Strategic Risk Report 4 July 2016

Transcription

1 Strategic Report 4 July 20

2 Haringey CCG Register Introduction The Strategic Report (historically known as the Board Assurance Framework) evidences Haringey Clinical Group s control over the delivery of its strategic objectives listed above. This report directly underpins the Annual Governance Statement (AGS) and is the subject of annual enquiry by Internal and External Audit. Function of the Strategic Report This report is a tool for the Governing Body corporately to assure itself (gain confidence, based on evidence) about successful delivery of the organisation s strategic objectives. The framework is designed to focus the Governing Body on controlling principal risks threatening the delivery of those objectives. It aligns principal risks, key controls and assurances on controls alongside each objective. Oversight of the management of individual risks is assigned to relevant Governing Body Committees. Where gaps are identified and key controls and assurances are insufficient to reduce the risk of non-delivery of objectives, action plans will be created where appropriate and overseen by the responsible committee. The Senior Management Team and the Audit Committee routinely review all risk on the Register, whereas the Governing Body receives a more high-level Strategic Report, containing risks rated 12 and above. The purpose of the Strategic Report may be summarised as: To provide: a comprehensive method for the effective and focused management of the principal risks to achieving strategic objectives; and a basis for the preparation of a fair and representative Annual Governance Statement. Governing Body responsibility for the Strategic Report It is the responsibility of the Governing Body as the corporate head of the CCG to: Establish strategic objectives. Identify the principal risks that threaten the achievement of these objectives. Identify and evaluate the design of key controls intended to manage these principal risks. Set out the arrangement for obtaining assurance on the effectiveness of key controls across all areas of principal risk Evaluate the assurance across all areas of principal risk. Identify positive assurances and areas where there are gaps in controls and / or assurances Ensure that plans are put in place to take corrective action where gaps have been identified in relation to principal risks and receive assurance Maintain dynamic risk management arrangements including, crucially, a well-founded risk register. Open risks and recently closed risks are set out in pages Closed risks are detailed in pages

3 Haringey CCG Register Strategic Heat Map Impact Likelihood

4 Strategic Summary Open s Haringey CCG Register Ref Priority Key changes since last review 10 There is a risk of continued poor performance against the A&E target at NMUH. 20 description and progress on actions have been updated. 24 There is a risk of being unable to implement health economy-wide strategic change across Barnet CCG, Enfield CCG, Haringey CCG and BEHMHT. 9 It is proposed that this risk is CLOSED as it is now being addressed via the Sustainability and Transformation Plan mental health workstream, which the CCG is part of. 26 There is a risk that BEHMHT will fail to deliver the required must do and should do improvements required, after the Trust was rated as requires improvement following an inspection by the CQC in December Progress on actions has been updated. There is a risk of failing to ensure effective systems and processes are in place to support, monitor and challenge NMUH to deliver: Progress on actions has been updated the NHS Constitution targets improvements to the A&E department as detailed by the CQC in the section 29A Warning Notice issued on 27 April 20 the Health Education England (HEE) improvement plan agreed following the Trust-wide MDT visit in March 20. There is a risk that the CCG is unable to demonstrate it has delivered its duty under the NHS Constitution to ensure patients have the right to access services within maximum waiting times. 20 Planned actions and progress on actions have been updated. 34 There is a risk of failing to deliver a balanced Financial Plan in 20/17. Assurances and planned actions have been updated

5 Haringey CCG Register Description Owner 10 1,2,3 There is a risk that the performance against the A&E target at NMUH will not improve in line with the agreed trajectory to achieve the target of 95% of patients being seen within 4 hours by the end of March 2017 and a risk that they will not achieve 89% by September 20 Owner Jill Shattock Director of (Old NCL 759) Committee Causes Poor patient flow throughout the Trust. Too much reliance on inpatient beds and admitting patients. Not enough assessment capacity. Lack of clinical leadership within the Emergency Department (ED). Consultant and middle grade vacancies leading to inconsistent senior cover for ED. Effects Too many patients waiting an unacceptably long time for assessment and treatment within the department. Potential for unforeseen patient harm caused by extended waits in ED. Unforeseen pressure on nursing resource in ED caused by department congestion. Failure to achieve associated unscheduled care Key Performance Indicators (KPIs) Ineffective and inefficient use of GP capacity Failure to reduce unwarranted A&E activity L = The Trust is acting on the findings of the full diagnostic report commissioned from North West Utilisation Management Unit to achieve agreed clinical outcomes. 2. Report and recommendations now incorporated as part of the Safer, Faster Better (SFB) work programme to implement recommended actions via four workstreams. 3. Development of a Trust action plan to protect patient safety in A&E which will be agreed jointly by the Trust Development Authority and NHS England. 4. An A&E patient safety dashboard, developed by the Trust following the Summit on 8.2., is in place. 5. Commissioners are working with the Trust, NHS England, NHS Improvement and the regulators to develop a comprehensive action plan which will address the concerns raised by the CQC on 6.6. via the Section 29 warning notice and the concerns raised by the HEE regarding the training environment for trainee doctors. 1. Report and recommendations presented and agreed by System Resilience Group May 20. 1/2. CCG (and partners) to review progress at monthly SRG meetings. 1/2. Bespoke programme governance created to oversee the programme. 1/2. CCG membership of the fortnightly SFB Sponsor Boards meetings (as part of above). 1/2. Dedicated Programme Director resource in place. 1/2. Weekly workstream meetings in place, progress reports produced weekly. 3/4/5. CQRG will receive the A&E dashboard on a monthly basis. The minutes will demonstrate robust oversight of key quality and safety metrics and the impact of escalation where performance deteriorated L = 5 20 Actions 1. CCG acting as convenor and lead for Out of Hospital workstream. Weekly project team meetings to be set up and partner organisation membership agreed. Karen Baggaley, Assistant Director of Quality Review of the GP See and Direct Pilot to ascertain evidence for extension. Jill Shattock, Director of CQRG to add A&E dashboard as a standing item from February 20 Jennie Williams Director of Quality February Out of hospital workstream now set up and weekly project meetings in place. Membership agreed and the Integrated Discharge Function (IDF) is being developed as a key part of the workstream. All integrated resilience schemes as part of this OOH group have now been agreed for funding. Plans no in place for implementation. Care Home Pathways and Falls Service review is underway, in line with BCF plan and will align with the SFB transformation programme. The A&E recovery trajectory has been agreed by the SRG. 2. The GP See and Direct pilot extended to incorporate three phases of continued development links to UCC, work with ENPs and paediatric pathway. 3. The review of the A&E quality and safety dashboard and action plan (agreed outcome from the Summit on 8.2.) is now a standing item at CQRG meetings.

6 Haringey CCG Register Description Owner Damage to CCG reputation Impact on waiting times for planned treatment. 24 1,2,3 There is a risk of being unable to implement health economy-wide strategic change across Barnet CCG, Enfield CCG, Haringey CCG and BEHMHT. It is proposed that this risk is CLOSED as it is now being addressed via the Sustainability and Transformation Plan mental health workstream, which the CCG is part of. Owner Jill Shattock - Director of (Old 2) Committee Causes Lack of available resource to pump-prime and test new models of care underpinning transformation Existing overperformance in the CCG s demand-led budgets means that any uncommitted funding is diverted to mitigating these pressures in the first instance. Immediate pressures on BEH budgets e.g. inpatient beds may make it difficult to invest strategically. Effects Failure to implement recommendations in the Joint Mental Health and Well Being (MHWB) Framework and in the Carnall Farrar report, with subsequent impact on: Ability to deliver transformational change, including the I = 3 L = BEH Strategic Partnership Transformation Board is now established. 2. There is NCL-wide commitment to programmes of transformation for mental health. A Senior Responsible Officer (SRO) has been appointed with effect from and a programme of work is being launched. 3. Process underway for implementation of the Haringey MHWB Framework (monitored via the Health and Care Integration Board (HACI). This process will inform business cases for service developments to deliver transformation. 1. BEH Strategic Partnership Board papers 2. Papers from NCL-wide structures as they are developed. 3. Minutes of HACI Board meetings. I = 3 L = 3 9 Action Progress through commissioning and Transformation Boards. (C) Jill Shattock/Sarah Price Ongoing The Carnall Farrar sustainability review concluded that the Trust is financially viable with some additional resource into the mental health system and if work is undertaken at an NCL-wide level to develop new models of care. The Haringey Mental Health Implementation Group has met and agreed a process for co-producing a plan to implement an enablement approach in Haringey. An Enablement Lead has been recruited and commenced on The new BEH Strategic Partnership Board has draft terms of reference and held its first meeting on This group will oversee implementation of the Carnall Farrar recommendations. There is now an NCL Mental Health Steering Group chaired by the Camden CCG Chief Officer with GP, provider and director of commissioning representation. There is a draft strategic plan and there has been one stakeholder workshop and another on 12th

7 Haringey CCG Register Description Owner implementation of an enablement approach. The future viability of the Trust. Patient experience and service quality being detrimentally affected. May. The strategic plan is due to be submitted to NHSE w/c The NCL-wide programme is currently being scoped and project management support identified. 26 1,2 There is a risk that BEHMHT will fail to deliver the required must do and should do improvements required, after the Trust was rated as requires improvement following an inspection by the CQC in December Owner Jennie Williams Executive Nurse and Director of Quality and Integrated Governance Quality Committee Causes Effect Lack of capacity/ capability to deliver the required improvements The Trust is unable to make the necessary improvements to services provided out of the St Anne s site due to unsatisfactory environment. There will be a further deterioration in the quality and safety of services and BEHMHT will be deemed not to meet regulatory standards in respect of CQC outcomes. L = 4 1. The delivery of the BEHMHT CQC improvement action plan will be overseen by the Joint Performance and Quality Group (JPQG) from June Haringey CCG will ensure the CQC improvement plan gives appropriate focus to improved outcomes for patients accessing services in Haringey. 1. JPQG minutes will provide evidence of review of the Trust s quality and delivery plan and the quality and safety dashboard, with specific focus on safeguarding, patient complaints and serious incidents. 2. The performance against key patient safety and experience metrics for services delivered in Haringey will demonstrate month on month improvements. L = 3 12 Action 1. Enfield CCG lead for quality to meet the Trust Director of Quality to review the draft Trust CQC improvement plan on and then brief the Executive Nurse and Director of Quality and Integrated Governance, Haringey CCG. Action Owner Jennie Williams By end of June To ensure the CCG senior management team and CCG Quality Committee are kept briefed on the progress made by the Trust to deliver the CQC improvement plan and the Chief Officer and Chair are informed of any emerging concerns relating to quality and safety. (C) Action Owner Jennie Williams 1. The Trust has published the 2015/ Quality Accounts. The priorities are aligned with the findings of the CQC inspection conducted in December

8 Haringey CCG Register Description Owner From June December , 2 There is a risk of failing to ensure effective systems and processes are in place to support, monitor and challenge NMUH to deliver: Owner the NHS Constitution targets improvements to the A&E department as detailed by the CQC in the section 29A Warning Notice issued on 27 April 20 the Health Education England (HEE) improvement plan agreed following the Trust-wide MDT visit in March 20 Jennie Williams Executive Nurse and Director of Quality and Integrated Governance Quality Committee Causes Lack of capacity and capability within the Trust to deliver quality and safety improvements Inability of the Trust to appoint substantively to consultant and middle grade posts in emergency medicine. Effects Deterioration in key quality and safety metrics Further deterioration of A&E performance leading to increased likelihood of poor quality, poor patient experience and delivery of poor clinical outcomes Increased likelihood that the GMC will suspend medical trainee placements in the A&E department. L = The monthly Clinical Quality Review (CQRG) and Contract Review Group (CRG) meetings led by commissioners are used to ensure close scrutiny of key quality and safety metrics and performance against the national targets. 2. A monthly Programme Oversight Group (POG) was implemented by NHS Improvement (NHSI) following the ED Summit on This group oversees delivery of the immediate and longer-term improvements required by the CQC and HEE and ensure short term actions lead to sustainable improvements. Haringey and Enfield CCG Chief Officers are members of this group. 3. An Operational Delivery Group (ODG) chaired by NHS England (NHSE) is in place to will ensure delivery of the required operational actions to support the Trust to meet the HEE requirements. 1a CQRG minutes demonstrate appropriate challenge and support and, where appropriate, escalation of quality and safety risks. 1b CRG minutes demonstrate appropriate challenge and robust use of contractual levers where NHS Constitution standards are breached. 2. Improved supervision and education are in place for medical trainees, evidenced by robust medical rotas, improved trainee feedback, and evidence of substantive medical appointments. HEE will confirm on behalf of the GMC that they are assured by the end of June Minutes of the monthly ODG demonstrate delivery of the HEE action plan within the agreed timeframe. I = 5 L = CCG to continue to give oversight to key ED quality and safety metrics within the ED dashboard created following the ED Summit on System oversight is in place via a weekly teleconference where the Trust presents the high level dashboard and actions i`n place to address poor performance to the quality leads for Haringey CCG, Enfield CCG, NHSE and NHSI. Action Owner Jennie Williams, Executive Nurse and Director of Quality and Integrated Governance Ongoing 2. Member of CRG will attend CQRG meetings to assure appropriate challenge and avoid duplication of requests for assurance. Action Owner Jennie Williams, Executive Nurse and Director of Quality and Integrated 1. (Update 4.7.) On 6.6. the CQC published the Warning Notice issued to Trust following the unannounced visit on which focused on ED. Publication of the report is due on The GMC met with NHSE, NHSI and the CQC on 1.7. and confirmed it was satisfied that sufficient progress had been made to improve the support and supervision of medical trainees. Whilst the GMC has decided not to remove the trainees from ED it is understood that it will require significant assurance that the HEE improvement plan will be delivered to deadline to evidence that quality and safety are being adequately protected. It is understood that NHSE is developing a comprehensive dashboard which will ensure close oversight of the delivery of the HEE and CQC improvement plans

9 Haringey CCG Register Description Owner (NOTE: this risk should also be cross-referenced with 10, where the risk relating to the Trust not meeting the agreed trajectory to achieve its 95% A&E target is described in detail). Governance Ongoing 3. Executive Nurse and Director of Quality and Chief Officer to attend ODG to maintain close oversight of Trust delivery of CQC Warning Notice actions and HEE action plan. Action Owner Jennie Williams, Executive Nurse and Director of Quality and Integrated Governance Ongoing 33 1,2,3 There is a risk that the CCG is unable to demonstrate it has delivered its duty under the NHS Constitution to ensure patients have the right to access services within maximum waiting times. Owner Jill Shattock Director of New Performance (Old NCL 717) (Old NCL 715) (Old HCCG 24) Causes Effects NCL acute providers failing to consistently achieve cancer and diagnostic standards. Inefficiency and ineffectiveness and poor experiences and outcomes for patients Increased risk of clinical harm due to longer waits of failure of Quality Premium relating to the constitutional standards. Currently 3 of the 4 Quality Premium constitutional targets will not be achieved. L = 4 1. The Director of is working closely with the CSU to ensure robust monitoring of constitutional standards. 2. Remedial action plans (RAP) have been agreed by host commissioners and are monitored at fortnightly RAP review meetings. RAPs deliver compliance for April 20 and for 20/2017. Patient Tracking Lists (PTL) are being used to monitor the recovery plan and trajectories. 3. HCCG is assured that agreed trajectories to deliver compliance will be delivered. 1. A London- wide Cancer Transformation Programme has been established to oversee the delivery of national cancer standards London-wide. 2. Minutes of RAP review meetings. Ongoing performance is monitored through the Integrated Contract Monitoring Report and other performance reports. 3. Minutes of CSU SLA and RAP review meetings. Actions plans are provided by underperforming trusts L = 4 1. Weekly cancer Patient Tracking Lists (PTL) supplied by both NMUH and RFL and monitored by host CCGs. Ongoing Jill Shattock, Director of 2. To achieve compliance with the national standards for Cancer for 20/17 from quarter two NMUH operational validation is under way. RFL provide a weekly PTL and progress report. 2. Trajectories are regularly reviewed at the RAP review meeting. UCLH is now planned to be compliant with the Diagnostics standard by the end of July 20.

10 Haringey CCG Register Description Owner Committee Reputational damage to the CCG due to failure to achieve standards at individual provider and borough level. and monitored by the CSU team. Jill Shattock, Director of Quarter Two 20 HCCG-wide and NMUH did not achieve the 62 Days Cancer Standard in April. HCCG did not achieve the Diagnostics Standard in April. RFL, UCLH and InHealth did not achieve the standard in April. A new work stream, led by the Chief Officer, Barnet CCG, has been established to address Royal Free London performance There is a risk of failing to deliver a balanced Financial Plan in 20/17. Owner David Maloney Chief Finance Officer Committee Cause 1. Failure to control acute activity during 20/ Failure to deliver 20/17 QIPP Plan. 3. Financial pressures in nonacute CCG budgets. 4. Requirement to set aside 1% of the CCG budget. Effect 1. Failure to fulfil the CCG s statutory financial duties. 2. Insufficient resources across North Central London to fund transformation agenda. L= 4 1.Appropriate financial governance systems in place 2. Review and ongoing scrutiny of the CCG s financial performance by Committee and Governing Body. 3. Review of 20/17 QIPP Plan at QIPP Delivery Group and Finance and Performance Committee meetings /17 budget setting process. 5. Approval of Financial Plan by Committee and Governing Body. 6. Rigorous contract management processes undertaken during 20/ Internal Audit reports produced by Internal Audit which cover financial procedures within the CCG. 2. Papers and minutes of Committee and CCG Governing Body. 3. Papers and minutes of QIPP Delivery Group and Committee. 4. Budget holders have signed off their 20/17 budgets which were uploaded onto the ledger in May 20. L= 4 1. Identification of additional areas for 20/17 QIPP. (C) : David Maloney Chief Finance Officer : First half of 20/ Monitoring of expenditure (C) : David Maloney Chief Finance Officer : Ongoing during 20/ The 2015/ QIPP Plan is a key focus of the fortnightly QIPP Delivery Group meetings and is also scrutinised monthly by the Senior Management Team. In addition to working up new QIPP areas for implementation in year, the reviews will also identify where planned savings are not being achieved and monitor the impact of any resulting mitigations. Monthly meetings are being held between NMUH and CCG clinicians to discuss and deliver in-year QIPP projects. In addition, work is being undertaken with Haringey Council to identify joint savings. 2. Monthly finance reports, including in-depth monitoring of variances and supporting lead

11 Haringey CCG Register Description Owner 5. Financial Plan was reviewed by the Finance and Performance Committee on and then approved by the Governing Body on Monthly contract meetings with NMH. Similar process in place for other contracts where the CCG has significant expenditure. Thorough discussion of the monthly financial position at the working day 6 meeting with CSU colleagues. 3. Monitoring by NHS England of CCG s control total. (A) : David Maloney Chief Finance Officer : Ongoing during 20/17. CCGs rigorous challenges of activity. 3. The CCG s in-year rating will be based upon the delivery of its control total, following the CCG s financial plan not being assured by NHS England due to the CCG not delivering a 1% surplus