Report no: GB 30b-19 NHS LIVERPOOL CLINICAL … · 5/24/2019 · the year ended 31 March 2019 for...

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Report no: GB 30b-19

NHS LIVERPOOL CLINICAL COMMISSIONING GROUP GOVERNING BODY

FRIDAY 24TH MAY 2019

Title of Report Adoption of Annual Report and Accounts

Lead Governor Mark Bakewell, Chief Finance & Contracting Officer

Senior Management Team Lead

Mark Bakewell, Chief Finance & Contracting Officer/Carole Hill, Director of Strategy, Communications & Integration

Report Author Mark Bakewell, Chief Finance & Contracting Officer/Carole Hill, Director of Strategy, Communications & Integration.

Summary The 2018/19 Annual Report & Accounts were signed off by the Audit Risk & Scrutiny Committee on 21st May 2019 for approval by the Governing Body:

i. Audit Findings Report ii. Letter of Representation

iii. Year End Accounts – HFMA suggested questions for Governing Body and management responses

iv. Annual Report v. Financial Statement & Accounts

Recommendation That Liverpool CCG Governing Body: note the management responses to

the questions posed prior to the formal approval of the financial statements

Approve the final Annual Report & Accounts 2017/18

Approve for the Accountable Officer and Chair to sign off the associated documents and submission to NHS England.

Relevant standards/targets

Statutory Duty, Department of Health Group Accounting Manual.

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© 2019 Grant Thornton UK LLP | Audit Findings Report for NHS Liverpool CCG | 2018/19

DRAFTThis version of the

report is a draft. Its

contents and subject

matter remain under

review and its contents

may change and be

expanded as part of the

finalisation of the report.

This draft has been

created from the

template dated

DD MMM YYYY

The Audit Findingsfor NHS Liverpool CCG

24 May 2019

Year ended 31 March 2019

GB 30b-19 (i)

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ContentsSection Page

1. Headlines 3

2. Financial statements 4

3. Value for money 12

4. Independence and ethics 15

Appendices

A. Audit adjustments

B. Fees

C. Audit Opinion

The contents of this report relate only to those matters which came to our attention during the conduct of our normal audit procedures which are designed for the purpose of expressing our opinion on the financial statements. Our audit is not designed to test all internal controls or identify all areas of control weakness. However, where, as part of our testing, we identify control weaknesses, we will report these to you. In consequence, our work cannot be relied upon to disclose all defalcations or other irregularities, or to include all possible improvements in internal control that a more extensive special examination might identify. This report has been prepared solely for your benefit and should not be quoted in whole or in part without our prior written consent. We do not accept any responsibility for any loss occasioned to any third party acting, or refraining from acting on the basis of the content of this report, as this report was not prepared for, nor intended for, any other purpose.

Grant Thornton UK LLP is a limited liability partnership registered in England and Wales: No.OC307742. Registered office: 30 Finsbury Square, London, EC2A 1AG. A list of members is available from our registered office. Grant Thornton UK LLP is authorised and regulated by the Financial Conduct Authority. Grant Thornton UK LLP is a member firm of Grant Thornton International Ltd (GTIL). GTIL and the member firms are not a worldwide partnership. Services are delivered by the member firms. GTIL and its member firms are not agents of, and do not obligate, one another and are not liable for one another’s acts or omissions.

Your key Grant Thornton team members are:

Andrew SmithDirector

T: 0161 953 6427

E: [email protected]

Georgia JonesSenior ManagerT: 0161 214 6383

E:[email protected]

Ashling ConwayIn-Charge Auditor

T: 0151 224 7237

E:[email protected]

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HeadlinesThis table summarises the key findings and other matters arising from the statutory audit of NHS Liverpool CCG (‘the CCG’) and the preparation of the CCG's financial statements forthe year ended 31 March 2019 for those charged with governance.

AcknowledgementsWe would like to take this opportunity to record our appreciation for the assistance provided by the finance team and other staff during our audit.

FinancialStatements

Under International Standards of Audit (UK) (ISAs) and theNational Audit Office (NAO) Code of Audit Practice ('theCode'), we are required to report whether, in our opinion:• the CCG's financial statements give a true and fair

view of the financial position of the CCG and its income and expenditure for the year; and

• The CCG’s financial statements, and the parts of the Remuneration and Staff Report to be audited, have been properly prepared in accordance with International Financial Reporting Standards, as interpreted and adapted by the Department of Health and Social Care (DHSC) group accounting manual 2018/19 (GAM).

We are also required to report whether other information published together with the audited financial statements in the Annual Report, is materially inconsistent with the financial statements or our knowledge obtained in the audit or otherwise appears to be materially misstated and whether the income and expenditure included in the financial statements has been applied for the purposes intended by Parliament (the regularity opinion).

Our audit work was completed on site during April and May. Our findings are summarised on pages 5 to 11. We did not identify any adjustments to the financial statements that have changed the CCG’s

retained surplus position. Audit adjustments are detailed in Appendix A. Our work is substantially complete and there are no matters of which we are aware that would require modification of our audit opinion Appendix C or material changes to the financial statements, subject to the following outstanding matters;• completion of final testing for journals, expenditure and secondary healthcare• completion of work on Agreement of Balances (Whole of Government Accounts)• receipt of management representation letter; and• review of the final set of financial statements.We have concluded that• the other information to be published with the financial statements, is consistent with our knowledge

of your organisation and the financial statements we have audited.• income and expenditure included in the financial statements have been applied for the purposes

intended by Parliament.Our anticipated audit report opinion will be unmodified.

Value for Money arrangements

Under the National Audit Office (NAO) Code of AuditPractice ('the Code'), we are required to report by exceptionif, in our opinion, the CCG has not made properarrangements to secure economy, efficiency andeffectiveness in its use of resources ('the value for money(VFM) conclusion’).

We have completed our risk based review of the CCG’s value for money arrangements. We have

concluded that NHS Liverpool CCG has proper arrangements to secure economy, efficiency and effectiveness in its use of resources.We have nothing to report by exception. Our findings are summarised on page 14.

Statutory duties The Local Audit and Accountability Act 2014 (‘the Act’) alsorequires us to:• report to you if we have applied any of the additional

powers and duties ascribed to us under the Act; and• To certify the closure of the audit.

We have not exercised any of our additional statutory powers or duties.We have completed the majority of work under the Code and expect to be able to certify the completion of the audit when we give our audit opinion.

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SummaryOverview of the scope of our auditThis Audit Findings Report presents the observations arising from the audit that are significant to the responsibility of those charged with governance to oversee the financial reporting process, as required by International Standard on Auditing (UK) 260 and the Code of Audit Practice (‘the Code’). Its contents have been discussed with management and the Audit Committee. As auditor we are responsible for performing the audit, in accordance with International Standards on Auditing (UK) and the Code, which is directed towards forming and expressing an opinion on the financial statements that have been prepared by management with the oversight of those charged with governance. The audit of the financial statements does not relieve management or those charged with governance of their responsibilities for the preparation of the financial statements.Audit approachOur audit approach was based on a thorough understanding of the CCG’s business and is

risk based, and in particular included:

• An evaluation of the CCG’s internal controls environment, including its IT systems and

controls• Substantive testing on significant transactions and material account balances, including

the procedures outlined in this report in relation to the key audit risksWe have not had to alter or change our audit plan, as communicated to you on 26 February 2019.ConclusionWe have substantially completed our audit of your financial statements and subject to outstanding queries being resolved, we anticipate issuing an unqualified audit opinion following the Governing Body meeting on 24 May 2019, as detailed in Appendix C. These outstanding items include:- receipt of management representation letter; and- review of the final set of financial statements.

Financial statements

Materiality calculations remain the same as reported in our audit plan We detail in the table below our determination of materiality for NHS Liverpool CCG.

Our approach to materialityThe concept of materiality is fundamental to the preparation of the financial statements and the audit process and applies not only to the monetary misstatements but also to disclosure requirements and adherence to acceptable accounting practice and applicable law.

CCG Amount (£) Qualitative factors considered

Materiality for the financial statements £18.151m • Control environment and sector the CCG operates within

Performance materiality £13.613m • Previous quality of the working papers and response to audit process. Quality of financial systems and processes and the nature of the CCG’s expenditure

and income streams

Trivial matters £0.300m • Capped to reflect National Audit Office requirements

Materiality for:• Senior officer remuneration

• Related Party transactions

2% of senior officer remunerationMaterial to either party

• We design our procedures to detect errors in specific accounts at a lower level of precision for Senior Officer Remuneration and Related Party transactions

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Significant findings - Going concernFinancial statements

Our responsibility

As auditors, we are required to “obtain sufficient appropriate audit evidence about the appropriateness of management's use o f the going concern assumption in the preparation and presentation of the financial statements and to conclude whether there is a material uncertainty about the entity's ability to continue as a going concern” (ISA (UK) 570).

Going concern commentary

Management's assessment processManagement has carried out an assessment of going concern to ensure the accounts are prepared on the appropriate basis. As part of this assessment management has considered:• Savings required for 2019/20• Previous performance in achieving required savings• CCG track record for delivering financial performance

requirements• Budget set for 19/20 and likely achievement of this• Mitigation of any financial risks – for example through

Acting as One contracts

Auditor commentary • Management’s assessment and consideration of going concern is appropriate.

• There is no indication within management’s assessment that the CCG's functions will cease in the foreseeable

future.• The CCG has met it's statutory duty for 18-19 and funding for 19-20 has been confirmed by NHSE.

Work performed We have considered the process management has completed in order to assess the validity of preparing the accounts on a going concern basis.We have assessed the adequacy of management’s

processesWe have considered the reasonableness any assumptions made by management.

Auditor commentary• Our consideration of management processes has not identified any material uncertainties in relation to going concern.• Our assessment is that it is appropriate that the CCG prepare its financial statements on a going concern basis.

Concluding comments Auditor commentary• We intend to give an unmodified audit opinion in relation to going concern.

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Significant findingsRisks identified in our Audit Plan Commentary

Improper revenue recognition - the revenue cycle includes fraudulent transactions

Auditor commentaryUnder ISA (UK) 240 there is a rebuttable presumed risk that revenue may be misstated due to the improper recognitionof revenue.In our audit plan we set out that we have rebutted this presumed risk for NHS Liverpool CCG because:• revenue does not primarily involve cash transactions• funding is principally an allocation from NHS England which is not accounted for in the Statement of Comprehensive

Net ExpenditureWe have not identified any issues that would significantly impact on our judgement in this are.We therefore do not consider this to be a significant risk for NHS Liverpool CCG.

Management override of controlsUnder ISA (UK) 240 there is a non-rebuttable presumed risk that the risk of management over-ride of controls is present in all entities. . The CCG faces external pressures to meet agreed targets, and this could potentially place management under undue pressure in terms of how they report performance.We therefore identified management override of control, in particular journals, management estimates and transactions outside the course of business as a significant risk, which was one of the most significant assessed risks of material misstatement.

Auditor commentaryWe performed the following procedures:• evaluated the design effectiveness of management controls over journals• analysed the journals listing and determine the criteria for selecting high risk unusual journals • Tested unusual journals made during the year and after the draft accounts stage for appropriateness and

corroboration• gained an understanding of the accounting estimates and critical judgements applied made by management and

consider their reasonableness • evaluated the rationale for any changes in accounting policies, estimates or significant unusual transactionsOur audit work has not identified any issues in respect of management override of controls.

Financial Statements

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Significant findingsRisks identified in our Audit Plan Commentary

Secondary healthcare expenditure – contract variations

A significant percentage of the CCG’s expenditure is

on contracts for healthcare with NHS providers and non-NHS providers, such as operations and hospital care. This expenditure is primarily derived through block contracts that are agreed up front for a predetermined cost or level of activity. Contract variations are agreed with the supplier throughout the year to recognise demand and price adjustments against the agreed contracts. Costs related to contract variations are recognised when the adjustment has been agreed with the provider, with accruals raised at the year-end for completed activity for which an invoice has not been issued.

We identified the accuracy and completeness of secondary healthcare expenditure – contract variations, and the accuracy and completeness of associated payables and accruals, as a significant risk, which was one of the most significant assessed risks of material misstatement.

Auditor commentary

We performed the following procedures:

• gained an understanding of the financial reporting processes used for the purchase of secondary healthcare and evaluate the design of the associated controls

• using the DHSC mismatch report, we investigated unmatched expenditure and payable balances with NHS bodies over the NAO £0.3m threshold, corroborating any unmatched balances not included in the CCG’s financial

statements to supporting evidence the CCG’s financial statements to supporting evidence

• obtained a listing of payments made after year end and agree, on a sample basis, that relevant payments for NHS and non-NHS secondary healthcare expenditure have been accounted for in the correct financial period through agreement to supporting evidence.

• agreed, on a sample basis, contracts, contract variations and associated payables and accruals relating to secondary healthcare to supporting evidence.

Our work identified that CCG has an accrual included within the financial statements of £1.487m in relation to the Royal Liverpool and Broardgreen University Hospital Trust. Our understanding is that this is a historic amount for partially completed spells relating which is assessed annually by the CCG. The CCG has not provided any supporting information to support the basis of the accrual. The CCG makes the accrual on the basis that at the end of the year there will be partially completed spells where the CCG would be liable to make a payment if the contract with the Royal for this type of treatment was not renewed and/or was awarded elsewhere. Our view is that the Acting as One contract removes the risk of under/over performance within contracts so we would not expect the CCG to accrue for additional expenditure. The CCG has chosen not to amend the accounts so in our view expenditure is overstated by £1.487m

At the time of writing our work in this area is still ongoing but to date our audit work has not identified any further issues in respect of secondary healthcare contract variations.

Financial statements

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Significant findings - accounting policiesFinancial statements

Accounting area Summary of policy Comments Assessment

Revenue recognition Revenue in respect of services provided is recognised when (or as) performance obligations are satisfied by transferring promised services to the customer, and is measured at the amount of the transaction price allocated to that performance obligation. Where income is received for a specific performance obligation that is to be satisfied in the following year, that income is deferred.

• The CCG has updated its revenue recognition policy to comply with IFRS 15 Revenue from Contracts with Customers as required;

• The policies are appropriate under the relevant accounting framework;

• The CCG has applied reasonable judgements to ensure revenue is appropriately recorded;

• The policies are adequately disclosed in the financial statements.

(Green)

Judgements and estimates Key estimates and judgements include:• Accruals and prescribing - the main

accrual is for prescribing costs for which information for actual drug costs prescribed in the year is provided two months in arrears. The actual data received at the Statement of Financial Position date is to 31 January 2018, and an estimate for February and March is required.

• Secondary healthcare accruals - The CCG has made an accrual for partially completed spells with the Royal Liverpool and Broardgreen University Hospital Trust as detailed on the previous page.

We have reviewed the accounting policies relating to significant judgements and estimates and have concluded that:: • These are appropriate under the relevant accounting framework• CCG has adequately disclosed these within the accounting

policies.We have reported on the previous page in relation to the specific accrual with the Royal Liverpool and Broardgreen University Hospital Trust.

(Amber)

Other critical policies The CCG has adopted the standard accounting policies as set out in the GAM.

We have reviewed the CCG’s policies against the requirements of

the GAM. The CCG has appropriately tailored the standard accounting policies to its individual circumstances.

(Green)

Assessment Marginal accounting policy which could potentially be open to challenge by regulators Accounting policy appropriate but scope for improved disclosure Accounting policy appropriate and disclosures sufficient

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Significant findings - other issuesFinancial statements

This section provides commentary on new issues and risks which were identified during the course of the audit that were not previously communicated in the Audit Plan and a summary of any significant deficiencies identified during the year.

Issue Commentary Auditor view

Journals Senior management (Chief Finance and Contracting Officer and Head of Financial Management) are able to both post and authorise journals. Allowing senior management to raise journals means there is a possible risk of manipulation of the CCG’s financial position. Our testing of journals has not identified any significant

issues but this is considered a deficiency in the control environment.

The CCG should consider the risks presented by allowing the senior management to have access right to post journals.

Management Response:Regarding the identified journal issue (which is a recognised weakness in the national ledger system) the CCG has implemented a number of internal controls to mitigate against identified risks. These include a monthly journal review process to ensure that the person who posting the journal is different to the person who approved the journal. This is reviewed as part of our documented approach, reviewed by the internal audit team with the CCG receiving a ‘high

assurance’ rating for our controls and processes in this area.

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Other communication requirementsFinancial Statements

We set out below details of other matters which we, as auditors, are required by auditing standards and the Code to communicate to those charged with governance.

Issue Commentary

Matters in relation to fraud We have previously discussed the risk of fraud with the Audit, Risk and Scrutiny Committee . We have been made aware of two minor

frauds (less than £1k each) which have been investigated by Merseyside Internal Audit Counter Fraud. We have not been made aware of any other incidents in the period and no other issues have been identified during the course of our audit procedures.

Matters in relation to related parties

We are not aware of any related parties or related party transactions which have not been disclosedOur work identified that the figures included in Note 20 Related Party Transactions in relation to ‘Amounts owed to related parties’ were

incorrect. Not all amounts had been included and so the figures were understated. This has now been corrected.

Matters in relation to laws and regulations

You have not made us aware of any significant incidences of non-compliance with relevant laws and regulations and we have not identified any incidences from our audit work.

Written representations A standard letter of representation has been requested from the CCG, which is included in the Governing Body papers.

Confirmation requests from third parties

We obtained confirmation of bank balances directly from the CCG's bank to assist in out audit work.

Disclosures Our review found no material omissions in the financial statements.

Audit evidence and explanations/significant difficulties

All information and explanations requested from management was provided.

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Other responsibilities under the CodeFinancial statements

Issue Commentary

Regularity opinion We are required to give a regularity opinion on whether the expenditure and income reported in the financial statements have been applied to

the purposes intended by Parliament and the financial transactions conform to the authorities which govern them (the regularity opinion).We have not identified any issues and propose to issue an unqualified regularity opinion.

Other information We are required to give an opinion on whether the other information published together with the audited financial statements (including the

Annual Report), is materially inconsistent with the financial statements or our knowledge obtained in the audit or otherwise appears to be materially misstated.No inconsistencies have been identified. We plan to issue an unmodified opinion in this respect – refer to appendix C

Auditable elements of Remuneration and Staff Report

We are required to give an opinion on whether the parts of the Remuneration and Staff Report subject to audit have been prepared properly in accordance with the requirements of the Act, directed by the Secretary of State with the consent of the Treasury.We have audited the elements of the Remuneration and Staff report, as required by the Code.We identified one minor issue in relation to the calculation of the pay multiple figure which has now been amended.We propose to issue an unqualified opinion

Matters on which we report by exception

We are required to report on a number of matters by exception in a number of areas:• If the Annual Governance Statement does not comply with guidance issued by NHS England or is misleading or inconsistent with the

information of which we are aware from our audit• The information in the annual report is materially inconsistent with the information in the audited financial statements or apparently materially

incorrect based on, or materially inconsistent with, our knowledge of the CCG acquired in the course of performing our audit, or otherwise misleading.

• If we have applied any of our statutory powers or dutiesWe have nothing to report on these matters.

Review of accounts consolidation schedulesand specified procedures on behalf of the group auditor

We are required to give a separate audit opinion on the CCG accounts consolidation schedules and to carry out specified procedures (on behalf of the NAO) on these schedules under group audit instructions. In the group audit instructions the CCG was selected as a non-sampled component.At the time of writing our work in this area is still ongoing.

Certification of the closure of the audit

We intend to certify the closure of the 2018/19 audit of NHS Liverpool CCG in the audit opinion, as detailed in Appendix C.

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Value for Money

Risk assessment We carried out an initial risk assessment in February 2019 and identified one significant risk in respect of specific areas of proper arrangements using the guidance contained in AGN03. We communicated these risks to you in our Audit Plan dated February 2019.

We have continued our review of relevant documents up to the date of giving our report, and have not identified any further significant risks where we need to perform further work.

We carried out further work only in respect of the significant risks we identified from our initial and ongoing risk assessment. Where our consideration of the significant risks determined that arrangements were not operating effectively, we have used the examples of proper arrangements from AGN 03 to explain the gaps in proper arrangements that we have reported in our VFM conclusion.

Value for MoneyBackground to our VFM approachWe are required to satisfy ourselves that the CCG has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources and report by exception where we are not satisfied. This is known as the Value for Money (VFM) conclusion.

We are required to carry out sufficient work to satisfy ourselves that proper arrangements are in place at the CCG. In carrying out this work, we are required to follow the NAO's Auditor Guidance Note 3 (AGN 03) issued in November 2017. AGN 03 identifies one single criterion for auditors to evaluate: “In all significant respects, the audited body takes properly informed decisions and

deploys resources to achieve planned and sustainable outcomes for taxpayers and local

people.”

This is supported by three sub-criteria, as set out below:

Informed decision making

Value for Money

arrangements criteria

Sustainable resource

deployment

Working with partners & other third

parties

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Our work

AGN 03 requires us to disclose our views on significant qualitative aspects of the CCG's arrangements for delivering economy, efficiency and effectiveness.

We have focused our work on the significant risk that we identified in the CCG's arrangements. In arriving at our conclusion, our main considerations were:

• The financial plan in place for 2019-20 and the assumptions and considerations supporting these;

• Reporting and monitoring of financial performance throughout 2018-19;

• Year end performance against planned financial targets;

• Reporting arrangements.

We have set out more detail on the risks we identified, the results of the work we performed, and the conclusions we drew from this work on page 14.

Overall conclusion

Based on the work we performed to address the significant risks, we are satisfied that the CCG had proper arrangements for securing economy, efficiency and effectiveness in its use of resources.

The text of our report, which confirms this can be found at Appendix C.

Significant difficulties in undertaking our work

We did not identify any significant difficulties in undertaking our work on your arrangements which we wish to draw to your attention.

Significant matters discussed with management

There were no matters where no other evidence was available or matters of such significance to our conclusion or that we required written representation from management or those charged with governance.

Value for Money

Value for Money

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Key findingsWe set out below our key findings against the significant risks we identified through our initial risk assessment and further risks identified through our ongoing review of documents.

Value for Money

Significant risk Findings Conclusion

Financial sustainabilityThe CCG has a brought forward cumulative surplus of £20.45m and has agreed a target outturn of a break even position in 2018/19. In order to achieve this the CCG will need to deliver CRES savings of £8.787m. The month 8 finance report forecasts that the CCG will meet its break even target.

We reviewed the CCGs efforts to secure financial stability and sustainability through its internal arrangements and engagement with partner organisations across the wider Merseyside health economy. We reviewed the CCG’s

identification of savings plans; and its arrangements for monitoring and managing delivery of its budget and savings plans for 2018/19.The CCG has met its control total for 2018/19 and has achieved its financial duties. Expenditure has been monitored and reported to the Governing Body through the year, with the CCG achieving its breakeven target. The CCG has delivered around £9.6m of savings in 2018/19 (against a target of £8.8m).The CCG has again managed its finances well whilst operating within what is continuing to be a very challenging financial environment. The CCG has set a savings requirement of around £13.8m for 2019/20 and has identified the areas to source these savings from. The CCG will need to monitor these areas carefully to ensure savings are achieved. The CCG is mindful of financial pressure points and for 2019/20 has again agreed ‘Acting as One’ contracts with its main providers to mitigate some of these key

pressures.CCG also continues to work with the council to ensure the Better Care Fund delivers its objectives and promotes closure links for health and social care.

Based on the work we performed to address the significant risk, we are satisfied that the CCG has put into place proper arrangements.

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Independence and ethics

We confirm that there are no significant facts or matters that impact on our independence as auditors that we are required or wish to draw to your attention. We have complied with the Financial Reporting Council's Ethical Standard and confirm that we, as a firm, and each covered person, are independent and are able to express an objective opinion on the financial statements We confirm that we have implemented policies and procedures to meet the requirements of the Financial Reporting Council’s Ethical Standard and we as a firm, and each covered person, confirm that we are independent and are able to express an objective opinion on the financial statements.Further, we have complied with the requirements of the National Audit Office’s Auditor Guidance Note 01 issued in December 2017 which sets out supplementary guidance on ethical requirements for auditors of local public bodies.Details of fees charged are detailed in Appendix B.

Audit and Non-audit servicesFor the purposes of our audit we have made enquiries of all Grant Thornton UK LLP teams providing services to the CCG. External auditors have been asked to provide assurance on the CCG’s compliance with the Mental Health Investment Standards for 2017/18 and 2018/19. This work is scheduled to take place in August & September 2019. The estimated fee for this work is £10,000 excluding VAT.No other non-audit services were identified.

Independence and ethics

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Audit AdjustmentsWe are required to report all non trivial misstatements to those charged with governance, whether or not the accounts have been adjusted by management.

Impact of adjusted misstatements

All adjusted misstatements are set out in detail below along with the impact on the key statements and the reported net expenditure for the year ending 31 March 2019.

DetailStatement of Comprehensive Net

Expenditure £‘000Statement of Financial

Position £’ 000

Impact on total net expenditure £’000

1 The CCG identified that amounts within note 10 – Trade and other receivables were misclassified. An amendment has been made to move NHS and NON NHS accrued income to the respective “contract

receivable not yet invoice / non-invoice” lines of the trade and other

receivables note. This is a classification change and has no overall effect on the financial statements.

0 0 0

Overall impact £0 £0 £0

Appendix A

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Audit AdjustmentsImpact of unadjusted misstatements

The table below provides details of adjustments identified during the 2018/19 audit which have not been made within the final set of financial statements. The Governing Body is required to approve management's proposed treatment of all items recorded within the table below:

DetailStatement of Comprehensive Net Expenditure £‘000

Statement of Financial Position £’ 000

Impact on total net expenditure £’000

Reason for not adjusting

1 Our work identified that CCG has an accrual included within the financial statements of £1.487m in relation to the Royal Liverpool and Broadgreen University Hospital Trust. Our understanding is that this is a historic amount for partially completed spells relating to a period prior to the Acting as One contracts being agreed and that the CCG has not received any supporting information to support the basis of the accrual. Our view is that the Acting as One contract removes the risk of under/over performance within contracts so we would not expect the CCG to accrue for additional expenditure. The CCG has chosen not to amend the accounts so in or view expenditure is overstated by £1.487m

(1,487) 1,487 (1,487) Regarding Partially Completed Spells (PCS), the CCG has continued to reflect its PCS accrual from previous financial years based on a combination of factors and being reflective of the contracting arrangements under the ‘Acting as One’

agreement with local providers

Overall impact £(1,487) £1,487 £(1,487)

Appendix A

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Audit AdjustmentsWe are required to report all non trivial misstatements to those charged with governance, whether or not the accounts have been adjusted by management.

Misclassification and disclosure changesThe table below provides details of misclassification and disclosure changes identified during the audit which have been made in the final set of financial statements.

. Disclosure omission Detail Adjusted?

Note 18 Related parties Our work identified that the figures included in Note 20 Related Party Transactions in relation to ‘Amounts owed

to related parties’ were incorrect. Not all amounts had been included and so the figures were understated. This

has now been corrected.✓

Remuneration report We have audited the elements of the Remuneration and Staff report, as required by the Code.We identified one minor issue in relation to the calculation of the pay multiple figure which has now been amended.

✓

Appendix A

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We confirm below our final fees charged for the audit. See also below in relation to non audit services still to be agreed.

Fee per financial statements are £65,000 – this is £54,256 + 20% VAT

The CCG has also included an accrual of £10k in relation to the scheduled mental health investment standard compliance work, which will take place in August – see below.

Non Audit Fees

Fees

Audit Fees Proposed fee Final fee

CCG Audit 54,256 54,256

Total audit fees (excluding VAT) £54,256 £54,256

Fees for other services Estimated fees

Audit related services:Mental Health Investment Standard Compliance Statement £10,000

£10,000

Appendix B

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Audit opinion - draftWe anticipate we will provide the CCG with an unmodified audit report

Independent auditor's report to the members of the Governing Body of NHS Liverpool CCG

Report on the Audit of the Financial Statements

Opinion

We have audited the financial statements of NHS Liverpool CCG (the ‘CCG’) for the year

ended 31 March 2019, which comprise the Statement of Comprehensive Net Expenditure, the Statement of Financial Position, the Statement of Changes in Taxpayers Equity, the Statement of Cash Flows and notes to the financial statements, including a summary of significant accounting policies. The financial reporting framework that has been applied in their preparation is applicable law and International Financial Reporting Standards (IFRSs) as adopted by the European Union, and as interpreted and adapted by the Department of Health and Social Care Group Accounting Manual 2018-19.

In our opinion, the financial statements:

• give a true and fair view of the financial position of the CCG as at 31 March 2019 and of its expenditure and income for the year then ended; and

• have been properly prepared in accordance with International Financial Reporting Standards (IFRSs) as adopted by the European Union, as interpreted and adapted by the Department of Health and Social Care Group Accounting Manual 2018-19; and

• have been prepared in accordance with the requirements of the Health and Social Care Act 2012.

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. We

are independent of the CCG in accordance with the ethical requirements that are relevant to our audit of the financial statements in the UK, including the FRC’s Ethical Standard, and we

have fulfilled our other ethical responsibilities in accordance with these requirements. We believe that the audit evidence we have obtained is sufficient and appropriate to provide a basis for our opinion.

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 CCG’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 Accountable Officer is responsible for the other information. The other information comprises the information included in the Annual Report, other than the financial statements and our auditor’s report thereon. Our opinion on the financial statements does not cover the

other information and, except to the extent otherwise explicitly stated in our report, we do not express any form of assurance conclusion thereon.

Appendix C

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21

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.

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

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

We have nothing to report in this regard.

Opinion on other matters required by the Code of Audit Practice

In our opinion:

• the parts of the Remuneration and Staff Report to be audited have been properly prepared in accordance with IFRSs as adopted by the European Union, as interpreted and adapted by the Department of Health and Social Care Group Accounting Manual 2018-19 and the requirements of the Health and Social Care Act 2012; and

based on the work undertaken in the course of the audit of the financial statements and our knowledge of the CCG gained through our work in relation to the CCG’s arrangements for

securing economy, efficiency and effectiveness in its use of resources, the other information published together with the financial statements in the Annual Report for the financial year for which the financial statements are prepared is consistent with the financial statements

Opinion on regularity required by the Code of Audit Practice

In our opinion, in all material respects the expenditure and income recorded in the financial statements have been applied to the purposes intended by Parliament and the financial transactions in the financial statements conform to the authorities which govern them.

Matters on which we are required to report by exception

Under the Code of Audit Practice, we are required to report to you if:

• we issue a report in the public interest under Section 24 of the Local Audit and Accountability Act 2014 in the course of, or at the conclusion of the audit; 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 make a written recommendation to the CCG under Section 24 of the Local Audit and Accountability Act 2014 in the course of, or at the conclusion of the audit.

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

Responsibilities of the Accountable Officer and Those Charged with Governance for the financial statements

As explained more fully in the Statement of Accountable Officer's responsibilities set out on pages 67 to 68, the Accountable Officer, is responsible for the preparation of the financial statements in the form and on the basis set out in the Accounts Directions, for being satisfied that they give a true and fair view, and for such internal control as the Accountable Officer determines is necessary to enable the preparation of financial statements that are free from material misstatement, whether due to fraud or error.

Appendix C

Audit opinion - draft

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In preparing the financial statements, the Accountable Officer is responsible for assessing the CCG’s ability to continue as a going concern, disclosing, as applicable, matters related to going

concern and using the going concern basis of accounting unless they have been informed by the relevant national body of the intention to dissolve the CCG without the transfer of its services to another public sector entity.

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

The Audit, Risk and Scrutiny Committee is Those Charged with Governance. Those charged with governance are responsible for overseeing the CCG’s financial reporting process.

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: www.frc.org.uk/auditorsresponsibilities. This description forms part of our auditor’s report.

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

Report on other legal and regulatory requirements – Conclusion on the CCG’s arrangements for securing economy, efficiency and

effectiveness in its use of resources

Matter on which we are required to report by exception - CCG’s arrangements for

securing economy, efficiency and effectiveness in its use of resources

Under the Code of Audit Practice, we are required to report to you if, in our opinion we have not been able to satisfy ourselves that the CCG has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources for the year ended 31 March 2019.

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

Responsibilities of the Accountable Officer

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

Auditor’s responsibilities for the review of the CCG’s arrangements for securing

economy, efficiency and effectiveness in its use of resources

We are required under Section 21(1)(c) and Schedule 13 paragraph 10(a) of the Local Audit and Accountability Act 2014 to be satisfied that the CCG has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources and to report where we have not been able to satisfy ourselves that it has done so. We are not required to consider, nor have we considered, whether all aspects of the CCG's arrangements for securing economy, efficiency and effectiveness in its use of resources are operating effectively.

We have undertaken our review in accordance with the Code of Audit Practice, having regard to the guidance on the specified criterion issued by the Comptroller and Auditor General in November 2017, as to whether in all significant respects, the CCG had proper arrangements to ensure it took properly informed decisions and deployed resources to achieve planned and sustainable outcomes for taxpayers and local people. The Comptroller and Auditor General determined this criterion as that necessary for us to consider under the Code of Audit Practice in satisfying ourselves whether the CCG put in place proper arrangements for securing economy, efficiency and effectiveness in its use of resources for the year ended 31 March 2019, and to report by exception where we are not satisfied.

Appendix C


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


DRAFT

23

We planned our work in accordance with the Code of Audit Practice. Based on our risk assessment, we undertook such work as we considered necessary to be satisfied that the CCG has put in place proper arrangements for securing economy, efficiency and effectiveness in its use of resources.

Report on other legal and regulatory requirements – CertificateWe certify that we have completed the audit of the financial statements of NHS Liverpool CCG in accordance with the requirements of the Local Audit and Accountability Act 2014 and the Code of Audit Practice.

Use of our report

This report is made solely to the members of the Governing Body of the CCG, as a body, in accordance with Part 5 of the Local Audit and Accountability Act 2014. Our audit work has been undertaken so that we might state to the members of the Governing Body of the CCG those matters we are required to state to them in an auditor’s report and for no other purpose.

To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the CCG and the members of the Governing Body of the CCG, as a body, for our audit work, for this report, or for the opinions we have formed.

Signature

Andrew Smith

for and on behalf of Grant Thornton UK LLP, Local Auditor

Liverpool

Date TBC

Appendix C


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DRAFT

© 2019 Grant Thornton UK LLP. All rights reserved.

‘Grant Thornton’ refers to the brand under which the Grant Thornton member firms provide assurance, tax and advisory services to their clients and/or refers to one or more member firms, as the context requires.

Grant Thornton UK LLP is a member firm of Grant Thornton International Ltd (GTIL). GTIL and the member firms are not a worldwide partnership. GTIL and each member firm is a separate legal entity. Services are delivered by the member firms. GTIL does not provide services to clients. GTIL and its member firms are not agents of, and do not obligate, one another and are not liable for one another’s acts or omissions.

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Ref: MB/lh/Final Letter of Representation 2018/19

NHS Liverpool Clinical Commissioning Group The Department

2 Renshaw Street Liverpool

L1 2SA Tel: 0151 247 6422

Email: [email protected] 24 May 2019

Grant Thornton UK LLP Royal Liver Building LIVERPOOL L3 1PS

Dear Sirs

NHS Liverpool CCG Financial Statements for the year ended 31 March 2019

This representation letter is provided in connection with the audit of the financial statements of NHS Liverpool CCG for the year ended 31 March 2019 for the purpose of expressing an opinion as to whether the financial statements give a true and fair view in accordance with International Financial Reporting Standards and the Department of Health and Social Care Group Accounting Manual 2018-19.

We confirm that to the best of our knowledge and belief having made such inquiries as we considered necessary for the purpose of appropriately informing ourselves:

Financial Statements

As CCG Governing Body members, we have fulfilled our responsibilities, as set out in the terms of the audit contract dated 16 December 2016, for the preparation of the financial statements in accordance with the Department of Health and Social Care Group Accounting Manual 2018-19 (GAM) and International Financial Reporting Standards which give a true and fair view in accordance therewith.

i. We have fulfilled our responsibilities for ensuring that expenditure and income areapplied for the purposes intended by Parliament and that the financial transactions inthe financial statements conform to the authorities which govern them.

ii. We have complied with the requirements of all statutory directions affecting the CCGand these matters have been appropriately reflected and disclosed in the financialstatements.

PA: Lynne Hill [email protected]

Tel: 0151 296 7195

GB 30b-19 (ii)

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mailto:[email protected]

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iii. The CCG has complied with all aspects of contractual agreements that could have a material effect on the financial statements in the event of non-compliance. There has been no non-compliance with requirements of the Care Quality Commission or other regulatory authorities that could have a material effect on the financial statements in the event of non-compliance.

iv. We acknowledge our responsibility for the design, implementation and maintenance of internal control to prevent and detect fraud.

v. Significant assumptions used by us in making accounting estimates, including those measured at fair value, are reasonable.

vi. We are satisfied that the material judgements used in the preparation of the financial statements are soundly based, in accordance with International Financial Reporting Standards and the GAM, and adequately disclosed in the financial statements. There are no other material judgements that need to be disclosed.

vii. Except as disclosed in the financial statements:

a. there are no unrecorded liabilities, actual or contingent

b. none of the assets of the CCG has been assigned, pledged or mortgaged

c. there are no material prior year charges or credits, nor exceptional or non-recurring items requiring separate disclosure.

viii. Related party relationships and transactions have been appropriately accounted for and disclosed in accordance with the requirements of International Financial Reporting Standards and the GAM.

ix. All events subsequent to the date of the financial statements and for which International Financial Reporting Standards and the GAM requires adjustment or disclosure have been adjusted or disclosed.

x. We have considered the adjusted misstatements, and misclassification and disclosures changes schedule included in your Audit Findings Report. The financial statements have been amended for these misstatements, misclassifications and disclosure changes and are free of material misstatements, including omissions.

xi. We have considered the unadjusted misstatements schedule included in your Audit Findings Report. We have not adjusted the financial statements for these misstatements brought to our attention as they are immaterial to the results of the CCG and its financial position at the year-end. We confirm that all other accruals included within the financial statements are in line with accounting policies, are fairly stated and are appropriately calculated based on the information available to the CCG.

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The financial statements are free of material misstatements, including omissions.

xii. In calculating the amount of expenditure to be recognised in the financial statements from other NHS organisations we have applied judgement, where appropriate, to reflect the appropriate amount of expenditure expected to be incurred by the CCG in accordance with the International Financial Reporting Standards and the GAM.

xiii. Actual or possible litigation and claims have been accounted for and disclosed in accordance with the requirements of International Financial Reporting Standards and the GAM.

xiv. We acknowledge our responsibility to participate in the Department of Health and Social Care's agreement of balances exercise and have followed the requisite guidance and directions to do so. We are satisfied that the balances calculated for the CCG ensure the financial statements and consolidation schedules are free from material misstatement, including the impact of any disagreements.

xv. We have no plans or intentions that may materially alter the carrying value or classification of assets and liabilities reflected in the financial statements.

xvi. We confirm that the financial statements have been properly considered and approved by an appropriate body in accordance with the CCG constitution.

Information Provided

xvii. We have provided you with:

a. access to all information of which we are aware that is relevant to the preparation of the financial statements such as records, documentation and other matters;

b. additional information that you have requested from us for the purpose of your audit; and

c. unrestricted access to persons within the CCG from whom you determined it necessary to obtain audit evidence.

xviii. We have communicated to you all deficiencies in internal control of which management is aware.

xix. All transactions have been recorded in the accounting records and are reflected in the financial statements.

xx. We have disclosed to you the results of our assessment of the risk that the financial statements may be materially misstated as a result of fraud.

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xxi. We have disclosed to you all information in relation to fraud or suspected fraud that we are aware of and that affects the CCG and involves:

a. management;

b. employees who have significant roles in internal control; or

c. others where the fraud could have a material effect on the financial statements.

xxii. We have disclosed to you all our knowledge of any allegations of fraud, or suspected fraud, affecting the CCG’s financial statements communicated by employees, former employees, regulators or others.

xxiii. We have disclosed to you all known instances of non-compliance or suspected non-compliance with laws and regulations whose effects should be considered when preparing financial statements.

xxiv. We have disclosed to you the identity of all of the CCG’s related parties and all the related party relationships and transactions of which we are aware.

xxv. We have disclosed to you all known actual or possible litigation and claims whose effects should be considered when preparing the financial statements.

Annual Report

The disclosures within the Annual Report fairly reflect our understanding of the CCG’s financial and operating performance over the period covered by the financial statements.

Governance Statement

We are satisfied that the Governance Statement fairly reflects the CCG’s risk assurance framework and we confirm that we are not aware of any significant risks that are not disclosed within the Governance Statement.

Approval

The approval of this letter of representation was minuted by the CCG’s Governing Body at its meeting on 24 May 2019.

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Yours faithfully

Name…………………………………….

Position(Chair)………………………….

Date…………………………………….

Name…………………………………..

Position (Accountable Officer)………………………….

Date……………………………….

Signed on behalf of the Governing Body

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Suggested Questions for Governing Body members reviewing the Annual Accounts CCG Response

Statement of Comprehensive Net Expenditure

CCGs receive funding from parliament, so that whilst accounting standards require a statement of comprehensive income the Department of Health Group - Group Accounting Manual (GAM) requires a statement of comprehensive net expenditure (SOCNE) instead. The SOCNE shows all amounts spent by the CCG in year less any income received for goods or services to other organisations.

Do the figures appear reasonable based on financial reports to the governing body throughout the year? In particular, does the CCG's performance against its financial targets agree with your expectations

Financial Planning information was discussed with the Governing Body at the start of the financial year 2018/19. A monthly summary of the financial position has been reported to Governing Body throughout the financial year which describes performance against the CCG notified programme and running cost allocations; achievement of planned surplus and non recurrent requirements. Monthly financial monitoring reports have been provided to the Finance, Procurement and Contracting Committee.

Do you understand the reasons for any significant differences from the comparative figures for the prior year? Where there is no significant movement year on year, are you satisfied that this is what is expected?

Explanation for significant movements in the statement of comprehensive net expenditure and the statement of financial position are provided in Appendix 1 to this report.

If the CCG has been involved in a transfer of functions in year, is there a reported net gain or loss on transfers by absorption? Is this as anticipated? Not Applicable - no transfers in year.There are rows in the SOCNE which CCGs would not be normally expected to use. If these are included in the CCG's SOCNE and are not showing as zero or a small number, do you understand why the CCG's activities differ from the norm? Nothing reported in rows within the SOCNE which would not be expected to be used.If the CCG has exceeded the resources (revenue, capital and administration) specified in directions by NHS England do you understand why? Are you satisfied with the plans in place to ensure the CCG meets these targets in the following period? Do you understand the consequences of exceeding these targets? The CCG did not exceed resource targets and achieved the planned break even position.If the CCG has failed to pay at least 95% of NHS or non NHS invoices within the target period do you understand why? Are you satisfied with the plans in place to ensure its invoices are paid as they fall due in the following period?

In 2018/19 the CCG achieved the 95% target for NHS and Non NHS invoices by value and target. The Finance team continues to work with Shared Business Services and Provider organisations to ensure prompt resolution to processing queries.

Statement of Financial PositionThe statement of financial position (SOFP) represents the financial position of the CCG at a specific date - 31st March 2019

Do the figures appear reasonable based on the financial reports to the governing body throughout the year?

A monthly summary of the financial position has been reported to Governing Body throughout the financial year which describes performance against the CCG notified programme and running cost allocations; achievement of planned break-even position and non recurrent requirements. Monthly financial monitoring reports which include the SOFP have been provided to Finance, Procurement and Contracting Committee.

Do you understand the reasons for any significant differences from the comparative figures for the prior year? Where there is no significant movement year on year. Are you satisfied that this is what is expected?


If there are balances which a CCG would not normally be expected to have, do you understand why this CCG is different? No unexpected balances

If receivables have increased significantly, are you satisfied that the CCG's credit control systems are operating effectively?


If payables have increased significantly, is the CCG having difficulties paying its payables? (Refer also to its performance against the Better Payments Practice Code)


Where provisions are significant, has the CCG factored future payment into its cash flow forecasts? No provisions for the financial year 17/18 and 18/19If the CCG does not have any significant provisions, are you satisfied that it has adequately considered any potential liabilities? Potential Liabilities are considered by the senior finance team, no significant liabilities identified.If an "other reserve" has been created are you aware that the CCG has had approval for this from NHS England and the Department? Not ApplicableHas the governing body considered whether the CCG is likely to continue in its current form for at least 12 months from the date of the SOFP and where there are material uncertainties have they been adequately disclosed in the accounts?

Going Concern assessment has been considered and a paper was provided to ARSC on 26 February 2019 outlining the reasons why the CCG considers itself to be a going concern. No Material Uncertainties have been identified following this review.

Statement of Changes in Taxpayers Equity

The statement of changes in taxpayers' equity (SOCITE) shows the movement in reserves and general fund in the financial year. The statement shows funding from parliament for the year.

If there is a prior period adjustment, has the reason for it been explained clearly to you and disclosed in the accounts? Not ApplicableIf there are significant balances where this is likely to be unusual, do you understand why this is the case? No unusual significant balances

Statement of Cash Flows

The statement of cash flows (SOCF) shows the actual cash flowing into and out of the CCG during the financial year. The statement starts with the SOCNE and lists the adjustments required to bring this back to the cash paid out or received in year.

Does the CCG end of year cash flow position correspond with that reported during the financial year?

Cash balance reduced to minimal levels at 31 March 2019 - in year cash levels have been reduced to comply with NHS England requirements

Do the figures appear reasonable based on other entries in the accounts? (For example, if there has been a significant rise in payables is this evident in the cash flows from operating activities?)


Are there any items that are not clearly explained which may indicate that they have been included only to ensure the net increase/ decrease in cash and cash equivalents agrees with the movement in the SOFP? Not Applicable

GB GB 30b-19 (iii)

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Accounting PoliciesAre you aware of any departures from the accounting policies set by NHS England? If so has the CCG received approval from NHS England? There have been no departures from the accounting policies set by NHS EnglandIf there have been any changes in applicable accounting policies this year, are you clear about the impact on the CCG's accounts? Have they been considered by the audit committee?

The accounting policies were noted by the Audit, Risk and Scrutiny Committee at the meeting on 26 Feb 2019.

Do the accounts set out clearly the key assumptions you are aware that management has made when preparing them?

Regular meetings between Audit Committee Chair, Accountable Officer and Chief Finance and Contracting Officer throughout the year. Organisational risks detailed in the annual report.

Do the accounts set out the key assumptions you are aware that management has made when preparing them and also any associated uncertainty in significant figures?

Critical judgements in applying Accounting Policies and Key sources of estimation uncertainty have been disclosed on the Accounting policies and have been applied in line with the GAM. These are used when the carrying amounts of assets and liabilities are not readily apparent from other sources.

Employee BenefitsDo you understand the reasons for any significant movements in employee benefits and/ or staff? See appendix 1 for movements in employee benefitsDoes the change in staff numbers or mix make sense in relation to any changes in overall employee benefits? See appendix 1 for movements in employee benefits

Do the disclosures for termination benefits, sickness absence and ill-health retirements make sense in relation to your knowledge of activity in these areas during the year?

The CCG is directed by NHSE to publish the Staff Sickness results which they have obtained from ESR. These can vary from sickness data provided by the CCG HR department given that we have Governing Body and clinical lead members on payroll. However, for consistency in consolidating the figures nationally, we are required to publish the figures provided centrally.

Operating Expenses

Does the analysis of expenditure appear reasonable to you based on your understanding of the CCG's operations?

A monthly summary of the financial position has been reported to Governing Body throughout the financial year. Regular Financial monitoring reports have been provided to Finance, Procurement and Contracting Committee.

Do you understand the reasons for any significant differences from the comparative figures for the prior year? Do you also understand the reasons for a lack of significant movement year on year?


Do you know the main elements of 'other' expenditure? Details of other expenditure is included in Appendix 1

Does the CCG operate from premises owned by NHS Property Services Ltd? Is the related expenditure shown under "premises"

No - Liverpool CCG headquarters are rented from a private landlord, however the CCG do pay for services and a small number of VOID properties owned by NHS Property Services Ltd and Community Health Partnerships Ltd.

Does expenditure on significant contracts, for example the contract held with the commissioning support unit look reasonable and is it consistent with what you know? YesTrade and other receivables

Does the analysis of trade and other receivables appear reasonable to you?Explanation for significant movements in the statement of comprehensive net expenditure and the statement of financial position are provided in Appendix 1 to this report.

Other than in the first year of operation, do you understand the reasons for any significant differences from the comparative figures for the prior year?


Did the agreement of balances exercise identify any significant differences between what the CCG is reporting and the equivalent figures reported by the counterparty? If so, are you satisfied with what is being done to reconcile them? Variance reports have been provided by NHS England - work is ongoing to eliminate discrepanciesTrade and other payables

Does the analysis of trade and other payables appear reasonable to you?Payable balances include accruals for invoices relating to 2018/19 - the main balances are - Prescribing accruals for Feb and March 2019 - £14.3m & NHS accruals - £9.5m

Other than in the first year of operation, do you understand the reasons for any significant differences from the comparative figures for the prior year?


Did the agreement of balances exercise identify any significant differences between what the CCG is reporting and the equivalent figures reported by the counterparty? If so, are you satisfied with what is being done to reconcile them? Variance reports have been provided by NHS England - no significant unadjusted issues remain.Losses and Special PaymentsDoes the number and value of losses and special payments agree with your expectations based on reports through the year? No Losses have occurred in 18/19 financial year. Losses register is reported to ARSC regularlyEvents after the reporting periodIs the information in this note consistent with your understanding of key events since the year end? No significant events after the reporting period identified.

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Appendix 1 2018/19 2017/18 Variance Variance Comments£'000 £'000 £'000 %

Gross employee benefitsEmployee benefits excluding governing body members

7,441 7,632 191- -3%Reduction in head count as a result of some vacancies not being filled and changes to SMT in year.

Executive governing body members

499 573 74- -13%

Changes in governing body in prior year had led to cross over in membership joining and leaving and increased costs in 17/18. This has meant that figures has subsequently reduced for CY.

Total gross employee benefits 7,940 8,205 265- -3%

Purchase of goods and services

Services from other CCGs and NHS England

2,525 2,818 293- -10%

Majority of the value in 17/18 related to a recharge from Halton CCG for the safeguarding nurses, but in 18/19 they became part of LCCG staffing costs so their budget costs is now in payroll. Additional costs in 18/19 for Addition PUPOC reviews

Services from foundation trusts

342,029 256,516 85,513 33%

Main variances are as follows:All Community services provided by Liverpool Community Services NHS Trust in 2017/18 transferred to Mersey Care NHS Foundation Trust as of 01/04/18. (£65,790k)£2.5m of LCH trust Non Core Services consolidated into Alder Hey FT SLA Baseline for 2018/19.2018/19 SLA £1.86m higher in value than in 2017/18. 17/18 non contract spend included £1m of Acute A&E MH Liaison, funded by national allocation. (£1,613K)CHESH/WIRRAL PART NHSFT :2018/19 £135k Liverpool ADHD - Service Transition. £70k increase in ADHD Drugs chargeable in 18/19 to 52161051. £811 increase in allocation funding in 18/19 for Perinatal Mental Health.

Services from other NHS trusts

261,115 337,144 76,029- -23%

Main variances are ad follows:£2.5m of LCH trust Non Core Services consolidated into Alder Hey FT SLA Baseline for 2018/19.All Community services provided by Liverpool Community Services NHS Trust in 2017/18 transferred to Mersey Care NHS Foundation Trust as of 01/04/18. This includes main SLA (52161051) and all non contract services (52161053) such as Podiatry. (£65,790k) RLBUHT: 2018/19 SLA £8.97m higher in value than in 2017/18 which includes £2.2m of LCH Non Core services and £1.2m Liverpool Diabetes Programme. RLUHT received a non recurrent payment of £3.502m towards EPR programme in 17/18. LCCG also settled on a £1.539m creditor payment in 2017/18. Non Contract 18/19 spend (52161017) includes non recurrent Winter pressures commitment of £400k and an increase in AQP spend of £152k.

Services from Other WGA bodies - - - #DIV/0! no significant movements

Purchase of healthcare from non-NHS bodies

119,772 106,497 13,275 12%

From: Independant/private organisations:1) Community services: significant increases in non nhs provider expenditure in 2018/19 including: 1] Spadmedica £210k, 2] BPAS £230k, 3] Specsvers £120k, 4] All other and AQP £166k.2) CHC: Although the number of CHC Packages has remained consistent over the period the average cost of a package has increased by an average of 21% compared to 2017-18. This suggests the complexity of care being provided has increased. The 2018-19 financial position reflects the annual rate increase to providers in line with LCC rates (ranging between 2% to 5.3%.)3) PHBs: No of PHB's increased from 28 PHBs in 2017-18 to 52 PHB's in 2018-19, of which 7 PHBs ended in 2018-194) CAAMHs increase of £716k - green paper project and waiting times initiative.5) Long Term conditions - Digital projects following succeful ETTF funding approvalVoluntary/not for profit:Increase spread over all categories, £418k in maternity BPAS, not coded to voluntary in PY, £400k increase in CHC, £500k increase in Mental HealthLocal Authorities:FNC: Overall reduction in Funded Nursing Care packages by 176 (26%) which increased slightly to the year end to 122 (19%) compared to 2017-18 outturn. The FNC rate increase in 2018-19 is 2%Devolved:Increase in A&E NCAs in year from Devolved administrations in Scotland and Wales

Prescribing costs85,268 89,743 4,475- -5% NCSO pressure in 17/18 which has subsequently fallen in 18/19

Pharmaceutical services 155 - 2,111 2% Not Dispensed Scheme commissioned in 18/19

GPMS/APMS and PCTMS

88,606 86,495 2,111 2%

Variances include: Public health LES recharged now correctly coded as a reduction in expenditure (prior year, this was an increase to inc/expenditure with nil impact). Changes in list sizesPrimary Care one off paymentPractice transformation is no longer funded (£-2,372k)Extended access commissioned in 18/19 (£1,443k)Inflation, list size growth and nationally set pay upliftLocum actuals lower in 18/19Increase in premises costsdisinvestment in seniority taking place nationally (£3,497k) Gp Forward View allocation received in 18/19 of £2.2m compared to £87k in 17/18

Supplies and services – general1,852 821 1,031 126%

Increases is in line with GMS / PMS increases, adhoc increases and changes in list sizes

Consultancy services

10 152 142- -93%

A one off external consultancy cost requested from NHS E in 17/18 for PWC not expected in current year, in addition, review of consultancy services identified that all spend in year was for Professional fees therefore adjustment made.

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Establishment

6,953 5,938 1,015 17%

£19k One off printing costs re the Health Action/PCC Dispersal £20k Aimes (digital)Costs(£267k) Indemnity fees are no longer funded£71k one off "Repeat prescribing" mailing was sent in year.ALTAS (CLARHC) expenditure higher in 2017/18 compared to 18/19.Increased spend in direct correlation to increased income under GPIT bids for 18/19. See increased revenue below.

Transport39 26 13 50%

More transport costs for staff in current year including flights regarding digital programmes and overseas events

Premises

7,557 7,780 223- -3%

Rent was accrued on the basis of a 10 year straight line depreciation, accumulated rent was shown in 17/18 (£548k)The FOT reflects an increase in sessional space for 18/19 and also some prior yr. cost pressures of circa £80k. An updated review of FOT follows meetings with CHP and NHSPS.

Audit fees65 65 - 0% reduction as a result of Audit tender exercise in year and reduction in fees agreed

Other non statutory audit expenditure· Internal audit services - - - 0% n/a

· Other services10 - 10 0%

NHS E have requested that assurance is received for the Mental Health Investment Standard for 18/19 and comparative figures. This is expected to take place in the summer.

Other professional fees excl. audit

528 289 239 83%

9 additional days for support for Stoma/Catheter Pilot and additional Stoma and Catheter projects that weren’t commissioned in 17/18 but commissioned in 18/19, Work commissioned in 18/19 for urgent care engagement project that wasn’t commissioned in 17/18 and Additional assessments commissioned in 2018/19 for CCG PuPOC review (excluded from MLCSU SLA)

Legal fees 159 158 1 -67% no significant movementsEducation and training 351 337 14 4% no significant movementsCHC Risk Pool contributions - - - #DIV/0! n/a - no costs expected for 18/19 as agreed with NHS England

Total Purchase of Goods and services 916,994 894,779 24,171 3%

Other Operating ExpenditureChair and lay membership body and governing body members

763 1,068 305- -29%Reduction as a result of changes to structure of gov body, and members pay. In addition, less overlap in starters and leavers than prior year.

Grants to Other bodies 270 813 543- -67% 3rd year grants cycle ended in prior year.Clinical negligence - - - 0% no significant movements

Research and development (excluding staff costs)2,878 2,569 309 12%

Increase in spend is in line with increased income for the CLAHRC research programme. Programme spend profile indicates increased spend in final year (18/19).

Non cash apprenticeship training grants16 5 11 -87%

additional apprentices joined scheme in current year therefore increased costs from levy

Other expenditure 17 127 110- -87% One off costs in 17/18 relating to C/M 5 year FWD view from Alder Hey

Total other operating expenditure 3,944 4,582 638- -14%Total operating expenditure 920,938 899,361 23,533 3%

36

2018/19 2017/18 Variance Variance Comments£'000 £'000 £'000 %

RevenueEducation, training and research - 67 67- -100% one off career engagement hub income in 17/18 - non expected in 18/19Charitable and other contributions to revenue expenditure: NHS - - - 0% no significant movementsCharitable and other contributions to revenue expenditure: non-NHS - - - 0% no significant movements

Non-patient care services to other bodies

36,815 34,654 2,161 6%

Additional income received in CY for CLARHC, GPIT, Transforming care programme and perinatal.STP money income recharged this year (£990k)Public health LES recharged now correctly coded as a reduction in expenditure (£576k)Increase in Digital bids.

Non cash apprenticeship training grants revenue 16 5 11 220% additional line per 17/18 final GAM

Other Contract income682 - 682 #DIV/0!

Changes to IFRS 15 has meant Revenue previously accounted at Other non contract income, has been reanalysed for the current year to other contract income

Other revenue - 1,127 1,127- -100% see above explanation for movement

Total 37,513 35,853 1,660 5%2018/19 2017/18 Variance Variance Comments

£'000 £'000 £'000 %

Trade and Other ReceivablesCCG

NHS receivables: Revenue 4,876 1,956 2,920 149%£4,071k of sales invoices non yet paid from NHS E regarding ETTF, GPIT digital bids and CEA recharge. (now received)

NHS prepayments - 669 669- -100% EPR prepayment to LWH in the prior year. Non at 18/19 year end.

NHS accrued income - 159 159- -100%Due to IFRS 15, NHS accrued income in 18/19 is now classified as NHS Contract receivable not yet invoiced/non-invoice

NHS Contract Receivable not yet invoiced/non-invoice 182 - 182 #DIV/0! Accrued income in respect Oakvale gardens recharges

Non-NHS and Other WGA receivables: Revenue 3,135 973 2,162 222%

£2,038k increase in receivable balances with from LCC (£1.3mBCF income from LCC, £283k CEDAS, £1.3m LCC for OAT and joint funded recharges) - prior year, more recharges held as accruals than sales invoices.

Non-NHS and Other WGA prepayments 500 219 281 128%

Various prepayments including £249k prepaid for PHBs, £154k support accommodation, £118k council tax £48k advice on prescription. PHB was not included in prepayments in prior year.

Non-NHS and Other WGA accrued income - 1,633 1,633- -100%Due to IFRS 15, Non-NHS accrued income in 18/19 is now classified as Non-NHS Contract receivable not yet invoiced/non-invoice

Non-NHS Contract Receivable not yet invoices/non-invoice 923 - 923 #DIV/0!

All receivable from the LCC. Change in prior year as a result of more invoices being raised in 18/19 and therefore included in Receivables above. £643 for S75 recharge, £22k your life your way and £241k paisley court recharge. LCC CEDAS contribution of £997k accrued in 17/18, already paid in 18/19

VAT 97 87 10 11% no significant movementsOther receivables and accruals - - - #DIV/0! no significant movements

Total CCG 9,713 5,696 4,017 71%2018/19 2017/18 Variance Variance Comments

£'000 £'000 £'000 %

Trade & Other Payables

NHS payables: Revenue 6,688 5,688 1,000 18%

Largest balances with Alder hey (£445k) Wirral Uni (£326k) Clatterbridge (£542k), Mersey care (£858k) Royal Liverpool BUHT (£798k) Walton centre (129k) NW Ambulance £331k Cheshire and Wirral £166k , Southport/Ormskirk £205k - in line with AOB exercise. variance from prior year due to more invoices being raised in current year end than PY.

NHS accruals 2,906 3,849 943- -24%

Largest balances with: RLB £967k, Mersey care £419k, Walton £356k, liv heart and chest £217k, Alder hey £205k, KNOWSLEY CCG £159k. Variance from prior year due to more invoices being raised in cy therefore less accruals needed manually.

Non-NHS and Other WGA payables: Revenue 7,609 9,371 1,762- -19%Largest balances with Liverpool city council £125k, CHP £541k, prop co £492k greater Glasgow and Clyde £161k and movement between accrued / invoiced

Non-NHS and Other WGA accruals 32,931 19,871 13,060 66%

Largest balances prescribing accrual increase of £400k £2.4m Children's JIMG (non in 17/18)£4m accruals for ETTF payments - non in 17/18 due to timing of the bids.£891k BCF LCC accruals in PY, invoiced in current yearGP dispersal funding accruals of £1.5m not included in 17/18.

Non-NHS and Other WGA deferred income 35 6 29 0% no significant movementsSocial security costs 105 106 1- -1% no significant movementsTax 94 92 2 2% no significant movements

Other payables and accruals 2,543 2,862 319- -11%Pension £796k (reduction of £308k from prior year) Digital accruals £730k (timing of the bids later this year, £547k GVA rent and £125k STP monies to 3rd sector

Total CCG 52,911 41,845 11,066 26%

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ANNUAL REPORT

NHS Liverpool CCG

Annual Report and Accounts 2018/2019

(NB: Front and back covers to be added into final version) 22 May 2019

GB 30b-19 (vi) & (v)

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Contents 1. Performance Report 1.1 Welcome and Introduction 5 1.2 Member Practices Introduction 8 1.3 Introduction to NHS Liverpool CCG 9 1.3.1 Introduction 9 1.3.2 Details of Governing Body Members and Staffing 10 1.3.3 Clinical Commissioning Group Profile 11 1.3.4 Commissioning Landscape 15 1.4 Overview Summary 18 1.5 Purpose and Activities of the Organisation 18 1.6 Key Issues and Risks 20 1.7 Performance Summary 22 1.8 Performance Analysis 26 1.9 Performance Measures 32 1.10 Financial Performance 33 1.11 CCG Improvement and Assurance Framework (IAF) 2018/2019 37 1.11.1 Better Health Indicators 37 1.11.2 Better Care Indicators 38 1.12 Friends and Families Test 39 1.13 Outcomes Framework and Local Indicators 41 1.14 Sustainable Development 41 1.15 Patient and Public Involvement 43 1.16 Improve Quality 48 1.17 Reducing Health Inequality 52 1.18 Health and Wellbeing Strategy 54 1.19 Better Care Fund 54

Case Studies:

NHS National Diabetes Prevention Programme 57

GP Extended Access 58

Liverpool Stroke Partnership 59

NHS App 60

NHS Bowel Screening 62

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2. Accountability Report 2.1 Members Report 63 2.1.1 Member Practices 63 2.1.2 Chair and Accountable Officer 65 2.1.3 Composition of the Governing Body 65 2.1.4 Committee(s), Including Audit Committee 66 2.1.5 Register of Interests 66 2.1.6 Personal Data Related Incidents 67 2.1.7 Statement of Disclosure to Auditors 67 2.1.8 Modern Slavery Act 68 2.2 Statement of Accountable Officer’s Responsibilities 68 2.3 Governance Statement 70 2.3.1 Introduction and Context 70 2.3.2 Scope of Responsibility 70 2.3.3 Governance Arrangements and Effectiveness 70 2.3.4 UK Corporate Governance Code 75 2.3.5 Discharge of Statutory Functions 75 2.3.6 Risk Management Arrangements and Effectiveness 75 2.3.7 Capacity to Handle Risk 75 2.3.8 Risk Assessment 76 2.3.9 Other Sources of Assurance 79 2.3.9.1 Internal Control Framework 79 2.3.9.2 Annual Audit of Conflicts of Interest Management 80 2.3.9.3 Data Quality 81 2.3.9.4 Information Governance (Including Data Security) 81 2.3.9.5 Business Critical Models 82 2.3.9.6 Third Party Assurance 82 2.3.10 Control Issues 82 2.3.11 Review of Economy, Efficiency and Effectiveness of Use of Resources 82 2.3.12 Delegation of Functions 83 2.3.13 Counter Fraud Arrangements 83 2.3.14 Head of Internal Audit Opinion 84 2.3.15 Emergency Preparedness, Resilience and Response 85 2.3.15.1 Accountable Officer EPRR Self-Certification 86 2.3.16 Principles Of Remedy 86 2.3.17 External Audit 86 2.3.18 Review of the Effectiveness of Governance, Risk Management and Internal 86

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Control 2.3.19 Conclusion 88 Remuneration Report 89 2.4 Remuneration and Staff Report 89 2.4.1 Introduction 89 2.4.2 Remuneration Committee 89 2.4.3 Appraisal of Chair and Chief Officer 89 2.4.4 Governing Body Members 89 2.4.5 Policy on The Remuneration of Senior Managers 90 2.4.6 Remuneration of Very Senior Managers 90 2.4.7 Pension Benefits as at 31st March 2018 92 2.4.8 Compensation on Early Retirement or for Loss of Office 93 2.4.9 Payments to Past Members 93 2.4.10 Pay Multiples 93

Staff Report 93 2.4.11 Number of Senior Managers 93 2.4.12 Staff Numbers and Costs 93 2.4.13 Staff Composition 94 2.4.14 Staff Absence Data 95 2.4.15 Staff Policies 95 2.4.16 Employee Consultation and Engagement 96 2.4.17 Expenditure on Consultancy 97 2.4.18 Off-Payroll Engagements 97 2.4.19 Exit Packages, Including Special (Non-Contractual) Payments 98 2.4.20 Analysis of Other Departures 98 2.4.21 The Trade Union (Facility Time Publication Requirements) Regulations

2017 98

2.5 Parliamentary Accountability and Audit Report 99

Independent Auditor’s Report to the Members of NHS Liverpool Clinical Commissioning Group

100

3 The Financial Statement 2018/2019 104

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1. Performance Report 1.1 Welcome and Introduction Welcome to the 2018/19 NHS Liverpool CCG Annual Report. This year has been one of further change for the CCG, both in terms of leadership and organisational development. I was appointed as permanent Chief Officer from 1st May 2018, from the interim role I had occupied from October 2017. CCG Chair Dr Simon Bowers was not re-elected as a GP Member, which necessitated an election of a new Chair. Dr Fiona Lemmens was elected as Chair by the Governing Body in the summer of 2018. Mark Bakewell, Interim Chief Financial Officer was appointed permanently to the role of Chief Finance and Contracting Officer following a national recruitment process and Jane Lunt was confirmed as Director of Quality, Outcomes and Improvement. Both posts are voting members of the Governing Body. My appointment and the Chair, Executive Directors and three new lay members, paved the way for the Governing Body to think about its future and ambition for the CCG, five years on from establishment, starting the 2018 financial year with new energy and to confirm the CCG’s vision, purpose and values for the years ahead. Over this year the CCG Governing Body has reflected deeply on how it effectively discharges its responsibilities, to uphold and promote quality and safety in all services, to reduce inequality and improve outcomes for the population. Learning from the Kirkup Review into the failings in the care provided by Liverpool Community Health will continue to be a central focus in the year ahead. The CCG remains financially stable, able to meet all our financial duties, despite increasing demand and cost pressures as well as meeting the mental health investment standard in 2018/19. This has been supported by a continuation for the second year of ‘Acting as One’ contracts with our main providers and a focus on efficiency savings in areas such as prescribing, service change and running costs. As Liverpool’s “Place” lead I have been working with leaders in Liverpool to commission and provide services differently, with greater integration and collaboration between organisations and services in order to reduce the long term health inequalities that leave the vulnerable and disadvantaged in our city with a poorer experience of care, fewer years of healthy life and earlier death. In 2018 the CCG co-produced with health and care partners an integrated place-based strategy - One Liverpool - setting out how together we will develop integrated services that respond to population, community and individual needs. One Liverpool is all age, unites primary care, social care, community, physical and mental health services, acute and specialist services and the voluntary and independent sector; harnessing collective efforts to organise care more effectively around three main aims: a radical upgrade in population health and prevention; integrated community services; and sustainable, standardised acute and specialist services.

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New partnership structures and alliances in Liverpool were introduced in 2018/19 to facilitate integration, encourage collaboration between commissioners and providers across organisational boundaries, including commissioning. The Liverpool Integrated Care Partnership Group, established in 2018, is a health and care system partnership of the CCG and Liverpool City Council as the commissioners of health and care services and all the city’s providers, including acute, community, primary care and the voluntary and community sector. This is where the local health and care system will work with a ‘one-team’ ethos to deliver One Liverpool and to shape services for better health, better care and better value for the Liverpool pound. The Liverpool Provider Alliance, brings together Health, Social Care, Third Sector and Housing providers, to translate the One Liverpool strategy into an annual delivery plan, using its collective resources to deliver new, joined up models of care. This year has seen the Provider Alliance embed the Integrated Community Care Teams which include staff from community nursing, social care, mental health, acute outreach and the voluntary and community sector to deliver services organised around the needs of the individual their family and community. These teams are organised into 12 neighbourhood teams, which on the whole reflects the Primary Care networks; groups of GP practices working together to support populations of 30,000 to 50,000 people. This is a new way of working for primary care, coming together with our community teams to better meet the population’s needs. These system developments are breaking down the traditional boundaries between commissioning and provision of health, social and public health. In accordance with this direction of travel Liverpool CCG has re-defined its purpose to become a more strategic commissioner with a focus on improving population outcomes and creating the environment for system integration, with delivery increasingly the responsibility of providers working in collaboration across organisations and all settings of care. The CCG is also working closely with Liverpool City Council to develop Joint Commissioning arrangements, establishing a single commissioning approach for prevention as well as community-based health and care services. In January 2019 the NHS Long Term Plan was published, which sets out how to preserve what’s good about our health service, but also how to tackle the pressures we face and to accelerate the redesign of patient care to future-proof the NHS for the decade ahead. The Long Term Plan aligns closely with One Liverpool, providing assurance that the city’s plans for the future of health and care services are reflective of the national agenda. The CCG continues to work closely with neighbouring CCGs to ensure commissioning is aligned for those services which span the wider North Mersey population and the CCG is a key partner in the Cheshire and Merseyside Health and Care Partnership, collaborating and sharing best practice with commissioners and providers across the whole region. The 2018/19 year began with major uncertainty over the completion of the much needed new Royal Liverpool Hospital, but thankfully ended with the good news that construction work could recommence due to a decision by Government to fund the capital project. The CCG is working closely with the trust to ensure that services remain safe and

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effective during the transition to the opening of the new hospital, which we anticipate will be in 2021. I would like to reflect on the time Dr Simon Bowers led the CCG Governing Body and thank him for his invaluable contribution and commitment to the CCG during his time as a Governing Body member and Chair. Dr Bowers was passionate about the city, it’s residents and health care; he took specific interest in everything digital and children. His infectious energy and enthusiasm was effective medicine during a difficult period for the CCG. I would also like to thank Dr Donal O’Donaghue for his expertise, unflappable style and approach not to mention the wisdom he brought to the Governing Body. He resigned in December in order to take on a national role with the Royal College of Physicians. Finally I would like to thank Ken Perry, Lay Member for patient and public engagement, whilst Ken’s role on the Governing Body was relatively short, his passion for reflective practice and engaging people in a conversation will put the CCG on the right path for the challenges ahead. I would also like to thank CCG staff and the GP membership for their ongoing commitment to improving services for patients. They have demonstrated their resilience and good humour during a significant period of uncertainty and change; however this will make us stronger and able to contend with the future demands and change that will inevitably come. This year the CCG led a number of public conversations, including obtaining views on urgent care services and issues connected with a number of GP Practices. Moving forward as a strategic commissioner, the CCG will scale up its public engagement and promote much greater involvement in shaping services and future priorities. Please let us have your views on the work of the CCG and look out for new ways of getting involved in 2019/20. Jan Ledward Chief Officer

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1.2 Member Practices Introduction The CCG’s success in pursuing its vision and aims is dependent upon comprehensive involvement and consistent support from the GP membership. The CCG recognises the challenges that GPs face in discharging their commissioning responsibilities, in addition to their primary role in providing the best care for patients. We are fortunate to have strong GP representative leadership and good commitment from member practices across the city. The new CCG leadership in place since 2018 and the mutual efforts made to rebuild relationships has brought us to a more positive place from the previous year when confidence in the CCG was adversely affected by governance and decision-making weaknesses, which have now been successfully addressed. Membership engagement has been strengthened this year, including quarterly membership meetings designed to share information, to network and to involve members in influencing the key issues and priorities for the CCG. There has been more concerted effort to understand the views of the membership and to reflect this in the CCG’s future plans. We would like to thank members for their involvement with this work. As GPs on the Governing Body we are committed to continuing to improve engagement with members. The Local Medical Committee (LMC) is playing a central role in representing General Practice in the development of system integration and transformation of services. The LMC Secretary is in attendance at the Governing Body and is a member of the Liverpool Integrated Care Partnership Group and the Liverpool Provider Alliance. The role of general practice is crucial to the success of integrated community services and wider population health which will be enhanced through the development of GP Networks. The CCG is committed to working with its membership to support them in successfully navigating the complexities of their dual roles, both as commissioners and providers of services for our population.

Dr Rob Barnett Secretary, Liverpool Medical Committee

Dr Fiona Lemmens, GP/Liverpool CCG Governing Body Chair

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1.3 Introduction to NHS Liverpool CCG 1.3.1 Introduction Liverpool Clinical Commissioning Group became operational as an NHS Body on 1st April 2013 and as at 31st March 2019 includes 86 GP Member Practices and is co-terminus with the boundaries of Liverpool City Council. The CCG serves a growing registered population of 543,100 and had a resource allocation of £891M for the 2018/19 financial year. During 2018/19 the formal Group Directions which had been imposed by NHS England in 2017 were lifted without condition, following the successful actions taken by the CCG to strengthen the governance and structures of the Governing Body. The accounts in this report have been prepared in accordance with the Department of Health Group Accounting Manual for 2018/19 and associated guidance. The CCG vision, values and strategic objectives are: Our Vision • By 2020, health outcomes for the people within Liverpool will have improved relative

to the rest of England, and health inequalities within Liverpool will have narrowed. • The quality of health care received by Liverpool patients will be consistent and first

class. They will be measured by patient feedback, provider assessment, and external review processes.

• Both will be achieved efficiently within the available resources. Our Values Patient Focused and Outcome Led - We will empower our patients to engage in improving their overall quality of life, to interact in their care plans, and to ensure that no decisions will be made without fully involving patients, both in the planning and monitoring of services.

Partnership and Collaboration - We believe in working in unity, both within our organisation and externally with our partners. We listen to, communicate with, and work effectively with all our partners including membership practices, Trusts, the Local Authority, and Commissioning Support Services.

Locally Focused - We will work through locality and neighbourhood groups to implement and deliver services that meet the needs of our communities.

Progressiveness - We encourage innovation and continuous improvement in all services we commission. We will target our resources in the most effective way to ensure we offer value for money in the services we provide, and equity for patients.

Accountability - We accept responsibility for our actions. We make and support business decisions through experience, evidence and good judgement, and we will deliver against our promises.

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Integrity and Respect - We will act with honesty and transparency in all our actions. We are committed to a teamwork environment, where every member of the CCG is valued, encouraged to contribute and recognised for their efforts. Our Strategic Objectives • To improve health outcomes • To maximise value from our financial resources and focus on interventions that will

make a major difference • To build successful partnerships which promote system working and integrated

service delivery • To hold providers of commissioned services to account for the quality of services

delivered • To effectively engage patients and the public in decision making • To ensure continuous improvement in primary care services The delivery of these strategic objectives has shaped and directed the commissioning strategies and business of the organisation during 2018/19. As a clinically led organisation it is the clinicians and other Governing Body members, informed by and working with member practices and other partners who have then determined the commissioning and investment strategies, transformational and change programme activities during the year. The integration journey being undertaken by the Liverpool health and social care system, reflected in the One Liverpool Strategy, prompted the commencement in 2018/19 of a review of the CCG’s vision, values and objectives, by the Governing Body, staff and stakeholders, which will be completed in 2019/20. 1.3.2 Details of Governing Body Members and Staffing For the year 2018/19 the office of Chair of the CCG was held by Dr Simon Bowers until 31st May 2018 and then by Dr Fiona Lemmens from 1st June 2018. The role of Chief Officer (Accountable Officer) has been held by Jan Ledward. The membership of the Governing Body up to the signing of the Annual Report and Accounts has been as follows: Governing Body Members: Mark Bakewell Chief Finance & Contracting Officer Dr Janet Bliss GP/Clinical Vice Chair (from 11th December 2018) Dr Simon Bowers GP/Chair (until 31st May 2018) Helen Dearden Lay Member Governance / Non-Clinical Vice Chair Dr Paula Finnerty GP North Locality (from 1st June 2018) Gerry Gray Lay Member Financial Management and Oversight Sally Houghton Lay Member / Audit Chair Dr Monica Khuraijam GP Jan Ledward Chief Officer (Accountable Officer)

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Dr Fiona Lemmens GP/Chair Jane Lunt Head of Quality, Outcomes and Improvement/Chief Nurse Professor Donal O’Donoghue

Secondary Care Doctor (until 1st January 2019)

Dr Fiona Ogden-Forde GP Dr Ian Pawson GP (from 1st June 2018) Kenneth Perry Lay Member Patient Engagement Dr Shamim Rose GP Dr Maurice Smith GP Dr Stephen Sutcliffe GP Co-opted Members (non-voting): Tina Atkins Practice Manager Representative Dr Rob Barnett Secretary, Liverpool LMC Cllr Paul Brant Cabinet Member Health and Social Care, Liverpool City

Council Representative Sandra Davies Director of Public Health, Liverpool City Council Dr Paula Finnerty GP North Locality (until 31st May 2018) Dr Jamie Hampson GP Matchworks Locality (until 31st May 2018) Page 71 provides details of the membership of CCG Committees. The Governing Body is not aware of any relevant audit information that has been withheld from the Clinical Commissioning Group’s external auditors, and members of the Governing Body take all reasonable steps to make themselves aware of relevant information and to ensure that this is passed to the external auditors where appropriate. The Governing Body (voting/full members) in post at 31st March 2019 comprises 6 male members and 10 female members. The CCG directly employs a total of 141 staff, comprising 37 male and 104 female (excluding office holders). This number excludes staff seconded from external organisations, agency staff and contractors. For 2018/19 the CCG employed a total of six Very Senior Management (VSM) posts; three of which were male (includes one Governing Body member) and four female (includes two Governing Body members). 1.3.3 CCG Profile The CCG comprises 86 GP Member Practices organised into several Primary Care Networks. Co-terminus with the boundaries of Liverpool City Council, the CCG serves a growing registered population of 543,100 and has an annual budget of £891M. Over the next ten years the largest population increase is predicted in the over 65s (27.1%) and the number of under 15s in the city set to increase by 6.8%. Liverpool is one of the most deprived areas of the country, with more than 4 out of 10 people living in the 10% most deprived neighbourhoods in England. Deprivation is strongly associated with poor health outcomes, from childhood through to old age. People in Liverpool’s more deprived communities begin to experience poor health and require care from a younger age, leading to significant health inequalities between

49

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Liverpool and the UK as well as within the city, where the difference in life expectancy is 10 years between the poorest and most affluent wards. The diagram below sets out the incidence of poor health and wellbeing:

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Reflecting the diverse recent and past history of our maritime city, figures from the 2011 Census indicate that 15.2% of the Liverpool population are from a minority ethnic group i.e. non-white British, equating to almost 71,000 residents. This is slightly higher than the regional average (12.9%), but lower than England (20.2%). The top 8 ethnic minority groups in Liverpool are:

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The CCG operates from headquarters in the Department, 2 Renshaw Street, Liverpool, L1 2SA.

The CCG governance structure can be illustrated as follows:

White (other) 12,272

Black African 8,490

Chinese 7,978

White Irish 6,729

Indian 4,915

Arab 5,629

Pakistani 1,999

Black Caribbean

1,467

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1.3.4 Commissioning Landscape Liverpool CCG is responsible for commissioning community, mental health and secondary care services, along with emergency and patient transport ambulance services, GP out of hours services and the NHS 111 service. The following list highlights hospital, community and mental health providers whose contract value in 2018/19 exceeded £0.5M in value. Acute Hospitals

• Aintree University Hospital NHS Foundation Trust • Alder Hey Children’s NHS Foundation Trust * • Royal Liverpool & Broadgreen University Hospitals NHS Trust * • Liverpool Heart & Chest Hospital NHS Foundation Trust * • Liverpool Women’s NHS Foundation Trust * • St Helens & Knowsley Teaching Hospitals NHS Trust • Southport & Ormskirk Hospitals NHS Trust • Spire Hospital Liverpool, Spire Healthcare Limited * • The Walton Centre NHS Foundation Trust * • Warrington & Halton Hospitals NHS Foundation Trust • Wirral University Teaching Hospitals NHS Foundation Trust • The Clatterbride Cancer Centre NHS Foundation Trust * • Manchester Univiersity NHS Foundation Trust • Wrightington, Wigan & Leigh NHS Foundation Trust Mental Health

• North West Boroughs Partnership NHS Foundation Trust • Mersey Care NHS Trust * • Cheshire & Wirral Partnership NHS Foundation Trust Community Services

• Mersey Care NHS Trust Other

• North West Ambulance Service NHS Trust (ambulance services and NHS 111) • Primary Care 24 Limited (GP out of hours provider) * * Where Liverpool CCG acts as the co-ordinating commissioner The Liverpool health economy infrastructure consists of a unique mix of eight NHS/Foundation Trusts (four of which are ‘specialist’ Trusts that are predominantly commissioned by NHSE Specialist Services), with strong interdependencies and relationships with primary and community providers, independent sector providers and numerous providers accredited under ‘any qualified provider’ (AQP). Liverpool is fortunate to have a wealth of voluntary, community and social enterprise (VCSE) partners and has a diverse but challenged market of nursing, residential home and domiciliary care providers.

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The CCG also has delegated commissioning responsibility from NHS England for primary care medical services for the 86 Practices in the city. In 2018 health and care partners in the city committed to a ‘One Team’ ethos, embodied in an integrated strategy - One Liverpool; setting out how the local health and care system will establish integrated services that respond to population, community and individual needs. In 2018/19 the CCG began to re-shape itself as a strategic commissioner, with an emphasis on improving population outcomes, shaping the environment, population involvement and co-production, and targeting our resources to tackle poor health and inequalities. Our commissioning intentions are also to reduce avoidable demand for health and care services, maximising the value of the Liverpool health and social care pound and supporting people to be healthy for longer. The CCG made a commitment with Liverpool City Council this year to develop joint all-age commissioning across community-based NHS and Social Care services and prevention. At the heart of our joint commissioning intentions is a community model with integrated Community Care Teams which bring together Community Nursing, Primary Care Networks, Social Care, Mental Health, acute outreach and the voluntary and community sector, serving populations of 30-50,000 people, delivering a joined-up approach to the delivery and planning of care. Late in 2017/18 Liverpool was selected as one of 20 systems to undergo a Care Quality Commission (CQC) system review of the interface between health and social care and specifically care delivered across all partnerships to older people. The findings, published in 2018/19, included a number of recommendations that are being implemented, including transforming the ambitious strategic vision for the city into a system-wide operational plan; strengthening relationships to ensure effective partnership working; strengthening system-level governance; supporting more people to access personal budgets and direct payments and improving information flows between services. In 2018/19 the primary care landscape in the city changed, with two providers of APMS services, operating 10 practices, giving notice on their contracts. This left the CCG, as commissioner, responsible for re- procuring these services or dispersing the patients to other GP practices in a way that served the best interest of patients. Despite the challenges of finding solutions at short notice, the CCG engaged with patients and was able to minimise disruption and achieve satisfactory solutions. New governance structures were established in 2018/19 year for integrated commissioning and provision. Health and care partners have established the Liverpool Integrated Care Partnership, involving commissioners and providers, working in collaboration to achieve the ambitions set out in One Liverpool. The Liverpool Provider Alliance, bringing together Health, Social Care, Third Sector, Care Home and Housing providers, has continued to develop and mature. The Provider Alliance is responsible for translating the One Liverpool strategy into delivery, using its collective resources to deliver new, integrated models of care designed to improve the health and wellbeing of our communities.

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A new CCG Joint Committee was established in 2018, comprising the four North Mersey CCGs – Knowsley, Liverpool, South Sefton and Southport and Formby. This committee, with delegated decision-making authority on specific programmes, has been established to enable streamlined and inclusive governance, particularly for acute services reconfiguration across the North Mersey geography. The Joint Committee made its first decision to approve the establishment of a single service for orthopaedics and ENT services across the city’s two adult acute trusts, in line with the One Liverpool vision for a University Teaching Hospital Campus with a single service, system-wide delivery, delivered through centres of clinical and academic excellence. The One Liverpool Strategy can be viewed here: https://www.liverpoolccg.nhs.uk/media/3066/one-liverpool-plan-2.pdf Further details of the city’s health can be found in the Annual Report of the Director of Public Health, Liverpool City Council available at: http://liverpool.gov.uk/council/strategies-plans-and-policies/adult-services-and-health/public-health-annual-report-phar/ During the year the CCG has been an active member of the Liverpool Health and Wellbeing Board. The work of the Board has informed this annual report, including the Accountability Report and in particular the Corporate Governance Report. The Health and Wellbeing Board has been engaged in a wide cross section of health and wellbeing activities and the following illustrates that breadth and some of the key areas considered during 2018/19 meeting cycle: June 2018 • Establishment of the Liverpool Integrated Partnership Group • New Model of Integrated Community Child and Family Services, 2018-2021 • Liverpool Inclusive Growth Plan • One Liverpool Plan • CQC Whole System Review • Better Care Fund 2018/19 July 2018 • Care Homes Needs Assessment • Making Every Contact Count September 2018 • Homelessness and Rough Sleeping Services • Mental Health and Wellbeing Joint Strategic Needs Assessment • Mental Health Awareness Toolkit • Winter Preparedness • Merseyside Fire & Rescue Wellbeing Support November 2018 • Children’s Mental Health and Wellbeing • Student Mental Health and Wellbeing • Liverpool Safeguarding Annual Report • Universal Credit Impact

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http://liverpool.gov.uk/council/strategies-plans-and-policies/adult-services-and-health/public-health-annual-report-phar/

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• 2019 Year of the Environment • Annual Report of the Director of Public Health January 2019 • Adult Safeguarding • Liverpool Domestic Violence & Abuse Strategy March 2019 • Joint Local Area Inspection for Liverpool • Liverpool Integrated All Age Carers Strategy, 2019-2023 • NHS Long Term Plan Liverpool CCG has played a key leadership role across the Health and Care Partnership for Cheshire and Merseyside during 2018/19, with the CCG Chief Officer the senior responsible officer (SRO) for the Liverpool ‘Place’, and a number of other senior staff and clinicians leading or participating in North Mersey, Cheshire and Merseyside work streams. 1.4 Overview Summary This report provided by the Chief Officer (Accountable Officer) sets out the performance of the organisation over the reporting period 2018/19. 1.5 Purpose and Activities of the Organisation NHS Liverpool CCG is a statutory organisation responsible for commissioning health services to meet the needs of the population of Liverpool, including those registered with the city’s 86 general medical practices and people resident in the city not registered with a GP. 2018/19 has been the sixth year of the CCG’s operation. This year saw the permanent appointment of a new Chief Officer and the establishment of a new structure for the executive team, designed to enable the CCG to move forward as a strategic commissioner, focused on system integration and continuing to ensure safe, effective and quality services which meet the local needs of the population and allow the CCG to discharge its statutory duties. During the year the CCG has met all of the required financial duties placed upon it and ends the year having delivered the required in year break even position against its resource allocation in line with it’s control total as set by NHS England. Throughout the year the CCG has sought to work effectively with a wide variety of partners including member GP Practices, commissioning partners - neighbouring CCGs and Liverpool City Council, the Health and Care Partnership for Cheshire and Merseyside, the commissioning regulator - NHS England and the CCGs’ providers. The CCG is committed to an evidence-based approach to commissioning, as well as meaningful engagement and involvement with patients and the population in order to respond to and commission services that meet local needs, improve health outcomes and reduce inequalities within the city and in comparison with other parts of the country.

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Performance in 2018/19 has been challenging with the NHS, both locally and nationally, experiencing increasing demand pressures, which are reflected in the performance summary in this report. A number of significant projects and milestones have been achieved during 2018/19 and the following section summarises some of the key areas of Governing Body business over the last twelve months: In 2018 the formal Governing Body meetings went to a bi-monthly schedule, enabling more time for Governing Body members to be involved in overseeing the CCG’s responsibilities around quality, improvement and financial effectiveness, as well as leading system development and transformation. Key Governing Body Business 2018/19: May 2018 • Continuing Healthcare Policies: Personal Health Budgets (PHBs) and Dispute

Resolution Policy • Continuing Healthcare Retrospective Reviews Update • MP Enquiries, FOIs, Subject Access Requests and Complaints Annual Report

2017/18 • Emergency Preparedness Resilience and Response (EPRR) Annual Report 2016/17 • Establishing a North Mersey Joint Committee of Clinical Commissioning Groups • 2017/18 Audit, Risk and Scrutiny Annual Report

July 2018 • Care Quality Commission (CQC) Local System Review • Changes to CCG Safeguarding arrangements following the Children & Social Care

Act 2017 • Governing Body Assurance Framework Quarter 4 and Final Position 2017/18 • Corporate Risk Register September 2018 • Continuing Healthcare Retrospective Reviews • Governing Body Assurance Framework progress Report Quarter 1 and Quarter 2

(2018/19) • Emergency Preparedness Resilience and Response Assurance 2018/19 • CCG Financial Control, Planning and Governance Self-Assessment

November 2018 • Assisted Conception and Criteria Based Clinical Treatments (CBCT) Policy Review • 2018/19 Operational Plan Month 6 Update • Governing Body Assurance Framework Progress Report: November 2018 • Clinical Leadership and Lay Member Remuneration Framework • Liverpool Community Health Look Back Exercise • Safeguarding Annual Report 2017/18 • Risk Management and Assurance Strategy 2018/19 • Travel Expenses Policy

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January 2019 • Finance Update November 2018 – Month 8 18/19 • CCG Corporate Performance Report Jan 2019 • Continuing Health Care : Previously Unassessed Periods of Care (PUPOCs) • Risk Management

o Governing Body Assurance Framework o Corporate Risk Register Update (January 2019) o Issues Log

March 2019 • Finance Update January 2019 – Month 10 18/19 • CCG Corporate Performance Report March 2019 • 2019/20 Financial Plan • Liverpool Joint Local Area SEND 0-25 Inspection • CCG responsibilities in relation to the new Multi-Agency Safeguarding Arrangements

for Children • Attendance Management Policy • Information Governance Policies • 2018/19 Audit Risk and Scrutiny Committee Annual Report to the Governing Body

Note: in addition to the above, each month the Governing Body receives updates from the Chief Officer, Chief Nurse and Public Health updates; Corporate Performance and Finance reports; minutes from Committee meetings; and there is an open session for questions from the public and staff who are welcome to attend the Governing Body meetings, all of which are held in public. 1.6 Key Issues and Risks Good governance and effective risk management, embedded at all levels of the CCG, are critical to ensuring the organisation can identify and effectively mitigate key risks. An effective assurance framework is a fundamental component of good governance, providing a tool for the CCG to identify key strategic risks and ensure that there is robust assurance regarding risk management. In 2018/19 the CCG Governing Body reviewed its approach to risk management and introduced a Governing Body Assurance Framework as a strategic tool to effectively manage risks through ensuring effective controls, assurance requirements and clear action plans which are performance managed on a continual basis. The CCG’s key strategic risks are summarised below: Strategic Objective Strategic Risk

Actions

Commissioning for Better Health Outcomes

Lack of commonly agreed ‘system’ understanding and agreement on health outcomes to commission for; impacting upon collaboration and measurable improvements in population health

• One Liverpool Strategy – whole system approved

• Improved planning & prioritisation approach

• System governance established • Clinical leadership reviewed

Ensure delivery of CCG is unable to • New CCG governance structure

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Strategic Objective Strategic Risk

Actions

high quality, safe and responsive health services

commission/deliver high quality services due to a lack of a shared vision and definition of quality for our population

• Evaluate findings from Kirkup Review

• Provider Organisational health framework

Reduce health inequalities

CCG does not take opportunities to influence the wider determinants and behaviours associated with health inequalities, leading to greater impact on CCG resources

• JSNA refresh informing One Liverpool strategy

• MoU with Voluntary & Community Sector

• Liverpool Population Health Framework

• Neighbourhood profiles to inform local priorities

• Engagement framework supports fulfilment of statutory duties

Ensure maximum value from available resources

Failure to understand/identify poor value in commissioning decisions, and delivery, threaten compliance with NHS business rules and achieving the 18/19 financial plan

• 2018/19 Service Reviews – urgent care, 0-25 pathway

• 2018/19 Better Care Fund • Financial reporting, including

Annual Report • One Liverpool framework for

evidence-led, prioritisation of resources

Decisions that are evidence-based and evaluated for maximum impact

CCG makes decisions that are risk averse which restricts opportunities for innovation

• Board development - ‘risk appetite’

• GB Assurance Framework • Hosting of CLAHRC research

resource The risks identified in the corporate risk register for 2018/19 relate predominantly to the achievement of the NHS constitutional standards; the achievement of improved health outcomes; maintaining high quality care; and financial sustainability. Some of the key risks managed in 2018/19 are summarised below: • At the start of the year the transition of the former Liverpool Community Health

Services to Mersey Care Trust from 1st April 2018 was considered a high risk, due to the scale of the services delivered and the quality, safety and governance issues that had affected the performance of the trust prior to transition. By March 2019 this risk was reduced to low, due to the assurance gained from the actions by commissioners and the new provider to ensure a stable transition and a robust plan for improvement.

• The current pressures on the Liverpool urgent care system present a risk that provider capacity and capability is unable to meet increased demand. This is being addressed through a commissioner-led review of urgent care services across the Liverpool, Sefton and Knowsley catchment, informed by national policy and guidance in the NHS Long Term Plan. The review will recommend a new clinical model in proposals that will come forward in 2019/20.

• Liverpool CCG, along with neighbouring North Mersey CCGs, proposed a new

Liverpool Women’s Hospital as the solution to the unsustainable clinical risks from

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having stand-alone women’s and neonatal services. The lack of availability of NHS capital to fund the development of a new hospital has stalled progress in being able to formally consult on the proposal and make a decision regarding the future of these services. The future sustainability of women’s and neonatal services remains a significant risk at the end of 2018/19. Commissioners and the provider continue to seek a way forward with NHS regulators and partners.

• The CCG’s intention to lead system integration as a means of improving population

health is ambitious as it requires a complex and diverse set of commissioners and providers to 'act as one'. The future clinical and financial sustainability of the local health and social care system depends upon the success of One Liverpool. This risk is being mitigated through the establishment of effective system governance, new ways of working for commissioners and providers, risk-sharing in the way commissioners contract for services and a shared commitment to doing the right things for our population.

1.7 Performance Summary 2018/19 The CCG has continued to robustly monitor provider performance against key NHS Constitutional measures. At March 2019 the CCG had made good progress in meeting several NHS mandated targets; including mental health standards such as Estimated Dementia Diagnosis rates, Early Intervention in Psychosis and 18-week/6-week Increased Access to Psychological Therapies (IAPT). Good performance has also been maintained for six of the nine national cancer waiting time standards, with Liverpool expected to meet its year-end targets for the numbers of patients receiving definitive treatment within 31 days of a cancer diagnosis. This financial year has also seen further reductions in the numbers of Mixed Sex Accommodation breaches. There are, however still a number of areas where Liverpool CCG has faced the significant challenges. Like many other CCGs nationally, Liverpool CCG will fail the year-end 95% A&E four-hour

operational standard in addition to the 18-week Referral to Treatment (RTT) metric, 6-week waiting time standard for diagnostic services and IAPT access and recovery rates. 1.7.1 A&E 4 Hour Standard Liverpool CCG’s performance against the national 4-hour A&E standard (set at 95% of patients being seen or treated within 4 hours of arrival) has followed a similar

trajectory to 2017/18. Liverpool’s cumulative year-to-date performance as at March 2019 was 88.8%, which is a decline on the 2017/18 position but slightly above the national average cumulative performance for March 2019. A&E attendances have also increased slightly in 2018/19, with year-to-date ‘Type 1’ activity 2.9% above planned levels. To put A& E performance into further perspective, Liverpool was ranked 4th out of its 11 ‘RightCare’ peers (CCGs of a similar size and demographic to Liverpool) as at January 2019. Although A&E performance has continued to be disappointing, a considerable amount of improvement work has been undertaken by partners to not only arrest the

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decline, but to enable a sustained recovery across the local health economy and, in the long-term, deliver an urgent and emergency care system which fully meets the needs of the local population. Liverpool CCG has continued to challenge local providers and work alongside key system partners (including NHS England and Liverpool City Council); through its role as a commissioner and as a member of the North Mersey AED Delivery Board. During 2018/19 Liverpool CCG commenced a comprehensive review into its urgent and emergency care pathways with the aim of improving consistent equity of access across the city (for both children and adults) and creating a streamlined system to enable patients to access the urgent and emergency care they need at the right time and in the most appropriate setting.

1.7.2 Referral to Treatment (RTT) – 18 weeks The 18-week Referral to Treatment (RTT) standard is a critical component of the NHS Constitution and mandates that no patient should wait more than 18 weeks from initial GP referral to receive treatment. At March 2019 Liverpool CCG’s year-to-date position for RTT was 89% against the 92% national target and will fail year-end

achievement. This is the third consecutive year the standard has been has failed. Performance against RTT incomplete pathways has been influenced by ongoing capacity issues which are similar to those experienced in 2017/18; particularly in specialties such as Ophthalmology, Dermatology and Trauma & Orthopaedics which have continued to struggle to match internal capacity against demand. Extended waiting times for diagnostic services in 2018/19 have also impacted negatively on RTT pathways, particularly within endoscopy and cardiac imaging. Total non-elective spells, although dramatically reduced compared to previous financial years, were also 4% above planned thresholds in 2018/19, whilst GP referrals were actually 1% below planned levels as at December 2018 and total elective spells at 2% below. Despite the multiple (and often complex) influences on overall RTT performance, Liverpool CCG has progressed significantly with various demand management strategies including the increased roll-out of ‘Advice & Guidance’ plans across specialties to improve access to ‘early advice’ and reduce unnecessary out-patient referrals. Improving waiting list efficiencies across pathways is also a priority area for the CCG and we have extensively engaged with providers in 2018/19 to explore the potential of re-designing the current out-patient model. At provider level, actions are now underway to better utilise existing theatre capacity, whilst a combination of ‘insourcing’ and ‘outsourcing’ of specific clinical services by acute trusts had started to positively influence performance during the last quarter of the financial year.

1.7.3 Diagnostics CCG performance against the NHS Constitutional mandate that no more than 1% of patients should wait more than 6 weeks for a diagnostic test has again been very

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disappointing in this financial year. Liverpool CCG’s year-to-date position (as at January 2019) was 4.48% against the 1% standard and, although this represents a significant improvement on the 2017/18 position of 10.4%, there is clearly still work to be done to ensure that all Liverpool

patients have consistent and timely access to diagnostic services. As described in the RTT summary above, capacity issues within high-demand diagnostic services such as endoscopy and cardiac imaging have again been a major factor in our local providers’ non-achievement of this standard. At specialist trust level there were delays in procuring new CT and MRI scanners and this also negatively impacted on diagnostic performance (although these particular issues should be quickly resolved with the expectation that the new CT and MRI scanners will be fully operational no later than July 2019). At the Royal Liverpool & Broadgreen University Hospital Trust a ‘new’ endoscopy service

provider was commissioned in February 2019. Once in place this ‘additional’ capacity began to have a positive effect on overall diagnostic access and performance in the latter stages of 2018/19 but was unfortunately unable to impact on year-end

achievement of the standard. We have continued to work diligently with local providers and other local commissioners to ensure implementation and delivery of key recovery/remedial action plans and rapid improvement plans to recover diagnostic performance, whilst simultaneously engaging with health professionals and referrers in primary care to analyse demand levels, explore alternative patient pathways and ensure consistent roll out of ‘Advice & Guidance’ within certain specialties. 1.7.4 Increased Access to Psychological Therapies (IAPT) Liverpool has some of the highest prevalence rates of anxiety and depressive disorders among its core city peers. IAPT is a ‘stepped care’ model designed to offer people suffering from anxiety and depression a realistic (and routine) ‘first line’ treatment which has the best chance of delivering positive outcomes. IAPT services are also subject to nationally mandated targets which include 6 and 18 week waiting times measures in addition to targets for access to treatment and recovery rates. Access targets are measured by the proportion of patients with ‘common’ mental health disorders who are assessed and receive treatment in accordance with NICE guidance,

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whilst recovery standards measure the rates of people with common mental health disorders who achieve reliable improvement in their presenting condition following treatment. Although Liverpool CCG has consistently achieved both6 and 18 week IAPT standards in 2018/19, the delivery of the access and recovery standards have once again proven difficult to achieve. National data for 2018/19 (which is analysed on a quarterly basis) shows that Liverpool CCG is failing to meet the mandated IAPT standards for both access and recovery rates. Overall IAPT ‘access’ performance for the 2018/19 financial year is forecast at 13% and is some way below the 17% national standard. CCG performance against IAPT recovery rates also remains below the nationally mandated 50% target, with Liverpool’s forecast position for the financial year 2018/19 at 43.9% (based on national data). Local data, which is more current than national data, shows a much more positive position however with forecasts showing that Liverpool will only narrowly miss the year-end 2018/19 target of 50% with performance of 49.6%. Roll out of a ‘new’ IAPT clinical model across the service during the second half of 2018/19 has had considerable success in reducing long waits for therapies and addressing sub-optimal recovery rates for Liverpool patients (building on the extremely positive input from the national IAPT Intensive Support Team in 2017/18). The vast majority of people receiving treatment for mental health problems do so within a primary care setting, and Liverpool CCG is therefore working extremely hard to ensure better integration with our local GP practices so that primary care staff are able to recognise the early signs of psychological distress within that setting (this also enables those with ‘low level’ mental health needs to receive timely support). 1.7.5 Incidences of Healthcare Associated Infections (HCAI) Liverpool CCG has continued to rise to the challenges of reducing risks and incidences of HCAIs across the health economy during 2018/19 and whilst considerable progress has been made, there is still much work to be done. Healthcare-associated infections cover a wide range of infections which pose a serious risk to patients, staff and visitors alike. Providers of healthcare services are required to report all incidences of methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile (C. difficile) and Escherichia coli (E. coli) and the following provides a summary of cases reported by our healthcare providers with the latest available data being January 2019: MRSA - although MRSA carries a nationally mandated ‘zero tolerance’ threshold, a total of 8 cases have been attributed Liverpool patients up to and including January 2019 which compares favourably with the 17 cases reported in 2017/18. Of these 8 cases a total of 5 were attributed to a hospital setting following robust Post Infection Review (PIR) with only 2 of those cases having no lapses in care identified following review. The CCG’s Quality Team collates all data relating to MRSA bacteraemia and tracks each case for Liverpool patients and providers where Liverpool CCG is the ‘lead commissioner’. All reported cases are also subject to robust multidisciplinary Post Infection Review (PIR), with actions identified in relation to any lapses in care monitored to completion. Learning from reviews is shared via the Liverpool CCG hosted Infection, Prevention & Control (IPC) network. Learning (as appropriate) can also be fed into the NHS England hosted regional HCAI meetings and into care home forums;

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C. difficile (CDI) – as at the end of January 2019 the rate of C. difficile infections across the local health economy had reached a total of 101, which was below the locally agreed tolerance (plan) of 114. The 2018/19 annual plan for C. difficile was set at 137 cases and it is therefore likely that Liverpool CCG will be below plan by the end of the financial year (based on the current average case rate of 10 per month); E. coli - E. coli is the most common causative organism in Gram-negative blood stream infections (GNBSI) and in some cases infections can lead to patient admissions to critical care. Although GNBSI cases can occur in hospital settings, at least half of all ‘community onset’ cases will have had some healthcare interventions from acute, primary or community care. As at January 2019 a total of 408 incidences of E. coli had been reported against a threshold (plan) of 330 cases and an ‘annual plan’ for 2018/19 set at 398 cases. Rates of E. coli continue to rise across England (highest prevalence is amongst the over 65 age group) and Liverpool CCG is fully engaged in the North Mersey Health Economy GNBSI Reduction Steering Group which has clear aims of sharing best practice, lessons learnt and innovative ideas as part of a ‘whole health economy approach’ with partners and key stakeholders (both locally and nationally). Our joint working with colleagues in Liverpool City Council is also essential in targeting education towards elderly people who live in their own homes. This is recognised as being the largest cohort of patients with GNBSI infections which, due to their limited exposure to (and engagement with) health improvement actions makes it difficult to measure both the scale of the problem and the effectiveness of joint working initiatives and plans to reduce infection rates. NHS Liverpool CCG has adhered to a local HCAI/Infection Prevention and Control (IPC) work plan for 2018/19 which monitors infection rates and compliance within provider organisations for the health and care services we commission. Under that plan service providers are required to submit monthly infection rates data to the CCG’s Quality Team for analysis and assurance purposes. The CCG has continued its ‘multifactorial’ approach in tacking Health Care Acquired Infections (HCAI) rates and builds on the close working relationships with providers to identify themes and trends using the ‘Post Infection Review’ mechanism; an extremely effective method for identifying and analysing infection control gaps and/or lapses of care. This financial year has also seen the commencement of the development of a ‘Healthcare Associated Infections Strategy’ which will link to the wider CCG Quality Strategy and ‘One Liverpool Plan’. The CCG’s Governing Body maintains robust oversight of the delivery of these key work streams though regular updates which highlight CCG and individual provider performance against HCAI rates. This enables the Governing Body to assess the level of assurance on actions completed (or underway) to remedy poor performance and mitigate risks. 1.8 Performance Analysis As already outlined the CCG Governing Body receives a comprehensive monthly performance report at each bi-monthly meeting which is supplemented on a quarterly basis with a profile of progress against key outcomes measures and benchmarking of Liverpool’s performance against other ‘Core Cities’. The performance report has been

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developed incrementally though the financial year; informed by changes in national and local reporting and through engagement with Governing Body members themselves to meet their needs. This financial year, reporting in some areas has been by exception, whilst ensuring that the Governing Body is well sighted on the emerging performance risks and operational issues which are affecting delivery of NHS Constitutional standards. The performance reporting framework has maintained the commitment to ensure expanded commentary is presented where performance in a particular area has fallen below a planned trajectory or otherwise deviated from plan. This ‘intelligent’ reporting beyond mere data makes an important contribution to the learning and appreciation of performance by the Governing Body members and contributes to strengthening their critical assurance role. Governing Body papers including this regular performance report are published on the CCG website and can be found at: https://www.liverpoolccg.nhs.uk/about-us/governing-body-meetings/2018/ for 2018

https://www.liverpoolccg.nhs.uk/about-us/governing-body-meetings/2019/ for 2019

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YTDApr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Actual 89.7% 89.9% 89.6% 89.9% 89.9% 87.9% 88.8% 88.2% 87.5% 86.7% 88.8%Plan 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

Referral to Treatment (RTT) & DiagnosticsActual 6.69% 6.60% 4.60% 4.40% 3.20% 2.47% 2.97% 2.40% 5.10% 6.45% 4.48%

Plan 4% 3% 2% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1%Actual 87.8% 88.5% 87.6% 87.1% 86.70% 86.1% 86.1% 86.6% 85.7% 85.4% 86.7%

Plan 89% 89% 89% 89% 90% 91% 91% 92% 92% 92% 92% 92% 89%

Actual 32,809 31,547 31,932 31,704 32,546 32,724 31,807 31,771 33,002 33,040 33,040

Plan 30,005 30,366 30,276 30,095 30,366 30,366 30,547 30,366 29,643 30,005 29,462 29,914 30,005Actual 13 9 13 18 14 9 13 13 10 4 116Plan 5 5 4 2 0 0 0 0 0 0 0 0 0

Actual 53% 55% 59% 60.3% 62.4% 65.2% 66.8% 64.8% 60.8% 60.6%Plan 85% 87% 90% 92% 95% 100% 100% 100% 100% 100% 100% 100% 87%

EMSAActual 0 0 0 0 2 1 0 0 0 3

Plan 0 0 0 0 0 0 0 0 0 0 0 0 0

CANCERCancer Waiting Times

Actual 92.2% 90.9% 87.8% 91.6% 92.2% 90.1% 91.3% 91.1% 92.1% 91.0%

Plan 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93%Actual 92.1% 98.0% 95.5% 92.7% 96.6% 96.7% 98.2% 95.7% 89.9% 95.1%Plan 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93%

Actual 97.2% 97.4% 96.3% 97.7% 98.1% 95.3% 97.7% 97.0% 96.8% 97.0%Plan 96% 96% 96% 96% 96% 96% 96% 96% 96% 96% 96% 96% 96%

Actual 100.0% 96.4% 100.0% 89.3% 95.9% 97.4% 97.6% 92.3% 88.9% 95.6%Plan 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94%

Actual 98.3% 100.0% 100.0% 99.1% 100.0% 100.0% 99.0% 100.0% 98.8% 99.5%Plan 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98%

Actual 98.6% 97.1% 100.0% 98.5% 96.1% 94.6% 100.0% 98.5% 98.0% 97.9%Plan 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94%

Actual 77.6% 77.1% 75.2% 77.4% 79.6% 72.6% 73.5% 60.6% 76.3% 74.3%Plan 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85%

4-Hour A&E Waiting Time Target % of patients who spent less than four hours in A&E

Metric

Liverpool CCG - Performance Dashboard 2018/19

Q1 Q2 Q3 Q4

e-Referral Utilisation

1718 and 1819 Trend

2018-19

URGENT AND EMERGENCY CAREAccident & Emergency

Incomplete Pathways% of RTT incomplete pathways (patients yet to start treatment) within 18 weeks

% of patients waiting 6 weeks or more for a diagnostic test

No of Incomplete Pathways Waiting over 52 weeks

NHS e-Referral Service (e-RS) Uilisation Coverage% of referrals for a 1st Outpatient appointment that are made using the NHS e-RS

REFERRAL TO TREATMENT TIMES & ELECTIVE CARE

Mixed sex accommodation breaches

% Patients seen within two weeks for an urgent GP referral for suspected cancer

% of patients seen within 2 weeks for an urgent referral for breast symptoms

% of patients receiving definitive treatment within 1 month of a cancer diagnosis -31 days

% of patients receiving subsequent treatment for cancer within 31 days (Surgery)

% of patients receiving subsequent treatment for cancer within 31 days (Drug Treatments)

% of patients receiving subsequent treatment for cancer within 31 days (Radiotherapy Treatments)

% of patients receiving 1st definitive treatment for cancer within 2 months (62 days)

Incomplete PathwaysTotal No of RTT incomplete pathways (patients yet to start treatment) within 18 weeks

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CANCER (continued)Cancer Waiting Times

Actual 84.6% 93.3% 85.7% 91.3% 100.0% 78.6% 66.7% 71.4% 94.1% 85.2%

Plan 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%

Actual 88.9% 87.5% 75.0% 88.9% 86.4% 72.7% 87.5% 83.3% 100.0% 86.0%

Plan 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85%

MENTAL HEALTHDementia Diagnosis

Actual 70.2% 70.5% 70.2% 70.97% 70.07% 69.9% 69.7% 69.6% 69.1% 68.5% 68.5%

Plan 67% 67% 67% 67% 67% 67% 67% 67% 67% 67% 67% 67% 67%

IAPT% of people who receive psychological therapies - Roll Out Actual 6.09%

Plan 8.401%

Actual 45%

Plan 50.00%

Actual 96.90% 97.20% 96.90% 98.10% 99.10% 98.75% 100.00% 98.80% 99%

Plan 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75.00%

Actual 100% 99% 100% 99% 100% 100.00% 100.00% 100.00% 100%

Plan 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95.00%

Early Intervention in Psychosis

Actual 56.00% 57.14% 56.25% 58.62% 54.16% 62.50% 55.00% 91.66% 56.50% 59.14%

Plan 53.0% 53% 53% 53% 53% 53% 53% 53% 53% 53% 53% 53% 53%

Care Programme Approach

Actual 95.60%Plan 95%

Improve Access rate to CYPMH

Actual 14%

Plan 8%

CYP - Eating Disorders

Actual 89.286%Plan 100.00%

Actual 67.00%Plan 100.00%

Metric


% of patients on (CPA) discharged from inpatient care who are followed up within 7 days

Percentage of children and young people aged 0-18 with a diagnosable mental health condition who are receiving treatment from NHS funded community services.

% of patients receiving treatment for cancer within 62 days from an NHS Cancer Screening Service

% of patients receiving treatment for cancer within 62 days upgrade their priority

Estimated diagnosis rates

% of people who finish treatment having attended at least two treatment contacts and are moving to recovery

IAPT Waiting Time -6 weeks% ended referrals that finish a course of treatment in period who received their first appointment within 6 weeks of referralIAPT Waiting Time - 18 weeks% ended referrals that finish a course of treatment in period who received their first appointment within 18 weeks of referral

Early intervention in Psychosis waiting times: % referrals to and within the Trust with suspected first episode psychosis or at ‘risk mental state’ that start a NICE-recommended package care package in the reporting period within 2 weeks of referral.

Q1 Q2 Q3 Q4 1718 and 1819 Trend

2018-19

Waiting Times for Routine Referrals to CYP Eating Disorder Services - Within 4 Weeks 90.0% 90.0% 100.0% 100.0%

96.66% 93.59% 96.27%95.0% 95.0% 95.0% 95.0%

100% 0%66.7% 66.7% 100.0% 100.0%Waiting Times for Urgent Referrals to CYP Eating Disorder Services - Within 1 Week

67%

8%8% 8% 8%

85.00% 85.7% 95.45%

50.0%

4.2% 4.2% 4.2% 4.8%

50.0% 50.0%

49.7% 44.8%

50.0%

3.16%

14.2%

2.93%

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Actual 34.60%Plan 55.769%

Actual 0 1 0 1 1 1 2 0 1 1 8Plan 0 0 0 0 0 0 0 0 0 0 0 0 0

Actual 11 7 7 11 10 12 14 9 12 8 101

Plan 11 11 11 11 11 11 11 11 11 11 11 11 114

Actual 42 44 39 38 37 52 43 38 44 31 408

Plan 33 33 33 33 33 33 33 33 33 33 33 33 330

ActualPlan

ActualPlan 92.00%

Actual

Plan 100%

Actual 10,363 10,552 9,936 9,960 9,665 9,632 10,405 10,012 8,008 88,533Plan 9,562 9,749 10,211 10,310 9,606 9,961 10,523 10,588 8,974 9,771 9,841 10,484 89,484

Variance 8% 8% -2.7% -3.4% 0.6% -3.3% -1% -5% -11% -100% -100% -100% -1.06%

Actual 6,926 7,631 7,364 8,016 7,391 6,941 8,153 7,961 6,634 67,017Plan 6,945 7,081 7,416 7,489 6,977 7,235 7,643 7,690 6,518 7,097 7,148 7,614 64,994

Variance 0% 8% -1% 7.0% 6% -4% 7% 4% 2% -100% -100% -100% 3.1%

Actual 17,289 18,183 17,300 17,976 17,056 16,573 18,558 17,973 14,642 155,550Plan 16,507 16,830 17,627 17,799 16,583 17,196 18,166 18,278 15,492 16,868 16,989 18,098 154,478

Variance 5% 8% -2% 1.0% 2.9% -4% 2% -2% -5% -100% -100% -100% 0.694%

Actual 14,131 14,805 14,403 14,955 14,027 13,993 16,406 15,539 11,791 130,050Plan 14,912 15,205 15,924 16,080 14,981 15,535 16,411 16,513 13,996 15,239 15,347 16,349 139,557

Variance -5.2% -3% -9.6% -7% -6% -10% 0% -6% -16% -100% -100% -100% -6.8%

ACTIVITYTotal GP Referrals (General and Acute)

Total Other Referrals (General and Acute)

Total Referrals (General and Acute)

Consultant Led First Outpatient Attendances

0.0% 100.0%

% of practices within a CCG which meet the definition of offering full extended access; that is where patients have the option of accessing pre-bookable appointments outside of standard working hours either through their practice or through their group.

1%

12.2 14.5 17.1 19.6Children Waiting more than 18 weeks for a wheelchair

Primary Care

69.20% 86.36%92.1%

Rate of PHBs per 100,000 GP registered population

% of children whose episode of care was closed within the quarter where equipment was delivered or a modification was made. 94.7% 97.4% 100.0%

16.14

Metric

Number of MRSA Bacteraemias Incidence of MRSA bacteraemia (Commissioner)

Number of C.Difficile infections Incidence of Clostridium Diffici le (Commissioner)


Q1 Q2 Q3 Q4 1718 and 1819 Trend

2018-19

OTHER COMMITMENTSPersonal Health Budgets

HEALTHCARE AQUIRED INFECTIONSHCAI

Number of E Coli infections Incidence of E Coli (Commissioner)

Patients aged 14 or over on the GPs Learning Disabi l i ty Regis ter receiving a heal th check within the quarter

LEARNING DISABILITIESAHCs delivered by GPs for patients on the Learning Disability Register

8.5% 13.2% 12.9%

18.6% 18.6% 18.6% 18.6% #NAME?

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Actual 28,453 29,889 28,901 29,831 28,178 27,747 31,910 31,172 23,550 259,631Plan 29,376 29,952 31,369 31,675 29,511 30,602 32,328 32,529 27,571 30,019 30,233 32,206 274,913

Variance -3.1% 0% -8% -5.8% -5% -9% -1.3% -4% -15% -100% -100% -100% -5.6%

Actual 5,377 5,686 5,657 5,957 5,702 5,212 5,933 5,846 4,435 49,805Plan 5,432 5,538 5,800 5,857 5,457 5,659 5,977 6,015 5,098 5,551 5,590 5,954 50,833

Variance -1.0% 3% -2% 2% 4% -8% -0.7% -3% -13% -100% -100% -100% -2%Actual 4,755 4,968 5,011 5,208 5,023 4,559 5,267 5,154 3,839 43,784Plan 4,790 4,884 5,115 5,165 4,812 4,990 5,271 5,304 4,496 4,895 4,930 5,251 44,827

Variance -0.7% 2% -2% 1% 4% -9% 0% -3% -15% -100% -100% -100% -2.3%Actual 622 718 646 749 679 653 666 692 596 6,021Plan 642 654 685 692 645 669 706 711 602 656 660 703 6,006

Variance -3.1% 10% -6% 8% 5% -2.4% -6% -3% -1% -100% -100% -100% 0.2%Actual 5,825 6,156 5,876 6,117 6,043 5,800 6,275 6,234 6,071 54,397Plan 5,673 5,937 5,757 5,951 5,770 5,729 5,954 5,735 5,797 5,882 5,467 6,085 52,303

Variance 2.7% 3.7% 2.1% 2.8% 5% 1% 5% 9% 5% -100% -100% -100% 4.00%

Actual 2,372 2,438 2,395 2,627 2,495 2,348 2,619 2,632 2,408 22,334

Plan 2,272 2,378 2,306 2,384 2,311 2,295 2,385 2,297 2,322 2,356 2,190 2,438 20,950

Variance 4% 2.5% 3.9% 10% 8% 2% 10% 15% 4% -100% -100% -100% 6.61%Actual 3,453 3,718 3,481 3,490 3,548 3,452 3,656 3,602 3,663 32,063Plan 3,401 3,559 3,451 3,567 3,459 3,434 3,569 3,438 3,475 3,526 3,277 3,647 31,353

Variance 1.5% 4.5% 0.9% -2.2% 2.6% 1% 2.4% 5% 5% -100% -100% -100% 2.3%Actual 13,926 15,196 14,600 15,103 13,712 13,994 15,051 15,016 14,472 131,070Plan 13,816 14,459 14,022 14,493 14,052 13,954 14,501 13,967 14,117 14,324 13,314 14,822 127,381

Variance 1% 5% 4% 4% -2% 0% 4% 8% 2.5% -100% -100% -100% 2.9%Actual 28,191 31,141 29,362 30,136 27,152 27,776 29,559 29,192 29,164 261,673Plan 28,218 29,531 28,638 29,600 28,700 28,499 29,617 28,526 28,832 29,255 27,192 30,275 260,161

Variance -0.1% 5.5% 2.5% 1.8% -5.4% -2.5% -0.2% 2.3% 1% -100% -100% -100% 0.6%

Type 1 A&E Attendances

ACTIVITY (continued)

Total A&E Attendances (excluding Planned Follow Ups)

Total Non-Elective Admissions - +1 LoS

Consultant Led Follow-Up Outpatient Attendances

Total Elective Admissions

Total Non-Elective Admissions

Metric


Q1 Q2 Q3 Q4 1718 and 1819 Trend

2018-19

Total Non-Elective Admissions - 0 LoS

Total Daycase Admissions

Total Ordinary Admissions

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1.9 Performance Measures The performance of the CCG is informed and influenced by a variety of relationships and key partnerships. Chief amongst these are the following: Member Practices: In 2018/19 GP locality structures evolved from three localities, providing GPs leadership into the Governing Body, into Primary Care Networks, which at the year end are settling into configurations across the city . GP practice structures are underpinned by twelve neighbourhoods of integrated primary and community teams. Other Commissioners: the CCG has continued to work closely with neighbouring CCGs, particularly in Sefton and Knowsley where there are providers and issues of common interest. Specific collaborative commissioning arrangements are in place for key Trusts and services which deliver services across multiple CCG boundaries and populations. Examples of the latter include the Collaborative Commissioning Forum around Aintree University Hospital and the wider North West arrangements effecting the commissioning of emergency and patient transport ambulance services and NHS 111. The CCG has continued with a strong relationship with the NHS England (Cheshire & Merseyside Sub Regional Team). In particular, the important relationship with Specialist Commissioning (Spec Comm) as the investment in specialist services at Trusts in the city is significant and a close working relationship and understanding between the commissioners is essential. Local residents and patients: city wide engagement events provide the opportunity for strategic input and engagement. Individual clinical programmes benefit from patient and public involvement in the service design and procurement of new or changed services. Liverpool Healthwatch is also invited to attend and participate in formal meetings of the Governing Body. Individual member practice Patient Participation Groups (PPGs) are also encouraged and supported, with the majority of practices in the city having PPGs established and operational, which link into patient forums at a locality level. Local Authority: Liverpool City Council are critical to the delivery of improved health services and health improvements across the city. At the strategic level Cllr Paul Brant Cabinet Member for Health & Social Care and the Director of Public Health attend meetings of the Governing Body, with the Director of Adult Social Care also in attendance. The CCG also continues to fully support the work of the Mayoral Health Commission participates in the Health & Wellbeing Board and associated Joint Commissioning Group. The importance of this relationship is evidenced by the commitment of the CCG to the ‘Better Care Fund’ and continuance of our formal Partnership Agreement (Section 75) between the Council and CCG and the further development of our joint approach to personalised health budgets. Performance of the BCF fund is directed against a set of nationally defined metrics: non-elective admissions; delayed transfers of care; individuals still at home 91 days after discharge from re-ablement services; and permanent admissions to care homes. In 2018/19 the BCF has supported a variety of schemes and initiatives across health and social care including end of life care, voluntary sector support,

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older people’s services, specialist rehabilitation and supporting social care capacity. Further details can be found in Section 1.19 on page 54. During the year the CCG has consistently attended meetings of the City Council Social Care and Health Select Committee and provided the Committee with updates and progress reports on key actions and activities, including the One Liverpool Plan delivery. During the year the Select Committee has received and considered reports on a wide variety of areas including: Integrated Working in Adult Social Care; Care Home Improvement Strategy 2017/2022; Urgent and Acute Care Winter Preparedness; Review of Services at Liverpool Women’s Hospital; Cancer Prevention; Alcohol Reduction; and Monitoring Quality in Care Homes. Service Providers: relationships with providers across the city are led by the clinical programme and locality leads from the Governing Body that are attached to specific Trusts. This emphasis upon direct engagement by clinical leaders has set the CCG apart from previous approaches and led to the development of a more direct, open and transparent relationship. Regular quality and contracting meetings with providers are supplemented by more strategic meetings between members of the Governing Body and individual Trust Executive teams. The continued development of the Provider Alliance in the city in 2018/19 has maintained an impetus and focus on the challenges facing the city and the CCG is invited to attend and participate in their regular meetings. North Mersey: the CCG has played a key leadership role in bringing together the CCGs in the North Mersey system to collaborate, conduct joint reviews and develop proposals for major service change. Health & Care Partnership for Cheshire & Merseyside The CCG Chief Officer is a member of the Partnership Board and leads on a number of key work streams across the Chershire and Mersey region. 1.10 Financial Performance 2018/2019 The financial duties of Clinical Commissioning Group are set out by NHS England and are listed below. • Expenditure not to exceed the revenue resource limit in any one year • Expenditure not to exceed the capital resource limit in any one year • To remain within the cash limit in any one year • To remain within the running costs target • To maintain a minimum of 1% recurrent surplus NHS Liverpool CCG delivered all of these duties in 2018-19. Further details can be found in this annual report, with the financial statements supporting this position being detailed in section 3. As the CCG has achieved a breakeven position in the financial year (and therefore did not exceed its revenue resource limit), it therefore retains a cumulative surplus of £20.453m as at 31st March 2019 (equivalent to circa 2.5%) in full compliance with the mandated NHSE business rules and exceeds the minimum 1% recurrent surplus duty as outlined above.

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Comparisons of expenditure and resources between the 2017/18 and 2018/19 financial years are shown in the table below

Whilst achieving a breakeven year end position, the CCG has experienced a number of financial challenges within the year and has required the utilisation of the 0.5% contingency reserves and slippage against other earmarked reserves. Whilst the CCG has had the benefit of the relative stability from Acting as One contracts with local NHS Providers, the CCG has experienced increased healthcare expenditure in relation to High Cost Drugs and Devices, other healthcare contracts (particularly Clatterbridge Cancer Centre, St Helens and Knowsley and Wirral University Teaching Hospitals) and continuing healthcare / joint funded packages of care. These pressures have been offset by lower spending within Prescribing and lower running costs expenditure due to staffing savings within the CCG. Financial Analysis The below analysis provide further information regarding the CCG expenditure analysis for the 2018-19 financial year. Allocation of Expenditure The pie chart below shows the relative percentage of 2018-19 expenditure against the reporting categories.

50%

10%

11%

10%

10%

5%

3% 1%

CCG Expenditure Acute Provision

Community Services

Delegated Primary Care

Prescribing Costs

Mental Health Services

Continuing Healthcare

Other Programme

Running Costs

Area of Expenditure

In Year Allocation Expenditure Surplus /

(Deficit) In Year

Allocation Expenditure Surplus / (Deficit)

£ 000’s £ 000’s £000’s £ 000’s £ 000’s £000’s

Programme 880,781 882,744 (1,963) 865,226 861,396 3,830

Running Costs 10,584 8,621 1,963 10,562 10,319 243

Total 891,365 891,365 0 875,788 871,715 4,073

2018/19 2017/18

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Provider Information The table below provides information with regards to CCG’s programme expenditure at a provider level in excess of £20m for the 2018-19 financial year. These 7 providers account for £554.91m or 62% of overall CCG expenditure and include a combination of contract and other programme expenditure.

Name of Provider £000's

The Royal Liverpool & Broadgreen University Hospitals NHS Trust 209,563

Mersey Care NHS Foundation Trust 137,527

Aintree University Hospitals NHS Foundation Trust 82,875

Liverpool Women's NHS Foundation Trust 44,923

Alder Hey Children's NHS Foundation Trust 34,214

North West Ambulance Service NHS Trust 23,164

St Helens & Knowsley Teaching Hospitals NHS Trust 22,641

Of the remaining 38% expenditure, primary care expenditure £100m (circa 11%), prescribing costs of £85m (circa 10% of overall spend), continuing healthcare and packages of care £43m (circa 5%) are not material at an individual contract level. Year on Year Comparisons

* Other Programme Includes - Better Care Fund Contributions, Property Services and other Programme expenditure

Year on Year Change

£000’s £000’s %

Acute Provision 448,325 437,656 2.44%

Community Services 92,136 90,781 1.49%

Primary Care (inc Delegated ) 99,674 95,184 4.72%

Prescribing Costs 85,742 89,546 -4.25%

Mental Health Services 90,204 88,211 2.26%

Continuing Healthcare / Packages of Care 43,045 38,366 12.20%

Other Programme * 23,618 21,652 9.08%

Running Costs 8,621 10,319 -16.46%

TOTAL 891,365 871,715 2.25%

Area of Expenditure 2018-19 2017-18

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Key Drivers for Year on Year increases: • Acute - Increase in costs due to tariff price inflation and contract growth (demographic

and non-demographic) and increases in expenditure on high cost drugs & devices and areas of non-contracted activity

• Community Services – Increased contract expenditure and digital (IM&T) expenditure • Primary Care – Global Sum and list size increases together with part year effect of

APMS contract transition

• Prescribing – Reduction in expenditure due to Category M price savings, NCSO pressures and areas of the CCG Cash Releasing Efficiency Savings

• Mental Health Services - Increase in costs due to tariff price inflation and contract growth, plus additional investment in support of the delivery of the Mental Health Investment Standard

• Continuing Healthcare & Packages of Care, Average cost of agreed packages have increased during 2018-19 combined inflationary increases up to 5.3% in line with Liverpool City Council rates

• Other Programme – Increased contribution to the Better Care Fund

• Running Costs – Reduction in running costs due to vacancies and turnover of staff. Cash Releasing Efficiency Savings The CCG required planned cash releasing efficiency savings of £8.8m for the 2018-19 financial year (around 1.1% of baseline revenue resources available) and has achieved savings of £9.6m as at the financial year end. The original planned schemes that made up the £8.8m savings target under-delivered by £0.8m but was supported by additional savings from new schemes, namely new Prescribing schemes of an additional £1.2m and £0.4m from running cost expenditure reductions. Future Financial Outlook Five year CCG allocations were published in January 2019 providing the organisation with greater certainty for planning and contracting purposes over this period. The CCG received a programme allocation growth of 5.6% for the 2019-20 financial year, reflecting the impact of changes in relation to national tariff and activity growth assumptions in line with NHS England planning assumptions. Lower relative growth of between 3 – 4% is confirmed for the period 2020/21 to 2023/24 and the CCG remains over it’s target allocation reducing from 1.81% in 2019/20 to 1.29% in 2023/24. The CCG’s governing body approved a plan for the 2019-20 financial year in March 2019 which was consistent with the requirements of NHS England’s Business Rules, but will require the CCG to make further savings against anticipated expenditure.

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Planning assumptions currently assume that savings in the region of £13.8m (circa 1.5% of overall resources available) are required with further challenges, should further risks materialise compared to planned expenditure. Despite the required level of financial savings required, the CCG remains in a relatively strong position due to a continuation of the Acting as One contract agreement with North Mersey providers, and subject to no material movement from its planning assumptions remains confident of delivery of NHS England Business planning rules. 1.11 CCG Improvement and Assurance Framework (IAF) 2018/19 In the Government’s mandate to NHS England, a CCG Improvement and Assessment Framework (IAF) has been established to bring clarity, simplicity and balance to discussions between NHS England and CCGs. It draws together in one place NHS Constitution and other core performance and finance metrics, outcome goals and transformational challenges, to capture the multi-faceted role of CCGs. The Clinical Commissioning Group Improvement and Assessment Framework (CCG IAF) comprises 58 metrics, which informs NHS England’s assessment of CCGs in 2018/19. The indicators are grouped into 4 areas: Better Health; Better Care; Sustainability and Leadership. Within the IAF the CCG has been benchmarked against a national position and against CCGs’ that have been identified as being similar to Liverpool CCG. The performance dashboards presented in section 1.8 provide a summary of CCG performance against NHS constitutional standards for 2018/19 – where data was available at the time of producing the Annual Report. An overview of performance against key Better Health and Better Care Indicators is presented below: 1.11.1 Better Health Indicators Better Health indicators demonstrate how the CCG and system partners are improving the health and wellbeing of the population and positively impacting on demand for services. The most up to date available is provided below: • Childhood Obesity: Overweight children will more likely than not become

overweight or obese adults, with consequent health problems. Liverpool is an outlier, with the 38.7% of children aged 10-11 classified as obese. This is a small improvement in performance on the previous reporting period (39%). Liverpool remains significantly above the national average of 33.9% and is in the bottom quartile nationally. The CCG with partners in the City Council signed up in September 2018 to the Local Government Declaration on Healthy Weight, which has 14 commitments including engaging with local businesses to promote healthier food and drink options; protecting children from inappropriate marketing in close proximity to schools; promotions within schools and at events on local authority controlled sites as well as promoting increased physical activity. In 2018/19 Liverpool also embarked on the journey to become a UNICEF UK Child Friendly City in March 2019.

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• Falls Leading to Emergency Admission: This indicator demonstrates how well the NHS, public health and social care are working together to tackle frailty and falls in older people. Data indicates an increase in the rate of injuries sustained through falls from 2,766 per 100,000 in Q2 2017/18 to 2,896 in Q3 2017/18. The rate had been reducing during 2016/17 and early 2017/18, but latterly increased. Local data for the rolling 12 month period March 2018 to February 2019 shows that the volume of emergency admissions due falls has increased on 2017/18 by 5%. The CCG has prioritised additional investment to commission new services to reduce injuries from falls from 2019/20.

• Health Inequalities: There are large inequalities in the rate of unplanned hospital admissions between the most and least deprived areas. Latest data for quarter 1 2018/19 indicates an increase in the rate from 3,447 per 100,000 in Q4 2017/18 to 3,646 in Q1 2018/19, with more recent performance indicating an increasing trend. Liverpool CCG is significantly higher than the national average of 2074 and is ranked in the bottom quartile nationally (187 out of 195). The Liverpool Inclusive Growth Plan and the One Liverpool Strategy have at their core the intention to reduce inequalities in health services and by responding to the wider determinanets of health in areas such as employment, education, good homes and communities and lifestyle behaviours.

1.11.2 Better Care Indicators Better Care indicators measure how care is being improved, including service re-design, performance of constitutional standards and health outcomes. • Learning Disability: This indicator measured reliance on specialist inpatient care

for people with a learning disability and/or autism, and whether the CCG is meeting its commitment to reduce the number of inpatients and transform services. Latest data for quarter 2 2018/19 reports 66 inpatients per million GP registered adult population, which is a small reduction on the previous reporting period (67). Liverpool CCG is ranked 8 out of 11 similar CCG’s and in the bottom quartile nationally (151 out of 195 CCG’s). The ways in which the CCG and partners are reducing reliance on specialist inpatient care can be read in section 1.16 of this report.

• Maternal Smoking at Delivery: Decreases in smoking during pregnancy result in

health benefits for the infant and mother, as well as cost savings to the NHS. Data for quarter 2 2018/19 identifies Liverpool CCG as an outlier with the percentage of mothers who smoke at the time of delivery at 14.8%, with a decline in performance on Q1 2018/19 (12.4%). More recent data for the quarter 3 2018/19 indicates that performance has improved (12.4%), but remains above the national position of 10.3%. Liverpool is delivering an ambitious tobacco control strategy to reduce smoking levels in the city. In 2018/19 the CCG and partners implemented a scheme to reduce smoking in pregnancy and after birth and to support people to stop smoking during their time in hospital, including training NHS staff in brief advice and interventions.

• Urgent & Emergency Care: Delayed Transfers of Care: This indicator measures timely discharge or transfer to the most appropriate care setting and promote

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smooth flow through the system for patients. November 2018 data identifies Liverpool as an outlier, with an average of 14.7 delayed transfers of care (delayed days) per day per 100,000, an increase on October (13.75). This is above national average of 10.4 for the same period. Delayed transfers of care are also monitored through the Better Care Fund on a Health and Wellbeing footprint. Latest data for Q3 2018/19 demonstrates that Liverpool was above the planned Q3 target with performance of 1,284 delayed days per 100,000 against a plan of 876. The last 2 quarters have seen the highest level of delayed days in the last 2 financial years. The reduction of delayed transfers of care is a whole-system challenge which requires, short term and longer term actions, which are prioritised by all partners.

The other IAF domains include sustainability and leadership. In 2018/19 the sustainability indicator measured the degree of Paper Free Point of Care, utilising the NHS e-referral service to enable choice at first routine elective referral. Liverpool CCG was an outlier, with utilisation being 66.8%, below the national position of 92.4%. However, there were issues with the data source for this indicator. The Paper Switch Off in October 2018 was successful for Liverpool CCG with all referrals to lead consultant first outpatient services being made via e-RS. The CCG’s performance in respect of Leadership has been strengthened by the appountment of the Chief Officer to a permanent role, the full establishment of the CCG Governing Body and a newly structured Senior Leadership Team designed to meet the future needs of a strategic commissioning organisation. 1.12 Friends and Families Test The Friends and Family Test (FFT) is a single question survey which asks patients whether they would recommend the NHS service they have received to friends and family. It was initially rolled out for providers of NHS funded acute services for inpatients (including independent sector organisations that provide acute NHS services) and patients discharged from A&E (type 1 and 2). Since it was initially launched in April 2013, the FFT has been rolled out in phases to most NHS funded services in England, giving patients the opportunity to leave feedback on their care and treatment. In previous years, NHS England proposed that all providers should achieve a 15% response rate for A&E and Inpatient FFT surveys. In 2015/16 the target was dropped as a mandated standard and as such is likely to be the reason why in Liverpool and across the country there has been a notable reduction in response rates during 2016/17 and 2017/18, particularly in A&E. Despite this, during 2018/19 the average response rates across Liverpool are above the England average. Friends and Family Test results for 2018/19 across the city are summarised below: Accident and Emergency: For Liverpool, during January 2019, the percentage of patients who would recommend A&E services has increased slightly on the same period in 2017/18 (from 88% in January 2018 to 89% in 2019). There has also been a decrease in the percentage of respondents who would not recommend the A&E service from 7% in January 2018 to 6.2% in 2019. The percentage of patients who would recommend A&E services at Liverpool providers is also above the England average of 86% in January 2019.

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Inpatients: On average 95% of respondents would recommend a Liverpool NHS provider as a place to receive inpatient care, which is an increase in the rate from January 2018 (94%). However, this is just below with the England average rate of 95.6%. The percentage of respondents who would not recommend inpatient services across Liverpool is 1.9%, just above the England average range of 1.7%. Outpatients: On average in January 2019 (across all providers) 93% of respondents would recommend outpatient services, which is just below the England average of 94%. This is also below with the rate reported in January 2018 (94%). The proportion of respondents stating they would not recommend outpatient services at Liverpool providers is 2% which is below the England average range (2.5%). Maternity: Due to extremely low number of responses it is not possible to produce meaningful analysis on the data relating to the four maternity questions in 2018/19. Community: Community services providers have maintained the rate of patient satisfaction with a recommendation rate of 98.4% in January 2019 (same as January 2018) The community providers have consistently been above the England average throughout 2018/19. Mental Health: There has been an increase in patient satisfaction in January 2019 (88.6%) compared to the same period in 2018 (86.5%). However, performance is below the England average of 90.1%. The percentage who would not recommend the service is positive compared to the England average (1.3% compared to England average of 3.4%) Primary Care (GPs): for January 2019, the percentage of patients who would recommend their general practice to friends and family in Liverpool has decreased on the same period in 2018 (from 93% in January 2018 to 91.1% in January 2019). However, this is above the England average with a rate of 90.3%. The percentage of respondents who would not recommend GP services across Liverpool is 4.2% and below the England average of 5.7%. Staff Friends and Family: This is a quarterly survey; the latest data available is quarter 2 2018/19. It is split into two areas. 1. Work: Across all Liverpool providers there has been an increase in the

percentage of staff who would recommend their provider as a place to work in quarter 2 2018/19 with a rate of 66.4% compared to 63% in 2017/18. The current average rate across all Liverpool providers is above the England average of 64%

2. Care: The percentage of staff who would recommend a Liverpool provider as a

place to receive treatment has also increased in quarter 2 2018/19 with a rate of 85.3% compared with 83.1% in 2017/18. The current average rate for all Liverpool providers remains above the England average of 81%.

Taken as a whole the FFT and Staff Friends and Family results in January 2018/19 are broadly positive and reflect a good level of staff and patient satisfaction.

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**Liverpool Providers include the following: Royal Liverpool and Broadgreen, Aintree University Hospital, Alder Hey, Liverpool Women’s Hospital, Liverpool Heart and Chest, Mersey Care, The Walton Centre and The Clatterbridge Centre for Oncology 1.13 Outcomes Framework and Local Indicators As described in sections 1.7 and 1.8 (performance analysis) Liverpool CCG has continued to develop and refine its performance reporting throughout 2018/19 to monitor and measure service performance from our locla hospitals, primary and community services, mental health services against a number of national outcome indicators in key areas such as A&E, Referral to Treatment, cancer and mental health access; ensuring patients rights within the NHS Constitution are maintianed. The table presented in section 1.8 provides a summary of CCG performanceagainst NHS Constitution indicators up to and including March 2019 (where data was available at the time of completing this report). 1.14 Sustainable development Liverpool CCG has provided good leadership in this area as an early developer of a Social Value and Sustainability Strategy and Action Plan which was co-developed with our NHS partners in the city. Building Social Value means using our position and responsibilities to increase the social, economic and environmental wellbeing of the people we serve. Our strategy brings together our obligations to set out a Sustainable Development Management Plan to comply with The Public Services (Social Value) Act 2012 and to place the approach at the centre of our thinking, policy, commissioning and practice. The strategy will be updated during 2019/20 to reflect new leadership and system integration. Liverpool CCG has also worked with the Cheshire and Merseyside Health and Care Partnership to bring forward proposals for a renewed focus on Social Value. It is recognised that most of the CCG’s carbon footprint is associated with commissioning health and care services, prescribing and the procurement of other services. Our priority remains to work with our main providers, Liverpool City Council and other partners to improve our performance and to minimise the harm and maximise the positive gain that can be made to health from the way NHS services operate. Information regarding how our key providers perform against The Public Services (Social Value) Act 2012 can be found within each Trusts Annual report. As a commissioning organisation, we need effective contract mechanisms to deliver our ambitions for sustainable healthcare delivery and clear outcomes for services and the system. The NHS policy framework already sets the scene for commissioners and providers to operate in a sustainable manner. The Climate Change Act 2008 set legally binding targets for the UK to reduce carbon emissions by 80% by 2050. The NHS is committed to reducing CO2e by 34% by 2020. Reports and evidence from all spheres- economic, social and environmental -highlight the unprecedented global and local risks of climate change.

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Liverpool CCG recognises the connections between the local actions we can influence and global patterns of carbon emissions and the gains to our local population from acting sustainably in our economic, social and environmental impact. • NHS Liverpool CCGs own operations, accommodation and practices contribute

towards carbon emissions. The figures below show resource consumption from our activity.

• 12tonnes of CO2e were generated by staff travel.

• More than 17510 tCo2e were generated from the pharmaceuticals used by

commissioned services (including General Practice) *

• More than 111150 tCo2e are produced by the providers of NHS care to local residents through our commissioning activity *

*Derived from an analysis of financial spend through the NHS Sustainability Unit. Liverpool CCG headquarters have generated 76 tCO2e from energy use. The CCG’s accommodation has a number of features specifically designed to reduce energy consumption, including: • The hot and cold water demands of the building are complete with flow restrictors

to reduce water consumption

• The heating and cooling of the office space is achieved via four-pipe fan coil units with 2 port pressure independent control valves to reduce energy consumption

• High efficiency, low energy LED lightening is provided in conjunction with a lightening controls system complete with presence (PIR)/absence detection and daylight harvesting to reduce energy consumption

• Facilities are provided for on-site recycling of waste. Liverpool CCG encourages employees to travel via public transport and offers to purchase an annual train or bus pass, which is repaid over the year. Provision for cyclists is also made by way of cycle storage and changing facilities. We also offer employees the opportunity to purchase a bike through the national cycle scheme, the cost of which is repaid over 12 months. In total 12.8% of staff cycle or walk to work. In addition, the CCG has purchased a number of passes for the Liverpool City Council run “Citi Bike” scheme where staff can use bikes to travel around the city. As part of the national requirements to plan to meet the likely climate change challenges ahead the CCG has, through the Emergency Preparedness and Resilience agenda, ensured that plans are cognisant of these risks and make provision for mitigating actions.

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1.15 Patient and Public Involvement Liverpool CCG recognises that in order to fulfil our commissioning responsibilities effectively we need to understand the experiences and expectations of local people. Public and patient involvement in our decision making, planning and delivery is vital to shaping our future direction, improving services and holding the local NHS to account. Our Governing Body includes a Lay member for Patient and Public Involvement whose responsibility is to ensure that effective opportunities are created for the local population to have a voice in all aspects of the CCGs business, and that appropriate arrangements are in place to ensure views are understood, reported and acted upon. The Governing Body also formally invites Healthwatch Liverpool to attend its meetings bringing additional scrutiny and links to public feedback. We aim to improve how the people of Liverpool participate in CCG work and decision making. The CCG has established a range of engagement infrastructure to support diverse and effective participation. We recognise that for some people and communities support is needed to create the right conditions to enable participation to benefit everyone involved. Planning, governance and management structures operate to ensure engagement is as effective and transparent as possible. A planned approach is adopted for all activity to provide the CCG with assurance that engagement is effective and meets both our legal and value based commitments to involving diverse members of our community. This also incorporates an Equalities Pre-Assessment to ensure the activity will engage any groups who may be particularly affected. The outcome of engagement processes are always reported back to patients and public and participants and through committees to the Governing Body. Details of engagement strategies, governance and planning documents are available at https://www.liverpoolccg.nhs.uk/get-involved/ We continue to be committed to working in partnership with our population, NHS partners, local government and voluntary, community and social enterprise (VCSE) organisations. Our duty is to reflect our city’s diverse populations and their needs in the way that services are commissioned. Our approach is also to ensure that engagement is conducted in ways which support individuals and community empowerment in achieving better health. The structures that underpin our approach and that have contributed towards comprehensive and effective engagement during 2017/18, include the following: - Public and Patient Engagement Group - This is a strategic CCG group, designed to oversee the delivery and implementation of NHS Liverpool CCG’s stakeholder engagement strategy. The group consists of representatives from Liverpool CCG, Liverpool City Council, Healthwatch Liverpool and patient/public voices from Liverpool CCGs volunteer programme. The group reviews engagement plans and processes and reflects on information from complaints and Health Watch reports.

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“From a Healthwatch perspective, I’ve found attending the group really useful. It’s helpful to have an understanding of and input into the ways that the CCG consults with and engages the local population. The volunteers really make the group as they come from a diversity of backgrounds and so can bring a wide range of different skills, experiences and perspectives.”– Rob Benn, Information and Project Officer, Healthwatch Liverpool

Patient Voices - Patient voices are local people with experience of using health services and with connections to local communities. Their role is to provide a patient voice within programme or project development and to use real life experiences to inform and improve planning. During 2018/19 patient voices have been sought through the participation frameworks and volunteers have had input into areas such as the Urgent Care Review.

Engagement Partners Programme - We aim to continuously improve how our population participate in decision making, including having a true diversity of representation. In 2015 the CCG established a network of VCSEs to work with us in involving people from the city’s diverse communities and individuals, using the expertise and reach that exists within the sector to facilitate dialogue and create the right conditions for meaningful engagement. We currently have 154 partners in the programme and are confident we have a strong reach into groups less likely to participate, groups who experience health inequalities, vulnerable groups or those with protected characteristics. An example of the diverse ways in which this community development approach to engagement delivers both excellent learning for LCCG and wider social is provided by This is My Story (TIMS); one of our community partners who worked with young people and their families for the Urgent Care Review. This is My Story, March 2019: “Recruiting young people from the volunteer pool to step up and to train in interview skills and be part of the interview team (went well). They worked with the facilitator to re-word the questionnaire into a ‘discussion stimulator’ so that young people would be more likely to respond. They took the forms home and spoke to family and friends, and once TIMS had parental permission where necessary, the wider family volunteered time and effort to support the completion of forms and offer ‘leads’ who would be interested in providing information. “As a direct result of the impact of their involvement with TIMS and this project in particular, one young interviewer is more likely to be able to leave care and return to the family home. “Everyone has said they enjoyed being involved and as well as learning about the proposal discussed they learned a lot about more about the areas and the people they were talking with. We have gained valuable insights into the dynamics of the communities we have engaged which will enhance future engagement work.” During 2018/19 we have worked with VCSE engagement partners who supported the CCG to hear views from people with Learning Disabilities, the D/deaf community, refugees and asylum seekers, young people and people with neurological conditions

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about urgent care services/ same day health care and from black, Asian, minority ethnic refugee communities regarding mental health services and adults with ADHD about ADHD services. The impact of engagement activity is detailed later in this report.

Volunteer Programme - The CCG volunteer programme was established to broaden opportunities for participation, to empower and support the wellbeing of individual volunteers and to inform health commissioning. The volunteer programme is in its fourth year and has gone from strength to strength, since April 2018 we have recruited 28 new volunteers. All volunteers are invited to attend a welcome session and role specific training, in 2018/9 we delivered 8 training sessions.

“I find that participating in this group provides me with a more rounded picture of healthcare in Liverpool and sometimes the opportunity to influence CCG decisions. As my husband has Alzheimer's Disease it is all too easy to focus only on those areas that are currently relevant to us. It is also very thought provoking, mentally stimulating and offers opportunities to see things from the perspective of others.” – Moira, CCG Volunteer

Volunteers have supported the following areas of work in 2018/19: GP Extended Access Procurement – Volunteers formed part of the team assessing proposals from providers who were bidding to deliver the Extended Primary Care Access Service in Liverpool. They used the scoring process to assess the non-medical aspects of the bids to inform the recommendation for a new provider. Urgent Care Engagement - Volunteers helped review the communications messages to support effective engagement for the review, surveyed patients at GP practices and Walk-in Centres across the city and were involved in the Urgent Care Co-Design Events to inform the development of options for the future.

COPD One-Stop Test Clinic –Patients often have to attend multiple appointments to find out what is wrong with their lungs. The one-stop clinic allows patients to access key health professionals in one clinic. A number of volunteers conducted surveys with patients to gather feedback about their experience of the new clinic to inform service improvement. Our volunteers are an important part of our participation programme, enabling engagement in a variety of ways across the work of the CCG in ways which support the goals of the participants. If you are interested in volunteering with NHS Liverpool CCG you can email [email protected] or call 0151 296 7537.

Patient Participation Groups (PPGs) - It is a contractual requirement for all practices to form a patient participation group (PPG) and to make reasonable efforts for this to be representative of the practice population. The CCG encourages GP practices with established patient groups to gather insight to inform decisions about their own care. PPGs have opportunities to influence at both individual practice and neighbourhood level.

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Public question time - Members of the public are welcomed to attend the formal meetings of the Governing Body and to question Governing Body members in an ‘open’ question session, providing an opportunity for issues and concerns to be raised and responded to.

Digital Engagement - Our digital engagement and social media presence has continued to develop, through the CCG website and social media as platforms for sharing information and seeking feedback. Our audience of each of these platforms continues to grow with each engagement activity, consultation or campaign. The @liverpoolccg Twitter account has 6,774 followers. From 1 April 2018 to 31 March 2019 our website - www.liverpoolccg.nhs.uk – attracted 37,894 users, and a total of 108,037 page views. We have increasingly using targeted Facebook campaigns as part of public engagement. After direct email, this was the second most common way for people who completed the urgent care review questionnaire to have heard about the engagement. The campaign also generated more than 2,000 click-throughs to the NHS Liverpool CCG website.

Continual Stakeholder mapping - A stakeholder database of local residents, community groups, organisations and other stakeholders has been developed and is continually updated enabling direct contact with interested parties about opportunities to participate. A summary overview of engagements conducted in 2018/19, along with what we learnt form engagement and how this information informed proposals, is presented below. Further information regarding these engagements can be found on our website www.liverpoolccg.nhs.uk and clicking ‘get involved’. Engagement

Activity Summary of Feedback Impact of engagement

Urgent Care Review Engagement

Feedback is currently being compiled and will be published on LCCG website. Early findings indicate key themes were that GPs are the preferred point of access; challenges with mental health access; north Liverpool residents felt their choices were lesser; walk-in services are valued but lack GP access and diagnostics.

The engagement findings are being fed in to the options development for future improvements to urgent care services.

BAMER Mental Health Services

This engagement began March 2018 and sought views regarding mental health support for BAMER communities and particularly the Community development Service (LCDS) for BAMER mental health.

The engagement is still live. Results will inform the revised specification of LCDS and mental health service delivery.

ADHD Services

Long wait times for adult ADHD assessment and treatment prompted LCCG to embark on an engagement to consider future deliver models. An organisation for adults with ADHD supported the CCG. Feedback indicated that quality of service

LCCG has revised the delivery model to achieve consistent quality of care with reducing waiting times. LCCG is also increasing

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Engagement Activity Summary of Feedback Impact of engagement

was good but that the wait times a problem. Strong support for non-medical support services was indicated.

the non-medical support provision for adults with ADHD.

CBCT

Liverpool CCG is currently collaborating with GPs across Merseyside to review a range of policies for Criteria Based Clinical Treatment.

The engagement is still live and findings will be used to inform the final policies.

Changes to GP Services

In January 2019 LCCG received notice from a GP provider to end their contract to deliver GP services at 6 practices in the city, affecting 18,000 patients. LCCG embarked on an engagement with patients to understand their preferences in terms of future service delivery. LCCG also engaged with local practices to determine possible ways of providing GP services to patients registered at those practices in future.

LCCG worked with Liverpool GP providers to find solutions to reduce the impact on patients and deliver high quality GP services in the future.

D/deaf Community

Liverpool CCG held a meeting with 66 members of the D/deaf community and representatives from local NHS Trusts to explore the difficulties D/deaf people were having in accessing health care. Merseyside Society for Deaf People are a key partner in this process. People reported problems with a wide range of issues including:-

Interpreter services - Making appointments - Urgent and emergency care - Communicating with NHS staff - Knowing what support they were

entitled to - Written information - Delays to appointments due to lack of

interpreters - Family members being expected to

interpret - Difficulty in understanding diagnosis

and treatment plans - Inpatient care - Making complaints

LCCG produced a report of the findings and an action plan. This was shared widely with providers. Actions completed include – Communications to inform staff of their responsibilities and patients of their rights. A review of all trusts BSL interpreter provision and contracts. Some changes to providers of interpretation services to improve quality and discussions are advancing to look at a joint procurement. A new approach agreed for enabling complaints to be made more easily and with a BSL guide to this approach. Improvements have been made to accessibility of documents. The action plan is published on the LCCG website.

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1.16 Improve Quality The CCG has continued to take a comprehensive approach to quality improvement in 2018/19, working in partnership with providers of commissioned services and other stakeholders. The CCG assumes responsibility for Quality Assurance by holding our providers to account for the delivery of their contractual obligations and quality standards. This localised approach involves systematic monitoring of quality requirements as laid out in the Quality Schedule, alongside coordination of collaborative forums and clinical quality and performance meetings for the eight providers for whom the CCG acts in the lead commissioner role. The internal governance route for escalation of strategic risks to quality continues to be via the CCG’s Quality, Safety and Outcomes Committee. The committee has moved to monthly meetings in recognition of the complexity of the provider landscape and the breadth of oversight required. There are clearly defined escalation processes which are known and understood when routine intervention has proven ineffective, using contractual processes where necessary. The CCG is aligned to NHS England quality concerns process, adopting the use of the trigger tool for escalation, alongside collaborative completion of the Quality Risk Profile tool, where appropriate. The CCG can demonstrate multiple examples where we have engaged and led to better understand quality related issues. Examples include the coordination and facilitation of a city wide approach to the review of provider Cost Improvement Plans in relation to the impacts on quality; revising the CCG Quality Impact Assessment Policy; developing the CCG Clinical Quality and Performance Group chair role and organising regular mini Quality Surveillance Group (QSG) meetings for the chairs. The CCG Serious Incident Policy has been rewritten, approved and implemented in 2018/19 and the format of the CCG serious incident panels has changed to include provider representation to present their reports. In relation to those areas identified in ‘MyNHS’ ( the NHS digital platform to access quality and outcomes data), the CCG can provide a comprehensive account of its approach in improving performance across the six priority areas as detailed below: Maternity - The latest available statistic for the number of live births to women resident in Liverpool is 5,906 in 2017. In 2017/18 (latest data), 5,169 (93% of deliveries) were delivered at Liverpool Women's Hospital (LWH). Neonatal mortality and still birth rates are included in the quality schedule for LWH and monitored by the CCG via the Clinical Quality and Performance Group. In addition, LWH has now adopted the Saving Babies’ Lives Care Bundle, in line with the Department of Health target of reducing the rates of stillbirth in England by 20% by 2020. This has also been incorporated into the Quality and Performance Schedule and progress is reported at the Quality meetings, enabling the CCG to monitor progress against the current rate to ensure improvement. The CCG remains a part of the Cheshire and Merseyside Local Maternity System (LMS) whose aim is to improve standards of care and reduce variation in quality.

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Liverpool Women’s Hospital reports a Friends and Family score across antenatal, postnatal ward and postnatal community all above the England national average. The birth score is below the England national average and is the focus of quality improvement. LWH is the first Maternity Choice and Personalisation Pioneer to be launched, which seeks to offer women greater choice of interventions as part of the antenatal, birth and postnatal pathways. In addition, the Cheshire and Mersey LMS has also been successful in its bid to be an Early Implementer for the implementation of the service improvement recommendations contained in the Better Births Report (Feb 2017). Diabetes - The CCG has seen an increase in the National Diabetes Audit (NDA) participation from 80% in 2016/17 to 97.9% in 2017/18. This year, for the first time, the data was automatically extracted from general practice systems which led to this significant improvement. The CCG received an ‘outstanding’ rating from NHS England for diabetes services in 2018/19. This rating is based on two key indicators – percentage of patients achieving the NICE treatment targets (43.6% compared with an England median of 40%) and attendance at structured education (11.3% compared with an England average of 7.3%). The CCG has a contractual arrangement through the Primary Care Quality Premium whereby local practices are monitored on their achievement of the eight NICE recommended treatment targets. The overall local performance for patients receiving all eight treatment targets is 74.8% at month 8 2018/19, indicating a significant improvement compared with the England average of 58.8%. The CCG has performed well with completion of BP <140/80 at 75.8%, which ranks Liverpool CCG second against its Right Care peers. Patients with a Cholesterol <5 is 80.4% which ranks the CCG as the top performer when benchmarked against our Right Care peers and compares well with the England average of 76.6%. Using 2017/18 month 8 performance data, outcomes are improving for people with diabetes, with hospital admissions reduced by 28 people for stroke; and a reduction in the number of people having amputations. Additionally, 139 fewer patients have developed kidney disease and 3 fewer have experienced kidney failure. In 2017/18, the CCG began the roll-out of ‘Healthier You’, the National Diabetes Prevention Programme in Liverpool. Further details can be seen in the case study in this report. Mental Health – Liverpool CCG has continued to work closely with Talk Liverpool Improving Access to Psychological Therapies services (IAPT) to consolidate improvements achieved in the previous year. A new model has been introduced with a number of changes including a greater proportion of group activity, online access and a streamlined initial assessment to support making the service more accessible. A programme of publicity including social media campaigns has gained traction and is beginning to result in increased numbers of people seeking a service. Pathways into therapy for people who have long term physical health conditions have been developed and are in the early stages of implementation.

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Liverpool CCG co-ordinates the North Mersey Crisis Care Concordat Action Plan bringing together Mersey Care, Merseyside Police, local authority social care representatives, voluntary sector colleagues and many more. The past twelve months have seen the consolidation of mental health liaison services in A&E/Acute settings, upgrading of the Triage Car service improving patient experience and reducing hospital admissions, as well as the connection of voluntary sector initiatives such as James’ Place and Liverpool Light Crisis Café to the network of statutory services available in an emergency. The group has developed a dashboard of indicators which help in assessing how the range of interventions impact on one another to inform future development. National standards for Early Intervention in Psychosis have now been implemented in full, significantly increasing the amount of people accessing the full range of evidence based interventions for a first episode of psychosis, and therefore reducing their chances of needing continued, high intensity support later in life. Liverpool CCG was part of a successful bid to double access to employment opportunities for people with severe and enduring mental ill health as part of a national programme of Individual Placement and Support. Child & Adolescent Mental Health Services (CAMHS) - The CCG is currently working towards implementing the 5 year Local Transformation Plan (LTP), 2015-2020, for Children and Young Peoples Mental Health and Emotional Wellbeing. This was refreshed in November 2018 and signed off by the Health and Wellbeing Board. Liverpool CCG is currently performing well on access rates (32% for 18/19), although we are underperforming for access to eating disorder support for those requiring an urgent response. Work is progressing with the provider to improve waiting times and further investment will be made in 2019/20 to increase capacity within this service. The Local Transformation Plan can be accessed here: https://www.liverpoolccg.nhs.uk/health-and-services/children-and-young-people/children-and-young-peoples-mental-health-camhs/ Learning Disability - The CCG has continued to work towards reducing inpatient rates for those with a learning disability. Effective working arrangements between commissioners, local delivery partners provide assurance that an admission to an inpatient unit will only happen if absolutely necessary and following agreement from all professionals involved. This is supported by the development of the new Intensive Support Function (ISF) within existing community learning disability teams across North Mersey in 2018/19. Liverpool and Sefton CCGs were allocated £250k from NHS England which has enabled us to work with Mersey Care NHS Trust to create the new team and provide extra capacity to support patients in their own homes at times of crisis. The CCG also provided investment for Mersey Care NHS Trust to recruit a forensic nurse specialist within the local community learning disability team; thereby ensuring sufficient skills and capacity are in place to meet an increasing complexity in patients’ presentation. Whilst the CCG is behind its discharge trajectory specified by NHSE for 2018/19, the opening of highly specialised residential provision in 2019/20, as a result of capital investment secured from NHS England, will enable us to facilitate the discharge of a more inpatients.

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The CCG recognises that more work needs to be done to improve the rates of people included in the learning disability register, and to increase access to an annual health check for people with a learning disability. At year end, the percentage of people with a learning disability on their GP register receiving an annual health check was 52.5%, slightly above the England average of 51.4%. Based on data for 2017/18, the CCG is ranked 4/11 of our Right Care peers. To support further improvements in the uptake of annual health checks, investment has been made by the CCG to provide an additional primary healthcare facilitator in the community learning disability team. Each healthcare facilitator now covers a specific neighbourhood based upon those already well-established in primary care. The CCG is working closely with people with learning disabilities to develop an action plan to increase the provision and uptake of health checks and improve access and experience in general practice. The CCG is aware that as part of the Learning Disabilities Mortality Review (LeDeR), there are a large number of reviews locally awaiting completion, although this very much mirrors the national perspective. In order to address this, the CCG has invested in a senior nursing post in Mersey Care NHS Trust to focus specifically on completing the reviews and addressing the backlog. Learning Disability: Children and Young People - Liverpool CCG has been leading on a project across Cheshire and Merseyside to develop Dynamic Support Databases (DSDs) for Children and Young People (CYP) with Learning Disabilities (LD) and/or Autism, who present with behaviour that challenges, including those with a mental health condition. The databases will enable CCGs and Local Authorities to respond quickly and appropriately to these needs in order to prevent avoidable admissions to Tier 4 CAMHS. Dementia - The January 2019 diagnosis rate stands at 68.5% against a national target of 66.7%, a fall of 2.7% since the same period last year. Increasing dementia diagnosis remains a priority area for Liverpool CCG. Member practices are encouraged to identify and diagnose dementia through a combination of clinical leadership, peer support and the Liverpool Quality Improvement Scheme. This approach has proven successful in the past. Dementia Action Liverpool were commissioned by Liverpool City Council to review and propose strategic priorities from 2019 onward. The proposal is complete and currently being considered by City Council and Liverpool CCG, to inform future commissioning plans. Cancer - Cancer performance remained challenging during 2018/19, with increased referrals from primary care, and increasing pressure on diagnostic services in local hospitals. The cancer team worked with the local trusts throughout the year to support changes in pathways to make the process smoother for patients, and to review the impact of longer waiting times on patients and quality. The team also took part in the quality surveillance process to check that local teams meet national quality standards for cancer.

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Local providers continued to implement the ‘recovery package’ for people affected by cancer, and numbers of patients receiving end of treatment summaries and holistic needs assessment continued to increase through the year. In addition, the CCG worked in partnership with Macmillan Cancer Support and Wellbeing Enterprises CIC (WE) delivering a two-year project (currently extended until November 2019) which aims to help people living with cancer to rediscover and reconnect with their strengths and talents, to help people learn new skills, boost confidence, and get the best out of life. The service commenced in August 2017 to offer people a holistic needs assessment in the community. In the first 15 months of operation over 550 referrals were received and over 400 first interventions had taken place including 202 people who have received a full intervention having also been signposted to support from community groups, leisure facilities and TALK Liverpool psychological therapies. 115 people had also attended social prescribing courses/day trips provided by Wellbeing Enterprises, such as Wellbeing Booster and Drumming up Confidence. The wellbeing officers have recently partnered (February 2019) with the Royal Liverpool Hospital to start delivering the ‘HOPE Programme’ in the hospital, which is designed to help people affected by cancer, also offering a chance to meet other patients and share experiences. A full independent evaluation commissioned by Macmillan is due in July 2019. Preliminary findings presented in March 2018 show encouraging qualitative feedback from service users, with 98% people saying that they found the intervention helpful, and they felt supported. 95% of people said they felt that the service will help them address their needs and concerns. There are a number of case studies which demonstrate the value of the service:

“It didn’t matter the time it took. The impression was that I had as long as I liked. If even there was an allotted time, I didn’t feel at any point rushed or hurried.”

“I am finding it easier to relax now since attending the course and it was great to meet other people, without your support to get the walking aid I would never have been able to attend” “It’s like a weight had been lifted. The worry isn’t there anymore, I’m not waking in the night in a panic”.

1.17 Reducing Health Inequality Under Section 14T of the National Health Service Act 2006 (as amended) the CCG has a legal duty to have regard to the need to reduce inequalities between patients in access to health services and the outcomes achieved. The CCG is required to exercise its functions with a view to securing that health services are integrated with health-related and social care services, where it is considered that this would improve quality, reduce inequalities in access to those services or reduce inequalities in the outcomes achieved. Tackling inequalities is at the heart of Liverpool CCG’s core purpose; commissioning services fairly and inclusively and with no community or group left behind in the improvements that will be made to health outcomes across the city. This is a central objective of the One Liverpool Strategy. The health profile of the city demonstrates

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there is a lot more to be done to reduce the health inequalities that exist between people in different parts of the city and within different cohorts of the population. Success in reducing inequalities will only come from a broader approach across health, social care and wider strategic partnerships pulling in the same direction to improve population health. Summarised below are the impacts and outcomes of some the key schemes in 2018/19: Physical Activity: Liverpool’s Physical Activity Programme, led jointly by Liverpool City Council and the CCG, continues to demonstrate success in its aim to get more of our citizens active. The city has improved from 7th out of the 8 English core cities in 2016 to joint 3rd most active core city in England (with Manchester). Inactivity rates have decreased by 3.7% since Nov 2016 and the number of people active for over 150 minutes a week has increased by 2.2%. Physical activity is known to be the most effective form of maintaining and improving health, with multiple benefits to the individual. As the programme has targeted areas with higher inactivity rates, which correlate with areas of higher deprivation, this programme is having a direct impact not only on improving health but also reducing health inequalities. Diabetes Prevention: People who are at risk of developing type 2 diabetes in Liverpool have started to benefit from the local roll-out of Healthier You – NHS England’s National Diabetes Prevention Programme (NDPP) over the past year. This nine-month support programme is designed to stop or delay the onset of the disease through a range of personalised lifestyle interventions, supporting people to make healthier food choices, lose weight, become more active and manage stress. In Liverpool 16,854 people are at risk of developing type 2 diabetes, which can lead to stroke, heart disease, limb amputation and early death. The programme was piloted in the West Derby neighbourhood and is now being extended to practices across the rest of the city, starting with higher deprivation neighbourhoods. Healthy Lung: The Liverpool Healthy Lung Programme has been running since 2016, starting in neighbourhoods with the highest lung cancer incidence and poor respiratory health. High risk populations are invited to a lung health clinic where assessment involves a calculation of risk of lung cancer, with those at high risk invited for a chest CT scan. Outside the programme typically 70% of lung cancers in Liverpool are diagnosed late stage, whereas in areas where this has been rolled out 70%+ of lung cancers are detected at an early stage and treated with curative intent. The programme is also finding high numbers of previously undiagnosed COPD. Everyone attending clinic also benefits from lifestyle advice/referrals. In 2018/19 the CCG re-funded neighbourhoods in Picton, Speke, Everton, Norris Green, to offer the service to the 71-75 population. The service was also rolled out in the City Centre, Kensington, Walton and Belle Vale. This scheme is making a tangible impact in reducing health inequalities by detecting and successfully curing more people with lung cancer, which is the biggest cause of cancer in Liverpool. There are a number of areas in which people in Liverpool continue to experience significant health inequalities. Liverpool remains significantly above the national average for childhood obesity. The CCG with the City Council signed up in 2018 to the Local Government Declaration on Healthy Weight, which has 14 commitments, referenced in section 1.11. In

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2018/19 Liverpool also embarked on the journey to become a UNICEF UK Child Friendly City in March 2019. These and an evidence-based range of other whole system intentions for the 0-25 years population are a key priority for the city going forward.

Cancer remains the city’s biggest killer and although improvements in survival are being seen, Liverpool is not closing the inequality gap with othe parts of the country. They key to reducing inequality is prevention and early detection, which are represented in future priorities for the CCG and our partners in the Cheshire and Merseyside Cancer Alliance.

1.18 Health and Wellbeing Strategy The delivery of the city’s Health and Wellbeing Strategy requires involvement from all member so the Liverpool Health and Wellbeing Board and its partner organisations. Liverpool CCG is formally represeted on the Health and Wellbeing Board and has been an integral partner since it was established in 2013. A summary of the business of the Health and Wellbeing Board can be found in section 1.3.4. In 2018/19 the work of the Board was informed predominantly by the strategic intentions set out in Liverpool Inclusive Growth Plan and the One Liverpool Strategy. The Inclusive plan provides an ambitious vision for Liverpool: a strong and growing city, built on fairness, with six aims: • Investing in children and young people. • People who live well and age well. • Quality homes in thriving neighbourhoods. • A strong and inclusive economy. • A connected and accessible city with quality infrastructure. • Liverpool - the most exciting city in the UK The One Liverpool Strategy sets out the direct and indirect contributions from the NHS and social care to realise this vision. 1.19 Better Care Fund (BCF) The Better Care Fund brings together NHS and local authority social care budgets to support more person centred, co-ordinated care. Amongst other things, the fund it to deliver against a set of nationally defined metrics:-

• Non-elective Admissions • Delayed Transfers of Care • Still at home 91 days after discharge from re-ablement services • Permanent admissions to care homes

The total value of the Liverpool BCF in 2018/19 was £103,996k; of which £59,344k was contributed by Liverpool City Council and £44,652k from Liverpool CCG.

A Section 75 Agreement has been in place between the CCG and City Council since the formation of the CCG in April 2013. The Agreement has been revised

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periodically to reflect the changing nature of the aligned funds and has been subject to formal approval annually by both the CCG and City Council.

The schemes that the Liverpool BCF supports have the following ambitions:

• Focus on prevention and population health management; building on prevention and early help services;

• Urgent care that is integrated with primary, community, mental health and social care, reducing the need for emergency or unplanned interventions;

• Ensuring people with ongoing care needs receive more coordinated care, with more services in the home and community settings, delivered by fully integrated, Community Care Teams including mental health, by linking hospital specialists to community-based care, and making greater use of technology to deliver care remotely;

• Supporting people with the most complex health needs through provision of a range of services in community settings.

As the CCG and Liverpool City Council move forward together in jointly commissioning establishing for a place-based, integrated system of care in Liverpool, there are opportunities for the BCF to be further harnessed as a vehicle to support the achievement of our joint strategic commissioning objectives and plans, as set out in the One Liverpool Strategy and the city’s Inclusive Growth Plan.

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CASE STUDIES

Healthier You: National Diabetes Prevention Programme GP Extended Access Service Liverpool Stroke Recovery Partnership NHS App Liverpool Bowel Screening Volunteer Programme

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Healthier You: National Diabetes Prevention Programme Roll Out People who are at risk of developing type 2 diabetes in Liverpool benefiting from the local roll-out of Healthier You – NHS England’s National Diabetes Prevention Programme (NDPP) over the past year. This nine-month support programme, delivered in a group setting, is designed to stop or delay the onset of the disease through a range of personalised lifestyle interventions, supporting people to make healthier food choices, lose weight, become more active and manage stress. Patient referrals can be made by doctors, nurses, health care assistants or any member of the GP practice team. In Liverpool, 16,854 people are currently at risk of developing type 2 diabetes, which can also lead to strokes, heart disease, limb amputation, and early death. Following a successful pilot phase of the programme, the programme is now also

being extended to practices across the rest of the city. By the end of February 2019, 132 people had engaged with the programme and a further 116 were booked in to start in March and April.

One service user, who is already benefiting from being a part of the programme is Steve Adams. He said: “When I was diagnosed as being pre-diabetic my state of mind was very negative. I feared that the prognosis was not good. The course made me realise that not only was developing diabetes not a certainty, but also that with sensible lifestyle changes, the situation can be managed. The course has helped me focus on my diet and exercise regime, which was previously non-existent. In a relatively short time, I have seen very positive results in my weight, fitness and mood. I would recommend this course because it helps you to realise that change does not have to be radical to make a difference, and it really can be achieved.”

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GP Extended Access Service In October 2018, a new seven-day service was launched in Liverpool which offers patients access to routine appointments with GPs and other health care professionals – including during evenings and weekends. The GP Extended Access Service is part of a national initiative and in Liverpool the

service is being delivered by Primary Care 24 (PC24), which provides Liverpool’s GP out-of-hours service. These additional evening and

weekend appointments are bookable through Liverpool GP practices and offer patients greater flexibility and choice about how and when

they can access primary care services. To make an appointment through the GP Extended Access Service, patients simply call their usual GP practice. The service offers both over the phone triage and advice, and face to face appointments, which are provided at a number of health centres around the city. In addition, in November 2018 the service also introduced the ability for NHS 111 to book directly into Extended Access weekend appointments. In the five months since launching, Liverpool’s Extended Access Service has been successfully providing additional capacity, over evenings and weekends, helping to alleviate pressures on the system, while also providing opportunity for appointments outside of regular GP hours.

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Liverpool Stroke Recovery Partnership Over the last two years, NHS Liverpool CCG has invested in the development of a pilot scheme to help enhance rehabilitation and recovery services for stroke patients in the city. Historically, stroke admissions in Liverpool have risen on average by 1% each year, due to the high prevalence of cardiovascular disease in the city. There were also some clear inequalities around access to stroke care for patients across different areas. Atrial fibrillation (AF) and high blood pressure are two major risk factors for stroke, leading to targeted interventions to improve the detection and management of both conditions, including treating more AF patients with anticoagulant drugs, which reduce severity if people do suffer a stroke. The CCG has invested to create the Liverpool Stroke Recovery Partnership, which is made up of Early Supported Discharge therapy teams from the Royal Liverpool and Aintree hospitals, the clinical psychology team, and the Stroke Association. This partnership is delivering a personally-tailored holistic package of recovery support to patients which includes occupational, physio and speech therapy, along with

emotional wellbeing, psychological and Life After Stroke support. In Liverpool, 59.3% of patients now receive this support, compared with just 33.8% nationally. Latest data shows that the trend towards rising stroke admissions is slowing down significantly in Liverpool – in the year to July 2017, the increase had reduced to 0.1%, compared against an annual 1% rise

previously. Admissions have also reduced by 3%, and stroke-specific bed days reduced by 14% (2,778 bed days) (source: Secondary Uses Service, NHS Digital). The NHS Long Term Plan increases the focus on stroke services with an emphasis on higher intensity care models for stroke rehabilitation. The embedding of emotional, psychological and life after stroke support alongside physical recovery, as in the Liverpool model, is recognised as an exemplar approach. Feedback from one Liverpool stroke survivor: “The six-month review was brilliant. The information that was provided gave me peace of mind and the tips around managing my recovery have been really useful. It really helped that I had time to talk and share what I was worried about – thank you.”

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NHS App Trialled in Liverpool In autumn 2018 Liverpool became one of only six areas of the country to trial the new NHS App. The app was tested with patients and staff across four GP practices in Liverpool, before its full national rollout began. The app provides access to a range of GP services from a smart phone, including: • Check symptoms using the health A-Z on the NHS website • Find out what to do when you need help urgently using NHS 111 online • Book and manage GP practice appointments & repeat prescriptions • Securely view GP medical records • Register as an organ donor Dr Ian Pawson, a Liverpool GP and CCG Governing Body member said: “We were really excited about being part of this early adoption phase in Liverpool. The NHS App is a really important digital health care innovation that offers a number of important benefits to patients and to the NHS.”

During the autumn 2018 pilot phase 385 Liverpool patients tested the app. All patients in Liverpool can now download the NHS App onto an apple or android device by visiting the app or google play store. You can find out more at: www.nhs.uk/nhsapp

Future developments for the app include electronic patient consultations, known locally as eConsult, which will offer patients a quick and convenient alternative to calling or attending for an appointment in person for advice about about non-urgent health problems. Over 2,000 electronic patient consultations were undertaken in Liverpool last year as part of a trial, and this functionality is now being made available to all practices in the city. Aintree Park Group Practice was the first GP practice in Liverpool to begin trialling the new system. Dr Mark Wigglesworth, a GP at the practice explains: “We’re finding that e-Consult is helping people from many different walks of life to communicate with their GP in a new way; whether that’s people living with long-term conditions who are able to manage medications changes from home more easily, or patients who might find it difficult to attend a surgery and talk to a doctor face to face about their health. Whilst we recognise that having an online

Karen McGarry, Practice Manager at Walton Medical Centre – the first practice in the country to use the NHS App

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appointment with their doctor is not going to be everyone’s preference, amongst those who have chosen to try e-Consult, there’s been some fantastic feedback so far.” As of March 2019, 20 out of 88 Liverpool practices had adopted eConsult, with more coming on board all the time. Patients can check their practice’s website to see if they offer this service.

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Liverpool Bowel Screening Volunteer Project Bowel cancer is the second biggest cancer killer and the fourth most common cancer type with 41,300 new cases diagnosed in the UK in 2014. The primary way to ensure that bowel cancer is caught early is for people to take part in the National Bowel Cancer Screening Programme for people aged 60-74. Currently only 58% of people do this nationally and only 52.8% across Liverpool. In some communities’ participation is lower than 35%. In 2018 Liverpool CCG recognised the success of a Manchester based programme to increase screening uptake and asked partners to come together to try the approach in Liverpool. The Liverpool Bowel Screening Volunteers Project first launched in 2018 and is managed and co-ordinated by Liverpool Public Health,

Liverpool CCG and partners such as Cancer Research UK, Liverpool John Moores University (LJMU), University of Liverpool and a Macmillan GP. The project aims to increase bowel cancer screening uptake in Neighbourhoods where participation in bowel cancer screening is lowest. Bowel screening uptake has been proven to increase when people have a non-pressured

conversation about the importance of completing the test and the process involved. Liverpool CCG Volunteers work alongside GP Practice staff in their surgery, phoning people who are aged 60 – 74 who have not yet completed their screening test. Since August 2018, volunteers have had 482 conversations with patients, and from this 208 patients gave consent to have a bowel screening kit sent to them. “I have found working on the Bowel Screening Project very rewarding. I know there will be patients who will have benefited from making the decision to take part in bowel screening after being contacted by myself or one of my fellow volunteers. As a member of the volunteer team at the CCG, I have been very well supported in all the projects I have been involved in and always been made to feel a valued member of the team. I have also had the opportunity of meeting truly inspirational people, which I consider to be a great privilege. – Valerie (Liverpool Bowel Screening Volunteer) If you are interested in taking part in the Liverpool Bowel Screening Volunteer Project you can email [email protected] or call 0151 247 6406

Liverpool Bowel Screening Volunteers (Cohort 1)

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2. Accountability Report 2.1 Members Report 2.1.1 Member practices The following table includes details of the 86 Practices that comprise the membership of Liverpool CCG as at the 31st March 2019: Central Locality Practice Name Practice Address Abercromby Health Centre Grove Street L7 7HG Benim Medical Centre 2 Penvalley Crescent L6 3BY Bigham Rd Medical Centre Bigham Road L6 6DW Brownlow @ Marybone Marybone Unit 1, 2 Vauxhall Road L3 2BG Brownlow Group Practice 70 Pembroke Place L69 3GF Brownlow Health Princes Park Health Centre, Bentley Road L8 0SY Brownlow Health Kensington Neighbourhood Centre, Jubilee Drive L7 8SJ Derby Lane Medical Centre 88 Derby Lane L13 3DN Dovecot Family Health Centre Longreach Road L14 0NL Dunstan Village Group Practice 131 Earle Road L7 6HD Earle Road Medical Centre 131 Earle Road L7 6HD Edge Hill Health Centre Kensington Neighbourhood Centre, Jubilee Drive L7 8SJ Fairfield Medical Centre 2 Penvalley Crescent L6 3BY Green Lane Medical Centre 15 Green Lane L13 7DY Hornspit Medical Centre Hornspit Lane L12 5LT Knotty Ash Medical Centre 411 East Prescot Road L14 2DE Old Swan Health Centre (Agarwal) Crystal Close L13 2GA Picton Green Medical Centre Picton Neighbourhood Health and Children’s

Centre, 137 Earle Road L7 6HD

Primary Care Connect Ltd Park View Medical Centre , Orphan Drive L6 7UN The Riverside Centre For Health ( D r J u d e )

Picton Neighbourhood Health and Children’s Centre 137 Earle Road

L7 6HD

Rock Court Surgery 4 Crystal Close L13 2GA Sefton Park Medical Centre Smithdown Road L15 2LQ St. James' Health Centre 29 Great George Street L1 5DZ Stoneycroft Medical Centre Stoneville Road L13 6QD Vauxhall Health Centre Limekiln Lane L5 8XR West Derby Medical Centre 3 Winterburn Crescent L12 8TQ Yew Tree Centre Bereford Road L14 4ED Vauxhall Health Centre Limekiln Lane L5 8XR West Derby Medical Centre 3 Winterburn Crescent L12 8TQ Yew Tree Centre Bereford Road L14 4ED

South Locality

Practice Name Practice Address Ash Surgery 1 Ashfield Road L17 0BY Belle Vale Health Centre Hedgefield Road L25 2XE Dingle Park Practice Park Street L8 6QP The Elms Medical Centre 3 The Elms L8 3SS Fulwood Green Medical Centre Jericho Lane L17 4AR Gateacre Medical Centre 49 Belle Vale Road L25 2PA Gateacre Brow Surgery 1 Gateacre Brow L25 3PA

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Practice Name Practice Address Grassendale General Practice 23 Darby Road L19 9BP Greenbank Drive Surgery 8 Greenbank Drive L17 1AW Greenbank Road Surgery 1B Greenbank Road L18 1HG Hunts Cross Health Centre 70 Hillfoot Road L25 0ND Lance Lane Medical Centre 19 Lance Lane L15 6TS The Margaret Thompson Medical Centre

105 East Millwood Road L24 6TH

Mather Avenue Surgery 584 Mather Avenue L19 4UG Primary Care Connect Ltd Netherley Health Centre, Middlemass Hey L27 7AF Primary Care Connect Ltd West Speke Health Centre, Blacklock Hall Road L24 3TY

Primary Care Connect Ltd Garston Family Health Centre, South Liverpool Treatment, 32 Church Road

L19 2LW

Oak Vale Medical Centre 215 Childwall Road L15 6UT Penny Lane Surgery 7 Smithdown Place L15 9EH Queens Drive Surgery 73 Queens Drive L18 2DU The Riverside Centre for Health

Park Street L8 6QP

The Riverside Centre for Health Park Street L8 6QP Rocky Lane Surgery 80 Rocky Lane L16 1JD Rutherford Medical Centre 1 Rutherford Road L18 0HJ Sandringham Medical Centre 1a Aigburth Road L17 4JP Speke Health Centre Mangarai) 75 South Parade L24 2XP Speke Health Centre (Singh) 75 South Parade L24 2XP Speke Health Centre (Thakur) 75 South Parade L24 2XP Storrsdale Medical Centre 1 Storrsdale Road L18 7YJ Valley Medical Centre 75 Hartsbourne Avenue L25 1RY Village Medical Centre 20 Quarry Street L25 5JA Village Surgery South Liverpool NHS Treatment Centre L19 2LW Woolton House Medical Centre 6 Woolton Street L25 5JA

North Locality Practice Name Practice Address Abingdon Family Health Care Centre

361 Queens Drive L4 8SJ

Aintree Park Group Practice 46 Moss Lane L9 8AL Albion Surgery 45 Everton Road L6 2EH Anfield Group Practice Townsend Lane Neighbourhood Centre, 98

Townsend Lane L6 0BB

Bousfield Health Centre (Roberts) Westminster Road L4 4PP Bousfield Health Centre (Shah) Westminster Road L4 4PP Ellergreen Medical Centre 24 Carr Lane L11 2RY Fir Tree Drive Medical Centre Fir Tree Drive South L12 0JE Gilmoss Medical centre 48 Petherick Road L11 0AG Great Homer Street Surgery 32 Conway Street L5 3SF Grey Road Surgery Breeze Hill Neighbourhood Health Centre 1-3 Rice

Lane L9 1AD

Islington House Surgery Islington House Medical Centre L3 8DD Jubilee Medical Centre 52 Croxteth Hall Lane L11 4UG Kirkdale Medical Centre 14 Waller Close L4 4QJ Langbank Medical Centre Broad Lane L11 1AD Long Lane Medical Centre Long Lane L9 6DQ Mere Lane Group Practice Mere Lane Neighbourhood Centre, Mere Lane L5 0QW Moss Way Surgery 53 Moss Way L11 0BL Primary Care Connect Ltd. Everton Road Health Centre, 45 Everton Rd (closed

29/3/19) L6 2EH

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Practice Name Practice Address Primary Care Connect Ltd (Anfield Health)

Townsend Lane Neighbourhood Centre, 98 Townsend Lane

L6 0BB

Poulter Road Medical Centre 34 Poulter Road L9 0HJ Priory Medical Centre Belmont Grove L6 4EW Stopgate Lane Medical Centre 6 Stopgate Lane L9 6AP Stanley Medical Centre (Harvey) Stanley Medical Centre L5 2QA Townsend Medical Centre (Dr Abdi) Townsend Lane Neighbourhood Centre, 98 Townsend

Lane L4 8SJ

Walton Medical Centre Breeze Hill Neighbourhood Centre, 1-3 Rice Lane L9 1AD Walton Village Medical Centre (Razvi)

172 Walton Village L4 6TW

Westminster Medical Centre Aldams Grove, Westminster Road L4 3TT Westmoreland GP Centre Aintree Hospital, Lower Lane L9 7AL

* Primary Care Connect Practices – shaded in blue 2.1.2 Chair and Accountable Officer For the year 2018/19 the office of Chair of the CCG was held by Dr Simon Bowers until 31st May 2018 and then by Dr Fiona Lemmens from 13th June 2018, whilst the role of Chief Officer (Accountable Officer) was held by Jan Ledward. 2.1.3 Composition of the Governing Body The membership of the Governing Body up to the signing of the Annual Report and Accounts has been as follows: Governing Body Members: Mark Bakewell Chief Finance Officer Dr Janet Bliss GP/Clinical Vice Chair (from 11th December 2018) Helen Dearden Lay Member Governance / Non-clinical Vice Chair Dr Paula Finnerty GP North Locality (from 1st June 2018) Gerry Gray Lay Member Financial Management and Oversight Sally Houghton Lay Member / Audit Chair Dr Monica Khuraijam GP Jan Ledward Chief Officer (Accountable Officer) Dr Fiona Lemmens GP/Chair Jane Lunt Head of Quality, Outcomes and Improvement/Chief Nurse Professor Donal O’Donoghue

Secondary Care Doctor (until 1st January 2019)

Dr Fiona Ogden-Forde GP Dr Ian Pawson GP (from 1st June 2018) Kenneth Perry Lay Member Patient Engagement Dr Shamim Rose GP Dr Maurice Smith GP Dr Stephen Sutcliffe GP

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Co-opted Members (non-voting): Tina Atkins Practice Manager Representative (until 1st November 2018) Dr Rob Barnett Secretary, Liverpool LMC Cllr Paul Brant Cabinet Member Health and Social Care, Liverpool City

Council Representative Sandra Davies Director of Public Health, Liverpool City Council Dr Paula Finnerty GP North Locality (until 31st May 2018) Dr Jamie Hampson GP Matchworks Locality (until 31st May 2018) 2.1.4 Committee(s), including Audit Committee The CCG has in place the following committees: • Audit Risk and Scrutiny • Primary Care Commissioning • Quality Safety and Outcomes • Finance Procurement and Contracting • Human Resources • Remuneration Further details of their role and membership can be found on pages 71 to 74 The membership of the Audit Risk and Scrutiny Committee is as follows: • Sally Houghton – Lay Member/Audit Committee Chair • Professor Donal O’ Donaghue – Secondary Care Doctor (until 1st January 2019) • Dr Stephen Sutcliffe – GP • Ken Perry – Lay Member (until 31st March 2019) • Helen Dearden – Lay Member In attendance: • Mark Bakewell – Chief Finance and Contracting Officer • Internal Audit Representative – Mersey Internal Audit Agency • Counter Fraud Representative - Mersey Internal Audit Agency • External Audit Representative – Grant Thornton UK LLP 2.1.5 Register of Interests Conflicts of interest are inevitable in commissioning and it is therefore essential that the CCG has robust arrangements in place to manage actual or potential conflicts appropriately. The CCG complies with the revised 2017 statutory guidance published by NHS England (NHSE) that includes a number of strengthened safeguards to mitigate the risk of real and perceived conflicts of interest arising in CCGs. All formal Governing Body and Committee meeting agendas commence with a ‘Declaration of Interest’ and the Chair of the meeting will address any declarations made in accordance with the formal Conflicts of Interest Policy; recording any such matters and actions in the formal minutes of the meeting. In January 2018 NHSE

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introduced an annual requirement for mandatory conflicts of interest training for specific groups including Governing Body Members, senior managers, and officers/ clinicians involved in commissioning and procurement. Liverpool CCG took the decision to mandate all staff to complete at least one module of the NHS England online training. Compliance with the NHSE requirements and uptake amongst staff is also regularly monitored in-year. All CCGs are required to make publicly available their Registers of Interest, Register of Gifts and Hospitality and Register of Procurement Decisions. The most up-to-date versions of each register can be found on the Liverpool CCG website using the following links: Register of Interests https://www.liverpoolccg.nhs.uk/media/3664/website-version-register-of-interest-2018-updated-february-2019.pdf Register of Gifts and Hospitality https://www.liverpoolccg.nhs.uk/media/3665/lccg-hospitality-register-new-format-2017.pdf Register of Procurement Decisions https://www.liverpoolccg.nhs.uk/media/3023/procurement-register-from-1st-april-2016-111017.xlsx All the above registers are also available in paper format and are accessible to the public at the CCG’s Headquarters in Liverpool City Centre. 2.1.6 Personal data related incidents During 2018/19 there were no Serious Incidents (SI) relating to data security breaches in the CCG and no incidents in the CCG that were required to be reported to the Information Commissioner. 2.1.7 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 reasonably aware, that there is no relevant audit

information of which the clinical commissioning group’s external auditor is unaware; and

• The member has taken all reasonable steps that they ought to have taken as a member in order to make them self-aware of any relevant audit information and to establish that the clinical commissioning group’s auditor is aware of that information.

In addition:

• All Governing Body members confirm that they were not aware of any unreported fraud, nor had they been subject to any investigation or litigation.

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https://www.liverpoolccg.nhs.uk/media/3664/website-version-register-of-interest-2018-updated-february-2019.pdf

https://www.liverpoolccg.nhs.uk/media/3665/lccg-hospitality-register-new-format-2017.pdf

https://www.liverpoolccg.nhs.uk/media/3023/procurement-register-from-1st-april-2016-111017.xlsx

https://www.liverpoolccg.nhs.uk/media/3023/procurement-register-from-1st-april-2016-111017.xlsx

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2.1.8 Modern Slavery Act Liverpool 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. 2.2 Statement of Accountable Officer’s Responsibilities The National Health Service Act 2006 (as amended) states that each Clinical Commissioning Group shall have an Accountable Officer and that Officer shall be appointed by the NHS Commissioning Board (NHS England). NHS England has appointed Jan Ledward to be the Accountable Officer of Liverpool CCG. 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 financial statements in the form and on the basis set out in the Accounts Direction. The financial statements are prepared on an accruals basis and must give a true and fair view of the state of affairs of the Clinical Commissioning Group and of its net expenditure, changes in taxpayers’ equity and cash flows for the financial year.

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In preparing the financial statements, the Accountable Officer is required to comply with the requirements of the Group Accounting Manual issued by the Department of Health and in particular to: • Observe the Accounts Direction issued by NHS England, including the relevant

accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis;

• Make judgements and estimates on a reasonable basis;

• State whether applicable accounting standards as set out in the Group Accounting Manual issued by the Department of Health have been followed, and disclose and explain any material departures in the financial statements; and,

• Prepare the financial statements on a going concern basis. To the best of my knowledge and belief, I have properly discharged the responsibilities set out under The National Health Service Act 2006 (as amended), Managing Public Money and in my Clinical Commissioning Group Accountable Officer Appointment Letter. I also confirm that: • As far as I am aware, there is no relevant audit information of which the CCG’s

auditors are unaware, and that as Accountable Officer, I have taken all the steps that I ought to have taken to make myself aware of any relevant audit information and to establish that the CCG’s auditors are aware of that information.

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

Jan Ledward Accountable Officer 24th May 2019

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2.3 Governance Statement 2.3.1 Introduction and context The Liverpool Clinical Commissioning Group is a body corporate established by NHS England on 1st April 2013 under The National Health Service Act 2006 (as amended) and is licenced by NHS England. The Clinical Commissioning Group’s statutory functions are set out under The National Health Service Act 2006 (as amended). The CCG’s general function is arranging the provision of services for persons for the purposes of the health service in England. The CCG is, in particular, required to arrange for the provision of certain health services to such extent as it considers necessary to meet the reasonable requirements of its local population. In August 2017 the CCG became subject to The NHS Liverpool Clinical Commissioning Group Directions 2017 which were issued under Section 14Z21 of The National Health Service Act 2006 by NHS England. Subsequently these Directions lapsed at the end of August 2018 and the CCG is no longer subject to any intervention by NHSE as at the 31st March 2019. 2.3.2 Scope of responsibility As Accountable Officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of the Clinical Commissioning Group’s policies, aims and objectives, whilst safeguarding the public funds and assets for which I am personally responsible, in accordance with the responsibilities assigned to me in Managing Public Money. I also acknowledge my responsibilities as set out under The National Health Service Act 2006 (as amended) and in my Clinical Commissioning Group Accountable Officer Appointment Letter. I am responsible for ensuring that the Clinical Commissioning Group is administered prudently and economically and that resources are applied efficiently and effectively, safeguarding financial propriety and regularity. I also have responsibility for reviewing the effectiveness of the system of internal control within the clinical commissioning group as set out in this governance statement. 2.3.3 Governance Arrangements and Effectiveness The main function of the governing body is to ensure that the group has made appropriate arrangements for ensuring that it exercises its functions effectively, efficiently and economically and complies with such generally accepted principles of good governance as are relevant to it. The CCG Constitution is constructed around the exemplar model constitution provided by NHS England, with the Governing Body advised as to the need for any specific amendments by our legal advisers Hill Dickinson LLP. The agreed amendments made from the exemplar model primarily reflected the landscape of the membership practices in the city and the committee structure adopted by the CCG.

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As a consequence of the Directions issued in August 2017 the CCG made a series of amendments, in agreement with NHSE to the terms of reference of the CCG committees and in particular the Remuneration Committee. The number of Lay Members also increased to four. The Constitution includes the ‘Scheme of Reservation and Delegation’ and outlines those matters that are reserved for the membership as a whole and those that are the responsibilities of the Governing Body and also deals with matters such as ‘whistle blowing’ and conflicts of interest. The Governing Body - During the year the Governing Body has provided clear strategic leadership and accountability for the organisation’s business and activities. Governance arrangements have been strengthened, with an expanded and new complement of lay members fully taking up their new roles, with oversight from the Chair and the Audit, Risk and Scrutiny Committee. Specific training has also been undertaken with regards to the management of conflicts of interest. Members of the Governing Body have continued to make significant and valuable contributions to the work of numerous collaborative commissioning forums, the Health and Wellbeing Board, Joint Commissioning Group and Safeguarding Board. Further attention has been paid during the year to external relationships and engagement, with Governing Body members leading partner and stakeholder engagement across North Mersey, alongside direct engagement with Trust Chief Executives, Chairs, Councillors and local MPs. The role of the Governing Body continues to develop and members have been afforded a variety of internal and external opportunities during the year to expand and develop their personal and collective knowledge and skills, alongside opportunities to share learning from Liverpool with regional and national colleagues. The ongoing monthly ‘informal’ development sessions have provided an important opportunity for greater discussion and debate on matters of policy and strategy, directly informing and shaping the formal business of the organisation. Such opportunities, particularly for shared learning play an important role in supporting the ongoing development of the organisation and its Governing Body, underpinned by an Organisational Development Plan. The CCG has continued to engage and involve members with a programme of city wide and neighbourhood events, strengthening relationships between the Governing Body members and our membership of practices.

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Governing Body and Committee meetings have overall been well attended and supported throughout the year, illustrated in the following table:

Member

Gov

erni

ng B

ody

(8)

Aud

it, R

isk

&

Scru

tiny

(5)

HR

(3)

Rem

uner

atio

n (5

)

Fina

nce,

Pr

ocur

emen

t &

Con

trac

ting

(13)

Qua

lity,

Saf

ety

&

Out

com

es (1

0)

Prim

ary

Car

e

Com

mis

sion

ing

(8)

Nor

th M

erse

y Jo

int

Com

mitt

ee (

2)

Com

mitt

ee(s

) In

C

omm

on

(5)

Mark Bakewell 8/8 – – – 13/13 – 8/8 – 2/5 Dr Janet Bliss 5/8 – – – – – – – – Helen Dearden 8/8 5/5 3/3 5/5 12/13 – 6/8 – – Dr Paula Finnerty (from June 2018) 6/6 – – – – – 4/4 2/2 – Gerry Gray 6/8 – – – 9/13 – – – – Sally Houghton 8/8 5/5 – – – – – 2/2 – Dr Monica Khuraijam 8/8 – – – – – – – – Jan Ledward 8/8 – 0/3 – 6/13 7/10 5/8 2/2 5/5 Dr Fiona Lemmens 8/8 – – – – 0/10 – – 5/5 Jane Lunt 6/8 – – – – 10/10 6/8 – – Dr Donal O’Donoghue (until 31.12.18) 3/6 3/4 – – – 5/8 – – 0/4 Dr Fiona Ogden-Forde 7/8 – – – – – – – – Dr Ian Pawson (from June 2018) 6/6 – – – 5/5 – – – – Ken Perry 7/8 4/5 2/3 5/5 – 8/10 8/8 – – Dr Shamim Rose 6/8 – 3/3 2/2 – 8/10 – – – Dr Maurice Smith 4/8 – 2/3 1/2 11/12 – – – – Dr Steve Sutcliffe 8/8 4/5 – – – 9/10 4/5 – – Note: For some meetings, GP governors will be excluded due to conflict of interests. The Governing Body holds its formal public meetings on a bi-monthly basis. The Governing Body and Committees have together led and overseen: • The continuing discharge of delegated commissioning responsibility for primary

care medical services covering 86 GP Practices in the city. • The development and adoption of key policies covering such areas as criteria

based treatment, information governance, continued health care and various human resources and health and safety policies.

• Mental Health Work Programme • Enhanced primary care access • Safeguarding children and adults • Review and ‘look back’ exercise of services provided by the former Liverpool

Community Health Trust • Strategic and 2018/19 ‘One Liverpool’ Strategy. The Committees of the Governing Body are as follows: Audit, Risk and Scrutiny – the Committee purpose is to review the establishment and maintenance of an effective system of integrated governance, risk management and internal control, across the whole of the CCG’s activities. It also ensures that there is an effective internal audit function that meets the mandatory NHS Internal

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Audit Standards and provides appropriate independent assurance. The Committee reviews the work and findings of the external auditors and considers the implications and management’s responses to their work. Other aspects of the Committee’s work include ensuring that adequate counter fraud arrangements are in place and as required review the outcomes of counter fraud work. The annual work plan for the committee is based around best practice guidelines from the NHS Audit Committee Handbook published by the HFMA. During the year the Committee has continued to play an important role in the continued oversight and assurance of the CCG’s governance arrangements and internal systems of control. This has included the setting and review of the annual internal audit cycle, local counter fraud activities (including receipt of the Counter Fraud Work Plan 2018/19) and the development of effective working relationships with the appointed external auditors. Throughout 2018/19 the Committee has overseen the CCG’s response(s) to a number of Internal Audit Recommendations including (but not limited to) primary medical care commissioning and contracting governance; healthcare associated infections; data quality and KPIs; data protection and security toolkit; Conflicts of Interest and the CCG’s Financial Control Environment. The Committee has also been instrumental in the oversight of key organisational policies such as the revised arrangements to comply with statutory guidance surrounding the management of conflicts of interest and mandatory training. Remuneration – the Committee role is to make recommendations and determinations about pay and remuneration for Governing Body members, Senior Managers and the wider senior leadership team (SLT). This remit includes setting pay levels, reviewing conditions of service and allowances. During the year the Committee has considered GP pay and pensions; safeguarding remuneration; clinical leadership and lay member remuneration and VSM remuneration, making recommendations to the Governing Body as required. Human Resources – the Committee role is to determine and recommend HR policies and salary frameworks for employees (other than Very Senior Managers), monitor corporate workforce organisational performance indicators and provide assurance to the Governing Body that performance is managed. During the year the Committee has reviewed and adopted a variety of key HR policies including travel expenses and managing sickness. The Committee has also supported the development of staff side representation in the organisation and reviewed equality and diversity in the workforce. Finance, Procurement and Contracting – the Committee has a lead role in monitoring the financial governance arrangements of the CCG. This includes responsibility for assuring the delivery of the CCG’s statutory financial duties and financial reporting arrangements on behalf of the Governing Body. The Committee has oversight of the delivery of the CCG financial plan and provides assurance regarding the procurement and contracting activities of the organisation. During the year the Committee has overseen the development of the organisation’s financial plans and reviewed monthly financial, contract and activity performance.

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Key areas of further work have included oversight of cash releasing efficiency savings, various procurement activities (including APMS), information governance compliance and scrutiny of investment proposals. Quality, Safety and Outcomes – the Committee is responsible for overseeing quality and safety processes across all commissioned services, ensuring alignment with delivery of the NHS Outcomes Framework and for assuring the Governing Body that quality and patient safety activity is co-ordinated and transparent, ensuring a coherent and systematic review of the system. During 2018/19, the Quality, Safety and Outcomes Committee continued to have oversight of the quality of commissioned services. The committee agenda is structured around an annual work plan to enable oversight of commissioned services from Primary Care through to Specialist services. This approach ensures the committee is proactive in oversight of services, but is also able to react to, and address, emerging risks and issues. The agenda includes; the management of serious incidents in line with the national framework; management and reduction of health care acquired infections; safeguarding performance and areas of quality related concern, such as mortality rates. The committee’s role is to seek assurance that commissioned services have robust systems and processes in place to ensure delivery of quality services and identify areas of concern, intervene early and improve quality, through a process of learning and support. Through the Committees work, insight and intelligence, with an assessment of associated risk, is provided to the NHS England Quality Surveillance Group (QSG) and other key groups which have a role in oversight of quality risks and concerns, or in promoting shared learning. Primary Care Commissioning Committee – From February 2015 the Primary Care Commissioning Committee was instituted following NHS England’s approval of the CCG’s revised Constitution and the successful application to assume delegated responsibility from NHS England for the commissioning of primary medical services. During 2018/19 the Committee has continued to oversee the CCG commissioning responsibility for the 86 GP Practices in the city. Key areas to note have included regular scrutiny of performance reports, concerns as to the delivery of the national primary care support service and prescribing performance and effectiveness. The Committee has also continued to review the reports from the continuation of the Care Quality Commission inspection regime of GP Practices and where appropriate intervene and support Practices to improve. The committee have continued to oversee the Local Quality Improvement Scheme, and also alongside the FPC Committee the APMS contracts. North Mersey Committee(s) in Common – the Committee brings together representatives from the four North Mersey CCGs; Liverpool, Knowsley, Southport & Formby and South Sefton, as well as NHS England Specialised Commissioning to provide oversight of the development of acute service change and other proposals that impact on our populations. During 2018/19 the agenda of the committee has included the exploration of shared Right Care priorities; the Royal Liverpool and Aintree Hospitals Trauma and

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Orthopaedics and ENT reconfiguration proposals; urgent and emergency care review; and the development of haemato-oncology services in North Mersey. North Mersey CCG Joint Committee - the committee was established in November 2018, comprising the four North Mersey CCGs – Knowsley, Liverpool, South Sefton and Southport and Formby. The committee has delegated decision-making authority on specific programmes to enable streamlined and inclusive governance, particularly for acute services reconfiguration across the North Mersey geography. The 2018/19 work programme included the proposals for a single service for orthopaedics and elective ENT services across the city’s two adult acute trusts and the proposal for a new Liverpool Women’s Hospital. 2.3.4 UK Corporate Governance Code We are not required to comply with the UK Corporate Governance Code. However, we have reported on our corporate governance arrangements by drawing upon best practice available, including those aspects of the UK Corporate Governance Code we consider to be relevant to the Clinical Commissioning Group and best practice. 2.3.5 Discharge of Statutory Functions In light of the recommendations in the 2013 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 senior manager or Governing Body member. Directorates have confirmed that their structures provide the necessary capability and capacity to undertake all of the Clinical Commissioning Group’s statutory duties. 2.3.6 Risk management Arrangements and Effectiveness As Accountable Officer, I have responsibility for reviewing the effectiveness of the system of internal control within the Clinical Commissioning Group. 2.3.7 Capacity to Handle Risk The risk management process is led by the Chief Operating Officer who provides professional leadership and oversight of both the overall process and its application throughout the organisation. Underpinned by a Risk Management Strategy and access to best practice and guidance, staff in lead roles across the CCG are appropriately trained and supported to ensure that the risk management approach is embedded at all levels in the CCG. Throughout the year use is made of opportunities, to share and learn from best practice, including shared learning from internal auditors and legal advisers who both regularly provide professional seminars and share good practice guidance.

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Risks as already described are assessed and managed in accordance with the Risk Management Strategy approved by the Governing Body. The effective management of risk is the responsibility of all members of staff and Governing Body members, who all play a role in ensuring that risks are managed and mitigated in an effective and sustainable manner. Strategic and significant operational risks are reported to the Governing Body via the Governing Body Assurance Framework and Corporate Risk Register and are subject to regular review, reassessment and profiling. 2.3.8 Risk Assessment The management and assessment of risks is governed by the CCG’s Risk Management and Assurance Strategy which outlines how risks are identified, assessed against impact and likelihood and managed through either the Governing Body Assurance Framework (GBAF), the Corporate Risk Register or directorate/ committee risk registers. A five stage process that can be illustrated as follows is in operation: The risk assessment undertaken will reflect both the likelihood and any consequences of the risk and its potential to: • Cause death, injury or ill health to individuals or groups; • Result in civil claims / litigation against the CCG, a Governing Body Member, or

member of staff; • Result in enforcement action to the CCG; • Cause damage to the environment; • Cause property damage / loss; • Impact on the day to day operational issues of the CCG; or • Result in reputational damage for the CCG; The level of risk is assessed using the CCG’s five by five risk matrix by judging the likelihood of the residual risk occurring and consequences for the CCG should the

Step 1 – Identify Risks

Step 2 – Analyse Risks

Step 3 – Evaluate Risks

Step 4 – Treat Risks

Step 5 – Monitor and Review

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event occur. This assessment results in an overall score ranging from 1 to 25 and a risk level of low, moderate, high or extreme. The major potential risks to governance, risk management and internal control can be summarised as follows: Governance Information Governance – Liverpool CCG strengthened its Information Governance arrangements in light of the introduction of the EU General Data Protection Regulations (GDPR) in May 2018. The CCG had been making preparations for implementation of GDPR over the preceding 12 months through its internal Information Governance Steering Group. A dedicated full time (fixed-term) role was created in July 2018 to project manage the impact of the new GDPR internally and ensure smooth coordination between CCG Information Asset Owners to identify and mitigate risks and operational issues, whilst providing ‘on demand’ technical knowledge, expertise and leadership to staff and in ensuring organisational compliance with the new Data Security and Protection Toolkit submission for 2018/19. The role was designed to provide an ‘enhanced’ IG compliance/management function along with the externally contracted Data Protection Officer (DPO) specialist role, outsourced technical support role and has been hugely successful in managing the necessary ‘cross working’ arrangements and interdependencies to ensure compliance with GDPR and DSP Toolkit submission for 2018/19.

Conflicts of Interest – as stated earlier in this report conflicts of interest are inevitable in the commissioning of health services and the CCG regularly updates and publishes its Registers of Interest, Register of Procurement Decisions and Register of Gifts and Hospitality on our external facing website to ensure continued public trust and transparency in our decision making. Since the CCG Approvals Committee was stood down during 2017/18 the ‘part two’ meeting of the Finance, Procurement and Contracting Committee have continued to exclude Governing Body GPs where matters of procurement such as APMS are considered, thereby ensuring decisions affecting or impacting upon general practice income are made with the best interests of the people of Liverpool and free from any perceived bias or undue influence. Risk Management During 2018/19 Liverpool CCG has strengthened its approach to risk management with the continued separation of strategic risks and operational risks via the Governing Body Assurance Framework (GBAF) and Corporate Risk Register respectively. Towards the latter stages of 2018/19 a Corporate ‘Issues Log’ was created to complement the GBAF and Corporate Risk Register (CRR) and ensure a clear demarcation between emerging risks and current operational issues affecting delivery of plans and objectives. The transfer of operational issues from the CRR to the Issues Log has led to a much greater focus at Governing Body level on the actual ‘risks’ to the organisation whilst enabling a more robust approach to the management and oversight of ‘operational’ issues.

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All ‘new’ risks added to the Corporate Risk Register in 2018/19 were reflective of this approach and highlighted the CCG’s commitment to following best practice and maintaining robust and effective governance arrangements. New risks added in-year included agreement with Liverpool City Council regarding the refreshed Section 75 agreement, implementation or recommendations and learning from the Kirkup review (and subsequent report) into Liverpool Community Health (LCH), the continued delivery and sustainability of services provided to Liverpool patients by ‘One to One’ midwifery service, the resolution of post April 2013 cases of Previously Unassessed Periods of Care (PUPoC) and achievement of 2018/19 NHS England Business Rules/Cash Release Efficiency Savings (CRES). Further information on key issues and risks in 2018/19 can be found in Section 1.6 of this report, or in detail by accessing the CCG Governing Body papers via the CCG website. Although the CCG’s appetite for risk is dynamic and an iterative process reflective of a changing environment, the CCG will not, under any circumstances accept any risk which would potentially/actually result in non-compliance with legislation, statutory responsibilities, cause significant financial loss or would compromise patient/staff safety. As a public body, there is naturally a low tolerance threshold for any risks which are of this nature. The CCG has a clear and documented process for the escalation of risks onto the Corporate Risk Register, with immediate inclusion of any which are a threat to the delivery of our strategic (or high level operational) objectives. The most prevalent risks for Liverpool CCG during 2018/19 are summarised below: • Non-delivery of emergency ambulance services within requirements of national

standards of safety and responsiveness;

• Risk of community health services not meeting commissioning requirements of quality and safety;

• Delivery of commissioned Urgent and Emergency Care services unable to meet rise in demand across health system;

• Resolution of open PUPoC cases (relating to post April 2013 NHS England

‘closedown’) All of the above were considered as significant risks to high level operational objectives and carried an individual residual score within the range of 15 and 25, placing them in the ‘Extreme’ category (red). This category of risk requires immediate corrective action, continued oversight and assurance on control measures actions to (and by) the Governing Body. In all cases risks have been presented to the Governing Body meeting in public session(s) and a variety of mitigating actions and steps are being taken in response to the risks that will continue unresolved in part or whole into 2019/20. The impact and consequences of the risks are subject to ongoing scrutiny and attention as the CCG seeks to agree and implement acceptable and sustainable solutions to mitigate residual risks going forward. Compliance with CCG Operating Licence

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In August 2017 NHS England enacted The NHS Liverpool Clinical Group Directions 2017 and a series of immediate actions were taken to ensure CCG compliance with the requirements set out in the Directions. These Directions ceased at the end of August 2018. 2.3.9 Other Sources of Assurance 2.3.9.1 Internal Control Framework A system of internal control is the set of processes and procedures in place in the Clinical Commissioning Group to ensure it delivers its policies, aims and objectives. It is designed to identify and prioritise the risks, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically. 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. My review of the effectiveness of the system of internal control is informed by the work of the internal auditors and the senior managers and clinical leads within the Clinical Commissioning Group who have responsibility for the development and maintenance of the internal control framework. I have drawn on performance information available to me. My review is also informed by comments made by the external auditors in their management letter and other reports. The Governing Body Assurance Framework and Corporate Risk Register provides me with evidence that the effectiveness of controls that manage risks to the clinical commissioning group achieving 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, the Audit Committee and the Quality, Safety and Outcomes Committee, if appropriate and a plan to address weaknesses and ensure continuous improvement of the system is in place. During the year the Governing Body and Audit Committee have kept under regular review the application of the system of internal control. With the support of Internal Audit where areas for improvement have been identified, appropriate actions have been taken and changes made to ensure that the systems in place remain robust and effective. The formal process of a quarterly assurance review of the CCG by NHS England Cheshire and Merseyside has also provided a further external insight and commentary as to the performance of the CCG. Overall the system of internal control in 2018/19 has been found to be effective and has met the needs of the organisation. However as already identified there have been some areas where issues and gaps in control have been identified and specific prompt action has been taken to address these gaps in an effective and sustainable manner.

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Following completion of the planned audit work for the financial year for the clinical commissioning group, the Head of Internal Audit issued an independent and objective opinion on the adequacy and effectiveness of the Clinical Commissioning Group’s system of risk management, governance and internal control. Overall the CCG is vigilant to the potential risks to the CCG operating licence and maintains a system of strong internal control and risk management. However no organisation can be complacent and the CCG recognises this and has taken steps during the year in a number of key areas to ensure that compliance with the operating licence is maintained and protected: • Adoption of a revised and updated remuneration framework for Governing Body

members and clinical lead roles in the organisation. • Continuation of four Lay Members on the Governing Body. • Constitutional amendments agreed with NHS England to strengthen and enhance

governance and in particular clarify the role and remit of the Remuneration Committee.

• Performance information – during the year the corporate performance report which is presented regularly to the Governing Body has been subject to regular review, refinement and further strengthening so as to fully meet the needs and requirements of the Governing Body and provide them with assurance as to compliance with the CCG’s licence and statutory duties.

2.3.9.2 Annual Audit of Conflicts of Interest Management The statutory guidance on managing conflicts of interest for CCGs (June 2017) requires CCGs to undertake an annual internal audit of conflicts of interest management. To support CCGs to undertake this task, NHS England published a template audit framework. The required audit exercise was conducted by MIAA, who found the CCG to be fully compliant in terms of its decision making processes and contract monitoring and for the reporting of concerns, identifying breaches and identifying areas of non-compliance. The CCG was found to be ‘partially compliant’ in the following areas: Governance arrangements: The 2018/19 review of the CCG’s governance arrangements found that the CCG’s Managing Conflicts of Interest Policy and Gifts and Hospitality Policy were both aligned to NHS England’s Statutory Guidance. The CCG also met the minimum requirements of having four lay members in place (one of whom fulfilled the Conflicts of Interest Guardian role). However, testing of staff compliance/uptake with Module 1 of NHS England’s Conflicts of Interest e-learning found that seven CCG employees had not completed the training. Follow-up enquiries confirmed that since the initial field work five of this cohort had completed the training since it was highlighted and that only one employee was still to complete it (the remaining employee had been on a career break at the time). It was also highlighted that Conflicts of Interest training compliance figures were not reported though the CCG’s Governing Body but were reported to NHS England. Internal arrangements were immediately strengthened in relation to these areas, with regular internal audits conducted to ensure continued compliance.

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Registers of interest, gifts, hospitality and procurement decisions: Testing of the CCG’s Register of Interests found that new starters and existing CCG staff who had changed roles within the organisation during the financial year did not always make their declarations within the mandated 28 days. Further testing confirmed that all CCG staff in decision making roles were included in the published Register of Interests where interests had been declared. Decision making processes and contract monitoring: Field work and previous audit testing in this area confirmed that the process around procurement decisions is managed jointly between the CCG and the Shared Business Service (SBS) and standard documentation issued to bidders included Conflicts of Interest forms and confidentiality forms. It was confirmed that the CCG had not conducted any procurement exercises during the financial year 2018/19 and as such, no tender waivers were actioned in this period. Reporting concerns and identifying and managing breaches/non-compliance: The annual review of the CCG’s processes and systems found that they are clearly outlined within its Conflicts of Interest Policy, including requirements for anonymised details of breaches to be published on the CCG’s website and reported to NHS England. 2.3.9.3 Data Quality During the year the Governing Body has on occasion expressed some concerns as to the quality of data provided to them, including in some cases by individual provider trusts. Immediate steps were taken to hold the providers of the data to account for the delivery of quality information and data through the contracting process. Similarly action was taken against individual providers whose data was not of an acceptable standard. The sustained provision of a significant and strengthened analytical resource internally within the CCG has assisted greatly in ensuring that the Governing Body has access to data of the highest quality and, subject to reporting limitations, in a timely fashion. 2.3.9.4 Information Governance (including data security) The NHS Information Governance Framework sets the processes and procedures by which the NHS handles information about patients and employees, in particular personal identifiable information. The NHS Information Governance Framework is supported by an information governance toolkit and the annual submission process provides assurances to the Clinical Commissioning Group, other organisations and to individuals that personal information is dealt with legally, securely, efficiently and effectively. The CCG achieved Level 3 (98%) compliance against the IG Toolkit requirements with no significant or unsatisfactory issues to highlight, a position strongly supported by ‘significant assurance’ from our Internal Auditors. We place high importance on ensuring there are robust information governance systems and processes in place to help protect patient and corporate information. We have established an information governance management framework and developed information governance processes and procedures in line with the

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information governance toolkit. We have ensured all staff undertake annual information governance training and have briefed staff to ensure they are aware of their information governance roles and responsibilities. There are processes in place for incident reporting and the investigation of serious incidents. Information risk assessment and management procedures are in place and we continue to strive towards fully embedding a risk culture throughout the organisation against identified risks. 2.3.9.5 Business Critical Models The CCG maintains a strong relationship with NHS Digital through the establishment of robust systems, processes, and data sharing agreements, demonstrating confidence in the CCG to manage personal identifiable information (PID) safely and securely where there is a legal basis to do so. The CCG is compliant with the Data Security and Protection Toolkit. All of the CCGs Business critical models have been identified and noted on the CCG Information Asset Registers. 2.3.9.6 Third Party Assurance The CCG seeks assurances from our providers of external support (as outlined in section 4.3.12) through a variety of means to provide assurance to the senior management team and Governing Body. Typically each area with the exception of the Capita primary care support services, which is the responsibility of NHSE, has a lead officer who maintains a client relationship with the service provider. Those relations extend to regular contact and meetings with the providers, participation in client satisfaction ratings and where required intervention where performance falls below a satisfactory level. As appropriate, external standards and service delivery levels are monitored and by exception any assurance failings brought to the immediate attention of the CCG. 2.3.10 Control Issues There are no significant control issues facing the CCG. 2.3.11 Review of Economy, Efficiency and Effectiveness of Use of Resources As part of the NHSE assurance process for CCGs, we are assessed as to the quality of leadership in the organisation. The final year end assessment from NHSE is not available in time for the publication of this Annual Report. We anticipate it will be available in July 2019 at www.nhs.uk/service-search/Performance/Search The Governing Body, informed by its committees and in particular the Finance, Contracts and Procurement Committee, oversees and directs the use of CCG resources. In doing so Governing Body members benefit from the experience and skills of a strong and competent senior management team, who work within a strong framework of performance management, benchmarking and comparative assessment. Programmes of work and service redesign and transformational

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programmes are all clinically led by Governing Body members who are supported by project leads and a project management infrastructure. All significant investment decisions are subject to a rigorous assessment and prioritisation process that is applied in such a way as to determine the relative effectiveness of the proposal, including the impact upon key strategic outcomes and objectives. Use is also made of data and support from our public health colleagues in the local authority. Where available, use is particularly made of comparative data, including that from the ‘Core Cities’ to ensure a rigour behind all decisions. Support is also provided by our internal auditors from the Mersey Internal Audit Agency who provide an important source of objective advice, assessment and oversight 2.3.12 Delegation of Functions During 2018/19 the CCG had delegated arrangements in place with providers external to the CCG for the following: • St Helens and Knowsley NHS Trust: Payroll processing

• Shared Business Services: Financial Systems – Transactional Processing

• Midlands and Lancashire Commissioning Support Unit: elements of Business Intelligence (including data processing); Continuing Healthcare (CHC), Funded Nursing Care and individual complex packages of care; Emergency Planning support; urgent care system reporting; Individual Funding Requests (IFR); strategic engagement advice and support; and some aspects of Continuing Healthcare processes.

• Capita: provision of support services to primary care practitioners (including General Practice)

During the year risks associated with these activities have been monitored through the development of close partnership working; participation at local user groups and regular monitoring including periodic evaluation of key performance indicators. Any identified risks have been monitored through the CCG’s governance and risk management processes. 2.3.13 Counter Fraud Arrangements The CCG is compliant with the relevant NHS Counter Fraud Authority standards for commissioners regarding fraud, bribery and corruption. Specifically the CCG commissions from Mersey Internal Audit Agency (MIAA) an appropriate and accredited Anti-Fraud (AF) service to directly assist and support the organisation through its existing Internal Audit, Anti-Fraud and Anti-Bribery and Corruption plans in ensuring that the additional necessary measures (or the amendment of existing policies) are carried out in a timely and integrated manner with minimal business interruption. Although bribery legislation has been in place for a number of years, the CCG regularly reviews its Anti-Bribery and Corruption Strategy through the work of MIAA’s Anti-Fraud Service in order to satisfy the adequate procedural defence.

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The executive lead role for Anti-Fraud and Anti-Bribery and Corruption sits with the Chief Finance Officer (as a member of the CCG Governing Body). The Anti-Fraud Specialist (AFS) attends the regular meetings of the Audit, Risk and Scrutiny Committee, providing formal updates against an agreed annual programme of activities. Those activities include: strategic governance work e.g. proactive testing of conflicts of interest; ‘prevent and deter’ work (e.g. National Fraud Initiatives); regular updates to CCG and general practice staff; the sharing of intelligence and fraud awareness training. If required the AFS would also undertake investigatory work. There were two CCG cases of fraud reported and investigated during 2018/19. Both cases were considered to be small in nature. One case was appropriately referred to Police and is considered closed, whilst the second case was open at the time of writing this report. Both cases are deemed to be of a value of £1000 or less. 2.3.14 Head of Internal Audit Opinion Following completion of the planned audit work for the financial year for the Clinical Commissioning Group, the Head of Internal Audit isued an independent and objective optionin on the adequacy and effectiveness of the Clinical Commissioning Group’s system of risk management, governance and internal control. The Head of Internal Audit Mr Tim Crowley, Director of Audit, Mersey Internal Audit Agency concluded that: Substantial Assurance can be given that that there is a good system of internal control designed to meet the organisation’s objectives, and that controls are generally being applied consistently.

This opinion is provided in the context that the Governing Body like other organisations across the NHS is facing a number of challenging issues and wider organisational factors. Financial Sustainability

The CCGs financial plan has been rated as Green by NHS England. The CCG has a challenging QIPP. The CCG is anticipating delivery of £13.8m will be fully achieved.

Annual Assessment

The CCG has been rated as Good by NHS England in its annual assessment of performance against key performance indicators.

Provider Performance

The CCG has continued to regularly report providers’ performance against a range of targets, including cancer waiting times but has struggled to maintain required performance levels for RTT (18 and 52 weeks), IAPT (recovery and access), HCAI and 1% diagnostic target

Leadership Senior management within the CCG has remained stable during 2018/19.

The CCG is part of the Cheshire & Mersey Health and Care Partnership, working in partnership to deliver transformation across the health and social care system,

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looking at how services are currently delivered and ways to make them more sustainable in the future, with the aim of helping people live longer and healthier lives, whilst at the same time, providing the best possible services to those who require them. In providing this opinion I can confirm continued compliance with the definition of internal audit (as set out in your Internal Audit Charter), code of ethics and professional standards. I also confirm organisational independence of the audit activity and that this has been free from interference in respect of scoping, delivery and reporting.

Tim Crowley Head of Internal Audit, MIAA March 2019

2.3.15 Emergency Preparedness, Resilience and Response The CCG has in place a suitably experienced and competent designated Senior Manager lead for emergency preparedness, resilience and response and has played a full and active role in the Merseyside Local Health Resilience Partnership and the associated ‘operational’ Health Resilience Group. The CCG commissions from the Commissioning Support Services Unit access to a professionally qualified and experienced emergency planner who provides access to any required additional support and advice to the CCG, supplementing the in-house resources. The CCG response plan has been subject to review during the year and is kept up to date and reflects national best practice and policy guidance. Key staff have participated in a variety of planning and response exercises during the year. Plans from all of the major providers from who the CCG commissions services have been subject to audit and review during the year and where required actions plans put into place to ensure full compliance with the national EPRR standards and requirement. Liverpool continued to play host to a series of national and international cultural and sporting events. 2018/19 has been a very busy year for events and activities as the city celebrates ten years on from being European Capital of Culture. Chief amongst these during the year were the Rock ‘n’ Roll Marathon, Liverpool International Music Festival, International Mersey River Festival, Clipper Yacht Race Finish, CBBC Summer Social, Red Bull Drift Shifters and most significantly of all the return of the Giants to Liverpool and also across on the Wirral. The latter event saw over 1million visitors to the city for the event, with the CCG leading on the planning and co-ordination of the health response to this international event. In all cases the CCG took a key role in planning and coordinating the health response and preparedness for the events. Working with health partners and in particular the North West Ambulance Service (NWAS), comprehensive plans for the events were developed, and subsequently tested and exercised, as required. The events passed off without any major incident or adverse impact upon health services in the city and the lessons learnt will be used to inform subsequent major event planning into 2019/20.

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In his letter of the 16th April 2019 the Director of Assurance Delivery for NHSE Cheshire and Merseyside confirmed the CCGs “substantial compliance” against the nationally mandated EPRR core standards. 2.3.15.1 Accountable Officer EPRR Self-certification I certify that NHS Liverpool Clinical Commissioning Group has incident response plans in place, which are fully compliant with the NHS Commissioning Board Emergency Preparedness Framework. The Clinical Commissioning Group regularly reviews and makes improvements to its major incident plan and has a programme for regularly testing this plan, the results of which are reported to the Governing Body. 2.3.16 Principles of Remedy The CCG complies fully with the ‘Principles for Remedy’ as published by the Parliamentary and Health Services Ombudsman. Such remedies are part of the CCG complaints handling procedures and would be applied as and when required in the handling of complaints made to the organisation. During the year the Parliamentary and Health Services Ombudsman has opened two cases with regards to complaints concerning continuing healthcare reviews, of these one has been closed with no further action and the outcome of the second has yet to be determined. 2.3.17 External Audit The CCG is externally audited by Grant Thornton LLP, for 2018/19 the total external audit fees were £75,107 • Audit services £65,107 including VAT • Further assistance services £0 • Other services £10,000 Other services from external audit of £10,000 have been accrued in respect of the 2018/19 Mental Health Investment Standard audit required by NHS England. The fee and audit plan has not yet been agreed, however, it is expected that this will be performed by the CCG’s external auditors. 2.3.18 Review of the Effectiveness of Governance, Risk Management and Internal Control My review of the effectiveness of the system of internal control is informed by the work of the internal auditors and the Senior Managers and clinical leads within the clinical commissioning group who have responsibility for the development and maintenance of the internal control framework. I have drawn on performance

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information available to me. My review is also informed by comments made by the external auditors in their management letter and other reports. The Governing Body Assurance Framework and associated Corporate Risk Register itself provides me with evidence that the effectiveness of controls that manage risks to the clinical commissioning group achieving its principles objectives have been reviewed. I have been advised on the implications of the result of my review of the effectiveness of the system of internal control by the Governing Body, the Audit, Risk and Scrutiny Committee and the Quality, Safety and Outcomes Committee, if appropriate and a plan to address weaknesses and ensure continuous improvement of the system is in place. During the year the Governing Body and Audit Committee have kept under regular review the application of the system of internal control. With the support of Internal Audit where areas for improvement have been identified, appropriate actions have been taken and changes made to ensure that the systems in place remain robust and effective. The formal Integrated Assurance Framework (IAF) review process of the CCG by NHS England Cheshire and Merseyside has also provided a further external insight and commentary as to the performance of the CCG. Overall the system of internal control has been found to be effective and has met the needs of the organisation. However as already identified there have been some areas where issues and gaps in control have been identified and specific prompt action has been taken to address these gaps in an effective and sustainable manner. The CCG has received one internal audit report (Primary Medical Care Commissioning and Contracting) with a limited assurance rating. The CCG has a plan to address the shortcomings identified. Following completion of the planned audit work for the financial year for the Clinical Commissioning Group, the Head of Internal Audit issued an independent and objective opinion on the adequacy and effectiveness of the Clinical Commissioning Group’s system of risk management, governance and internal control. Overall the CCG is vigilant to the potential risks to the CCG operating licence and maintains a system of strong internal control and risk management. However no organisation can be complacent and the CCG recognises this and has taken steps during the year in a number of key areas to ensure that compliance with the operating licence is maintained and protected. Effective governance arrangements – as highlighted above, the CCG keeps under constant review the governance structures and committees that support the Governing Body in the discharge of its role and responsibilities and intends in 2019/20 to bring forward changes to the organisations committee structure that will be reflected in revisions to the current Constitution Performance information – during the year the corporate performance report which is presented formally on a bi-monthly basis to the Governing Body has been subject to

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regular review, refinement and further strengthening so as to fully meet the needs and requirements of the Governing Body and provide them with assurance as to compliance with the CCG’s licence and statutory duties. Governance and risk – over the last twelve months the CCG has developed its Governing Body Assurance Framework, revised risk register and associated issues log as further enhancements to strengthen the organisations approach and management of risk. 2.3.19 Conclusion Whilst some risks have been identified in the main body of the Governance Statement above, none present a significant control issue. Jan Ledward Accountable Officer NHS Liverpool CCG 24th May 2019

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2.4 Remuneration and Staff Report Note: Sections marked with # are auditable elements of the Remuneration Report 2.4.1 Introduction Section 234B and Schedule 7A of The Companies Act, as interpreted for the public sector in the Government Financial Reporting Manual, requires NHS bodies to prepare a Remuneration Report containing information about directors’ remuneration. In the NHS, the report will be in respect of the Senior Managers of the NHS body. ‘Senior Managers’ are defined as: ‘those persons in senior positions having authority or responsibility for directing or controlling the major activities of the NHS body. This means those who influence the decisions of the Clinical Commissioning Group as a whole, rather than the decisions of individual directorates or departments.’ For the purposes of this report, this includes the CCG’s Governing Body members. 2.4.2 Remuneration Committee The Committee role is to make recommendations and determinations about pay and remuneration for Governing Body members, senior managers and the wider senior management team. This remit includes setting pay levels, reviewing conditions of service and allowances. During the year the Committee has considered the Accountable Officer remuneration package, the Chief Finance and Contracting Officer remuneration, a Clinical Leadership and Lay member Remuneration Framework and VSM remuneration. Membership of the Committee can be found on page 72. 2.4.3 Appraisal of Chair, Governing Body Members and Chief

Officer The CCG has in place a robust procedure for assessing the performance and delivery of the Chair, Chief Officer and Governing Body members. The CCG operates a ‘mutual’ appraisal arrangement between the Chair, Vice Chair/Chair of Audit Committee and Chief Officer. The Chair appraises the performance and delivery of the Chief Officer, the Chief Officer then appraises the Vice/Chair of Audit Committee and the Vice Chair appraises the Chair. Governing Body members are subject to appraisal by the Chair. Objectives are set for each person alongside agreement as to any developmental needs, with full records of the appraisal meetings made and retained. 2.4.4 Governing Body Members The dates of contracts and unexpired terms of office for the Governing Body members are shown in the table below.

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2.4.5 Policy on the Remuneration of Senior Managers Senior Managers (Officers) hold permanent contracts of employment and are subject to six months’ notice. Governing Body members, excluding the Chief (Accountable) Officer, Chief Finance and Contracting Officer and Director of Quality, Outcomes and Improvement, are Office Holders and have various lengths of tenure as highlighted in the table above. Amendments to salary are recommended by the Remuneration Committee to the Governing Body. When required the Remuneration Committee can access professional advice from the CCG’s HR team, MLCSU HR team and also the CCG legal advisers, Hill Dickinson LLP. In setting policy for current and future years, the Committee has access to guidance, best practice and benchmarking information from comparative CCGs, such as those in the ‘core cities’ group. Senior Manager performance is monitored through the formal appraisal process, based on organisational and individual objectives. Senior managers are not subject to an element of performance related pay as part of their remuneration packages. 2.4.6 Remuneration of Very Senior Managers CCG senior managers with salaries in excess of £150,000 remuneration have been determined by the Remuneration Committee. In reaching this decision the Committee has taken into account comparisons made to the salaries of similar posts in other CCGs across England, in local NHS providers and in the NHSE ‘regional’

Name Appointment Start Date

Appointment End Date

Mark Bakewell Acting appointment from 12th September 2017 Permanent appointment from 1st December 2018

N/A Permanent contract of employment

Dr Janet Bliss Re-appointed 1st June 2018 31st May 2021 Dr Simon Bowers Re-appointed 1st June 2015 31st May 2018 Helen Dearden 30th January 2018 29th January 2022 Dr Paula Finnerty 1st June 2018 31st May 2021 Gerry Gray 1st January 2018 31st December 2021 Sally Houghton Re-appointed 9th May 2018 8th May 2020 Dr Monica Khuraijam Re-appointed 1st June 2018 31st May 2021 Dr Fiona Lemmens Re-appointed 4th July 2017 3rd July 2020 Jan Ledward Interim appointment from

2nd October 2017 Permanent appointment from 1st May 2018


Jane Lunt 11th November 2012 Employment from 1st April 2013


Professor Donal O’Donoghue Re-appointed 1st October 2015 31st December 2018 Dr Fiona Ogden-Forde Re-appointed 1st June 2018 31st May 2021 Dr Ian Pawson 1st June 2018 31st May 2021 Ken Perry 1st February 2018 Resigned 31st March 2019 Dr Shamin Rose Re-appointed 1st June 2018 31st May 2021 Dr Maurice Smith Re-appointed 4th July 2017 3rd July 2020 Dr Stephen Sutcliffe 4th July 2017 3rd July 2020

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teams to determine that these salaries are reasonable. The following table provides details of senior managers remuneration, including salary and pension entitlements:

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Page | 92

Nam

eTi

tle

Not

es

2018

/19

2017

/18

2018

/19

2017

/18

2018

/19

2017

/18

2018

/19

2017

/18

2018

/19

2017

/18

2018

/19

2017

/18

£'00

0£'

000

£'£'

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000

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000

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Ledw

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ody

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Chi

ef O

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era)

b)

150

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00

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ark

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and

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on

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her a

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as

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and

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1 M

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cos

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by N

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& S

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to L

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. Dur

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the

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each

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ical

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ctit

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bod

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embe

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at, i

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ross

pay

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lary

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Page | 93

2.4.7 Pension Benefits as at 31st March 2019 #

Pensio

n Bene

fits as

at 31 M

arch 2

019#

Name

Title

Notes

Real in

crease

in pen

sion a

t pensi

on age

(bands

of £2,

500)

Real in

crease

in pen

sion lu

mp su

m at

pensio

n age

(bands

of £2,

500)

Total a

ccrued

pensi

on at p

ension

age a

t 31

March

2019

(bands

of £5,

000)

Lump s

um at

pensio

n age

relate

d to

accrue

d pens

ion at

31 Ma

rch 20

19 (ba

nds of

£5,000

)

Cash E

quival

ent

Transf

er Valu

e at 1

April 2

018

Real in

crease

in Cas

h Equ

ivalen

t Trans

fer

Value

Cash E

quival

ent

Transf

er Valu

e at 31

Ma

rch 20

19

Emplo

yer’s

contrib

ution

to sta

kehold

er pens

ion

£000

£000

£000

£000

£000

£000

£000

£00

Jan Le

dward

Chief O

fficer

a) c)

2.5 - 5

2.5 - 5

55 - 60

170 - 1

751,1

57167

1,324

0

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akewe

llChi

ef Fina

nce & C

ontrac

ting

Office

ra) c

)2.5

- 52.5

- 525

- 3050

- 55267

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0

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untDir

ector o

f Qual

ity, Ou

tcome

s & I

mprov

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a) b) c)

0 - 2.5

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931117

1,048

0

b) In li

ne wit

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roup A

ccount

ing Ma

nual Gu

idance

18/19

, when

the rea

l incre

ase in

pensio

n or lu

mp su

m retu

rns a n

egative

value

, the d

isclosu

re must

be am

ended

to zero

. a) T

he pen

sion e

ntitle

ment a

bove is

the tot

al pens

ion en

titlem

ent for

each

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ning B

ody me

mber,

is not s

plit acr

oss oth

er orga

nisatio

ns and

may h

ave be

en par

tly acc

rued in

a non

senior

manag

er capa

city.

c) Cash

Equiv

alent T

ransfe

r Valu

es at 1

April 2

018 ha

ve bee

n recal

culate

d to inc

lude 3

% infl

ation w

hich is

the dif

ferenc

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I betwe

en Sep

tember

2016

and Se

ptemb

er 2017

and is

calcul

ated in

accord

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ith SI

2008 N

o. 1050

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emes

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08 (33

)d) R

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in Cash

Equiv

alent T

ransfe

r Valu

e is the

increa

se in C

ETV tha

t is fun

ded by

the Em

ployer

. It doe

s not i

nclude

the inc

rease

in accr

ued pe

nsion

due to

inflati

on or c

ontrib

utions

paid b

y the e

mploy

ee (in

cludin

g the v

alue o

f any b

enefits

tra

nsferr

ed fro

m anot

her pe

nsion

schem

e or ar

rangem

ent).

e) Non-

Execut

ive Go

vernin

g Body

lay me

mbers

do no

t recei

ve pen

sionab

le rem

unerat

ion an

d there

fore n

o discl

osure i

s requi

red in

respec

t of pe

nsions

.f) T

he CCG

has d

eterm

ined th

at GP G

overni

ng Bod

y mem

bers, f

or the

purpos

es of t

he rem

unerat

ion rep

ort are

classif

ied as

contra

ct 'for

' servic

e prac

titione

rs and

theref

ore, in

line w

ith the

Group

Accou

nting

Manua

l, pens

ion dis

closur

es for

these

individ

uals

are no

t requi

red to

be dis

closed

.

131

Page | 94

2.4.8 Compensation on Early Retirement or for Loss of Office #

During 2018/19 (Nil 2017/18) the CCG has not made any payments of compensation for early retirement or for loss of office. 2.4.9 Payments to Past Members # During 2018/19 (Nil 2017/18) the CCG has not made any payments to any past members. 2.4.10 Pay Multiples # Reporting bodies are required to disclose the relationship between the remuneration of the highest-paid director/member in their organisation and the median remuneration of the organisations workforce. The banded remuneration of the highest paid director in Liverpool CCG in the financial year 2018/19 is £157.5k (2017/18 £137.5k). This was 3.57 times (2017/18 3.23) the median remuneration of the workforce, which was banded £42.5k (2017/18: £42.5k). In 2018/19, no (2017/18: nil) employees received remuneration in excess of the highest-paid director/member. Remuneration ranged from £10-15k to £155-160k (2017/18: £5-10k to £135-140k). The highest paid director in the financial year was the Chief Officer (2017/18: Chief Officer). Total remuneration includes salary, non-consolidated performance-related pay, benefits-in-kind, but not severance payments. It does not include employer pension contributions and the cash equivalent transfer value of pensions. The increase in median pay is as a result of the Chief Officer becoming permanently employed during the year, receiving a one-off, non-recurrent, relocation allowance of £8,000 in year and recurrent taxable expenses in respect of a car allowance. Staff Report 2.4.11 Number of Senior Managers The CCG employs a total of 6 senior managers on a VSM contract, including three Governing Body members (Chief Officer, Chief Finance and Contracting Officer and Director of Quality, Outcomes & Improvement). 2.4.12 Staff Numbers and Costs #

Staffing numbers by occupation can be summarised in the following table:

Permanent Employees Other* Admin & Estates 126.45 6.92 Medical & Dental 0.78 0.13 Nursing & Midwifery 3.00 0.00 Scientific/Therapeutic/Technical 1.0 0.10 Total 131.23 7.15

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*Includes: FTC employees, agency workers and seconded workers (from external organisations). The staffing costs associated are summarised in the following table: Employee benefits expenditure. 2018-19 2017-18

Total Permanent Employees

Other Total Permanent

Employees

Other

£000 £000 £000 £000 £000 £000 Employee Benefits

Salaries and wages* 6,401 6,259 142 6,666 6,456 210 Social security costs 679 679 - 687 687 - Employer contributions to NHS pension scheme 839 839 - 832 832 - Other pension costs 1 1 - - - - Apprenticeship Levy 20 20 - 20 20 - Other post-employment benefits - - - - - - Other employment benefits - - - - - - Termination benefits - - - - - - Gross employee benefits expenditure 7,940 7,798 142 8,205 7,995 210 Less recoveries in respect of employee benefits - - - - - - Total - Net admin employee benefits including capitalised costs 7,940 7,798 142 8,205 7,995 210 Less: Employee costs capitalised - - - - - - Net employee benefits excluding capitalised costs 7,940 7,798 142 8,205 7,995 210 Note: NHS Liverpool CCG policy is for all annual leave due to be taken in the year it is earned, the cost of leave earned but not taken is minimal and has not therefore been included in expenditure. 2.4.13 Staff Composition Breakdown of staff* by gender at the 31/3/2019: Male Female Governing Body (office holders) 5 8 Very Senior Managers (not included above)** 3 3 Other members of staff 37 104 *This excludes workers seconded from external organisations, agency staff and contractors ** Employed on a VSM contract

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Page | 96

2.4.14 Sickness Absence Data

Source: NHS Digital - Sickness Absence Publication - based on data from the ESR Data Warehouse. Period covered: January to December 2018 Data items: ESR does not hold details of the planned working/non-workings days for employers so days lost and days available are reported based upon a 365-day year. For Annual Report and Accounts the following figures are used: The number of FTE-days available has been taken directly from ESR. This has been converted to FTE years in the first column by dividing by 365. The number of FTE-days lost to sickness absence has been taken directly from ESR. The adjusted FTE days lost has been calculated by multiplying by 225/365 to give the Cabinet Office Measure. The average number of sick days per FTE has been estimated by dividing the FTE Days by the FTE days lost and multiplying by 225/365 to give the Cabinet Office measure. This figure is replicated on returns by dividing the adjusted FTE days lost by Average FTE.

2.4.15 Staff Policies The CCG is committed to an environment that promotes equality and embraces diversity in its performance as an employer. It adheres to legal and performance requirements and mainstreams its equality and diversity principles through its policies, procedures and processes. To ensure that our policies do not have an adverse impact in response to the requirements of The Equality Act 2010, policies are screened for relevance during policy development processes and an impact assessment conducted where necessary. The CCG will take action when necessary to address any unexpected or unwarranted disparities and monitor workforce and employment practices to ensure that employment policies are fairly implemented. The Organisation is committed to ensuring that staff receive appropriate awareness training in Equality and Diversity to undertake their role. Equality and Diversity training is mandatory for all staff commensurate with the duties that they are required to undertake.

Average FTE 2018

Adjusted FTE days lost to Cabinet Office Definitions

FTE-Days Available

FTE-Days Lost to Sickness Absence

Average Sick Days per FTE

Liverpool CCG 146 1,188 53,229 1,926 17.03

Figures converted by DH to Best Estimates of Required Data Items

Statistics Produced by NHS Digital from ESR Data Warehouse

134

Page | 97

We operate a fair and objective system for recruiting, which places emphasis on individual skills, abilities and experience. This enables a full diversity of people to demonstrate their ability to do a job. Selection criteria contained within our Job Descriptions and Person Specifications are regularly reviewed to ensure that they are justifiable and so do not unfairly discriminate directly or indirectly and are essential for the effective performance of the role. We offer a guaranteed interview scheme for disabled applicants who meet our essential selection criteria. We have ‘Positive About Disabled People/2 Tick’ accreditation. We are committed to making reasonable adjustments in the workplace, including appropriate training, to support the continuation of employment. We strive to enable all staff to achieve their full potential in an environment of dignity and mutual respect. This is underpinned by ensuring that every employee is in possession of a Personal Development Plan (PDP) and is annually appraised in a Performance Development Review (PDR). All employees are supported to develop the skills and abilities they require to carry out their current and any likely future role in the organisation. 2.4.16 Employee Consultation and Engagement The CCG places a high importance on the delivery of effective communications, involvement and engagement with all of its employees. It discharges these duties through a variety of means including: • A weekly Friday morning ‘floor meeting’ which provides a valuable opportunity for

the Chief Officer and senior managers to brief staff on important matters concerning the business and operations of the organisation, and to hear views and news from all team members.

• The CCG has a Staff Listening Group, made up of staff representing their department, to actively encourage two way communications between staff and management. The work of the group includes reviewing the staff survey and supporting the development of a subsequent action plan, supporting the delivery of the organisational development action plan, engaging on the development of policies and the implementation of policies and discussing general organisational issues or concerns.

• A weekly electronic bulletin available to all staff that provides a short and digestible summary of key internal and external issues of relevance to the staff and CCG.

• An internal online intranet resource.

• A staff suggestions mailbox for staff to post ideas if they would like to make changes and improvements to the workplace.

• A Healthy Workforce fund to support initiatives devised by the workforce, to improve employee health, wellbeing and engagement.

135

Page | 98

2.4.17 Expenditure on Consultancy During the financial year ended 31st March 2019 the CCG spent £9,756 on external consultancy from Ernst & Young in respect Governing Body remuneration review (GP Impact). 2.4.18 Off-payroll Engagements Table 1: Off-payroll engagements longer than 6 months - For all off-payroll engagements as of 31st March 2019, for more than £245 per day and that last longer than six months. All engagements relate to payments made for clinical leads supporting determined areas of CCG activities. Number Number of Existing Engagements as of 31st March 2019 22 of which that have existed for … less than one year at time of reporting between one and two years at time of reporting between two and three years at time of reporting between three and for years at time of reporting four or more years at time of reporting

0 4 1 0 17

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. Table 2: New Off-payroll Engagements - Number of new engagements, or those that reached six months in duration, for more than £245 per day between 1st April 2018 and 31st March 2019:

Number Number of new Engagements, or those that reached six months in duration, between 1st April 2018 and 31st March 2019 Of which … No. assessed as caught by IR35 No. assessed as not caught by IR35 No. engaged directly (via PSC contracted to department and are on the departmental payroll No. of engagements reassessed for consistency/assurance purposes during the year No. of engagements that saw a change to IR35 status following the consistency review

0

0 0 0

0

0

Table 3: Off Payroll Board Member/Senior Official Engagements For any off payroll engagements of Board members and/or senior officials with significant financial responsibility between 1st April 2018 and 31st March 2019.

Number No. of off-payroll engagements of Board members and/or senior officials with significant financial responsibility between 1st April 2018 and 31st March 2019 No of individuals that have been deemed “Board members and/or senior officials with significant financial responsibility” during the financial year. This figure should include both off-payroll and on-payroll engagements.

0

18

136

Page | 99

2.4.19 Exit Packages, Including Special (non-contractual) Payments Table 1: Exit Packages

Exit package

cost band

(inc. any special

payment element

Number of compulsory redundancies

Cost of

compulsory redundancies

Number of other

departures agreed

Cost of other

departures agreed

Total number of exit

packages

Total cost of

exit packages

Number of

departures where special

payments have

been made

Cost of special

payment element

included in exit

packages

£s £s £s £s TOTALS 0 N/A 0 N/A 0 N/A 0 N/A 2.4.20 Analysis of Other Departures Agreements Total Value

of Agreements

Number £000s Voluntary redundancies including early retirement contractual costs 0 N/A Mutually agreed resignations (MARS) contractual costs 0 N/A Early retirements in the efficiency of the service contractual costs 0 N/A Contractual payments in lieu of notice* 0 N/A Exit payments following Employment Tribunals or court orders 0 N/A Non-contractual payments requiring HMT approval** 0 N/A TOTAL 0 N/A 2.4.21 The Trade Union (Facility Time Publication Requirements) Regulations 2017 In compliance with the above Regulations the following information is provided: Relevant union officials - What was the total number of your employees who were relevant union officials during the relevant period?

Number of your employees who were relevant union officials during the relevant period

Full time equivalent number

1 0.04 Percentage of time spent on facility time - How many of your employees who were relevant union officials employed during the relevant period spent a) 0%, b) 1% - 50%, c) 51% - 99% or d) 100% of their working hours on facility time ?

Percentage of time Number of employees 0% 0

1-50% 1 51% - 99% 0

100% 0

137

Page | 100

Percentage of pay bill spent of facility time - Provide the figures requested in the first column of the table below to determine the percentage of your total pay bill spent on paying employees who were relevant union officials for facility time during the relevant period

Provide the total cost of facility time £787 Provide the total pay bill £7,940,000

Provide the percentage of the total pay bill spent on facility time, calculated as: (total

cost of facility time / total pay bill) x100

0.01%

Paid trade union activities - As a percentage of total paid facility time hours, how many hours were spent by employees who were relevant union officials during the relevant period on paid trade union activities ? Time spent on paid trade union activities as a percentage of total paid facility time hours calculated as: (total hours spent on paid trade union activities by relevant union officials during the relevant period / total paid facility time hours) x 100

(7 hours/ 28.5 hours) x 100 = 24.5%

2.5 Parliamentary Accountability and Audit Report NHS Liverpool 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 from pages 104 onwards. An external audit certificate and report is also included in this Annual Report at page 99.

Name: Jan Ledward Accountable Officer NHS Liverpool CCG 24th May 2019

138

Page | 101

Independent auditor's report to the members of the Governing Body of NHS Liverpool CCG Report on the Audit of the Financial Statements Opinion We have audited the financial statements of NHS Liverpool CCG (the ‘CCG’) for the year ended 31 March 2019, which comprise the Statement of Comprehensive Net Expenditure, the Statement of Financial Position, the Statement of Changes in Taxpayers Equity, the Statement of Cash Flows and notes to the financial statements, including a summary of significant accounting policies. The financial reporting framework that has been applied in their preparation is applicable law and International Financial Reporting Standards (IFRSs) as adopted by the European Union, and as interpreted and adapted bythe Department of Health and Social Care Group Accounting Manual 2018-19. In our opinion, the financial statements: • give a true and fair view of the financial position of the CCG as at 31 March 2019 and of its expenditure and

income for the year then ended; and • have been properly prepared in accordance with International Financial Reporting Standards (IFRSs) as

adopted by the European Union, as interpreted and adapted by the Department of Health and Social Care Group Accounting Manual 2018-19; and

• have been prepared in accordance with the requirements of the Health and Social Care Act 2012. 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. We are independent of the CCG in accordance with the ethical requirements that are relevant to our audit of the financial statements in the UK, including the FRC’s Ethical Standard, and we have fulfilled our other ethical responsibilities in accordance with these requirements. We believe that the audit evidence we have obtained is sufficient and appropriate to provide a basis for our opinion. 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 CCG’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 Accountable Officer is responsible for the other information. The other information comprises the information included in the Annual Report, other than the financial statements and our auditor’s report thereon. Our opinion on the financial statements does not cover the other information and, except to the extent otherwise explicitly stated in our report, we do not express any form of assurance conclusion thereon. In connection with our audit of the financial statements, our responsibility is to read the other information and, in doing so, consider whether the other information is materially inconsistent with the financial statements or our knowledge obtained in the 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.

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Other information we are required to report on by exception under the Code of Audit Practice Under the Code of Audit Practice published by the National Audit Office on behalf of the Comptroller and Auditor General (the Code of Audit Practice) we are required to consider whether the Governance Statement does not comply with the guidance issued by the NHS Commissioning Board or is misleading or inconsistent with the information of which we are aware from our audit.We are not required to consider whether the Governance Statement addresses all risks and controls or that risks are satisfactorily addressed by internal controls. We have nothing to report in this regard. Opinion on other matters required by the Code of Audit Practice In our opinion: • the parts of the Remuneration and Staff Report to be audited have been properly prepared in accordance with

IFRSs as adopted by the European Union, as interpreted and adapted by the Department of Health and Social Care Group Accounting Manual 2018-19 and the requirements of the Health and Social Care Act 2012; and

• based on the work undertaken in the course of the audit of the financial statements and our knowledge of the

CCG gained through our work in relation to the CCG’s arrangements for securing economy, efficiency and effectiveness in its use of resources, the other information published together with the financial statements in the Annual Report for the financial year for which the financial statements are prepared is consistent with the financial statements.

Opinion on regularity required by the Code of Audit Practice In our opinion, in all material respects the expenditure and income recorded in the financial statements have been applied to the purposes intended by Parliament and the financial transactions in the financial statements conform to the authorities which govern them. Matters on which we are required to report by exception Under the Code of Audit Practice, we are required to report to you if: • we issue a report in the public interest under Section 24 of the Local Audit and Accountability Act 2014 in the

course of, or at the conclusion of the audit; 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 make a written recommendation to the CCG under Section 24 of the Local Audit and Accountability Act

2014 in the course of, or at the conclusion of the audit. We have nothing to report in respect of the above matters. Responsibilities of the Accountable Officer and Those Charged with Governance for the financial statements As explained more fully in the Statement of Accountable Officer's responsibilities set out on pages 68 to 69, the Accountable Officer, is responsible for the preparation of the financial statements in the form and on the basis set out in the Accounts Directions, for being satisfied that they give a true and fair view, and for such internal control as the Accountable Officer determines is necessary to enable the preparation of financial statements that are free from material misstatement, whether due to fraud or error. In preparing the financial statements, the Accountable Officer is responsible for assessing the CCG’s ability to continue as a going concern, disclosing, as applicable, matters related to going concern and using the going concern basis of accounting unless they have been informed by the relevant national body of the intention to dissolve the CCG without the transfer of its services to another public sector entity. The Accountable Officer is responsible for ensuring the regularity of expenditure and income in the financial statements.

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The Audit, Risk and Scrutiny Committee is Those Charged with Governance. Those charged with governance are responsible for overseeing the CCG’s financial reporting process. 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: www.frc.org.uk/auditorsresponsibilities. This description forms part of our auditor’s report. We are also responsible for giving an opinion on the regularity of expenditure and income in the financial statements in accordance with the Code of Audit Practice. Report on other legal and regulatory requirements - Conclusion on the CCG’s arrangements for securing economy, efficiency and effectiveness in its use of resources Matter on which we are required to report by exception - CCG’s arrangements for securing economy, efficiency and effectiveness in its use of resources Under the Code of Audit Practice, we are required to report to you if, in our opinion we have not been able to satisfy ourselves that the CCG has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources for the year ended 31 March 2019. We have nothing to report in respect of the above matter. Responsibilities of the Accountable Officer As explained in the Governance Statement, the Accountable Officer is responsible for putting in place proper arrangements for securing economy, efficiency and effectiveness in the use of the CCG's resources. Auditor’s responsibilities for the review of the CCG’s arrangements for securing economy, efficiency and effectiveness in its use of resources We are required under Section 21(1)(c) and Schedule 13 paragraph 10(a) of the Local Audit and Accountability Act 2014 to be satisfied that the CCG has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources and to report where we have not been able to satisfy ourselves that it has done so. We are not required to consider, nor have we considered, whether all aspects of the CCG's arrangements for securing economy, efficiency and effectiveness in its use of resources are operating effectively. We have undertaken our review in accordance with the Code of Audit Practice, having regard to the guidance on the specified criterion issued by the Comptroller and Auditor General in November 2017, as to whether in all significant respects, the CCG had proper arrangements to ensure it took properly informed decisions and deployed resources to achieve planned and sustainable outcomes for taxpayers and local people. The Comptroller and Auditor General determined this criterion as that necessary for us to consider under the Code of Audit Practice in satisfying ourselves whether the CCG put in place proper arrangements for securing economy, efficiency and effectiveness in its use of resources for the year ended 31 March 2019, and to report by exception where we are not satisfied. We planned our work in accordance with the Code of Audit Practice. Based on our risk assessment, we undertook such work as we considered necessary to be satisfied that the CCG has put in place proper arrangements for securing economy, efficiency and effectiveness in its use of resources. Report on other legal and regulatory requirements - Certificate We certify that we have completed the audit of the financial statements of NHS Liverpool CCG in accordance with the requirements of the Local Audit and Accountability Act 2014 and the Code of Audit Practice.

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Use of our report This report is made solely to the members of the Governing Body of the CCG, as a body, in accordance with Part 5 of the Local Audit and Accountability Act 2014. Our audit work has been undertaken so that we might state to the members of the Governing Body of the CCG those matters we are required to state to them in an auditor’s report and for no other purpose. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the CCG and the members of the Governing Body of the CCG, as a body, for our audit work, for this report, or for the opinions we have formed. Signature Andrew Smith for and on behalf of Grant Thornton UK LLP, Local Auditor Liverpool Date TBC

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3. The Financial Statement 2018/2019

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 3 (37,497) (34,721) Other operating income 3 (16) (1,132) Total operating income

(37,513) (35,853)

Staff costs 5 7,940 8,205 Purchase of goods and services 6 916,994 894,784 Other Operating Expenditure 6 3,944 4,577 Total operating expenditure

928,878 907,566

Net Operating Expenditure for the financial year 891,365 871,713

Finance expense 8 - 2 Total Net Expenditure for the Financial Year 891,365 871,715 Other Comprehensive Expenditure

- -

Comprehensive Expenditure for the year ended 31 March 2019 891,365 871,715

The notes on pages 108 to 140 form part of this statement.

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Statement of Financial Position as at 31 March 2019

31 March 2019 31 March 2018

Note £000 £000

Current assets:

Trade and other receivables 10 9,713 5,696

Cash and cash equivalents 11 1 1

Total current assets 9,714 5,697

Total assets 9,714 5,697

Current liabilities:

Trade and other payables 12 (52,911) (41,845)

Total current liabilities

(52,911) (41,845)

Total Liabilities Employed (43,197) (36,148)

Financed by Taxpayers’ Equity

General fund

(43,197) (36,148)

Total taxpayers' equity: (43,197) (36,148)


The financial statements on pages 104 to 140 were approved by the Governing Body on 24

May 2019 and signed on its behalf by:

Jan Ledward Chief Accountable Officer 24th May 2019

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Statement of Changes in Taxpayers’ Equity for the Year Ended 31 March 2019

General fund

Revaluation reserve

Other reserves

Total reserves

£000 £000 £000 £000 Changes in taxpayers’ equity for 2018-19

Balance at 1 April 2018

(36,148) - - (36,148)

Changes in the Liverpool CCG taxpayers’ equity for 2018-19

Net operating expenditure for the financial year

(891,365) - - (891,365)

Net Recognised NHS CCG Expenditure for the Financial Year

(891,365) (891,365)

Net funding

884,316 - - 884,316

Balance at 31 March 2019

(43,197) - - (43,197)

General fund

Revaluation reserve

Other reserves

Total reserves

£000 £000 £000 £000 Changes in taxpayers’ equity for 2017-18

Balance at 1 April 2017

(38,417) - - (38,417)

Changes in the Liverpool CCG taxpayers equity for 2017-18

Net operating expenditure for the financial year

(871,715) - - (871,715)

Net Recognised NHS CCG Expenditure for the Financial Year

(871,715) - - (871,715)

Net funding

873,984 - - 873,984

Balance at 31 March 2018

(36,148) - - (36,148)

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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 3, 6, 8 (891,365) (871,715) (Increase)/decrease in trade & other receivables 10 (4,017) 722 Increase/(decrease) in trade & other payables 12 11,066 (2,991) Provisions utilised 13 0 0 Increase/(decrease) in provisions 13 0 0 Net Cash Inflow (Outflow) from Operating Activities

(884,316) (873,984)

Net Cash Inflow (Outflow) before Financing (884,316) (873,984)

Cash Flows from Financing Activities

Net funding received

884,316 873,984

Net Cash Inflow (Outflow) from Financing Activities

884,316 873,984 Net Increase (Decrease) in Cash & Cash Equivalents 11 0 0

Cash & Cash Equivalents at the beginning of the financial year

1

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

1

1


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1. Notes to the Financial Statements

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.

The accounting policies contained in the GAM 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 DHSC Group Accounting Manual permits a choice of accounting policy, the accounting policy

that 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 are described below. They have been applied consistently in dealing with items

considered material in relation to the accounts.

Going Concern

These accounts have been prepared on the going concern basis.

Public sector bodies are assumed to be going concerns where the continuation of the provision of

a service in the future is anticipated, as evidenced by inclusion of financial provision for that

service in published documents.

Where a Clinical Commissioning Group ceases to exist, it considers whether or not its services will

continue to be provided (using the same assets, by another public sector entity) in determining

whether to use the concept of going concern for the final set of Financial Statements. If services

will continue to be provided the Financial Statements are prepared on the going concern basis.

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.

Movement of Assets within the Department of Health 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

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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 Group are accounted for in

line with IAS 20 and similarly give rise to income and expenditure entries.

Joint arrangements

Arrangements over which the clinical commissioning group has joint control with one or more other

entities are classified as joint arrangements. Joint control is the contractually agreed sharing of

control of an arrangement. A joint arrangement is either a joint operation or a joint venture.

A joint operation exists where the parties that have joint control have rights to the assets and

obligations for the liabilities relating to the arrangement. Where the clinical commissioning group is

a joint operator it recognises its share of, assets, liabilities, income and expenses in its own

accounts.

See note 19 for further information on the Liverpool Clinical Commissioning Group’s joint

arrangements.

A joint venture is a joint arrangement whereby the parties that have joint control of the

arrangement have rights to the net assets of the arrangement. Joint ventures are recognised as an

investment and accounted for using the equity method. The Liverpool CCG does not have any

joint ventures.

Pooled Budgets – Joint operation

Liverpool CCG has entered into a pooled budget arrangement with Liverpool City Council in

accordance with section 75 of the NHS Act 2006. Under the arrangements, funds are pooled for

the provision of Integrated Community Equipment and Disability Advice Services (ICEDAS) and to

operate a pooled budget for the required Better Care Fund arrangements and note 19 provides

details of the income and expenditure.

The Better Care Fund is hosted by Liverpool City Council. The ICEDAS is hosted by the Liverpool

CCG. Liverpool CCG accounts for its share of the assets, liabilities, income and expenditure

arising from the activities of the pooled budget, identified in accordance with the pooled budget

agreement.

Operating Segments

Income and expenditure are analysed in the Operating Segments note and are reported in line

with management information used within the Clinical Commissioning Group.

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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.

Revenue in respect of services provided is recognised when (or as) performance obligations are

satisfied by transferring promised services to the customer, and is measured at the amount of the

transaction price allocated to that performance obligation.

Where income is received for a specific performance obligation that is to be satisfied in the

following year, that income is deferred.

Payment terms are standard reflecting cross government principles. 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.

Employee Benefits

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.

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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.

Retirement Benefit Costs

Past and present employees are covered by the provisions of the NHS Pensions Scheme. The

scheme is an unfunded, defined benefit scheme that covers NHS employers, General Practices

and other bodies, allowed under the direction of the Secretary of State, in England and Wales. The

scheme is not designed to be run in a way that would enable NHS bodies to identify their share of

the underlying scheme assets and liabilities. Therefore, the scheme is accounted for as if it were a

defined contribution scheme: the cost to the Clinical Commissioning Group of participating in the

scheme is taken as equal to the contributions payable to the scheme for the accounting period.

For early retirements other than those due to ill health, the additional pension liabilities are not

funded by the scheme. The full amount of the liability for the additional costs is charged to

expenditure at the time the Clinical Commissioning Group commits itself to the retirement,

regardless of the method of payment.

The schemes are subject to a full actuarial valuation every four years and an accounting valuation

every year.

NEST pension scheme

Some employees who cannot, or do not wish to be members of the NHS Pension Scheme, are

members of the NEST scheme. NEST is a workplace pension, set up by the government in

advance of the changes to auto enrolment. The scheme is a defined contribution scheme and

therefore the cost to the Clinical Commissioning Group of participating in the scheme is taken as

equal to the contributions payable to the scheme for the accounting period.

Other Expenses

Other operating expenses are recognised when, and to the extent that, the goods or services have

been received. They are measured at fair value of the consideration payable.

Grants payable

Where grant funding is not intended to be directly related to activity undertaken by a grant

recipient in a specific period, the Clinical Commissioning Group recognises the expenditure in the

period in which the grant is paid. All other grants are accounted for on an accruals basis

Government grant funded assets

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Government grant funded assets are capitalised at current value in existing use, if they will be held

for their service potential, or otherwise at fair value on receipt, with a matching credit to income.

Deferred income is recognised only where conditions attached to the grant preclude immediate

recognition of the gain.

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 as Lessee

Property, plant and equipment held under finance leases are initially recognised, at the inception

of the lease, at fair value or, if lower, at the present value of the minimum lease payments, with a

matching liability for the lease obligation to the lessor. Lease payments are apportioned between

finance charges and reduction of the lease obligation so as to achieve a constant rate on interest

on the remaining balance of the liability. Finance charges are recognised in calculating the Clinical

Commissioning Group’s surplus/deficit.

Operating lease payments are recognised as an expense on a straight-line basis over the lease

term. Lease incentives are recognised initially as a liability and subsequently as a reduction of

rentals on a straight-line basis over the lease term.

Contingent rentals are recognised as an expense in the period in which they are incurred.

Where a lease is for land and buildings, the land and building components are separated and

individually assessed as to whether they are operating or finance leases.

Services Received

The fair value of services received in the year is recorded under the relevant expenditure headings

within ‘operating expenses’.

Cash

Cash is cash in hand and deposits with any financial institution repayable without penalty on notice

of not more than 24 hours.

In the Statement of Cash Flows, cash is shown net of bank overdrafts that are repayable on

demand and that form an integral part of the Clinical Commissioning Group’s cash management.

Cash, bank and overdraft balances are recorded at current values.

Provisions

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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:

Early retirement provisions are discounted using HM Treasury’s pension discount rate of positive

0.29% (2017-18: positive 0.10%) in real terms. All general provisions are subject to four separate

discount rates according to the expected timing of cashflows from the Statement of Financial

Position date:

• 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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Clinical Negligence Costs

NHS Resolution currently operates a risk pooling scheme under which the Clinical Commissioning

Group pay an annual contribution to NHS Resolution, which in return settles all clinical negligence

claims. The contribution is charged to expenditure. Although NHS Resolution is administratively

responsible for all clinical negligence cases the legal liability remains with the Clinical

Commissioning Group.

Non-clinical Risk Pooling

The Clinical Commissioning Group participates in the Property Expenses Scheme and the

Liabilities to Third Parties Scheme. Both are risk pooling schemes under which the Clinical

Commissioning Group pays an annual contribution to NHS Resolution and, in return, receives

assistance with the costs of claims arising. The annual membership contributions, and any

excesses payable in respect of particular claims are charged to operating expenses as and when

they become due.

Carbon Reduction Commitment Scheme

The Carbon Reduction Commitment scheme is a mandatory cap and trade scheme for non-

transport CO2 emissions. The clinical commissioning group is registered with the CRC scheme,

and is therefore required to surrender to the Government an allowance for every tonne of CO2 it

emits during the financial year. A liability and related expense is recognised in respect of this

obligation as CO2 emissions are made.

The carrying amount of the liability at the financial year end will therefore reflect the CO2

emissions that have been made during that financial year, less the allowances (if any) surrendered

voluntarily during the financial year in respect of that financial year.

The liability will be measured at the amount expected to be incurred in settling the obligation. This

will be the cost of the number of allowances required to settle the obligation.

Allowances acquired under the scheme are recognised as intangible assets.

Contingent liabilities and contingent assets

A contingent liability is a possible obligation that arises from past events and whose existence will

be confirmed only by the occurrence or non-occurrence of one or more uncertain future events not

wholly within the control of the clinical commissioning group, or a present obligation that is not

recognised because it is not probable that a payment will be required to settle the obligation or the

amount of the obligation cannot be measured sufficiently reliably.

A contingent liability is disclosed unless the possibility of a payment is remote.

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A contingent asset is a possible asset that arises from past events and whose existence will be

confirmed by the occurrence or non-occurrence of one or more uncertain future events not wholly

within the control of the clinical commissioning group. A contingent asset is disclosed where an

inflow of economic benefits is probable.

Where the time value of money is material, contingencies are disclosed at their present value.

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;

• Financial assets at fair value through other comprehensive income and;

• Financial assets at fair value through profit and loss.

The classification is determined by the cash flow and business model characteristics of the

financial assets, as set out in IFRS 9, and is determined at the time of initial recognition.

1.1.1 Financial Assets at Amortised cost

Financial assets measured at amortised cost are those held within a business model whose

objective is achieved by collecting contractual cash flows and where the cash flows are solely

payments of principal and interest. This includes most trade receivables and other simple debt

instruments. After initial recognition these financial assets are measured at amortised cost using

the effective interest method less any impairment. The effective interest rate is the rate that

exactly discounts estimated future cash receipts through the life of the financial asset to the gross

carrying amount of the financial asset.

1.1.2 Financial assets at fair value through other comprehensive income

Financial assets held at fair value through other comprehensive income are those held within a

business model whose objective is achieved by both collecting contractual cash flows and selling

financial assets and where the cash flows are solely payments of principal and interest.

1.1.3 Financial Assets at Fair Value Through Profit & Loss

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Financial assets measure at fair value through profit and loss are those that are not otherwise

measured at amortised cost or fair value through other comprehensive income. This includes

derivatives and financial assets acquired principally for the purpose of selling in the short term.

1.2 Impairment

For all financial assets measured at amortised cost or at fair value through other comprehensive

income (except equity instruments designated at fair value through other comprehensive income),

lease receivables and contract assets, the clinical commissioning group recognises a loss

allowance representing the expected credit losses on the financial asset. The clinical

commissioning group adopts the simplified approach to impairment in accordance with IFRS 9,

and measures the loss allowance for trade receivables, lease receivables and contract assets at

an amount equal to lifetime expected credit losses. For other financial assets, the loss allowance

is measured at an amount equal to lifetime expected credit losses if the credit risk on the financial

instrument has increased significantly since initial recognition (stage 2) and otherwise at an

amount equal to 12 month expected credit losses (stage 1). HM Treasury has ruled that central

government bodies may not recognise stage 1 or stage 2 impairments against other government

departments, their executive agencies, the Bank of England, Exchequer Funds and Exchequer

Funds assets where repayment is ensured by primary legislation. The clinical commissioning

group therefore does not recognise loss allowances for stage 1 or stage 2 impairments against

these bodies. Additionally DHSC provides a guarantee of last resort against the debts of its arm's

lengths bodies and NHS bodies and the clinical commissioning group does not recognise

allowances for stage 1 or stage 2 impairments against these bodies.

For financial assets that have become credit impaired since initial recognition (stage 3), expected

credit losses at the reporting date are measured as the difference between the asset's gross

carrying amount and the present value of the estimated future cash flows discounted at the

financial asset's original effective interest rate. Any adjustment is recognised in profit or loss as an

impairment gain or loss.

1.3 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.

1.3.1 Financial Guarantee Contract Liabilities

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Financial guarantee contract liabilities are subsequently measured at the higher of:

· The premium received (or imputed) for entering into the guarantee less cumulative

amortisation; and,

· The amount of the obligation under the contract, as determined in accordance with IAS

37: Provisions, Contingent Liabilities and Contingent Assets.

1.3.2 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.

1.3.3 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.

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.

Foreign Currencies

The Clinical Commissioning Group’s functional currency and presentational currency is pounds

sterling and amounts are presented in thousands of pounds unless expressly stated otherwise.

Transactions denominated in a foreign currency are translated into sterling at the exchange rate

ruling on the dates of the transactions. At the end of the reporting period, monetary items

denominated in foreign currencies are retranslated at the spot exchange rate on 31 March.

Resulting exchange gains and losses for either of these are recognised in the Clinical

Commissioning Group’s surplus/deficit in the period in which they arise.

Third Party Assets

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Assets belonging to third parties (such as money held on behalf of patients) are not recognised in

the accounts since the clinical commissioning group has no beneficial interest in them.

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).

Critical Accounting Judgements & Key Sources of Estimation Uncertainty

In the application of the Clinical Commissioning Group’s accounting policies, management is

required to make various judgements, estimates and assumptions. These are regularly reviewed.

Critical Judgements in Applying Accounting Policies

The following are the critical judgements, apart from those involving estimations (see below) that

management has made in the process of applying the Clinical Commissioning Group’s accounting

policies that have the most significant effect on the amounts recognised in the financial

statements:

• Accruals, have been included in the financial statements to the extent that the CCG

recognises an obligation at the 31 March 2019 for which it had not been invoiced. Estimates of

accruals are undertaken by management based on the information available at the end of the

financial year, together with past experience.

• 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. Management have made an assessment for the period ended 31 March 2019

and conclude that no provisions are required as at 31 March 2019.

• Better Care Fund accruals have been based upon information available at the year end and

a review of the joint commissioning group approved schemes. For those Better Care Fund

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schemes which are based upon activity, critical judgements apply. When information has been

delayed, a best estimate of the activity to year end has been used.

Key Sources of Estimation Uncertainty

The following are assumptions about the future and other major sources of estimation uncertainty

that have a significant risk of resulting in a material adjustment to the carrying amounts of assets

and liabilities within the next financial year:

• Activity is accounted for in the financial year it takes place, and not necessarily when cash

payments are made or received. The Clinical Commissioning Group has a robust process for

identifying that activities have taken place and for identifying the appropriate accounting period.

Therefore the degree of estimation uncertainty is considered to be low.

The prescribing accrual for the final month of the year is based upon forecasted figures provided

by the Business Services Authority and estimates undertaken by management based on

information available at the end of the financial year, together with past experience. The total

prescribing accrual as at 31/3/2019 was £14.6m (2017-18 - £14.2m).

Gifts

Gifts are items that are voluntarily donated, with no preconditions and without the expectation of

any return. Gifts include all transactions economically equivalent to free and unremunerated

transfers, such as the loan of an asset for its expected useful life, and the sale or lease of assets

at below market value.

Research & Development

Research and development expenditure is charged in the year in which it is incurred, except

insofar as development expenditure relates to a clearly defined project and the benefits of it can

reasonably be regarded as assured. Expenditure so deferred is limited to the value of future

benefits expected and is amortised through the Statement of Comprehensive Net Expenditure on

a systematic basis over the period expected to benefit from the project. It should be re-valued on

the basis of current cost. The amortisation is calculated on the same basis as depreciation.

Accounting Standards that have been issued but have not yet been adopted

The DHSC Group Accounting Manual 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.

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• IFRS 16: Leases - Application required for accounting periods beginning on or after 1

January 2019, but not yet adopted by the FReM: early adoption is not therefore permitted.

• IFRS 17: Insurance Contracts - Application required for accounting periods beginning on or

after 1 January 2021, but not yet adopted by the FReM: early adoption is not therefore permitted.

• IFRIC 23: Uncertainty over Income Tax Treatments - application required for accounting

periods on or after from 1 January 2019.

The application of the Standards as revised would not have a material impact on the accounts for

2018-19, were they applied in that year.

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2. Financial Performance Duties

Financial Performance Targets

Clinical commissioning groups have a number of financial duties under the National Health Service Act 2006 (as amended).The Clinical

Commissioning Group’s performance against those duties was as follows:

National Health

Service Act Section

2018/19 2018/19 2017/18 2017/18

Maximum Performance

Duty Achieved? Maximum Performance

Duty Achieved?

Duty £’000 £’000 £’000 £’000

223H(1) Expenditure not to exceed income 928,878 928,878 Yes 911,647 907,568 Yes

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

- - Yes

6

-

Yes

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

891,365

891,365 Yes

875,788

871,715 Yes

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

- - Yes

- - Yes

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

- - Yes

- - Yes

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

10,584

8,621 Yes

10,562

10,319 Yes

Note: For the purposes of 223H(1); expenditure is defined as the aggregate of gross expenditure on revenue and capital in the financial year; and, income is defined as the aggregate of the notified maximum revenue resource, notified capital resource and all other amounts accounted as received in the financial year (whether under provisions of the Act or from other sources, and included here on a gross basis). The In-year surplus for the year ended 31 March 2019 was £nil (2017/18 - £4.07m).

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3. Other Operating Revenue

2018-19

2017-18

Total

Total

£’000

£’000

Income from sale of goods and services (contracts) Education, training and research - 67 Non-patient care services to other bodies 36,815 34,654 Patient transport services - - Prescription fees and charges - - Dental fees and charges - - Income generation - - Other Contract income 682 - Recoveries in respect of employee benefits - - Total Income from sale of goods and services 37,497 34,721

Other operating income Rental revenue from finance leases - - Rental revenue from operating leases - - Charitable and other contributions to revenue expenditure: NHS - - Charitable and other contributions to revenue expenditure: non-NHS - - Receipt of donations (capital/cash) - - Receipt of Government grants for capital acquisitions - - Continuing Health Care risk pool contributions - - Non Cash apprenticeship training grants revenue 16 5 Other non contract revenue - 1,127 Total Other operating income 16 1,132

Total Operating Income 37,513 35,853

Non-patient care services to other bodies includes income received from the local authority in respect of public health services. Admin revenue is revenue received that is not directly attributable to the provision of healthcare or healthcare services. Revenue in this note does not include cash received from NHS England, which is drawn down directly into the bank account of the CCG and credited to the General Fund. No other fees or charges have been received by the CCG in the current year (2017/18: nil)

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4. Disaggregation of Income – Income from sale of goods and services (contracts)

Non-patient care services to other bodies Other Contract income

£’000 £’000

Source of Revenue NHS 9,150 - Non NHS 27,665 682 Total 36,815 682

Non-patient care services to

other bodies Other Contract income £’000 £’000 Timing of Revenue Point in time 9,150 - Over time 27,665 682 Total 36,815 682

Revenue as noted above is totally from the supply of services. The Clinical Commissioning Group

receives no revenue from the sale of goods.

4.1 Transaction price to remaining contract performance obligations

Contract revenue expected to be recognised in the future periods related to contract performance

obligations not yet completed at the reporting date.

2018-19 Total

Revenue

expected from NHSE Bodies

Revenue expected from Other DHSC

Group Bodies

Revenue expected from

Non-DHSC Group Bodies

£’000 £’000 £’000 £’000

Not later than 1 year - - - - Later than 1 year, not later than 5 years

- - - -

Later than 5 Years - - - - Total - - - -

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5. Employee Benefits & Staff Numbers

5.1 Employee benefits

5.1.1 Employee benefits expenditure

2018-19 2017-18

Total

Total

Total Total


Other


Other

£000 £000 £000 £000 £000 £000

Employee Benefits

Salaries and wages* 6,401 6,259 142 6,666 6,456 210 Social security costs 679 679 - 687 687 - Employer contributions to NHS pension scheme

839 839 - 832 832 -

Other pension costs 1 1 - - - - Apprenticeship Levy 20 20 - 20 20 - Other post-employment benefits - - - - - - Other employment benefits - - - - - - Termination benefits - - - - - - Gross employee benefits expenditure 7,940 7,798 142 8,205 7,995 210 Less recoveries in respect of employee benefits

- - - - - -

Total - Net admin employee benefits including capitalised costs

7,940 7,798 142 8,205 7,995 210

Less: Employee costs capitalised - - - - Net employee benefits excluding capitalised costs

7,940 7,798 142 8,205 7,995 210

5.1.2 Average number of people employed

2018-19 2017-18

Total Other

Permanent Employees

Total

Number Number Number Number r

Total CCG (WTE) 138.38 7.15 131.23 146.65

Of the above:

Number of whole time equivalent people engaged on capital projects - - -

-

*Tables 5.1.1 and 5.1.2 do not include expenses nor WTE for those governing body members not directly employed by the CCG.

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5.2 Ill health retirements

Ill-health retirement costs are met by the NHS Pension Scheme. Where the Clinical

Commissioning Group has agreed early retirements, the additional costs would be met by the

Clinical Commissioning Group and not by the NHS Pension Scheme. The Clinical

Commissioning Group had no ill health retirements in 2018/19 (2017/18: £nil).

5.3 Exit packages agreed in the financial year

There were no exit packages agreed in the financial year (2017/18 - Nil)

5.4 Pension costs

Past and present employees are covered by the provisions of the two NHS Pension

Schemes. Details of the benefits payable and rules of the Schemes can be found on the

NHS Pensions website at www.nhsbsa.nhs.uk/pensions. Both are unfunded defined benefit

schemes that cover NHS employers, GP practices and other bodies, allowed under the

direction of the Secretary of State 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:

5.4.1 Accounting valuation

A valuation of scheme liability is carried out annually by the scheme actuary (currently the

Government Actuary’s Department) as at the end of the reporting period. This utilises an

actuarial assessment for the previous accounting period in conjunction with updated

membership and financial data for the current reporting period, and is accepted as providing

suitably robust figures for financial reporting purposes. The valuation of the scheme liability

as at 31 March 2019, is based on valuation data as at 31 March 2018, updated to 31 March

2019 with summary global member and accounting data. In undertaking this actuarial

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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.

5.4.2 Full actuarial (funding) valuation

The purpose of this valuation is to assess the level of liability in respect of the benefits due

under the schemes (taking into account recent demographic experience), and to recommend

contribution rates payable by employees and employers.

The 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 £839k in respect of staff pensions, were payable to

the NHS Pensions Scheme (2017-18: £832k) at the rate of 14.38% of pensionable pay.

These costs are included in the NHS pension line of note 5.1.1

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6. Operating Expenses

2018-19 2018-19 2018-19

2017-18

Total Admin Programme

Total

£000 £000 £000 £000 Purchase of goods and services

Services from other CCGs and NHS England 2,525 687 1,838

2,818 Services from foundation trusts 342,029 6 342,023

256,516

Services from other NHS trusts # 261,115 - 261,115

337,144 Provider Sustainability Fund (Sustainability Transformation Fund 1718) - - - Services from other WGA bodies - - -

-

Purchase of healthcare from non-NHS bodies 119,772 - 119,772

106,497 Purchase of social care - - - - Prescribing costs 85,268 - 85,268 89,743 Pharmaceutical services 155 - 155 GPMS/APMS and PCTMS 88,606 46 88,560 86,495 Supplies and services – general 1,852 97 1,755 821 Consultancy services 10 10 - 152 Establishment 6,953 302 6,651 5,938 Transport 39 38 1 26 Premises 7,557 685 6,872 7,780 Audit fees* 65 65 - 65 Other auditor’s remuneration · Internal audit services - - - - - Other Services** 10 10 - - Other professional fees excl. audit 528 288 240 289 Legal fees 159 159 - 158 Education and training 351 69 282 337 CHC Risk Pool contributions - - - - Total Purchase of goods and services 916,994 2,462 914,532 894,779 Provision expense Change in discount rate - - - - Provisions - - - - Total Provision expense - - - - Other operating Expenditure Chair and lay membership body and governing body members 763 751 12 1,068 Grants to other bodies 270 - 270 813 Clinical Negligence - - - Research and development (excluding staff costs) 2,878 - 2,878 2,569 Expected credit loss on receivables - - - Expected credit loss on other financial assets (stage 1 and 2 only) - - - Non cash apprenticeship training grants 16 16 - 5 Other expenditure 17 - 17

127

Total Other Operating Expenditure 3,944 767 3,177 4,582

Total Operating Expenditure 920,938 3,229 917,709 899,361

*External audit fees as disclosed above are inclusive of VAT ** Other services from external audit of £10,000 have been accrued in respect of the 18/19 Mental Health Investment Standard audit required by NHS England. The fee and audit plan has not yet been agreed, however, it is expected that this will be performed by the CCG’s external auditors. # Internal audit services during the year were provided by Mersey Internal Audit Agency, hosted by The Royal Liverpool and Broadgreen University Hospitals NHS Trust. Internal audit costs are included in Services from other NHS trusts 2018/19: £68.8k (2017/18: £68.8k)

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6.1 Limitation on auditor’s liability

Following legislative changes, namely the Local Audit Accountability Act 2014, The CCG has

appointed Grant Thornton as external auditors from 2018/19. Prior to this appointment, the

external auditors were appointed centrally by a transitional body, Public Sector Audit

Appointments Limited. As such, in accordance with SI 2008 no.489, The Companies

(Disclosure of Auditor Remuneration and Liability Limitation Agreements) Regulations 2008,

where a CCG contract with its auditors provides for a limitation of the auditor’s liability, the

principal terms of this limitation must be disclosed in a note to the accounts.

The limitation on auditors' liability for external audit has been confirmed as £2m.

Auditor's liability is limited with regard to the following:

Limitation period - Any claim must be brought no later than two years after the claimant

should have been aware of the potential claim and, in any event, no later than four years

after any alleged breach.

Liability - Total liability (including interest) for all claims connected with the services (including

but not limited to negligence) is limited to three times the fees payable for the services or

£2m, whichever is the greater.

7. Better Payment Practice Code

7.1 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 16,431 258,186 14,319 252,489 Total Non-NHS Trade Invoices paid within target 16,232 255,912 14,048 250,276 Percentage of Non-NHS Trade invoices paid within target 98.79% 99.12% 98.11% 99.12% NHS Payables

Total NHS Trade Invoices Paid in the Year 3,439 620,183 3,425 605,033 Total NHS Trade Invoices Paid within target 3,391 617,847 3,389 603,540 Percentage of NHS Trade Invoices paid within target 98.60% 99.62% 98.95% 99.75%

The Better Payment Practice Code requires the Clinical Commissioning Group to aim to pay

all valid invoices by the due date or within 30 days of receipt of a valid invoice, whichever is

later. Currently the target set by the Department of Health is 95%.

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7.2 The late payment of commercial debtors (interest) act 1998

2018-19

2017-18

£000 £000

Amounts included in finance costs from claims made under this legislation - 2 Compensation paid to cover debt recovery costs under this legislation - 0 Total - 2

The CCG made a payment to NHS Greater Glasgow and Cylde in April 2017 in relation to an

overdue NCA invoice.

8. Finance costs

2018-19

2017-18

£000 £000 Interest

Interest on late payment of commercial debt - 2 Other interest expense - - Total interest - 2 Other finance costs - - Total finance costs - 2

9. Operating Leases

9.1 As lessee

Lease payments shown below include:-

Payments to Community Health Partnerships Ltd (CHP) and NHS Property Services, include

the cost of use of properties leased from these organisations where the costs are not fully

recovered from the occupants (void / subsidy charges). These are currently paid by the CCG

as it commissions the services in these buildings and the funding sits within the CCG

allocation.

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9.1.1 Payments recognised as an expense

2018-19

2018-19

2018-19

2018-19

2017-18

Land

Buildings

Other

Total Total

£000 £000 £000 £000 £000 Payments recognised as an expense

Minimum lease payments - 1,271 19 1,290 1,681 Total - 1,271 19 1,290 1,681

9.1.2 Future minimum lease payments

Whilst our arrangements with Community Health Partnership’s Limited and NHS Property

Services Limited fall within the definition of operating leases, rental charge for future years

has not yet been agreed. Consequently, the following future minimum lease payments for

Buildings are in respect of the Clinical Commissioning Groups headquarters only:

2018-19 Buildings

2018-19 Other

2018-19 Total

2017-18 Buildings

2017-18 Other

2017-18 Total

£’000 £’000 £’000 £’000 £’000 £’000

Payable:

No later than one year 320 - 320 320 - 320 Between one and five years 1,279 - 1,279 1,279 - 1,279 After five years 520 - 520 840 - 840 Total 2,119 - 2,119 2,439 - 2,439

The lease on Liverpool CCG Headquarters expires on 17 November 2025.

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10. Trade & Other Receivables

Current

Current

2018-19

2017-18

£000 £000

NHS Receivables: Revenue 4,876

1,956 NHS Prepayments - 669 NHS accrued income - 159 NHS Contract Receivable not yet invoiced/non-invoice 182 - NHS Non Contract trade receivable (ie pass through funding) - - NHS Contract assets - - Non-NHS and Other WGA receivables: Revenue 3,135 973 Non-NHS and Other WGA prepayments 500 219 Non-NHS and other WGA accrued income - 1,633 Non-NHS Contract Receivable not yet invoiced/non-invoice 923 - Non-NHS Non Contract trade receivable (ie pass through funding) - - Non-NHS Contract assets - - Expected credit loss allowance-receivables - - VAT 97 87 Other receivables and accruals - - Total Trade & Other Receivables 9,713 5,696

There were no non –current receivables in 2018/19 (2017/18 – nil)

Included above:

Prepaid pensions contributions

- -

The great majority of trade is with NHS England. As NHS England is funded by Government

to provide funding to Clinical Commissioning Groups to commission services, no credit

scoring of them is considered necessary.

The Clinical Commissioning Group has estimated the credit loss on financial assets at stage

3 and concluded that the estimated credit loss is immaterial. Therefore, no adjustment has

been made in the current year.

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10.1 Receivables past their due date but not impaired

2018-19 DHSC Group

Bodies

2018-19 Non DHSC

Group Bodies

2017-18 DHSC Group

Bodies

2017-18 Non DHSC

Group Bodies

£’000 £’000 £’000 £’000

By up to three months 4,425 2,927 651 274 By three to six months - 95 4 144 By more than six months 194 113 258 562 Total

4,619 3,135 913 980

£5,683k of the amount above has subsequently been recovered post the statement of

financial date (as at 24th May 2019)

10.2 Impact of application of IFRS 9 on financial assets at 1 April 2018

Trade and other

receivables – NHSE bodies

Trade and other receivables – other DHSC

bodies

Trade and other receivables -

external

Other financial

assets Total £’000 £’000 £’000 £’000 £’000

Classification under IAS 39 as at 31 March 2018

Financial Assets held at FVTPL - - - - - Financial Assets help at Amortised cost

1

2,115

- 2,606

4,722

Financial assets held at FVOCI - - - - - Total at 31 March 2018 1 2,115 - 2,606 4,722 Classification under IFRS as at 1 April 2018

Financial Assets designated to FVTPL

-

-

- -

-

Financial Assets mandated to FVTPL

-

- - -

-

Financial Assets measured at amortised cost

1

2,115

- 2,606

4,722

Financial Assets measured at FVOCI

-

-

- -

-

Total at 1 April 2018 1 2,115 - 2,606 4,722 Changes due to change in measurement attribute

-

-

-

-

-

Other changes - - - - - Change in carrying amount - - - - -

The Clinical Commissioning Group has estimated the credit loss on financial assets at stage

3 for the prior year and concluded that the estimated credit loss is immaterial. Therefore, no

adjustment has been made in respect financial assets as at 1 April 2018.

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11. Cash & Cash Equivalents

2018-19 2017-18

£000 £000 Balance at 1 April 2018 1 1 Net change in year (0) (0) Balance at 31 March 2019 1 1

Made up of: Cash with the Government Banking Service 1 1 Cash with Commercial banks - - Cash in hand - - Current investments - - Cash and cash equivalents as in statement of financial position 1 1

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

Balance at 31 March 2019 1 1 Patients’ money held by the clinical commissioning group, not included above

-

-

12. Trade & Other Payables

Current

Current 2018-19

2017-18

£000 £000

NHS payables: Revenue 6,688

5,688 NHS accruals 2,906 3,849 NHS Contract Liabilities - - Non-NHS and Other WGA payables: Revenue 7,609

9,371

Non-NHS and Other WGA accruals 32,931

19,871 Non-NHS and Other WGA deferred income 35 6 Non-NHS Contract Liabilities - - Social security costs 105

106

Tax 94

92 Other payables and accruals 2,543

2,862

Total 52,911 41,845

There were no non–current payables in 2018/19 (2017/18 – nil)

No liabilities due in future years are included above under arrangements to buy out liability

for early retirement over 5 years.

Other payables include £796k outstanding pension contributions at 31 March 2019 (2017/18

£1,041k).

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From 2017/18 the Clinical Commissioning Group became responsible for collecting and

paying over the pension contributions of Liverpool GPs in respect of co-commissioning

arrangements.

12.1 Impact of Application of IFRS 9 on financial assets at 1 April 2018

Trade and other

payables – NHSE bodies

Trade and other

payables – other DHSC

group bodies

Trade and other

payables - external

Other borrowings (including

finance lease

obligations)

Other financial liabilities Total

£’000 £’000 £’000 £’000 £’000 £’000

Classification under IAS 39 as at 31 March 2018

Financial Assets held at FVTPL - - - - - Financial Assets help at Amortised cost

1

2,115

-

2,606

4,722

Financial assets held at FVOCI - - - - - Total at 31 March 2018 1 2,115 - 2,606 4,722 Classification under IFRS as at 1 April 2018

Financial Assets designated to FVTPL

-

-

-

-

-

Financial Assets mandated to FVTPL

-

- -

-

-

Financial Assets measured at amortised cost

1

2,115

-

2,606

4,722

Financial Assets measured at FVOCI

-

-

-

-

-

Total at 1 April 2018 1 2,115 - 2,606 4,722 Changes due to change in measurement attribute

-

-

-

-

-

Other changes - - - - - Change in carrying amount - - - - -

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13. Provisions

Under the Accounts Direction issued by NHS England on 12 February 2014, NHS England is

responsible for accounting for liabilities relating to NHS Continuing Healthcare claims relating

to periods of care before establishment of the Clinical Commissioning Group. However, the

legal liability remains with the Clinical Commissioning Group.

14. Contingencies

The Clinical Commissioning Group has assessed that the likelihood of contingent assets and

liabilities is remote as at 31 March 2019.

15. Clinical Negligence Costs

The value of provisions carried in the books of the NHS Litigation Authority in regard to

CNST claims as at 31 March 2019 was £nil (2017/18 £37,500).

16. Other Financial Commitments

The Clinical Commissioning Group has not entered into any non-cancellable contracts (which

are not leases, private finance initiative contracts or other service concession arrangements).

17. Financial Instruments

17.1 Financial risk management

International Financial Reporting Standard 7: Financial Instrument: Disclosure 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 the 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 Clinical Commissioning Group’s standing financial

instructions and policies agreed by the Governing Body. Treasury activity is subject to review

by the Clinical Commissioning Group’s internal auditors.

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17.1.1 Currency risk

The 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 Clinical

Commissioning Group has no overseas operations. The Clinical Commissioning Group

therefore has low exposure to currency rate fluctuations.

17.1.2 Interest rate risk

Because the 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 Croup 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.

17.1.3 Credit risk

Because the majority of the Clinical Commissioning Group’s revenue comes from

parliamentary funding, the 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.

17.1.4 Liquidity risk

The Clinical Commissioning Group is required to operate within revenue and capital resource

limits, which are funded from resources voted annually by Parliament. The Clinical

Commissioning Group draws down cash to cover expenditure, as need arises. The Clinical

Commissioning Group is not, therefore, exposed to significant liquidity risks.

17.1.5 Financial Instruments

As the cash requirements of NHS England are met through the Estimate process, financial

instruments play a more limited role in creating and managing risk than would apply to a non-

public sector body. The majority of financial instruments relate to contracts to buy non-

financial items in line with NHS England's expected purchase and usage requirements and

NHS England is therefore exposed to little credit, liquidity or market risk.

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17.2 Financial assets

Financial Assets measured at

amortised cost 2018-19

Total 2018-19

£’000 £’000

Trade and other receivables with NHSE bodies

4,968 4,968 Trade and other receivables with other DHSC group bodies

996 996

Trade and other receivables with external bodies

3,152 3,152 Other financial assets

- -

Cash and cash equivalents

1 1 Total at 31 March 2019 9,117 9,117

17.3 Financial liabilities

Financial Liabilities measured at

amortised cost 2018-19

Total 2018-19

£’000 £’000

Trade and other payables with NHSE bodies

427 427 Trade and other payables with other DHSC group bodies

10,202 10,202

Trade and other payables with external bodies

39,505 39,505 Other financial liabilities

2,543 2,543

Total at 31 March 2019 52,677 52,677

Fair values have been considered and are consistent with the disclosures for financial assets

and financial liabilities above.

18. Operating Segments

The Clinical Commissioning Group has only one segment: Commissioning of Healthcare

Services.

Gross expenditure

Income

Net expenditure

Total assets

Total liabilities

Net liabilities

£'000 £'000 £'000 £'000 £'000 £'000 Commissioning of Healthcare Services

928,878 (37,513) 891,365 9,714 (52,911) (43,197)

Total 928,878 (37,513) 891,365 9,714 (52,911) (43,197)

19. Joint Arrangements – Interest in joint arrangements

The Clinical Commissioning Group has entered into the following joint arrangements with

Liverpool City Council.

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Better Care Fund

With effect from 1st April 2015, the CCG has had arrangements in place (using powers under

Section 75 of the National Health Service Act 2006) to operate a pooled budget for the

required Better Care Fund arrangements.

The Better Care Fund functions as a joint arrangement, consequently the CCG has

recognised expenditure in 2018/19 when an obligation has arisen. Liverpool City Council

operates as host Commissioner for services and transactions have been accounted for

accordingly as per the CCG’s accounting policies.

The CCG contribution to the pooled budget in 2018/19 was £44,652k (2017-18: £44,134K)

which was used to commission a range of health and social care services in line with the

agreed objectives of the BCF. This contribution to the BCF is recognised within the financial

statements as CCG expenditure. Total BCF expenditure across Liverpool CCG & Liverpool

City Council was £103,996k (2017-18: £91,279k).

Integrated Community Equipment and Disability Advice Services

A partnership agreement was entered into by the predecessor organisation, Liverpool

Primary Care Trust (using powers under Section 75 of the National Health Service Act 2006),

to ‘pool’ budgets from the two organisations for the creation of a single budget for the

provision of Integrated Community Equipment and Disability Advice Services (ICEDAS). This

Partnership came into effect on 1 January 2004.

The ICEDAS pool acts as a joint arrangement, consequently the CCG has recognised

expenditure in 2018/19 when an obligation has arisen. Liverpool CCG (LCCG) acts as host

commissioner in this agreement and procures this service from Mersey Care NHS

Foundation Trust (previously Liverpool Community Health NHS Trust) with Liverpool City

Council (LCC) contributing to the service through payments made to the CCG. An element of

the ICEDAS pool is included within the Better Care Fund pool and has therefore been

disclosed below.

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The Clinical Commissioning Group’s share of the income and expenditure compared to the previous financial year were:

2018/19 2018/19 2018/19 2018/19 2017/18 2017/18 2017/18 2017/18

Name of arrangement

Parties to the arrangement

Description of principal activities Assets Liabilities Income Expenditure Assets Liabilities Income Expenditure

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Better Care Fund

Liverpool City Council

Better care fund – joint health and

Social care arrangement 1,301 - (1,000) 45,652 997 (1,810) (997) 45,140

ICEDAS (not included above)

Liverpool City Council

Community Equipment pool - - (1,061) 1,061 - - (1,043) 1,043

Total 1,301 - (2,061) 46,713 997 (1,810) (2,040) 46,183

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20. Related Party Transactions

Details of related party transactions with individuals are as follows:

Name of Governing Body member Practice

Payments to related

party Receipts from Related Party

Amounts owed to Related

Party

Amounts due from Related

Party

£'000 £'000 £'000 £'000

Dr Fiona Lemmens Aintree Group Practice 5,077 - 513 - Dr Simon Bowers (to 31 May 2018)

Fulwood Green Medical Centre 192 - - -

Dr Janet Bliss The Grey Road Surgery 2,443 - 211 -

Dr Monica Khuraijam Oak Vale Medical Centre 368 - 85 -

Dr Maurice Smith Mather Avenue Surgery 2,873 - 299 -

Dr Stephen Sutcliffe Dingle Practice 1,720 - 202 - Dr Ian Pawson (from 1 June 2018)

Brownlow Group Practice 6,646 - 529 -

Dr Ian Pawson (from 1 June 2018)

Brownlow Health – Princes Park 1,936 - 158 -


Brownlow Health – Kensington Park 1,677 - 339 -


Brownlow Health – Marybone 1,173 - 86 -

Dr Paula Finnerty (from 1 June 2018)

Ellergreen Medical Centre 3,991 - 457 -

The Department of Health is regarded as a related party. In the financial year 2018-19 the

Clinical Commissioning Group has had a significant number of material transactions with

entities for which the Department is regarded as the parent, including:

• NHS England

• NHS Business Services Authority.

• Royal Liverpool and Broadgreen University Hospitals NHS Trust

• Aintree University Hospital NHS Foundation Trust

• Mersey Care NHS Foundation Trust

• Liverpool Women’s Hospital NHS Foundation Trust

• Alder Hey Children’s NHS Foundation Trust

• North West Ambulance Service NHS Trust

• St Helens and Knowsley Hospitals NHS Trust

• Liverpool Heart and Chest NHS Foundation Trust

• Walton Centre NHS Foundation Trust

• NHS Midlands and Lancashire CSU

• Community Health Partnership

• NHS Property Services

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In addition, the Clinical Commissioning Group has had a number of material transactions with other government departments and other central and local government bodies. Most of these transactions have been with Liverpool City Council.

21. Events After the Reporting Period

There are no post balance sheet events which will have a material effect on the financial

statements of the Clinical Commissioning Group.

22. Effect of application of IFRS 15 on current year closing balances

The impact of IFRS 15 is deemed to be not material to the current year.

23. Losses & Special Payments

The Clinical Commissioning Group did not incur any losses nor any special payments cases

during 2018/19 (2017/18 – nil)

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Report no: GB 30b-19 NHS LIVERPOOL CLINICAL … · 5/24/2019 · the year ended 31 March 2019 for...

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Transcript of Report no: GB 30b-19 NHS LIVERPOOL CLINICAL … · 5/24/2019 · the year ended 31 March 2019 for...