Chief Accountable Officer Director Transformation and Quality. Director Transformation and Quality Chief Accountable Officer

Transcription

1 Governing Body Assurance Framework (July/August 2016) Introduction The Governing Body Assurance Framework identifies the CCG s principal, strategic objectives and the principal risks to their delivery. The controls in place to manage those identified risks are summarised. The internal and external assurances that controls are in place and have the impact intended are set out. Where there are gaps in controls or assurances these are described and the actions planned to mitigate these gaps are explained. The table below gives and overall summary of the CCG Governing Body Assurance Framework. The detailed framework is at page 3 Risk Lead Initial Risk score Principal Objectives: D1 Better Health GBAF D1 R1 there is a risk that the CCG is not assured that it is working to improve the health and wellbeing of the population GBAF D1 R2 there is a risk that the CCG is not assured that it is working towards addressing health inequalities Principal Objectives: D2 Better Care GBAF D2 R1 there is a risk that providers deliver poor quality care and do not meet quality standards GBAF D2 R2 there is a risk that System wide or specific provider capacity problems emerge to prevent delivery of NHS Constitution Standards Principal Objectives: D3 Sustainability GBAF D3 R1 there is a risk that CCG fails to meet financial statutory duties and there is a deterioration in financial resilience Principal Objectives: D4 Leadership GBAF D4 R1 there is a risk that Work force capacity in provider organisations may impact on the delivery of the CCG Operational Plan GBAF D4 R2 there is a risk that failure to engage with Primary Care may impact on the delivery of the CCG Operational Plan Transformation and Quality Transformation and Quality Financial Financial Current risk score Risk appetite Trend Gaps in controls assurance no yes no no yes yes no yes Page 1 of 10

2 likelihood of happening GBAF D4 R3 there is a risk that failure to act with probity and integrity results in challenge to decisions and loss of public and stakeholder confidence no NHS England CCG Assurance Framework ( NHS England Improvement and Assessment Framework) On the 28 April 2016 the CCG met with NHS England for the final assurance review meeting of 2015/16. The final ratings are as stated below. They are yet to be confirmed following national moderation. When they are published nationally at the end of June they will be mapped to the 2016/17 CCG Assessment and Improvement Framework ratings, which have also been given, though to be confirmed. NHS England Assurance Framework Component 2015/16 Framework Final Rating 2016/17 New Framework Rating Conversion 1. Well led organisation Limited assurance Better Health Limited assurance 2. Delegated functions Good Better Care Limited assurance 3. Finance Limited assurance Sustainability Limited assurance 4. Performance Limited assurance Leadership Limited assurance 5. Planning Limited assurance Overall rating Requires improvement Overall rating Limited assurance 2015/16 rating categories were: Outstanding, Good, Limited assurance and Not assured. 2016/17 rating categories are: Outstanding, Good, Requires improvement and Inadequate. The CCG risk scoring matrix as set out in the Risk Management Strategy and Policy is: Risk Assessment scoring matrix Almost certain = likely = possible = unlikely = Rare = Insignificant = 1 Minor Moderate = 2 = 3 Impact Major = 4 Catastrophic = 5 2

3 Governing Body Assurance Framework (July/August 2016) Principal Objectives: D1 Better Health Lead Jill Shepherd 22 July 2016 Improve the health and wellbeing of our population Address health inequalities, where appropriate with our partners Indictor progress against objective including Framework indicators: percentage of indicators green/red/amber per quarter (add Q) Note: RAG ratings are taken from the latest available period. Grey indicates that performance data is unavailable for both current and previous period. Actions to address performance are detailed in the monthly performance reports GBAF D1 R1 there is a risk that the CCG is not assured that it is working to improve the health and wellbeing of the population Low 1-3 Operational Plan 2016/17 includes key clinical priority areas Monthly scrutiny of detailed performance reports at Governing Body Planning structure in place with embedded subcommittees clinical leadership Scrutiny of performance through Better Better Care structure in place with partners Care governance structure Formal collaborative commissioning arrangements in place Monthly reports and minutes from subcommittees received by Governing Portfolio Management Office in place Body Better Care performance reported to Governing Body Monthly Integrated Performance, Quality and Finance Reports received by Governing Body Internal Audit report: Performance Monitoring and Management (Sept 2016) Internal Audit report Continuing Health Care (Nov 2016) Internal Audit report: CCG response to NHS 5 Year forward view (July 2016) Gaps in and Assurances: Operational Plan 2016 to be formally approved Mitigating actions Date Comment Operational Plan 2016 approval by Governing Body outstanding due to further investigation of key elements 05/07/16 To be resolved 31/07/16 Page 3 of 10

4 GBAF D1 R2 there is a risk that the CCG is not assured that it is working towards addressing health inequalities Transformation and Quality Low 1-3 JSNA in place and reviewed for 2016/17 Annual Health Inequalities Report to Health & Wellbeing Board oversight Governing Body Joint Health and Wellbeing Strategy in place and refreshed for 16/17 reports and minutes from subcommittees received by Governing Business Case template includes requirement Body to explain how proposals address health inequalities Summary report from Health and Wellbeing Board to Governing Body Business case approvals process established via Finance, Performance and Planning Committee Internal Audit report: CCG response to NHS 5 Year forward view (July 2016) Gaps in and Assurances: Health Inequalities priority areas to be translated into action plans Dedicated Performance and Planning Committee not established Operational Plan 2016 to be formally approved Mitigating actions date Health Inequalities priorities to be added to operational plan 2016/17 Performance and Planning Committee to be established 5/07/16 To be agreed by Governing Body Operational Plan 2016 approval by Governing Body outstanding due to further investigation of key elements 05/07/16 To be resolved 31/07/16 4

5 Principal Objectives: D2 Better Care Lead Jill Shepherd 22 July 2016 Work meet NHS Constitutional Standards and the Better Care Fund conditions Make progress to develop a sustainable model of care for our population Ensure system resilience and safe, quality services Indictor progress against objective including Framework indicators: percentage of indicators green/red/amber per quarter (add Q) Note: RAG ratings are taken from the latest available period. Grey indicates that performance data is unavailable for both current and previous period. Actions to address performance are detailed in the monthly performance reports GBAF D2 R1 there is a risk that providers deliver poor quality care and do not meet quality targets Lead Transformati on and Quality Low 1-3 Quality Standards included in contracts Governing Body receives: minutes of Quality premium agreed Quality and Governance Committee Safeguarding teams established and policies and procedures in place Exception reports from Quality and Governance Committee Serious Incident policy in place (SI policy) Reporting of CQC inspection reports, Infection Control governance arrangements in place provider action plans, CCG monitoring and actions to Governing Body Integrated Contract Quality and Performance meetings in place across all main providers Annual Quality Report from committee Governing Body receives and scrutinises Quality and Governance Committee established with clinical membership and ToR setting responsibility for overseeing CCG activities re quality including agreeing actions to be taken monthly Integrated Quality, Performance and Finance Report Quality and Governance Committee discusses and takes action re detailed quality reports, including safeguarding reports and care home reports, SI reports, Infection controls reports, CCG membership of NHS E Quality Surveillance Group with reports back to Quality and Governance Committee Internal Audit report Continuing Health Care (Nov 2016) Internal Audit report Clinical Safety Monitoring and Improvement CQC Inspection Reports for Providers: AWP CQC Inspection Reports for Providers: NBT CQC Inspection Reports for Providers: UHBT (July2016) (Sep 2014) Enforcement actions Taken (Apr 2016)Requires Improvement (Dec 2014)Requires Improvement 5

6 Gaps in and Assurances: No gaps in controls or assurances currently identified Mitigating actions None date GBAF D2 R2 there is a risk that System wide or specific provider capacity problems emerge to prevent delivery of NHS Constitution Standards Lead Low 1-3 Performance and activity discussed at subcommittees with terms of reference setting out responsibilities for overseeing and agreeing actions to be taken regarding performance Governing Body receives minutes of all subcommittees Exception reports from subcommittees Monthly Integrated Quality, Performance Integrated Contract Quality and Performance meetings in place across all main providers and Finance report Quarterly steering group progress Clinical leads established for core areas and key contracts reports Reports on STP Operational Plan System Resilience Group in place with relevant partners as members System Leadership Group in place with relevant partners as members Better Care programme in place with governance structure Internal Audit report: Performance Monitoring and Management (August 2016) Internal Audit report: CCG response to NHS 5 Year forward view (July 2016) Gaps in and Assurances: System wide Sustainability Transformation Plan to be agreed Mitigating actions Date Sustainability and Transformation Plan (STP) to be developed and agreed with NHS England 30/6/16 NHSE to agree STP 6

7 Principal Objectives: D3 Sustainability Lead Nicola Dunn 22 July 2016 Maintain financial resilience whilst meeting our statutory duties Secure good value for patients and the public from the money we spend Ensure the effective use of enablers such as estates, IT etc Indictor progress against objective including Framework indicators: percentage of indicators Framework domain assessment requires improvement green/red/amber per quarter (add Q) Note: RAG ratings are taken from the latest available period. Grey indicates that performance data is unavailable for both current and previous period. Q1 Actions to address performance are detailed in the monthly performance reports GBAF D3 R1 there is a risk that CCG fails to meet statutory duties and there is a deterioration in financial resilience Financial Low 1-3 Budget Managers and cost centres agreed Monthly scrutiny of detailed PMO established performance reports at Governing Body Governance process to identify slippage and gaps in delivery of QIPP established, including weekly reports to s, and review at formal monthly review at Senior Leadership group with QIPP as weekly standing item subcommittees Scrutiny of performance through Better Care governance structure Better Care Performance reported to Governing Body Cost containment strategy and non-financial KPIs in place for Monthly reports and minutes from subcommittees received by Governing Monthly meetings with providers to discuss financial position Body Better Care Performance reported to Financial governance structure established Governing Body Subcommittees in place with terms of reference setting out responsibilities for monitoring and agreeing actions Monthly Integrated Performance, Quality and Finance Reports received by Governing Body Financial policies in place Management accounting systems established Detailed finance reports discussed monthly at Finance, Performance and Planning Committee Better Care governance structure in place Internal Audit report: main accounting (Dec 2016) Internal Audit report Continuing Health Care (Nov 2016) Internal Audit report: financial planning and monitoring (August 2016) Gaps in and Assurances: Finance specific subcommittee not in place Operational Plan 2016 to be formally approved Mitigating actions date Financial review Committee to be established with specific remit re financial performance 05/07/16 ToR to be agreed 7

8 Operational Plan 2016 approval by Governing Body outstanding due to further investigation of key elements Sustainability and Transformation Plan (STP) to be developed and agreed with NHS England 05/07/16 To be resolved 31/07/16 30/6/16 NHSE to agree STP GBAF D3 R2 there is a risk that CCG fails to contain costs and identify required QIPP savings for 2016/17 (Reported on Corporate Risk Register as above threshold) Financial Low 1-3 Budget Managers and cost centres agreed Monthly scrutiny of detailed PMO established performance reports at Governing Body Cost containment strategy and non-financial KPIs in place for subcommittees Monthly reports and minutes from QIPP assurance group established subcommittees received by Governing Monthly meetings with providers to discuss financial position Body Monthly Integrated Performance, Financial governance structure established Quality and Finance Reports received Subcommittees in place with terms of by Governing Body reference setting out responsibilities for monitoring and agreeing actions Financial policies in place Management accounting systems established Detailed finance reports discussed monthly at Finance, Performance and Planning Committee Governance process to identify slippage and gaps in delivery of QIPP established, including weekly reports to s, and review at formal monthly review at Senior Leadership group with QIPP as weekly standing item Internal Audit report: main accounting (Dec 2016) Internal Audit report Continuing Health Care (Nov 2016) Internal Audit report: financial planning and monitoring (August 2016) Gaps in and Assurances: Finance specific subcommittee not in place Mitigating actions date Financial review Committee to be established with specific remit re financial performance Sustainability and Transformation Plan (STP) to be developed and agreed with NHS England 05/07/16 ToR to be agreed 30/6/16 NHSE to agree STP 8

9 Principal Objectives:D4 Leadership Lead Jill Shepherd 22 July 2016 develop a shared vision and plan for our health and social care economy with our partners work effectively with our members act with probity and integrity Value and develop our workforce Indictor progress against objective including Framework indicators: percentage of indicators Framework domain assessment requires improvement green/red/amber per quarter (add Q) Note: RAG ratings are taken from the latest available period. Grey indicates that performance data is unavailable for both current and previous period. Q1 Actions to address performance are detailed in the monthly performance reports GBAF D4 R1 there is a risk that Workforce capacity in provider services may impact on the delivery of the CCG Operational Plan Lead Initial risk score l c s Current risk score l c s Risk Appetite trend Low 1-3 Workforce issues reported to Quality and Governance Committee Monthly reports and minutes from subcommittees received by Governing Performance issues reported to Performance Body Committee Monthly Integrated Quality, Performance and Finance Report to Governing Body CQC Inspection Reports for Providers: AWP CQC Inspection Reports for Providers: NBT CQC Inspection Reports for Providers: UHBT Provider CQC Inspection Reports Provider Staff Survey Reports (Sep 2014) Enforcement actions Taken (Apr 2016)Requires Improvement (Dec 2014)Requires Improvement Gaps in and Assurances: No gaps in controls or assurances currently identified Mitigating actions date None GBAF D4 R2 there is a risk that failure to engage with Primary Care may impact on the delivery of the CCG Operational Plan Lead Initial risk score l c s Current risk score l c s Risk Appetite trend Low 1-3 Established locality structures in place Reports and minutes from joint committee Strong primary care involvement through received by Governing Body governance structures and clinical lead roles Monthly Integrated Quality, Performance and Finance Report to Governing Body process for delivery of enhanced services established joint commissioning committee in place 9

10 Outcome of 360 CCG Stakeholder survey See below Gaps in and Assurances: 360 CCG Stakeholder Survey identified areas for further development re communication with GP practices Mitigating actions Target Action plan to be agreed and governance route for reporting progress against implementation to be confirmed date 26/07/16 For discussion at seminar GBAF D4 R3 there is a risk that failure to act with probity and integrity results in challenge to decisions and loss of public and stakeholder confidence Initial risk score l c s Current risk score l c s Risk Appetite trend Low 1-3 CCG Constitution, scheme of delegation and standing orders established Key Policy review by Audit Committee Exception reports on key governance Governance structure with clinical leadership in place matters eg management of conflicts of interest made to Governing Body Risk management strategy and policy established Governing Body receives minutes, reports and annual reports from Standards of business conduct policy in place detailing management of conflicts of interest, and management of hospitality and gifts, bribery subcommittees NHS England approval of constitution changes Counter Fraud policy in place Raising Concerns policy in place HR policies and procedures established Internal Audit report: Corporate Governance Arrangements Nov 2016 Internal Audit report: Head of Internal Audit Opinion March 2017 Internal Audit report: HR/other corporate systems July 2016 Gaps in and Assurances: No gaps in controls or assurances currently identified Mitigating actions none Date 10