Strategic Report 1 March 2018
Haringey CCG Register Introduction The Strategic Report (historically known as the Board Assurance Framework) evidences Haringey Clinical Commissioning 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 6-17. 2 1.3.18
Strategic Heat Map Haringey CCG Register 5 10 4 26 = 40 42 Impact 3 2 41 1 1 2 3 4 5 Likelihood 3 1.3.18
Strategic Summary Open s Haringey CCG Register Ref Priority Key changes since last review 10 There is a risk that the performance against the A&E target at NMUH will not improve in line with the trajectory for 2017/18 agreed with NHS England, NHS Improvement and the A&E Delivery Board. The trajectory outlines a sustained improvement in the achievement of the target of 95% of patients being seen within 4 hours, with the 95% target being achieved by the end of March 2018. 15 There have been no changes in this review. 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 2015. 38 There is a risk of failing to deliver a balanced Financial Plan in 2017/18. This risk has been CLOSED as financial pressures in Acute and Continuing Care Services are likely to result in the CCG not meeting the control total. The CCG will work to mitigate pressures locally to achieve financial balance across North Central London. A new risk (risk 41) has been opened to ensure the CCG manages the financial position reported to NHS England in order to achieve financial balance across North Central London. 12 16 There have been no changes in this review. 40 There is a risk of quality and access to dermatology care deteriorating as a result of cessation of North Middlesex to provide dermatology from March 2018. 41 There is a risk of the financial position worsening before the 2017/18 year-end. 6 This is a new risk. 12 Progress against actions has been updated. 42 There is a risk is of continued overspend on the Continuing Healthcare (CHC) budgets, resulting in the CCG being unable to meet its financial duty to deliver services within its resources. 16 This is a new risk. 4 1.3.18
Haringey CCG Register Description Owner 10 1,2,3 (Background: NHS England s expectation is that all NHS Trust s performance against the 4 hour target will show month on month improvement). There is a risk that the performance against the A&E target at NMUH will not improve in line with the trajectory for 2017/18 agreed with NHS England, NHS Improvement and the A&E Delivery Board. The trajectory outlines a sustained improvement in the achievement of the target of 95% of patients being seen within 4 hours, with the 95% target being achieved by the end of March 2018. Owner Tony Hoolaghan, Chief Operating Officer Finance and Performance Committee and Quality Committee reworded in its current form 4.4.17 Causes Poor patient flow throughout the Trust and back in to the community Too much reliance on inpatient beds and admitting patients. Inconsistent implementation of agreed new ways of working in the department. Lack of senior clinical leadership within the Emergency Department (ED). Consultant and middle grade vacancies leading to inconsistent senior cover for ED Workforce challenges within the A&E department are impacting on the trust s ability to deliver high quality care. Effects Too many patients waiting an unacceptably long time for assessment and I = 4 L = 5 20 1. The Trust is acting on recommendations from the Emergency Care Improvement Programme to improve streaming and patient flow through the department, particularly at times of pressure. 2. Embedding of the Safer, Faster Better (SFB) work via four workstreams. 3. Refresh of A&E Delivery Board governance in October 2017. The Trust CEO now chairs the Delivery Board. 4. Use of the quality surveillance process to escalate emerging concerns about quality and safety and ensure a single shared view of risks to quality and safety in the A&E department. 5. In 2017/18 a programme of CCG led Insight Visits to NMUH will be informed by CQC recommendations and the Trust Improvement Plan. 1/2. CCG (and partners) to continue to review SFB programme progress at monthly A&E Delivery Board meetings. The Director of Performance, Planning and Delivery attends Safer, Faster, Better steering group. 1/2. Bespoke programme governance created to oversee the programme and link to wider Trust improvement programme. 1/2. Dedicated Programme resource in place. 3. A&E Delivery Board minutes provide evidence that performance improvement and target recovery are overseen effectively and appropriate challenge is made. 5 1.3.18 I = 5 L = 3 15 Actions 1. CCG acting as convenor and lead for Out of Hospital workstream of the SFB programme. Weekly project team meetings set up and partner organisation membership agreed. Action owner Marco Inzani, Head of Integrated Commissioning (Adults) From 30.5.16 2. Recovery target agreed and managed as part of the STF (Sustainability and Transformation Fund) arrangements for 2017/18. 1/2. Haringey CCG priorities are: 1. Preventing people from being admitted to the Trust. Primary care hub appointments available 7 days a week and blocked appointments held specifically for patients being redirected form the acute Trust. Additional winter resilience funding for additional staff to support admission avoidance activity. A senior CCG nurse has been based in the Trust four days a week since September 2017 to support the discharge work. 2. Moving patients out of the hospital as soon as they are well enough to be discharged. Haringey and Enfield have increased the number of patients going through our
Haringey CCG Register Description Owner treatment within the department. Patients do not receive timely assessment and clinically appropriate, high quality care 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 Damage to CCG reputation Impact on waiting times for planned treatment. 4. Quality Stocktake meeting convened by NHSE on 28.9.17. 5. The CCG will ensure regular visits to the ED department to seek assurance that safety is being protected. CQRG minutes will record the outcome of Insight Visits and evidence that Trust is acting on the recommendations. Action owner Tony Hoolaghan, Chief Operating Officer From 1.4.17 Discharge to Assess (D2A) pathways. The senior CCG nurse is chairing the MO/DToC meeting and discharge pathway, working with the Trust discharge team and community teams to pull patients out of the Trust. This is through identifying and unblocking any challenges to achieving earlier discharges Identification of issues and actions agreed in Haringey to increase patients being discharged through discharge to assess (D2A) pathway 3 for Haringey patients. The out of hospital workstream was set up from May 2016 and weekly project meetings are in place, alternating between steering group discussions and wider group meeting with local health and social care partner organisations. Local partners are working together to implement priority actions identified to support urgent care improvements. New governance agreed 6 1.3.18
Haringey CCG Register Description Owner and implemented for the SFB programme in 2017/18, with oversight continuing to be part of the A&E Delivery Board responsibilities. This includes development of a steering group where work stream leads from the 4 areas ensure the system is working together to deliver key priorities. 3. The NCL Accountable Officer and Director of Nursing and Quality to work with regulators and the Trust to ensure the safety concerns which led to a quality stock take meeting in September 2017 are addressed. Action owner Jennie Williams Director of Nursing and Quality From 28.9.17 3. There is a robust approach in place to ensure improvements required by the GMC are evidenced, which includes oversight by the CCG at a weekly meeting. It is anticipated that a further quality stocktake meeting will be convened in January 2018 to provide the system with assurance that the broader quality issues have been addressed. 4. CCG to ensure that quality and safety within A&E are being protected during this period of 4. The NMUH Medical Director provides a neartime brief on the protection 7 1.3.18
Haringey CCG Register Description Owner increased risk and enhanced surveillance. Action owner Jennie Williams Director of Nursing and Quality From February 2018 of quality and safety at every CQRG meeting. The CCG undertook an assurance visit on 7.12.17 with NHS England and NHS Improvement to review progress with the implementation of the quality and safety checklist. The Emergency Care Improvement Plan (ECIP) has reported that it continues to support the Trust to embed the checklist. The CCG Director of Nursing and Quality and the Trust Medical Director will work to develop an ED dashboard which the ED team will embed. This will be used for assurance at CQRG. The estimated time for production of the dashboard is 6 weeks. 5. The CCG to ensure that quality and safety within A&E are being protected during this period of increased risk and enhanced surveillance. 5. The Director of Nursing and Quality undertakes regular visits to ED during the week and weekends. The primary purpose is to ensure safety is being protected and safe staffing is in place. 8 1.3.18
Haringey CCG Register Description Owner Action owner Jennie Williams Director of Nursing and Quality From February 2018 The Chair of the CCG will undertake a visit to ED on 19.02.18 accompanied by the Assistant Direction of Quality and Patient Safety. 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 2015. Owner Jennie Williams Director of Nursing and Quality Quality Committee reworded in its current form 15.6.15 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. I = 4 L = 4 16 1. The delivery of the BEHMHT CQC improvement action plan will be overseen by the Clinical Quality Review Group (CQRG) bimonthly from April 2017. 2. Haringey CCG will ensure the CQC improvement plan gives appropriate focus to improved outcomes for patients accessing services in Haringey. 3. Appropriate escalation to CCG Quality Committee and Commissioning and Finance and Performance meetings where funding issues impact on quality. 1. CQRG 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. 3. The CCG Quality Committee and Finance and Performance Committee minutes demonstrate escalation of concerns to commissioning and finance colleagues where 9 1.3.18 I = 4 L = 3 12 Action 1. Commissioners to receive CQC improvement plan full update 6-monthly at the CQRG meeting, with bimonthly exception reporting of key risks and remedial actions. Action Owner Jennie Williams, Director of Nursing and Quality By end of September 2016 1. In September 2017 the CQC undertook a comprehensive inspection of eight core mental health services and one community service, with a return visit to inspect three further areas. On 12.1.18 the CQC published the inspection report which gave the Trust an overall rating of Requires Improvement with Good for caring, responsive and well-led. The safe and effective domains were rated as Requires Improvement Immediately after the inspection in September 2017 the Trust was asked to take actions to address issues relating to risk
Haringey CCG Register Description Owner delivery of CQC actions is at risk. management.haringey community based services (adults) in Haringey were rated as Requires Improvement. The CQC will convene a Quality Summit to present the findings to stakeholders and provide the Trust with an opportunity to respond. 2. To ensure the CCG executive management team and CCG Finance and Performance and 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) 2. The Director of Nursing provides regular briefings to the Accountable Officer and the Executive Management Team. Regular updates are also provided at Quality Committee meetings. Action Owner Jennie Williams, Director of Nursing and Quality From June 2016 10 1.3.18
Haringey CCG Register Description Owner 38 1 There is a risk of failing to deliver a balanced Financial Plan in 2017/18. Owner Simon Goodwin Chief Finance Officer Finance and Performance Committee added to Register 17.1.17 This risk has been CLOSED as financial pressures in Acute and Continuing Care Services are likely to result in the CCG not meeting the control total. The CCG will work to mitigate pressures locally to achieve financial balance across North Central London. Causes 1 Significant level of QIPP required in financial plan. 2 Work needed to implement STP interventions. 3 Limited capacity in CCG budget to mitigate financial issues in 2017/18. 4 Impact of HRG+4. I = 5 L= 4 20 1. Appropriate financial governance systems in place 2. Review and ongoing scrutiny of the CCG s financial performance by Finance and Performance Committee and Governing Body. 3. Review and identification of 2017/18 QIPP Plan at QIPP Delivery Group and Finance and Performance Committee meetings. 4. 2017/18 budget setting process. 5. Approval of Financial Plan by Finance and Performance Committee and Governing Body. 6. Pan-NCL work to implement and deliver the STP interventions. 1. Internal Audit reports produced by Internal Audit which cover financial procedures within the CCG. 2. Papers and minutes of Finance and Performance Committee and CCG Governing Body. 3. Papers and minutes of QIPP Delivery Group and Finance and Performance Committee. 4. Budget holders to sign off their 2017/18 budgets by March 2017. 5. Financial Plan to be reviewed regularly by the Finance and Performance Committee, following approval by the Finance and Performance Committee and the Governing Body. 6. Discussion of NCL financial position at Financial and Activity Modelling Group. I = 4 L= 4 16 1. Implement STP interventions. (C) Simon Goodwin Chief Finance Officer March 2017. 2. Identify additional QIPP projects, both CCG and NCL-wide. (C) Simon Goodwin Chief Finance Officer Ongoing 2017/18. 3. Discussions with NHS England and NHS Improvement regarding overall NCL financial gap. (C) Simon Goodwin Chief Finance Officer Ongoing 2017/18. 1. STP QIPP interventions currently being delivered and developed in conjunction with providers. Updated Project Initiation Documents being produced with implementation and delivery timelines agreed with CCG commissioners. 2. Work is continuing to identify additional QIPP. 3. Ongoing monthly calls held with NHSE to ensure `CCG and NCL plans remain on target. Financial Strategy being developed for NCL CCGs to allow some future mitigation in the event plans do not balance. The control totals are now managed collectively across NCL CCGs. The expectation is that the NCL-wide control total will be achieved. 11 1.3.18
Haringey CCG Register Description Owner 4. Pan-NCL Share agreement to mitigate risk of NCL CCGs failing to meet control totals in 17/18. (C) 4. This was agreed at the GB meeting held on 9.11.17. Simon Goodwin Chief Finance Officer August/Sept 2017/18 5. Development of a Financial Recovery Plan for the CCG in order to manage system pressures and create headroom/reserves. (C) Anthony Browne Deputy Chief Finance Officer August 2017/18 (ongoing). 5. Finance & Performance update report on financial management plan is being presented to the Finance and Performance Committee on 14.7.17. Relaunch of plan to Commissioning Senior Management Team (CSMT) in November 2017. 12 1.3.18
Haringey CCG Register Description Owner 40 1,2, 3 There is a risk of quality and access to dermatology care deteriorating as a result of cessation of North Middlesex Hospital (NMUH) to provide dermatology from March 2018. Owner Clare Henderson, Director of Commissioning, Haringey CCG Quality Committee and Finance and Performance Committee. added to register 22.9.17 Causes Ongoing failure to recruit to Consultant dermatology posts at NMUH, leading to nonviability of this service continuing to be provided by the Trust. Effects NMUH is unable to treat patients. I 4 L 5 20 1. Establishment of joint task-andfinish group with NMUH to develop and evaluate options. 2. Clinical partnership with Royal Free Hospital (RFH) dermatology department is being explored 3. Performance is routinely monitored at Contract Review Group meetings. 1. Updates at CQRG and Contract Review Group 2. Regular progress review through Task and Finish Group 3. Minutes of Contract Review Group meetings. L 4 I 3 12 1. Director of Commissioning to oversee development of longer-term approach, including one which mitigates risks at RFH. Action owner Clare Henderson, Director of Commissioning July 2018 2. NMUH to subcontract service to Concordia from 8.1.18 for 12 months. Action owner Clare Henderson, Director of Commissioning 8.1.18 1. Commissioners are taking an options paper to the Joint Commissioning Committee on 1.3.18. Commissioners continue to meet regularly to oversee progress and development of future model 2. The Concordia service has now been commissioned and is delivering services from NMUH. 13 1.3.18
Haringey CCG Register Description Owner 41 1 There is a risk of the financial position worsening before year end 17/18. Owner Simon Goodwin Chief Finance Officer Finance and Performance Committee added to Register 19.2.18 Causes 1. Financial Pressures with Acute Contracting, national pressures on Prescribing stock availability and Continuing Health Care cost and volume pressures 2. Lack of CCG reserves / contingency to stabilise financial position should costs increase over contract value 3. Significant level of QIPP required in financial plan. 4. Impact of HRG+4 tariff increases and changes to responsible commissioner identification rules. I = 4 L= 3 12 1. Appropriate financial governance systems in place 2. Review and ongoing scrutiny of the CCG s financial performance by Finance and Performance Committee and Governing Body. 3. Review and identification of 2017/18 QIPP Plan at QIPP Delivery Group and Finance and Performance Committee meetings. 4. Pan-NCL work to implement and deliver the STP interventions. 1. Internal Audit reports produced by Internal Audit which cover financial procedures within the CCG. 2. Papers and minutes of Finance and Performance Committee and CCG Governing Body. 3. Papers and minutes of QIPP Delivery Group and Finance and Performance Committee. 4. Financial Plan to be reviewed regularly by the Finance and Performance Committee, following approval by the Finance and Performance Committee and the Governing Body. 5. Discussion of NCL financial position at Financial and Activity Modelling Group. I = 3 L= 2 6 1. Financial Management Plan in place (C) Anthony Browne Deputy Chief Finance Officer Ongoing 2017/18 2. Increased QIPP governance and monitoring to identify and mitigate slippage, both CCG and NCL-wide. (C) Simon Goodwin Chief Finance Officer Ongoing 2017/18. 3. Discussions with NHS England and NHS Improvement regarding overall NCL financial gap. (C) Simon Goodwin Chief Finance Officer Ongoing 2017/18. 1. F&P Committee approved Finance Management Plan. Review of actions on a monthly basis. 2. Senior level finance, executive and clinical engagement through QIPP Leads meeting Work is continuing to identify areas of slippage and begin 18/19 QIPP schemes in Q4 1718 where appropriate. 3. Ongoing monthly calls held with NHSE to assure CCG and NCL plans. Control totals are now managed collectively across NCL CCGs. The expectation is that the NCL-wide control total will be achieved. 14 1.3.18
Haringey CCG Register Description Owner 4. Pan-NCL Share agreement to mitigate Delegated Primary Care pressures (C) Simon Goodwin Chief Finance Officer Sept 2017/18 4. This was agreed at the GB meeting held on 9.11.17. 42 1,2,3 There is a risk is of continued overspend on the Continuing Healthcare (CHC) budgets, resulting in the CCG being unable to meet its financial duty to deliver services within its resources. These budgets include expenditure on the female Psychological Intensive Care Unit (PICU), inpatient rehabilitation, patients to whom the CCG has a Section 117 duty and people with learning disabilities. owner: Clare Henderson, Director of Commissioning Causes: Demographic changes in the frail elderly population Bed pressures in acute and mental health services. Limited care homes/domiciliary care market Lack of preventative work at an early stage with vulnerable children and young people to ensure packages are appropriate when they transition to adulthood Poor pathways for LD and mental health L = 5 I = 4 20 1. Review of higher cost packages to ensure that they are still required to meet needs, provide value for money and to review CHC eligibility where this is assessed as appropriate. 2. Domiciliary Care tracking to ensure CCG is only funding care delivered by the provider. 3. A female PICU opened by Camden and Islington Foundation Trust (CIFT). 4. NCL wide-work on identifying value for money and sustainable rates for care homes. 1, 2, 3. Monthly CHC budget monitoring meetings to ensure accuracy of forecast and reports to Finance and Performance Committee. 4. Regular reports received by Joint CCG/Haringey Council Commissioning and Finance Management 15 1.3.18 L = 4 I = 4 16 1. NCL-wide review of CHC considering brokerage and market management options Kay Matthews Chief Operating Officer, Barnet CCG To be confirmed. 2. Procurement of domiciliary care project with Haringey Council to improve the market. 1. This review is currently being considered by the NCL Senior Management Team. 2. The CCG is currently considering an options paper on whether this is a viable option.
Haringey CCG Register Description Owner Lead committee: Finance and Performance Committee added to register: 1.3.18 Effects patients resulting in delays for patients in services that are higher cost Lack of reviews of CHC patients resulting in patients who are not eligible remaining on CHC Discharges from forensic units results in increased demand Haringey Council also ensuring that reviews are up to date and that clients are given CHC eligibility where appropriate. Continued increase in CHC budget costs. Lack of opportunities to invest in developing improved pathways that will result in reduced costs in the longer term. Group, and the Finance and Performance Partnership Board. Temmy Fasegha, - Vulnerable Adults Commissioning Manager To be confirmed. 3. Review of budget structure to bring mental health and learning disabilities budgets under the responsibility of lead commissioners to improve strategic pathway development. Action owners: Shelley Shenker - Assistant Director, Mental Health Commissioning/ Temmy Fasegha, - Vulnerable Adults Commissioning Manager To be confirmed. 4. Recruitment of 5 WTE clinical reviewers to clear the backlog of 300 reviews. 3. Initial review meeting to take place on 6.3.18, as part of a wider review of the recovery plan. 4. Proposal to be considered by Finance and Performance Committee on 25.4.18. 16 1.3.18
Haringey CCG Register Description Owner Temmy Fasegha, - Vulnerable Adults Commissioning Manager April 2018. 5. Development of commissioning plans to ensure the delivery of interventions that are early as possible, maximise independence and reduce delays in moving on to the next appropriate provision. Action owners: Shelley Shenker - Assistant Director, Mental Health Commissioning June 2018. 17 1.3.18