954 0 386 0

Non-NHS and Other WGA prepayments 535 0 1,029 0

Non-NHS and Other WGA accrued income 103 0 10,331 0

Expected credit loss allowance-receivables (17) 0 (17) 0

VAT 34 0 340 0

Other receivables and accruals 0 0 443 0

Total Trade & other receivables 7,547 0 27,041 0

Total current and non current 7,547 27,041

Included above: Prepaid pensions contributions 0 0

The great majority of trade is with NHS organisations and Local Governmentorganisations. As NHS organistions and Local Government organisations are funded by

Government to provide funding to Clinical Commissioning Groups to commission services no credit scoring of them is considered necessary.

The 2017-18 comparable figures include £8.7m relating to Inter CCG trading between the preceding organisations This trading relates to a risk share agreement in place between the two

organisations based on the revenue resource limit at the start of 17/18. The majority of the risk share relates to staff costs and joint care (including Continuing Healthcare costs) hosted by

Chiltern Clinical Commissioning Group. These charges are included in NHS receiveables and are contra'd with items shown within the Creditors Note 13.

11.2 Receivables past their due date but not impaired

2018-19 2018-19 2017-18 2017-18

DHSC Group Non DHSC DHSC Group Non DHSC

Bodies Group Bodies Bodies Group Bodies

£'000 £'000 £'000 £'000

By up to three months 1,752 387 1,201 194

By three to six months 0 0 0 9

By more than six months 10 26 17 1

Total 1,762 413 1,218 204

11.3 Impact of Application of IFRS 9 on financial assests at 1 April 2018

There is no material impact on the application of IFRS9 on the Clinical Commissionings Groups accounts.

12 Cash and cash equivalents

2018-19 2017-18

£'000 £'000

Balance at 01 April 2018 20 33

Net change in year (10) (13)


Made up of: Cash with the Government Banking Service 10 20

Cash and cash equivalents as in statement of financial position 10 20

Total bank overdrafts 0 0


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

153


Current Non-current Current Non-current

13 Trade and other payables 2018-19 2018-19 2017-18 2017-18

£'000 £'000 £'000 £'000

NHS payables: Revenue 5,333 - 17,281 -

NHS accruals 8,241 - 12,933 -

Non-NHS and Other WGA payables: Revenue 6,918 - 6,351 -

Non-NHS and Other WGA payables: Capital 90 - 18 -

Non-NHS and Other WGA accruals 31,566 - 35,481 -

Social security costs 71 - 67 -

Tax 71 - 68 -

Other payables and accruals 783 - 1,020 -

Total Trade & Other Payables 53,073 - 73,219 -

Total current and non-current 53,073 73,219 Other payables include £628k outstanding pension contributions which includes employees and GP contributions at 31 March 2019.

The 2017-18 comparable figures include £8.7m relating to Inter CCG trading between the preceding organisations This trading relates

to a risk share agreement in place between the two organisations based on the revenue resource limit at the start of 17/18. The

majority of the risk share relates to staff costs and joint care (including Continuing Healthcare costs) hosted by Chiltern Clinical

Commissioning Group. These charges are included in NHS payables and are contra'd with items shown within the Creditors Note 11.

14 Provisions

Current Non-current Current Non-current

2018-19 2018-19 2017-18 2017-18

£'000 £'000 £'000 £'000

Continuing care 551 67 293 67

Total 551 67 293 67

Total current and non-current 618 360

Continuing Care Other Total

£'000 £'000 £'000

Balance at 01 April 2018 360 0 360

Arising during the year 258 0 258 Balance at 31 March 2019 618 0 618

Expected timing of cash flows: Within one year 551 0 551

Between one and five years 67 0 67

Balance at 31 March 2019 618 0 618

£0 is included in the Provisions of the NHS Litigation Authority as at 31 March 2019 in respect of clinical negligence

liabilities of the Clinical Commissioning Group (31 March 2018 £0)

Provision for Continuing Healthcare of £618k. The Clinical Commissioning Group is responsible for providing Continuing

Healthcare to its population once potential patients have been assessed and deemed to meet criteria to qualify for funding.

The provision covers those who have not beed assessed where there could be a high probability of a financial liability.

154


15 Financial instruments

15.1 Financial risk management

Financial reporting standard IFRS 7 requires disclosure of the role that financial instruments have had during the period in

creating or changing the risks a body faces in undertaking its activities.

Because NHS clinical commissioning group is financed through parliamentary funding, it is not exposed to the degree of financial

risk faced by business entities. Also, financial instruments play a much more limited role in creating or changing risk than would

be typical of listed companies, to which the financial reporting standards mainly apply. The clinical commissioning group has

limited powers to borrow or invest surplus funds and financial assets and liabilities are generated by day-to-day operational

activities rather than being held to change the risks facing the clinical commissioning group in undertaking its activities.

Treasury management operations are carried out by the finance department, within parameters defined formally within the NHS

clinical commissioning group standing financial instructions and policies agreed by the Governing Body. Treasury activity is

subject to review by the NHS clinical commissioning group and internal auditors.

15.1.1 Currency risk

The NHS clinical commissioning group is principally a domestic organisation with the great majority of transactions, assets

and liabilities being in the UK and sterling based. The NHS clinical commissioning group has no overseas operations. The NHS

clinical commissioning group and therefore has low exposure to currency rate fluctuations.

15.1.2 Interest rate risk The clinical commissioning group is able to borrow 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 has no borrowing but if there were the

clinical commissioning group would have a low exposure to interest rate fluctuations"

15.1.3 Credit risk

Because the majority of the NHS clinical commissioning group and revenue comes parliamentary funding, NHS clinical

commissioning group has low exposure to credit risk. The maximum exposures as at the end of the financial year are in

receivables from customers, as disclosed in the trade and other receivables note.

15.1.4 Liquidity risk

NHS clinical commissioning group is required to operate within revenue and capital resource limits, which are financed from

resources voted annually by Parliament. The NHS clinical commissioning group draws down cash to cover expenditure, as the

need arises. The NHS clinical commissioning group is not, therefore, exposed to significant liquidity risks.

155


15 Financial instruments cont'd

15.2 Financial assets

Financial Assets Financial Assets

measured at measured at

amortised cost Total amortised cost Total

2018-19 2018-19 2018-19 2018-19

£'000 £'000 £'000 £'000

Trade and other receivables with NHSE bodies 2,687 2,687 0 0

Trade and other receivables with other DHSC group bodies 1,995 1,995 12,949 12,949

Trade and other receivables with external bodies 787 787 10717 10,717

Other financial assets (0) (0) 443 443

Cash and cash equivalents 10 10 20 20

Total at 31 March 2019 5,479 5,479 24,129 24,129

15.3 Financial liabilities

Financial Financial Liabilities Liabilities

measured at measured at

amortised cost Total amortised cost Total

2018-19 2018-19 2018-19 2018-19

£'000 £'000 £'000 £'000

Trade and other payables with NHSE bodies 556 556 0 0

Trade and other payables with other DHSC group bodies 13,018 13,018 30,214 30,214

Trade and other payables with external bodies 38,575 38,575 42,870 42,870

Other financial liabilities 783 783 0 0

Total at 31 March 2019 52,932 52,932 73,084 73,084 Note: In 17/18 there is inter group trading between the previous Clinical Commissioning Groups in Buckinghamshire in relation to risk share agreements of £8.7m which contra between NHS receiveable and NHS payables. There is also a coding error of £10.7m in relation to a recoding that is included in

receivables with external bodies but should be netted off in payables.

156

HS Buckinghamshire Clinical Commissioning Group - Annual Accounts 2018-19

16 Operating segments

The Clinical Commissioning Group consider they have only one segment: commissioning of healthcare services.

17 Joint arrangements - interests in joint operations

The NHS Clinical Commissioning Group has entered into a pooled budget agreements with Buckinghamshire

County Council and these agreements are hosted by Buckinghamshire County Council.

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

2018-19 2017-18

£'000 £'000

Income 49,249 45,713

Expenditure (49,249) (45,713)

Under the arrangement funds are pooled under section 75 of the NHS Act 2006 for provision of Mental Health and Continuing Care Services within the Buckinghamshire community.

The memorandum accounts for pooled budgets are :

Children and Adolescence Mental Health Services (CAMHS)

Pool Budget with Buckinghamshire Clinical Commissioning Group and Buckinghamshire County Council for the provision of Children and Adolescence Mental Health Services for the period 1 April 2018 to 31 March 2019. Buckinghamshire County Council is the host and lead authority for this pooled fund arrangement.

2018-19 2017-18

£000 £000

Expenditure

Pooled fund CAMHS 7,281 6,585

Income

Contribution from Buckinghamshire County Council (1,791) (1,621)

Contribution from NHS Buckinghamshire Clinical Commissioning Group (5,490) (4,964)

Total (7,281) (6,585)

Balance 0 0 Speech and Language Therapy Pooled Budget

Pooled budget with Buckinghamshire Commissioning Group and Buckinghamshire County Council for the provision of Speech & Language Therapy for the period 1st April 2018 to 31st March 2019. Buckinghamshire County Council is the host and lead authority.

2018-19 2017-18

£'000 £000

Expenditure

Pooled Fund SALT 3,791 3,779

Income



Total (3,791) (3,779)

Balance 0 0

Residential Respite Short Breaks Pooled Fund Pooled Budget with Buckinghamshire Clinical Commissioning Group for the period 1 April 2018 to 31 March 2019. Buckinghamshire County Council is the host and lead authority.

2018-19 2017-18

£'000 £'000

Expenditure

Pooled fund Residential Respite Short Breaks 1,933 2,215

Income


Contribution from NHS Buckinghamshire Clinical Commissioning Group (527) (610)

Total (1,933) (2,215)

Balance 0 0

157


17 Joint arrangements - interests in joint operations Cont'd.

Integrated Community Equipment Service Contract Management Pooled Fund

Pool Budget with Buckinghamshire Clinical Commissioning Group and Buckinghamshire County Council for the provision of Integrated Community Equipment Service Contract Management for the period 1 April 2018 to 31 March 2019.

Buckinghamshire County Council is the host and lead authority for this pooled fund arrangement.

2018-19 2017-18

£'000 £'000

Expenditure

Pooled fund expenditure 92 84

Income

Contribution from Buckinghamshire County Council (30) (27)

Contribution from NHS Buckinghamshire Clinical Commissioning Group (62) (57)

Total Income (92) (84)

Balance 0 0

Integrated Community Equipment Service Pooled Budget

Pool Budget with Buckinghamshire Clinical Commissioning Group and Buckinghamshire County Council for the provision of Integrated

Community Equipment Service (including Adult Social Care, Telecare and Children & Young People's Service) for the period of 1st April 2018

to 31st March 2019. Buckinghamshire County Council is the host and lead authority for this pooled fund arrangement. . The Joint Pooled Fund supports the procurement. storage, delivery, installation and technical demonstration. Subsequent collection, cleaning, recycling, maintenance and repair of equipment for eligible client's use.

2018-19 2017-18

£'000 £'000

Expenditure

Pooled fund expenditure 8,207 7,821

Income Contribution from Buckinghamshire County Council (2,575) (2,466)


Total Income (8,207) (7,821)

Balance 0 0

Better Care Fund Pool Budget with Buckinghamshire Clinical Commissioning Group and Buckinghamshire County Council for the provision of the Better Care Fund.The Better Care Fund is a pooled budget set up for health and social care for the period of 1st April 2018 to 31st March 2019. The Joint Pooled Fund supports the provision of community health teams and social care activites for the population of Buckinghamshire.. Buckinghamshire County Council is the host and lead authority for this pooled fund arrangement

2018-19 2017-18

£'000 £'000

Pooled Fund Expenditure 35,437 34,466



Contribution from NHS Milton Keynes Clinical Commissioning Group (318) (312)

Total Income (35,437) (34,466)

0 0

S117 Pool Budget with Buckinghamshire Clinical Commissioning Group and Buckinghamshire County Council for the provision for Section 117 clients - roviding care packages that are suitable for the clinets requirements. Buckinghamshire County Council is the host and lead authority for this pooled fund arrangement.

2018-19 2017-18

£'000 £'000

Pooled Fund S117 Expenditure 14,943 10,784

Income Contribution from Buckinghamshire County Council (7,592) (5,726)


Total (14,943) (10,784)

Balance 0 0

158


18 Related party transactions

Details of related party transactions with individuals are as follows:

Name Title

Dr. Graham Jackson (1) Member GP

Dr Raj Bajwa (63501) Clinical GP Chair

Robert Parkes Lay Member

Tony Dixon Lay Member

Member GP / Clinical

Dr Karen West Commissioning Director for

Integrated Care

Dr Rebecca Mallard- Clinical Commissioning

Smith Director - Urgent Care

Dr Robin Woolfson Hospital Doctor

Crystal Oldman Registered Nurse

Lou Patten Accountable Officer

Robert Majilton Deputy Chief Officer

Debbie Richards Director of Commissioning

and Delivery

Nicola Lester Director of Transformation

Colin Seaton Lay Member

Gary Heneage Chief Finance Officer

Relationship GP Partner Member Director Co-Chair Trustee Wife works at Board Member Wife is GP GP Partner & 50%

owner Member Participated in advisory &

training On call Doctor University of Oxford SFO (Senior Financial Officer) Chair Director GP Partner Member Husband GP Partner Member Partnership

Shareholder Partner Shareholder - Portfolio with no

controlling interest (minimal

investments) Nephrology speciality private

practice Consultant Nephrologist

and Divisional Medical Director CEO Member Chair of the working group of primary and community services (nursing & AHP)

Member of Nurses Forum

Technical Advisor

Member of Brunel Business School

Strategic Advisory Board Husband -

Global Directorship role Son -

Employee Wife works at Niece

works at Nominated

CCG Governor

Husband works at

Husband is Chair

Husband is Member

Husband is Trustee

Husband is CEO n/a Founder/Director Spouse - Sport & Exercise Consultant

Related Party Whitehill Surgery FedBucks Bucks Berks Oxon LMC Secretariat Ltd NHSCC Board NHS Confederation Fedbucks formally (CV Health) Chiltern Health NHS Clinical Commissioners Unity Health (formally known as Wellington House) Little Chalfont Surgery FedBucks Pharmaceutical Companies Florence Nightingale House Hospice MSc student Chearsley Parish Council East Berkshire College of Further Education Windsor Theatre Ltd Haddenham Medical Centre FedBucks Brain Lab - Medical Software and Hardware Innovators John Hampden Surgery FedBucks Fedbucks formally (CV Health) Chiltern Health London Clinic Kidney Centre LLP

Various shares

Several private hospitals in Central London only. Royal Free London NHS FT Queen's Nursing Institute Member of the strategic group Transforming Nursing for Community & Primary Care

This is a working group of the NHS Improvement Programme Board for 'Safe Sustainable Staffing' NHS Clinical Commissioners - the membership organisation of clinical commssioning groups. National Association of Primary Care (NAPC)

Brunel University DHL (Logistics) Frimley Health NHS Foundation Trust Vodafone Group as Customer Delivery Manager Oxford Health NHS Foundation Trust (finance) Oxford Health NHS Foundation Trust NHS Health Research Authority (HRA) as Non-Executive

Director Herts Urgent Care Institute of Cancer Research CLIC Sargent (Children's Cancer Charity) Vaccine development R&D company ( IMMBio ) n/a CSMentoring Ltd Circle Hospital (Reading)

(1) Dr Graham Jackson left the organisation in March 2019

159


18 Related party transactions cont'd

Where the Clinical Commissioning Group has a transactional (financial) relationship , then these values are included in the following

tables. If the related party is not shown then the Clinical Commissioning Group does not thave a transactional (financial) relationship. Details of related party transactions with individuals are as follows:

Payments to Amounts owed to Receipts from Amounts due from

Related Party Related Party Related Party Related Party

£'s £'s £'s £'s

(CV Health) Chiltern Health 289,724 0 0 0

Circle Hospital (Reading) 292,327 2,316 0 0

Oxford Health NHS Foundation Trust 46,146,710 1,708,669 0 0

Queen's Nursing Institute 11,201 0 0 0

NHS Confederation 8,500 7,425 0 0

Buckinghamshire Healthcare NHS Trust 291,279,803 1,003,421 740,046 259,463

Frimley Health NHS Foundation Trust 58,118,463 2,827,342 68,160 68,160

Oxford University Hospitals NHS Foundation Trust 20,885,418 11,424 0 0

Milton Keynes NHS FT 10,473,075 130,970 0 0

South Central Ambulance Service NHS Foundation Trust 22,875,855 1,782 0 0

NHS South Central and West CSU 5,910,484 143,955 0 10,154

NHS England 24,946 2,225 7,009,047 2,594,934

FedBucks 2,842,494 0 0 0

Vodafone 7,812 0 0 0

Previous year comparables 17-18

Payments to Amounts owed to Receipts from Amounts due from

Related Party Related Party Related Party Related Party

£'s £'s £'s £'s

(CV Health) Chiltern Health 672,017 0 0 0

Oxford Health NHS Foundation Trust 38,758,254 3,632,452 0 0

Queen's Nursing Institute 617 0 0 0

NHS Confederation 6,000 8,500 0 0

Buckinghamshire Healthcare NHS Trust 249,481,738 (3,227,947) 648,149 224,799

Frimley Health NHS Foundation Trust 48,077,365 66,825 0 0

Oxford University Hospitals NHS Foundation Trust 19,798,655 (104,755) 0 0

Milton Keynes NHS FT 8,469,606 834,022 0 0

South Central Ambulance Service NHS Foundation Trust 22,605,901 20,501 0 0

NHS South Central and West CSU 5,769,874 259,331 4,800 10,154

NHS England 1,169,028 (167,485) 4,053,136 603,781

FedBucks 0 0 0 0

Vodafone 0 0 0 0

160


18 Related party transactions cont'd

Details of related party transactions with individuals are as follows:

2018-19 2017-18

Payments to Payments to

Related Party £ Related Party £

(expenditure) (expenditure)

Buckinghamshire CCG Practices

ASHCROFT SURGERY 817,720 754,641

BERRYFIELDS MEDICAL CENTRE 857,992 848,100

CROSS KEYS SURGERY 1,736,794 1,499,805

EDLESBOROUGH SURGERY 1,351,757 1,347,717

HADDENHAM MEDICAL CENTRE 1,170,348 1,101,358

MANDEVILLE PRACTICE 1,082,202 1,345,094

MEADOWCROFT SURGERY 1,518,283 1,426,521

NORDEN HOUSE SURGERY 1,768,468 1,750,492

OAKFIELD SURGERY AYLESBURY 606,076 551,363

POPLAR GROVE SURGERY 2,488,643 2,371,391

SWAN PRACTICE 107,799 233,526

UNITY HEALTH (formally as Wellington House & Trinity Health) 3,487,154 3,215,056

WING SURGERY 904,905 869,478

WADDESDON SURGERY 1,194,163 1,142,661

WESTONGROVE PARTNERSHIP 3,920,342 3,857,129

WHITCHURCH SURGERY AYLESBURY 981,030 951,291

WHITEHILL SURGERY 1,511,656 1,338,024

NORTH END SURGERY 4,070,694 3,652,966

AMERSHAM HEALTH CENTRE 1,314,194 1,241,741

BURNHAM HEALTH CENTRE 2,411,191 2,465,357

CARRINGTON HOUSE SURGERY 1,093,778 1,069,413

CHERRYMEAD SURGERY 1,225,583 1,202,992

CHILTERN HOUSE MEDICAL CENTRE 409,252 1,034,602

CRESSEX HEALTH CENTRE 1,246,134 1,279,419

DENHAM MEDICAL CENTRE 1,304,220 1,156,864

DESBOROUGH AVENUE SURGERY 1,446,085 1,229,356

DR ALLAN AND PARTNERS 3,928 7,110

DR R FIRTH & PARTNERS 0 3,840

GLADSTONE SURGERY 525,795 485,968

HALL PRACTICE 1,020,265 958,787

HAWTHORNDEN SURGERY 434,651 812,677

HIGHFIELD SURGERY HIGH WYCOMBE 731,636 741,568

HUGHENDEN VALLEY SURGERY 11,841 70,471

IVER MEDICAL CENTRE 1,012,634 987,588

JOHN HAMPDEN SURGERY 353,452 344,710

KINGSWOOD SURGERY HIGH WYCOMBE 1,007,046 1,045,449

LITTLE CHALFONT SURGERY 550,945 588,325

MARLOW MEDICAL GROUP 3,119,992 3,164,548

MILLBARN MEDICAL CENTRE 896,942 815,006

MISBOURNE SURGERY 1,444,714 1,367,872

POUND HOUSE SURGERY 966,849 880,111

PRACTICE PROSPECT HOUSE 583,538 374,407

PRIORY AVENUE SURGERY HIGH WYCOMBE 1,258,203 1,190,840

RECTORY MEADOW SURGERY 1,147,809 1,095,421

RIVERSIDE SURGERY 1,091,049 1,118,695

SIMPSON CENTRE 1,863,826 1,770,917

SOUTHMEAD SURGERY 720,443 800,128

STOKENCHURCH MEDICAL CENTRE 898,287 925,915

THREEWAYS SURGERY 781,890 751,418

TOWER HOUSE SURGERY HIGH WYCOMBE 993,572 959,965

WATER MEADOW SURGERY 1,317,509 1,328,157

WYE VALLEY SURGERY 1,022,619 1,138,865

NEW SURGERY 1,013,922 990,249

GRAND TOTAL 63,982,101 63,655,364

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19 Events after the end of the reporting period

The Clinical Commissioing Group is not aware of any events that will impact on the reporting period

20 Financial performance targets

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

2018-19 2018-19 2017-18 2017-18

Target Performance Duty Achieved Target Performance Duty Achived

Expenditure not to exceed income 721,319 721,224 Yes 687,266 702,695 No

Capital resource use does not exceed the amount specified in Directions 105 105 Yes 65 65 Yes

Revenue resource use does not exceed the amount specified in Directions 705,665 706,710 No 684,186 699,616 No

Capital resource use on specified matter(s) does not exceed the amount specified in Directions 0 0 Yes 0 0 Yes

Revenue resource use on specified matter(s) does not exceed the amount specified in Directions 0 0 Yes 0 0 Yes

Revenue administration resource use does not exceed the amount specified in Directions 11,693 10,553 Yes 11,635 11,024 Yes

The Clinical commissioning Group achieved a £95k in year surplus for 2018-19 which comprised of an over spend on Programme Costs of £1,045k offset by an under spend for Administrative costs of £1,140k.

21 Impact of IFRS 15

There is no material impact of IFRS 15 on current year closing balances.

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€¦ · developing an integrated team – in north and central aylesbury, and south...

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