item e appendix 1 board assurance framework e... · risk rating director of delivery (scott...

1

Item E Appendix 1 Board Assurance Framework

Document information

Version Version 3.0

Reported to To be reported to Newham CCG Board meeting – 08.01.2014

Next review February 2014

Author Luke Moore – Governance and Risk Manager

Chair: Dr Zuhair Zarifa Accountable Officer: Steve Gilvin

2

Contents

2. Purpose and Scope ........................................................................................................... 3

2.1 Board Assurance Framework ...................................................................................... 3

2.2 Risk Management Governance ................................................................................... 3

2.3 Risk Areas ................................................................................................................... 4

2.4 Risk Identifiers ............................................................................................................. 4

3. Board Assurance Framework ............................................................................................ 5

3.1 Risk profile ................................................................................................................... 5

3.2 Risk Area 1- To reduce health inequalities, improve access and reduce variation ........... 6

3.3 Risk Area 2 - To develop Integrated Care, in particular to support improved management

of long term conditions ........................................................................................................ 13

3.4 Risk Area 3 - To ensure robust patient and public engagement is embedded in the

operations of Newham CCG and at all stages of the commissioning cycle .......................... 14

3.5 Risk Area 4 -To ensure that Newham CCG achieves robust financial stability and

balance to supporting effective working and implementation of our plans ........................... 15

3.6 Risk Area 5 - To support quality improvements in primary care services to ensure they

are fit for purpose and able to support the shift in care out of hospital ................................. 19

3.7 Risk Area 6 - To ensure that Newham CCG has transparent and effective corporate and

clinical governance arrangements in place to comply with relevant legislation and mitigate

the risk of non-delivery of strategic objectives ..................................................................... 25

4. How to interpret the Newham CCG BAF ......................................................................... 27

4.1 Risk profile ................................................................................................................. 27

4.2 Full BAF risk entries ...................................................................................................... 28

5. Newham CCG Risk Grading Matrix ................................................................................. 29

3

2. Purpose and Scope

2.1 Board Assurance Framework

The primary purpose of the Newham CCG Board Assurance Framework (BAF) is to:

1) Act as a mechanism for alerting and appraising the Board of the main risks to

achieving to the CCG in terms of achieving strategic objectives as set out in

the Operating Plan

2) List, evaluate and provide assurance to the Board regarding the mitigations in

place to the reduce the likelihood or impact of the risk

3) Summarise to the Board the remedial or proposed actions that further

mitigate the likelihood or impact of the risk

The BAF is also an important document for providing external assurance (to NHS England,

Internal Audit and patients and public) that the CCG is sighted on its risks and has a robust

system of internal control.

A guide to interpreting individual BAF entries is shown at 4. How to interpret the Newham

CCG BAF

The risk scoring matrix to establish initial risk ratings is shown at 5. Newham CCG Risk

Grading Matrix

2.2 Risk Management Governance

Risk Management is embedded in Newham CCG’s Governance Structure:-

The Audit Committee is responsible for scrutinising the group’s Risk Management policies

and procedures. Accountable to the group’s Board, the Committee provides the Board with

an independent and objective view of the group’s financial systems, financial information and

compliance with laws, regulations and directions governing the group in so far as they relate

to finance.

The Executive Committee is responsible for approving internal control arrangements, risk

sharing and pooling agreements.

The Chief Officer is responsible for approving the group’s arrangements for business

continuity and emergency planning.

The Chief Finance Officer is responsible for approving the group’s Counter Fraud, Security

Management and Risk Management arrangements.

The Governing Board is responsible for approving and monitoring the Board Assurance

Framework.

4

2.3 Risk Areas

BAF risks have been categorised into six main risk areas. Five of these risks areas link to

the core strategic objectives of Newham CCG, as outlined in the Newham CCG Operating

Plan. These are:

1. To reduce health inequalities, improve access and reduce quality variation

2. To develop Integrated Care, in particular to support improved management of long

term conditions

3. To ensure robust patient and public engagement is embedded in the operations of

Newham CCG and at all stages of the commissioning cycle

4. To ensure that Newham CCG achieves robust financial stability and balance to

supporting effective working and implementation of our plans

5. To support quality improvements in primary care services to ensure they are fit for

purpose and able to support the shift in care out of hospital

The Board has taken the view to include a sixth risk area to highlight the importance of

establishing and maintaining good governance practices to enable the CCG to effectively

deliver against its core strategic objectives:

6. To ensure that Newham CCG has transparent and effective corporate and clinical

governance arrangements in place to comply with relevant legislation and mitigate

the risk of non-delivery of strategic objectives

It is recognised that a number of BAF risks will be linked to one or more of the above risk

areas. This will be noted where applicable on the risk profile template (section 3.1).

2.4 Risk Identifiers

Each BAF risk will be assigned a unique risk identifier (number). This will be based upon the

primary area of risk identified from the five designed risk areas and subsequently the order in

which the risk is added to the BAF. For example, the first risk added to the BAF with a

primary risk area of category 1 (to reduce health inequalities… etc.) would be assigned a risk

identifier of 1.1.

5

3. Board Assurance Framework

3.1 Risk profile

Risk

Identifier

Linked to

Risk AreasRisk Summary Risk Owner

Initial Risk

rating (April

2013)

November

2013

forecast

Trend

End of

Year

Target

Difference

between

target and

forecast

Date risk last

reviewed

1.1 1,2,4,5 Failure to deliver QIPP Plans within target Scott Hamilton 15 8 8 0 23.12.2013

1.2 1,2,4,5Failure to develop future QIPP plans appropriate to the evolving needs of the CCG

in a timely and robust mannerScott Hamilton 12 12 8 4 23.12.2013

1.3 1,2 CSU ability to deliver on contracted services due to capability / capacity. Scott Hamilton 20 8 5 3 23.12.2013

1.4 1 Quality of Commissioned Services at Barts Health Chetan Vyas 15 10 5 5 22.11.2013

1.5 1,2Failure to establish and/or maintain effective enagement and collaborative working

arrangements with the Local AuthoritySatbinder Sanghera 9 6 3 3 19.12.2013

1.6 1,2,4,5,6 Failure to recruit develop and retain key staff Steve Gilvin 20 9 6 3 29.11.2013

1.7 1,4,5Non delivery of the Sir Ludwig Guttmann Centre resulting in financial liability to

Newham CCGSteve Gilvin 20 10 10 0 19.12.2013

2.1 1,2Failing to develop models of integrated care and robust cost and savings

assumptions to support the shift to care out of hospitalScott Hamilton 15 15 10 5 18.12.2013

3.1 1,2,3Failing to embed meaningful patient and public engagement at all levels of the

CCGSatbinder Sanghera 10 10 5 5 19.12.2013

4.1 4Monitoring and planning for the possible impact to CCG from Barts Health financial

performanceChad Whitton 20 10 10 0 18.12.2013

4.2 4 Failure to monitor performance and activity at Barts Health Chad Whitton 15 10 10 0 18.12.2013

4.3 4 Financial management of the CCG Chad Whitton 16 8 4 4 18.12.2013

4.4 4Transfer of a proportion of the specialised commissioning budget from NCCG to

NHS EnglandScott Hamilton 20 10 10 0 23.12.2013

5.1 5 Failing to build appropriate capacity and support for Primary Care Jane Lindo 12 12 4 8 29.11.2013

5.2 5,6 Staff skills and competencies within the CCG Chetan Vyas 16 8 4 4 22.11.2103

5.3 5,6 Board skills and competencies within NCCG Chetan Vyas 12 8 8 0 22.11.2013

5.4 4,5Failure to develop practices as the "power house" of commissioning through

development of Clusters as CommissionersMargaret Chirgwin 12 16 8 8 19.12.2013

5.5 5Failing to develop new and functional Extended Primary Care Providers/Shared

Services ProvidersMargaret Chirgwin 12 8 8 0 19.12.2013

6.2 6 NCCG is underpreared for its role in emergency planning procedures Satbinder Sanghera 12 8 2 6 19.12.2013

6.3 6 Information Governance arrangements for NCCG are in an undeveloped state. Satbinder Sanghera 15 9 3 6 19.12.2103

Risks last reviewed: December 2013 (for January 2014 update to Newham CCG Board)

6

3.2 Risk Area 1- To reduce health inequalities, improve access and reduce variation

Internal External Control Assurance

Risk 1.1. Failure to deliver QIPP Plans within target: Date Risk last reviewed: 23-12-2013

Risk DescriptionRisk Lead

1.1 1,2,4,5

Proposed Actions

Target

Risk

Rating

Assurances GapsRisk

Ref

Linked

to Risk

Areas

Initial

Risk

Rating

Controls

Current

Risk

Rating

Director of

Delivery

(Scott

Hamilton)

No formal

process (i.e.

threshold) in

place for

exception

reporting to

Board as

trackers are

reviewed in

the context of

individuals

schemes (it is

expected that

this would be

picked up

through

Quality /

Executive

Committees

and reported

to Board via

special

discussion

paper as and

when

required)

Failure to deliver QIPP

plans could result in:

- A reduced ability to

deliver local service

improvements for

patients (this year and

beyond)

- An increase in the

likelihood of

performance

management

measures from NHS

England

- Adverse media

coverage

- Failure to meet

national QIPP financial

targets and a

deterioration in the

CCG financial position

which impact the

CCG's ability to

implement service re-

design and invest to

save initiatives to

support

improvements in

commissioned care

and the shift in care

out of hospital

- Risk of arbitration

remins unitl actute

contract is signed

between CCG and

Barts.

Seve

re (

5)

x P

oss

ible

(3

) =

Hig

h R

isk

(15

)

Programme Boards

(*Commissioning

Committees from Aug 2013)

have responsibil ity for

managing/monitoring QIPP

schemes with oversight from

Quality and Delivery PG and

Executive Committee

- QIPP trackers developed

for each initiative to monitor

progress against objective -

led by Carl Edmonds for CSU

and Scott Hamilton for CCG

- QIPP trackers are reported

to NCCG Quality Committee

and fed back to CCG Board

as part of Activity and

Finance report

- QIPP trackers also

scrutinised at NCCG

Executive with input from

QIPP leads to report on

mitigations to keep trackers

on target

- Senior management

meeting between CCG and

CSU relating to finance

activity and performance

- Regular monitoring of

shadoww performance

metrics in Barts contrcat

*Upadte Dec 2013 - CCg

activity is not above plan

and in l ine with forecase

basline projection.

- Terms of

reference,

agendas,

minutes of

Commissioning

Committee

meetings, Q&D

PB and CCG

Executive

Committee (for

oversight)

demonstrate

CCG focus on

delivery

- Service level

agreement

between NCCG

and NEL CSU

demonstrates

CSU support in

development

and monitoring

of QIPP

initiatives

- management

leads are in post

working with

CSU teams (e.g.

Borough Team

and Health

Intelligence) to

ensure delivery

within financial

envelope.M

ajo

r (4

) x

Un

like

ly (

2)

= M

ed

ium

Ris

k (8

)

- McKinsey

Consulting were

commissioned

by NHS England

to undertake a

review and

report on the

robustness of

NCCG QIPP Plans

and identify

scope for further

initiatives and

savings.

Actions completed

- QIPP business cases template

amended to include a scoring matrix

to asses Qipps against key strategic

priorities, PPE engagement and

clinical governance

- Executive Committee has overall

remit (following CCG Governance re-

structure) for receiving monthly

reports on Qipps from committees and

transformation programmes. reports

are RAG rated to allow exceptions

reporting of QIPPs to monitor

projected under delivery. Executive

provide support and guidance to

committees as QIPP owners and can

determine escalation to Board on

exceptions basis.

- Delivery Improvement Unit (DIU)

commissioned on a short term basis

to provide support on recovering the

QIPP position on Virtual Ward acute

elderly rehab beds

- Other key QIPP risk is Barts

Productivity. Both this and VW QUIPP

are being actively managed as

standing agenda items at CCG Acute

Commissioning Committee.

Furthermore, CSU team have been

requested to shadow monitor

productivity metrics in Barts contract

to mitigate against risk of over

performance against reported activity

levels

- AQP services tender completed

internally (October 2013)

- Strenghtening of performance

management metrics for acute and

community contracts with the

expectation 2014/15 will deliver full

value QIPP

- Coding challange issued on Q1 and

Q2 elederly rehab activity with an

expectation to recover a portion of

cost related to incorrectly coded

activity

- NHS England

sign-off of

CCG QIPP

initiatives by

March 2013

- QIPP tracker

regularly

reviewed by

SMT

- Prepare and submit

detailed QIPP plans with

a focus on low level

implementation for

2013/14/15/16.

- Revise QIPP plans to

ensure they contain

high level strategic

intentions and delivery

plans until 2014-15

*Deadline 8th

November for

submission of

commissioning

intentions and 2014/14

QIPP plans in draft form.

Qipps to go to Board on

13 Nov for review. Any

remaining amber to go

to Board Development

on 28 Nov. Full business

cases for approved

qipps to be finalised by

18 December for final

sign-off in January 2014.

- Focus on stakeholder

and PPE strategy to

ensure patients and

public are effectively

engaged in the detail of

QIPP initiatives

Maj

or

(4)

x U

nlik

ely

(2

) =

Me

diu

m R

isk

(8)

7


Proposed ActionsRisk

Ref

Linked

to Risk

Areas

Risk Lead Risk Description

Initial

Risk

Rating

Detailed

remedial

process to be

identified.

N/A

ControlsAssurances Current

Risk

Rating

Gaps

Internal audit review of

QIPP - results to be

reviewed and process

adjusted to reflect

recommendations.

Development of

remedial process to be

agreed by Quality

Committee and

Executive Committee.

Development of source

and apps financial

model to determine

2014/15 and 2015/16

QIPP requirements.

Development of

detailed plan for QIPP

identification, scheme

development and risk

rating as integral part of

CSP planning.

Internal audit review of

current Qipps completed

- All Qipps to be reviewed

by finance team to provide

assurance on data and

finance projections.

- Business case template

updated to include

requirement for full costs

and savings breakdown

- CCG commissioning

intentions and scoping

documents developed

(October 2013) l inked to

each of the CCGs

commissioning

committees.

- Full review of all business

cases by NCCG Executive in

December 2013. CCG has

received 2014/15 financial

allocation and expectation

that final review and sign-

off of approved QIPP

business cases by NCCG

Board in January 2014 will

be supported by further

refinement to business

cases to target savings

towards efficiencies and

value spend

- The Integrated care team

have undertaken a deep

dive into all acute activity

to further refine business

case specifications to

ensure targets are

deliverable and

quantifiable based upon

available data and activity

Actions completed

Target

Risk

Rating

Risk 1.2 Failure to develop future QIPP plans appropriate to the evolving needs of the CCG in a

timely and robust mannerDate risk last reviewed: 23-12-2013

1.2 1,2,4,5 Director of

Delivery

(Scott

Hamilton)

Failing to develop

future QIPP plans in a

timely and/or robust

manner could result

in:

- Failure to reach

savings targets due to

inaccuracies in

underlying savings

assumptions

- Reputational damage

to CCG

- The possibility of

performance

measures

Maj

or

(4)

x P

oss

ible

(3

) =

Me

diu

m R

isk

(12

)

- 13/14 QIPP process fully

mapped with QIPP

identified, Lead Senior

Officers appointed, risk

assessed plans and KPIs,

and summarised in

trackers.

- Trackers updated and

reviewed monthly at

H6Executive Committee.

- Outcomes and QIPP

progress reported

monthly to Board.

- Quarterly QIPP review

meetings with input form

CCG QIPP leads, finance

and CSU to look in-depth

at in-year delivery of

QIPP to date, forward

assessment for 2014/15

with assessment of need

to carry over QIPP plans +

gap identification for

additional savings

requirements (Outputs

form QIPP review

meetings to be cascaded

through CCG Practice

Member Council and

clusters in parallel with

14/15 commissioning

round

Monthly update

and review of

trackers inc

financial and KPI

delivery.

Monthly review

by Executive

Committee.

Monthly update

in A&F report to

Board. Remedial

process

available to

ensure targets

are met. On-

going review to

identify further

QIPP. 14/15

target and early

development

programme core

to CSP.

Maj

or

(4)

x U

nlik

ely

(2

) =

Me

diu

m R

isk

(8)

QIPP identified

at scheme level

and risk rated in

Operation Plan

financial

template.

Monthly report

to NHSE.

McKinsey

assessment

provided to CCG

and NHSE and

NHSE assurance

provided

through a deep

dive assessment

in July 2013.

Maj

or

(4)

x P

oss

ible

(3

) =

Me

diu

m R

isk

(12

)

8


GapsProposed Actions

Risk

Ref

Linked

to Risk

Areas


Initial

Risk

Rating

WELC POD

meeting every

two weeks to

review

performance

- Monthly CSU

Executive

Meeting for

escalation

Maj

or

(4)

x U

nlik

ely

(2

) =

Me

diu

m R

isk

(8)


Risk

Rating

- Finalise KPIs

for CSU

including local

Newham KPIs

- Establish a

CCG network

for

performance

management

of CSU

- Develop

contingency

plans for

alternative

commissionin

g support

arrangements

- Embed CSU

into the CCG

governance

structure

- NELCSU have provided

service l ine costing of SLA

to NCCG. CCG have

requested further detail in

terms of in-depth

breakdown within service

l ines

- Agreement reached to

establish a single CSU team

to focus on Barts health for

WELC CCGs, to be based at

WHK

- CCG review of CSU service

requirements continuing, to

be finalised by January

2014 for April 2014

contract negotiations

- Co-flow contract

management database tool

developed to support

contract management from

a financial and

procurement standpoint

- Exercise being undertaken

to look at redeveloping CSU

roles in terms of

accountability and

responsibil ity for NCCG

facing CSU staff - i .e.

working relationships and

reporting structures

Target

Risk

Rating

Actions completed

Risk 1.3 NEL CSU ability to deliver on contracted services due to capability or capacity Date risk last reviewed: 23-12-2013

1.3 1,2 Director of

Delivery

(Scott

Hamilton)

NEL CSU failing in

capability/capacity to

deliver on contracted

services could result

in:

- the increased

likelihood of failure to

deliver CCG strategic

objectives, including:

- Delivering QIPP plans

on time and on target

- Monitoring and

resolution of quality

issues with service

providers

Seve

re (

5)

x Li

kely

(4

) =

Hig

h R

isk

(20

)

- Documented

process for

escalation and

contract levers

to manage

performance

- Market test exercise to be

undertaken. Seek to secure

support in negotiation for

improvement in the quality

of services delivered

- Service l ine price l ist from

CSU

- Options under discussion

for the creation of a multi-

disciplinary (MDT) team at

WHK to specifically focus

on the detail of the Barts

Health contract.* Dec 2013

update: From 2nd January a

CSU Barts Team - funded by

the WELC Collaborative

CCGs will be fully located

at WHK to work specifically

on the Barts Contract

- There will also be another

specialist team based at

WHK to focus on the detail

of all WELC non acute

contracts

- Intention to shift

identified resources to be

managed in-house by CCG

from April 2014 to

strengthen direct oversight

and improve local control

over delivery

Seve

re (

5)

x R

are

(1

) =

Low

Ris

k (5

)

- Monthly SLA review

meetings between

Senior CCG and CSU

teams

- Quarterly review

meeting with CSU Chief

Executive

- Annual review to test

services provided under

SLA are fit for purpose

with marketing testing

- SLA between

NCCG and NEL

CSU sets out

agreed service

areas and

performance

requirements

covered under

the contract

- CSU KPI's and

meeting

schedules

9


Actions completed Target

Risk

Rating

Risk 1.4 Quality of Commissioned Services at Barts Health Date risk last reviewed: 22.11.2013


Risk

Rating


Risk

Ref

Linked

to Risk

Areas


Initial

Risk

Rating

1.4 1,2 Deputy

Director of

Quality

(Chetan

Vyas)

Failure to manage and

effectively monitor

the quality of

commissioned care

providers could result

in:

- Failure to meet

contractual targets

which will negatively

impact upon the

healthcare of the local

population, CCG

finances and

reputation.

- Poor value for money

for the CCG and the

taxpayer

- Potential risk in

falling to adequately

identify, monitor and

manage quality

performance issues

which could result in

unacceptable

standards of care and

the possibility of

serious incidents

occurring

Seve

re (

5)

x P

oss

ible

(3

) =

Hig

h R

isk

(15

)

• Barts Health CQRM and

SPR meetings which

include trend analysis

and assurance reports

across key quality

indicators (plus CAG

specific presentations on

a rolling basis)

• WELC POD Quality

Leads meetings to

commence in July 13

• Quality Leads of WELC

CCGs routinely share

information and

intelligence regarding

Barts Health

• CSU Quality and

Contracting Team

working with DD of

Quality

• Refreshed Amber Alerts

mechanism rolled out

across Member Practices

July 2013

• CCG Quality and

Delivery Programme

Board (*Quality

Committee from August

2013) where quality of

services at Barts Health is

discussed

- ToRs in place

for routine

meetings

- Agenda and

papers for 1st

Quality Leads

meeting

- Amber Alerts

received and

responded to by

Barts Health

- Quality reports

that indicate the

quality of

services at Barts

Health

- Minutes from

Quality and

Delivery

Programme

Board (*Quality

Committee from

August 2013)

Seve

re (

5)

x R

are

(1

) =

Low

Ris

k (5

)

- SLA with CSU to

support contract

and

performance

monitoring

arrangements

- Agendas and

minutes of Barts

health CQRM

and SPR

meetings

Seve

re (

5)

x U

nlik

ely

(2

) =

Me

diu

m R

isk

(10

)

- Embedded

quality

monitoring of

Barts Health

- Robust

recovery

action plans

from provider

to remedy

quality

concerns

- CCG capacity

to fully

understand

the quality of

services across

Barts Health

upon

commenceme

nt of Lead

Commissioner

Role

- None

identified at

present

• Review quality

management processes

with CSU (on-going)

• Agree ways of working

with WELC CCG Quality

Leads

• Review Amber Alerts

process after one

quarter and provide a

report to the Quality

and Delivery

Programme Board and

CCG Board

- NCCG Board

Development session

on 25/07 with specific

focus on Barts quality,

performance and

finance

- Barts Health Summit

meeting scheduled for

02/08 to involve key

stakeholders: TDA,

WELC CCGs, NHSE and

NELCSU

• Explore the possibility

of securing extra

resources to support the

quality management of

Barts Health upon

commencement of Lead

Commissioner role

- Formal monthly WELC

CGGs Quality leads

meeting/Serious

Incident panel

established to focus on

collaborative ways of

working in relation to

Barts Health Quality

issues.

- NCCG Board

Development session

was held with a specific

focus on addressing

Barts quality,

performance and

finance issues

- Barts Health CIP

programmes under on-

going review to asses

quality impacts

- Barts Health Summit

took place with relevant

stakeholders

- Continuous review of

amber alerts process

with monthly analysis

undertaken and report

to Quality

Commissioning

Committee and NCCG

Board. Assurance is

sought form providers

that required services

improvements have

10



Risk

Ref

Linked

to Risk

Areas


Initial

Risk

Rating

- Joint agenda

and work

programme

agreed for

Partnerships

Committee,

Health and

Wellbeing and

Integrated Care

Mo

de

rate

(3

) x

Un

like

ly (

2)

= M

ed

ium

Ris

k (6

)


Risk

Rating

- Awaiting

NHS England

monitoring /

performance

management

process for

novated

services such

as Health

Visiting,

School

Nursing etc.

- Newham CCG Comms and

Engagement Strategy

approved by Board,

December 2013

- H&W Board wi l l focus on

what CCG and LBN are doing

jointly around prevention

- Clari fication on LBN CCG

Board representation: LBN

wi l l have a voting rep on

CCG Board and CCG Chair

wi l l be Vice-Chair of Health

and Wel lbeing Board

subject to further review

- Agreed approach

developed on partnership

working i ssues i .e. jointly

owned CCG/LBN strategies

and plans . Jointly owned

s trategies wi l l be

discussed fi rs t at CCG

Partnerships

Commiss ioning Committee

to agree approach before

taking to Health and

Wel lbeing Board.

- Dr Lizzie Goodyear and

Satbinder Sanghera

confi rmed as CCG reps on

LBN Chi ldren's Trust Board.

Sub Boards(LBN

lead)focussed on therapies

and chi ldren's

commiss ioning have been

establ ished with NCCG

cl inica l representation

Target

Risk

Rating

Actions completed

Risk 1.5 Failure to establish and/or maintain effective engagement and collaborative working

arrangements with the local authorityDate risk last reviewed: 19-12-2013

1.5 1,2 Head of

Governance

and

Engagement

(Satbinder

Sanghera)

Failure to establish

effective engagement

and collaborative

working with the Local

Authority could result

in:

- Reputational damage

and/or increased

complaints/ adverse

media coverage

- Duplication of effort

e.g. around jointly

commissioned care

areas

- Services which fail to

meet population

needs

- Poor value for money

through missed

opportunities

Mo

de

rate

(5

) x

Po

ssib

le (

3)

= M

ed

ium

Ris

k (9

)

- None

identified at

present

- Development of a

communications and

engagement strategy to

highlight the range of

communication

mediums used to

engage and collaborate

with stakeholders.

- Further clarification on

the role of LBN

representation on CCG

Board and the working

partnership on the

Health and Wellbeing

Board.

- Identify CCG

representation on other

LBN Partnership Boards

such as Children's Trust

- NCCG and LBN to

prepare a joint strategy

on priorities relating to

Children's services.

Mo

de

rate

(3

) x

Rar

e (

1)

= Lo

w R

isk

(3)

- Joint Commissioning

Programme Board

(*Partnership

Commissioning

Committee from August

2013) meets monthly

with LA input with a focus

on jointly commissioned

areas of care.

- Monthly joint ops

meeting with LA to

discuss areas of

commonality to ensure

VFM and to identify

further joint working

opportunities

-Section 75/256 contracts

agreed with LBN

- Health and Well Being

Board

- Integrated Care

Transformation

Programme

- Work plan and

membership of

Partnership

Commissioning

Committee

established with

LBN Senior Team

and CCG GP

Chair.

- S75/256

agreements and

MOUs in place

for joint working

and joint

services to

continue.

- H&W strategy

and

implementation

plan that both

organisations

have agreed and

are jointly

implementing

- Clarity on

governance

arrangements

for the

Integrated Care

Transformation

Board

11


- One

substantive

post in CCG

structure

currently

vacant that is

not out to

advert

(Performance/

QIPP lead).

This post is

currently

being filled on

an interim

basis.

- PDPs for all CCG staff

completed and signed

off by relevant line

managers September

2013

- CCG Head of

Performance and

Information post

appointed as at July

2013

- CCG Governance and IT

post appointed as at

November 2013

- CCG vacant posts for:

Committee Officer x2,

Board Secretary and

Communications

Manager out to advert

November 20913 with

expectation that all

substantive posts be

filled by January 2014.

Target

Risk

Rating

Actions completed

Risk 1.6 Failure to recruit develop and retain key staff Date risk last reviewed: 29-11-2013

1.6 1,2,4,5,6 Chief

Executive

Officer

(Steve Gilvin)

Failure to recruit and

or retain key staff

across the

organisation could

result in:

- loss of organisation

memory

- Increased difficulty

in monitoring and

meeting QIPP targets

and strategic

objectives

- Negative financial

implications as a result

of increased

recruitment costs

Seve

re (

5)

x Li

kely

(4

) =

Hig

h R

isk

(20

)

- All staff to undertake

an appraisal process

with PDPs to support

career and skills

development

- Initial appraisals and

agreed 2013/14 PDPs for

all staff to be finalised

and signed-off by end

September 2013

Min

or

(2)

x P

oss

ible

(3

) =

Me

diu

m R

isk

(6)

- Nearly all permanent

posts now recruited to

- External recruitment

being undertaken if no

suitable candidates in

internal redeployment

pool

- Temporary staff

recruited if business

need is agreed

- Training and

skills

development

programme in

place for all staff

to support

succession

planning and the

development of

future

organisational

leaders.

- NEL CSU

support for

temporary/short

term

recruitment and

substantive

recruitment

processes

Mo

de

rate

(3

) x

Po

ssib

le (

3)

= M

ed

ium

Ris

k (9

)


Risk

Rating


Risk

Ref

Linked

to Risk

Areas


Initial

Risk

Rating

12


Risk 1.7 Non delivery of the Sir Ludwig Guttmann Centre resulting in financial liability to

Newham CCGDate risk last reviewed: 19.12.13

Risk

Ref

Linked

to Risk

Areas


Initial

Risk

Rating


Risk

Rating

GapsProposed Actions Actions completed

Target

Risk

Rating

1.7 1,4,5 Steve Gilvin,

Accountable

Officer

Key risks to non

delivery are as

follows:

- Expect limited

APMS/Pharmacy

service start in early

December, possible

temporary service

sooner.

- Risk that NCCG will

need to pick up vacant

premises cost

projected £360k for

remainder of 2013/14

and £882k for 2014/15

if building remains

unoccupied

- Contracts remain

unsigned with acute

and community

providers (earliest

projected occupation

from January 2014)

- To date no signed

provider service

contracts

Seve

re (

5)

x Li

kely

(4

) =

Hig

h R

isk

(20

)

- CCG has a managed

programme with

individual lines of

accountability around

negotiations with CCG

commissioned providers

- Monthly SLG

programme group with

inputs and updates from

all leads and monthly

reporting to Newham

CCG Board. - CCG

Senior Management

Team is meeting monthly

with NHSE London

leaders. This includes

assurance discussions

around SLG delivery.

Temporary contract

agreed between NHSE

and Hurley - interim

service working well.

Aiming for full contract

signature on 1 Feb 2014.

Proposed temporary

pharmacy service will

not be provided - aiming

for full service from

mid/late March 2014. To

mitigate any short-term

risks, arrangements

have been made with

some other local

pharmacies with whom

the Hurley Group will co-

operate in the interim.

Additional building fit

out work now

completed. Large

quantity of furniture,

fittings and equipment

starting to be delivered

from storage and

assembled.

Internal/external

signage, room

numbering and graphics

in process of being

installed. Remaining ICT

installations underway

to enable SLG building

Seve

re (

5)

x U

nlik

ely

(2

) =

Me

diu

m R

isk

(10

)

Positive

commitment

from main

commissioning

organisations -

CCG, NHSE,

NHSPS and

providers (e.g.

Barts, ELFT,

Homerton,

Moorfields) to

deliver agreed

range of

services, with

mobilisation

plans in

advanced stage

of development

CCG liability for

vacant premises

cost is time-

limited and will

expire on 1st

April 2015 when

this

responsibility is

transferred to

NHS Property

Services

Seve

re (

5)

x U

nlik

ely

(2

) =

Me

diu

m R

isk

(10

)

Significant

control gaps in

that NCCG has

no direct

control over

transfer of

lease from

ODA to NHSPS

and timeline

around APMS/

Pharmacy

procurements

CCG working

with NHSPS,

NHSE, ODA

and partners

to expedite

procurements

and service

transfers as

soon as

possible

SLG Programme Group

has individual leads

working to secure the

final service

configurations. Contract

variation details being

prepared for services

transferring from Barts,

ELFT, Homerton and

Moorfields. Planned

that Homerton service

transfer first as part of

phased series of moves

from Feb 2014 onwards.

SLG Team now in

process of handing over

work to CCG by end of

Jan 2014.

13

3.3 Risk Area 2 - To develop Integrated Care, in particular to support improved management of long term

conditions


Risk 2.1. Failing to develop models of integrated care and robust cost and savings assumptions to

support the shift of care out of hospitalDate risk last reviewed: 19.12.2103


Risk

Rating

GapsActions completed

Risk

Ref

Linked

to Risk

Areas


Initial

Risk

Rating

- Oct 2013 - LBN

Transformation Manager

in post

- Dec 2023 - P/T Public

Health analyst recruited

- Project lead for self-

care management

recruited

Proposed Actions

Target

Risk

Rating

2.1 1,2 Scott

Hamilton,

Integrated

Care

Programme

Director

- Increased activity

levels in acute and

increased cost under

PBR arrangements

- Fragmentation of

care pathways and a

lack of joined up

services

- Lack of clarity around

national IG guidelines

for risk stratification

and integrated care

could impede linking

of patient data across

providers

- Failure to work

collaboratively with

providers to ensure

flows of money

effectively follow the

patient journey could

lead to cost

duplication, i.e. an

increase in costs for

community provision

without subsequent

reduction in acute

capacity

- Failure to properly

evaluate IC model may

lead to negative

impact resulting from

investment/dis-

investment decisions

Seve

re (

5)

x P

oss

ible

(3

) =

Hig

h R

isk

(15

)

3 dedicated integrated

care work streams

established: -

1. Rapid Response

2. Discharge support -

including Mental Health

liaison and discharge

support (RAID model)

3. Care Coordination

- CCG and local authority

leads for IC appointed to

lead development of IC

in Newham

- WELC wide Evaluation

group set up to look at

options available for

evaluation and

monitoring of IC

programme

- IC Programme

Board (* IC

Transformation

Board from August

2013) and delivery

work streams (ToR,

Minutes)

- WELC Integrated

Care Board to look

at elements of IC

that can be

effectively

developed and

delivered across

WELC

- NCCG IC

Programme Board

receives regular

reports and

integrates with

WELC IC Board. _

Monthly reports

from NCCG IC

Transformation

Board to NCCG

Board to track and

monitor progress

of the development

of Integrated Care

- Weekly Project

Team meetings are

in place to ensure

progress against

milestones

monitored, issues

and risks captured

/ escalated later.

UC streamer

model supports

appropriate A&E

admissions

avoidance

- Consultant

input into

development of

raid response

and supported

discharge

models to

ensure an

agreed approach

across all

stakeholders

involved in the

delivery of

integrated care.

Seve

re (

5)

x P

oss

ible

(3

) =

Hig

h R

isk

(15

)

Specification

for rapid

response

model to be

finalise

- work to

identify shift

in finance

flows to

follow patient

journey

remains

incomplete

none at

present

Work closely with

providers to develop

appropriate

reimbursements models

aimed at ensuring the

money follows the patients

and where appropriate

releasing capacity savings

in acute (recognition that

savings may not be only

financial but also

possibil ity in freeing up

Consultant time to provide

step down support to

Community and Primary

Care).

- Ensure full engagement in

IC programme for all

stakeholders at a high level

to ensure coordinated buy-

in and joined up approach

- Pilots for discharge

support and care

coordination expected to

go live in 3 GP practice

clusters in January 2014.

- Continue to monitor

progress of work streams

against required

timescales for delivery

(broadly on target as at

December 2013)

- To include a standard

item on the IC Committee

for Stakeholders to inform

the IC team about how they

have been cascading key

messages within their

practices, to patients and

the wider public, to help

identify work to be done

and how practices can be

best supported.

Seve

re (

5)

x U

nlik

ely

(2

) =

Me

diu

m R

isk

(10

)

14

3.4 Risk Area 3 - To ensure robust patient and public engagement is embedded in the operations of Newham

CCG and at all stages of the commissioning cycle


- Appointment

of Board Lay-

Member

responsible for

PPE

- Head of

Governance and

Engagement and

PPE Manager

posts in place

- PPE Strategy

and action plan-

Complaints

monitoring

process adds

additional level

of assurance

around capturing

patient feedback

- PPE Manager to

build capacity of

CCG staff to

deliver effective

PPE and embed

across all levels

of the CCG

- CCG website

- PPE support

commissioned

through Forum

for Health and

Wellbeing

- Patient forums

and PPGs act as

mediums to

capture

feedback

Risk

Ref

Linked

to Risk

Areas


Initial

Risk

Rating

ControlsAssurances

3.1 1,2,3 Head of

Governance

and

Engagement

(Satbinder

Sanghera)

Failure to implement

meaningful PPE

strategies could result

in:

1. CCG unable to

deliver on Section 242

of the NHS Act 2006,

which mandates NHS

organisations to

involve patients in the

planning,

development of

proposals and

commissioning of

healthcare services.

2. Reputational

damage and / or

increased complaints /

adverse media

coverage

3. Services which fail

to meet population

needs (and

consequently offer

poor value)

Seve

re (

5)

x U

nlik

ely

(2

) =

Me

diu

m R

isk

(10

)

Established PPE

platforms:

- Newham Patient Forum,

Community Reference

Group, Health and Social

Care Network and PPGs

Seve

re (

5)

x U

nlik

ely

(2

) =

Me

diu

m R

isk

(10

)

-

Development

of a CCG

Comms. and

Engagement

Strategy

- More detail

required

around

processes in

place to

monitor the

effectiveness

of patient

engagement

activities

- PPE Manager

leading on

engagement

strategy with

support from

CSU on

comms.

element

Development of a

communications and

engagement strategy

and action plan to build

on existing engagement

platforms and develop

new platforms to

increase borough wide

participation and

strengthen inclusion of

hard to reach groups

- Conduct a scoping

exercise to potentially

further develop the role

of PPGs at cluster level

- Develop a forward plan

to track and coordinate

PPE needs across the

CCG and ensure the CCG

is delivering on its duty

to involve

- Increase promotion of

how to get people

involved through

community outreach

and CCG communication

channels

Seve

re (

5)

x R

are

(1

) =

Low

Ris

k (5

)

Comms and Engagement

strategy approved by

NCCG Board, December

2013.

- Requirement to

develop forward plan to

track and coordinate PPE

needs has been

included as mandatory

in all Committee and

Transformation

Programme ToRs to

achieve consistency of

approach throughout

the CCG (majority have

been developed as at

December 2013)

- CCG run mini-

community launches

October -Nov 2013

focussing at connecting

with different parts of

the community: Carers,

Vulnerable Homeless,

Young People and a

Locality event.

- NCCG Twitter account

launched Oct 2013 to

improve PPE comms

channels

Risk 3.1 Failing to embed meaningful and measurable patient engagement at all levels of the CCG

structure and throughout the commissioning cycleDate risk last reviewed: 19-12-2013

Proposed Actions

Target

Risk

Rating

Current

Risk

Rating


15

3.5 Risk Area 4 -To ensure that Newham CCG achieves robust financial stability and balance to supporting

effective working and implementation of our plans


Target

Risk

Rating

Risk 4.1 Monitoring and planning for the possible impact to NCCG arising from the financial

performance of Barts HealthDate risk last reviewed: 18.12.2013

4.1 4 Chief Finance

Officer

(Chad Whitton)

Failure to monitor and

plan for the impact on

the CCG arising from

the financial

performance at Barts

Health could result in:

- Reduced ability to

plan for/shift care out

of hospital

- reduction in local

acute services

Requirements for

allocation of

contingency funding

to support Barts

Health which could

reduce CCGs

bargaining power in

other provider

contract negotiations

Seve

re (

5)

x :L

ike

ly (

4)

= H

igh

Ris

k (2

0)

- Co-ordination

of monitoring

and control -

triangulation

with Specialised

commissioning

activity

- Clarification of

commitment to

WELC CCGs

through risk

share on impact

of turnaround

- Input and

agreement

required with

Commissioning

Lead to Barts

Health

Turnaround Plan

- Board development

session to focus on

mitigation strategies for

Barts financial risk.

Development of BH

Productivity

Improvement Plan

- CSU dedicated team to

monitor contract. *From

January 2014

supplemented by Barts

Collaborative CCGs

appointed BH

contracting team.

- Barts Turnaround

programme in progress.

CCG have been sighted

into turnaround

programme

- NCCG have reviewed

BH Turnaround

programme from a

quality perspective and

mechanisms are in place

to raise objections if

CCG are not satisfied

from quality assurance

perspective. NCCG have

no direct control over

financial plans as TDA

has overall

responsibility for Barts

financial position.

Seve

re (

5)

x U

nlik

ely

(2

) =

Me

diu

m R

isk

(10

)

- WELC Mgt and

Collaborative

Commissioning

Governance Structure

overseeing

implementation of

contract including in-

depth analytics, claim

management.

- CCG Acute

Commissioning

Committee overseeing

CCG specific analysis.

- Dedicated CCG/CSU

capacity to ensure

effective monitoring and

contract control

- Updates on Barts

financial performance

picked up through

discussions with

collaborative leads

through the WELC Clinical

Strategy Groups

- Barts Health provide an

update on the CIP

programme to the WELC

Clinical Strategy group

attended by COs, Chair's,

and CFOs of all WELC

CCGs - pertinent updates

will be fed back via

reporting to NCCG Board

CCG Acute

Commissioning

Committee

*From January

2014:

Establishment of

a dedicated

Barts Health

Contracting

Team including a

Director and

Senior Finance

Lead for Barts

Health

Commissioning,

jointly funded

by CCGs in the

Barts

Collaborative

agreement to

work with the

NELCSU Barts

MDT Team

- CEO input to

regular meeting

with TDA and

Monitor around

Barts

Turnaround.

WELC Mgt and

Collaborative

review, Monthly

contract

meetings,

monitoring

against

projected

activity including

agreed BH

Productivity

Improvement

Plan

- CCG review of

Barts CIP plan to

sign-off that CCG

are happy there

are no material

quality

implications as a

result of

proposed

savings

Seve

re (

5)

x u

nlik

ely

(2

) =

Me

diu

m R

isk

(10

)

- In depth

analysis of Barts

Health Cost

Improvement

Programme (CIP)

- Formal access

and input to

Barts Health

Turnaround and

other associated

plans

- Timely access

to Barts Health

financial

reporting


Risk

Rating


Risk

Ref

Linked

to Risk

Areas


Initial

Risk

Rating

16


- NCCG

Informatics /

information

analyst post

remains

vacant -

*Recruited

July 2013

- Emerging

national IG

regulations

may prohibit

CCGs from

accessing PID

data around

financial

activity which

could prevent

clinical

challenge

- Activity levels

reviewed and broadly in

line with plan based on

month 6 outturn

- Dedicated analytics

resource available via

dedicated BH

Contracting team form

January 2014 (and also

via CCG Head or

Performance and

Information)

Target

Risk

Rating

Actions completed

Risk 4.2 Failure to monitor performance and activity levels at Barts Health Date risk last reviewed: 18-12-2013

4.2 4 Chief Finance

Officer

(Chad

Whitton)

Failure to monitor

performance and

activity at Barts Health

could result in:

- Increased risk of over

performance due to

loss of 5% cap and

collar arrangement

and move to PBR

contract for 2013/14

with associate risk of

uplift in contract

value.

- Reduced bargaining

position in contract

negotiations with

other providers

- Reduction in the

CCG's budget to

support the shift in

care out of hospital

and integrated care

work streams

- Disaggregation of

specialised

commissioned

services could lead to

duplication of charge

Seve

re (

5)

x P

oss

ible

(3

) =

Hig

h R

isk

(15

)

- Strong well

established

collaborative

working

arrangements

with other

significant

commissioners

(WELC)

- Robust

alignment with

specialised

commissioning

- Development of

demand management

targets at cluster level

- Triangulation with

specialised

commissioning contract

and monitoring teams

- Continuation of regular

update via weekly

CFO/WELC Collaborative

Telcons with Lead

Commissioner CFO

- Triangulation with

TDA/NHSE on

turnaround to ensure

limited liability

- Recruitment of

informatics/analytics

capacity to work with

CSU to enhance

effectiveness of

monitoring

Seve

re (

5)

x U

nlik

ely

(2

) =

Me

diu

m R

isk

(10

)

- Focus on demand

management initiatives

at cluster level

- Contractual levers

including KPIs and

CQUINS

- Monthly CQRM and SPR

meetings to review

quality and performance

issues at the Trust

- Urgent Care re-

procurement and service

re-design to support the

management of patients

in non acute setting and

appropriate streaming of

patients to non-urgent

community care settings

- Development of virtual

ward to reduce

admissions and LOS

- Clinical engagement in

Barts Health productivity

agreement

- Regular update via

weekly CFO/WELC

Collaborative Telcons

with Lead Commissioner

CFO

- Minutes of

cluster meetings

to demonstrate

work around

demand

management

- Clinical

engagement

into CQRM and

SPR processes

- Monthly high

level service

review meetings

between NCCG

and Barts Health

- *From January

2014:

Establishment of

a dedicated

Barts Health

Contracting

Team including a

Director and

Senior Finance

Lead for Barts

Health

Commissioning,

jointly funded

by CCGs in the

Barts

Collaborative

agreement to

work with the

NELCSU Barts

MDT Team

SLA with CSU for

contract and

finance activity

monitoring

arrangements

- NHS England

performance

management

processes would

ensure that a

development

plan is initiated

upon major

slippages

- Tripartite

formal

agreement

between NHS

London, DH and

Barts Health (on

Merger FBC and

Barts CIP)

Seve

re (

5)

x U

nlik

ely

(2

) =

Me

diu

m R

isk

(10

)


Risk

Rating


Risk

Ref

Linked

to Risk

Areas


Initial

Risk

Rating

17


- Review of

standing

financial

instructions

and scheme of

delegation

- Final Board

approved

Procurement

strategy

- Internal audit

completed in October

2013 with no significant

concerns raised

- Prime financial policies

agreed and finalised

subject to ratification at

January 2014 audit

committee

- Budget holder scheme

of delegation finalised.

Target

Risk

Rating

Actions completed

Risk 4.3 Financial management of Newham CCG Date risk last reviewed: 18-12-2013

4.3 4 Chief Finance

Officer

(Chad

Whitton)

Failure to plan for a

sustainable financial

future could result in:

- Major impact on the

CCG's ability to deliver

its strategic objectives

and QIPP targets

- Severe impact on

CCG finances and the

likelihood of a

deterioration in the

budget position with

the possibility of a

deficit budget at year

end

- Severe damage to

CCG reputation

- The possibility of

performance

management

measures being

imposed by NHS

England

Maj

or

(4)

x Li

kely

(4

) =

Hig

h R

isk

(16

)

- Final

financial plan

- Scheme of

delegation

- Review of core governance

policies including prime

financial policies in

Sept/Oct 2013 agreed with

NCCG Audit Committee

*Revised policies due to be

submitted to Audit

Committee in January 2013

- Internal audit review

agreed for the following

areas: Continuing Care;

Clinical Governance &

Quality;

Governance Framework -

Phase One & Two;

Budgetary Control,

Financial Reporting &

QIPP;

Commissioning & Contract

Management ;

Contract Monitoring –

Commissioning Support

Unit ;

Payroll & Financial

Feeders;

Risk Management / Board

Assurance Part Two;

Remuneration of Members.

- CCG Procurement sub-

committee working to

finalise procurement

strategy to report to NCCG

Board in February 2014.

Maj

or

(4)

x R

are

(1

) =

Low

Ris

k (4

)

- Finance plan for 2013/14

has a 1% surplus target

and will provide 2% non-

recurrent headroom and

1% contingency, 50% of

which is to cover acute

contracting risk. There

will be a risk reserve of

£2.3 million and plans to

commit the balance of

£3.8m brought forward

12/13 surplus on non-

recurrent pump-priming

initiatives.

- Detailed monthly

reporting to NCCG Board

and Q&D Programme

Board

- Monthly FIMS return to

NHS England

- Substantive

CFO in post

- Documented

NCCG Board

approval of

Financial Plan

- Audit

Committee TOR,

agenda and

minutes

- CCG Board and

Q&D PG minutes

- Financial

reports process

to Board

provides

indicative

position at

ledger close

- CCG

Procurement

group

established as

sub-committee

of CCG Executive

to develop CCG

procurement

strategy

- NHS England

approval of

financial plan as

part of the

authorisation

process

Maj

or

(4)

x U

nlik

ely

(2

) =

Me

diu

m R

isk

(8)


Risk

Rating


Risk

Ref

Linked

to Risk

Areas


Initial

Risk

Rating

18


Deep dive into

the detail of

the main areas

of specialist

commissionin

g to be

undertaken

jointly

between CCG

Informatics

Lead and

NELCSU team.

- Allocation of £12.2m

returned to NCCG in

Sept 2013.

- Inherent risk remains

due to possibility of

another in-year top slice

being taken from CCG

allocation. As a result a

proportion of funds

returned have been

retained in contingency

to mitigate this risk.

- Dec 2013 - no further in-

year risk but potential

remains for 2014/15 risk

based upon 13/14 data

and 14/15 allocations.

This is being mitigated

by continuing scrutiny

and involvement from

CFO around allocations

for specialised

commissioning.

Target

Risk

Rating

Actions completed

Risk 4.4 Transfer of a proportion of the specialised commissioning budget from NCCG to NHS

EnglandDate risk last reviewed: 23-12-2013

4.4 4 Director of

Delivery

(Scott

Hamilton)

There is a risk that the

CCG will not be able to

fully recover funding

transferred pro-rata to

NHS England to enable

the Londonwide costs

of specialised

commissioning to be

met. As a result:

- This could impact the

CCG's ability to reach

acceptable Heads of

Terms with providers

(* though outline HoT

have been agreed

with major Acute and

Community providers

for 2013/14)

Seve

re (

5)

x Li

kely

(4

) =

Hig

h R

isk

(20

)

- Detailed work to be

undertaken by

NCL/NELC CCG in

conjunction with the

CSU contracting team to

monitor and challenge

the contract value of

specialist

commissioning services

transferred to NHS

England

- Capturing and coding

of CCG specialist

commissioning activity

to be established with

activity flows linked to

established pathways

and protocols

- CCG to define and

referral activity and

guidelines for

specialised

commissioning

Seve

re (

5)

x U

nlik

ely

(2

) =

Me

diu

m R

isk

(10

)

- The NCCG Board holds

overall responsibility for

commissioning services

within budget

- Programme Boards

(*Commissioning

Committees from August

2013) hold devolved

budgets for their defined

areas of commissioning

- CCG providers are

engaged through

Programme Boards and

contract negotiation

meetings.

Director of

Delivery holds

overall

responsibility

for acute

commissioning

- A technical

group led by the

London area DoF

and including

CCG

representatives

is working with

the SCG to

ensure CCGs

contributions

are matched to

commitments

throughout the

year with

appropriate

repatriation of

excess funding

Seve

re (

5)

x U

nlik

ely

(2

) =

Me

diu

m R

isk

(10

)


Risk

Rating


Risk

Ref

Linked

to Risk

Areas


Initial

Risk

Rating

19

3.6 Risk Area 5 - To support quality improvements in primary care services to ensure they are fit for

purpose and able to support the shift in care out of hospital


- Statistically

valid analytics

to support

clusters and

practices to

understand

where there is

true quality

variation with

national and

other useful

benchmarks

Development

of the CHN

services

focussed on

supporting

practices and

patients to

avoid

emergency

admissions

(Virtual Ward,

Rapid

Response,

Extended

Primary Care

Team)

- District Nurse Pilot

fully operational in 6

practices covering 6

clusters. Pilot extended

to March 2014.

- First draft of Primary

Care Strategy completed

and Primary Care

Transformation

programme Established

to lead on this.

- Performance

framework established

from October 2013 to

monitor cluster plans

with monthly dashboard

reporting.

- Newham Education

and Training Academy

(NETA) established to

support strategic

development and

training for education

and clinical skills within

primary care from HCA

level up

Target

Risk

Rating

Actions completed

Risk 5.1 Failing to build appropriate capacity and support for the development of Primary Care Date risk last reviewed: 29-11-2013

5.1 5 Deputy

Director of

Delivery

(Jane Lindo)

Failure to build

appropriate skills,

capacity and support

for primary care

providers could result

in:

- Adverse

media/reputational

risk

- An under-resourced

workforce

- Primary Care

Facilities not fit for

purpose

- Lack of capacity to

manage expected

increase in demand

for Primary Care

services as a result in

the planned shift in


-Unnecessary

unscheduled

admissions

- Failure to meet

outcome framework

indicators

Maj

or

(4)

x P

oss

ible

(3

) =

Me

diu

m R

isk

(12

)

- Monthly

cluster reports

Development of a

primary care strategy

that incorporates a

workforce skills and

education mapping

exercise to be

undertaken to identify

gaps and plan

contingencies

Development of a

Performance framework

to monitor cluster plans

Strongly performance

manage CSU data

reporting function. At

present NELIE and other

reports not meeting

basic requirements.

Development of

integrated care

programme including

extended Primary Care

Team to support

practices to keep

patients out of hospital -

extended district nurse

pilot covering 6

practices will become

fully operational end of

September

Maj

or

(4)

x R

are

(2

) =

Low

Ris

k (4

)

- Development of Primary

Care Strategy to include

development of Performance

Management Support to

clusters and practices and

development of future

models of primary care

providers e.g. federated

models/networks.

Development of Cluster

plans to support primary

care targets and demand

management initiatives.

- Prescribing team

supporting practices

- Monthly cluster meeting to

review activity and quality

data and other reports,

discuss ideas, share

concerns and share best

practice between practices

and other clusters

- Monthly cluster leads

meeting to coordinate ideas,

share concerns and share

best practice between

clusters to feed up through

the CCG structure

- educational curriculum

with monthly GP educational

meetings reflecting key

priorities

- Introduction of EMIS web

and training to support use

-Monthly MDTs in place for

Diabetes.

- Each NCCG

cluster has

dedicated

Practice

Facilitator

support

- Project Director

for Primary Care

Strategy

appointed to

lead the

development of

a primary care

strategy for

Newham

- Agendas and

papers from

cluster and

cluster leads

meetings

- Cluster Plans

- Extended hours

schemes help to

support

improved access

- Working

collaboratively

with NHS

England to

identify and

mitigate against

risks in primary

care skills and

capacity gaps

- Working

collaboratively

NBC to ensure

the primary care

role in

prevention is

not reduced or

lost

Maj

or

(4)

x U

nlik

ely

(2

) =

Me

diu

m R

isk

(8)


Risk

Rating


Risk

Ref

Linked

to Risk

Areas


Initial

Risk

Rating

20


- A process has been

implemented via SMT

management leads to

cascade relevant

learning and

development

opportunities to CCG

staff.

- Training needs

assessment captured via

CCG PDP/PDR and

appraisal process - PDPs

finalised for all CCG staff

in October 2013.

Target

Risk

Rating

Actions completed

Risk 5.2 Staff skills and competencies within NCCG Date risk last reviewed: 22.11.2013

5.2 5,6 Deputy

Director of

Quality

(Chetan

Vyas)

Failure to bridge skills

and competency gaps

throughout the

organisation could

lead to:

- Errors or significant

incidents resulting in

financial and/or

reputational loss

- Difficulty with

succession planning

-Failure to deliver

objectives on time and

on-target

Maj

or

(4)

x Li

kely

(4

) =

Hig

h R

isk

(16

)

Analysis of

Gaps to be

undertaken

subsequent to

the

completion of

the Training

Needs

Analysis

- Training Needs

Assessment (TNA) of

CCG staff to understand

their requirements

- Continue Staff

Development sessions

- Roll-out of Personal

Development Review

process to ensure all

staff have objectives

and PDPs

- Initial appraisals and

2013/14 PDPs for all staff

to be finalised and

signed-off by end Sept

2013

- CCG wide staff

development session

planned in January 2014

with a further joint

development session

involving CCG staff and

Newham facing CSU

staff post January 2014.

- Roll-out of Learning

and Development policy

to access CCG funds

- Understand what

learning and

development

opportunities CCG staff

can access via the CSU

Maj

or

(4)

x R

are

(1

) =L

ow

Ris

k (4

)

- Staff Development

Sessions have

commenced

- Staff meetings are being

re-shaped to encourage

collective development

in meetings

- SMT development day

held to develop the SMT

SMT Devt Day

agenda

None identified

at present

Maj

or

(4)

x U

nlik

ely

(2

) =

Me

diu

m R

isk

(8)


Risk

Rating


Risk

Ref

Linked

to Risk

Areas


Initial

Risk

Rating

21


• Board Code of Conduct

to be drafted

• Board Conflicts of

Policy to be reviewed

and amended

• Review of how the

Board has collectively

performed

- Newham CCG COI

policy approved by

Board October 2013

- Newham CCG Board

Code of Conduct policy

approved by Board

October 2013

- Personal Development

review process for all

Board members agreed

and rolled out from

November 2013. Every

NCCG Board member

will have a one to one

PDR meeting with the

CCG Chair with the

outcome of an agreed

PDP plan with on-going

appraisal and

monitoring throughout

the year. Initial PDP

reviews expected to be

completed by January

2014.

Actions completed

Target

Risk

Rating

Risk 5.3 Board skills and competencies within NCCG Date risk last reviewed: 22-11-2013

5.3 5,6 Deputy

Director of

Quality

(Chetan

Vyas)

Failure to bridge skills

and competency gaps

in the Board of NCCG

could lead to:

- Errors or significant

incidents resulting in

financial and/or

reputational loss

- Significant

reputational damage

and/or adverse media

interest

- Difficulty with

succession planning

-Failure to deliver

objectives on time and

on-target

- Potential for

enforced performance

management

conditions from NHSE

Maj

or

(4)

x P

oss

ible

(3

) =

Me

diu

m R

isk

(12

)

- Board Development

Plan in place signed off

via the authorisation

process

- Board Development

schedule in place

- Board

Development

Plan

- Board

Development

Meetings

- Agendas of

Board

Development

Meetings

Maj

or

(4)

x U

nlik

ely

(2

) =

Me

diu

m R

isk

(8)

Maj

or

(4)

x U

nlik

ely

(2

) =

Me

diu

m R

isk

(8)

Review of the

effectiveness

of the Board

Development

Plan to

understand

progress made

by the Board

development


Risk

Rating


Risk

Ref

Linked

to Risk

Areas


Initial

Risk

Rating

22


- Review relevant sections

of the constitution

-Take paper to the Board on

budget allocation formula

to practices and clusters

for 2013/14 for shadow

budget and process for

14/15 budget allocations

-Take paper to the Board on

risk sharing proposals

within and between

clusters

- Take paper to the Board

on how propose to manage

cluster under and over

spends at end of 2013/14

- Agree CCG Management

and finance support

required to develop

clusters as commissioners

(recommend an 8D

supporting 2 clusters +

finance to attend cluster

meetings)

- * Proposed actions above

are contingent upon

approval of Primary Care

Strategy - expected 2014.

- Meeting took place in

November 2013 to take

forward a review into

practice budget

allocations

- Cluster development

working group

established to support

developing clusters as

commissioners and to

review the remit of the

cluster leads group to

ensure it is

appropriately aligned

with the objectives of

the primary care

strategy

Actions completed

Target

Risk

Rating

5.4 Failure to develop practices as the "power house" of GP commissioning through

development of Clusters as CommissionersDate risk last reviewed: 19-12-2013

5.4 4,5 Project

Director for

Primary Care

Strategy

(Margaret

Chirgwin)

Failure to build

appropriate skills,

capacity and support

for clusters as

commissioners could

result in:

- CCG failure to live

within budget

- Lack of provision for

expected increase in

demand for PC





and therefore cost

under Barts PBR

- Failure to meet

outcome framework

indicators

Maj

or

(4)

x P

oss

ible

(3

) =

Me

diu

m R

isk

(12

)

- Development of

Primary Care Strategy to

include development of

Commissioning role of

clusters

- Monthly cluster

meeting to discuss ideas,

share concerns and share

best practice between

practices and other

clusters

- Monthly cluster leads

meeting to coordinate

ideas, share concerns and

share best practice

between clusters to feed

up through the CCG

structure

- CCG engagement LES

requiring attendance at

cluster and CCG wide

events

- Monthly Practice

Member Council

Meetings

- Each NCCG

locality

(covering 2

clusters)has

dedicated

Practice

Facilitator

support

- Programme

Director for

Primary Care

Strategy

appointed to

lead the

development of

a primary care

strategy for

Newham

Maj

or

(4)

x U

nlik

ely

(2

) =

Me

diu

m R

isk

(8)

None identified

Maj

or

(4)

x Li

kely

(4

) =

Hig

h R

isk

(16

)

- CCG constitution

clearly defines the

Clusters as

Committees of the

Board and their

commissioning

roles and

responsibil ities

- Agreement on

budget allocation

methodology to

practices and

clusters

- Agreement on

risk sharing

between practices

and clusters

- Agreement on

management of

cluster under and

overspends at the

end of year

- Financial

reporting at

cluster and

practice level

- Financial and

commissioning

support to

clusters

- CCG resource

needs to be

further developed

to support the

development of

clusters as

commissioners.

-Board papers

- Changes to

constitution


Risk

Rating


Risk

Ref

Linked

to Risk

Areas


Initial

Risk

Rating

24


- NELCSU in discussion

with NCCG to develop a

new draft procurement

strategy for discussion

and approval by NCCG

Board

- Procurement sub-

committee of Newham

CCG Executive working

on developing a

procurement strategy to

submit for final Board

approval (expected

February 2014)

- To secure agreed

support from CEG in

2014/15 contract around

developing resources to

monitor and

remunerate practices

against delivery of

extended primary care

services

First draft of primary

care strategy includes

proposed procurement

strategy for primary care

extended services

Actions completed

Target

Risk

Rating

Risk 5.5 Failing to develop new and functional Extended Primary Care Providers/Shared Services

ProvidersDate risk last reviewed: 19.12.2013

5.5 5 Project

Director for

Primary Care

Strategy

(Margaret

Chirgwin)

Failing to develop new

Extended Primary Care

Providers/Shared

Services Providers

could result in:

- Adverse

media/reputational

risk

- An under-resourced

workforce

- Lack of provision for

expected increase in

demand for PC





under Barts PBR

- Unnecessary

unscheduled

admissions

- Failure to meet

outcome framework

indicators

- Widening gap in life

expectancy between

best and worst off

decile of the Newham

population and

between Newham and

England average

Maj

or

(4)

x P

oss

ible

(3

) =

Me

diu

m R

isk

(12

)

- Development of

Primary Care Strategy to

include development of

Extended Primary Care

Providers including how

this market should be

developed and how the

CCG will commission

these kinds of services

and service

developments

- Engagement with

Member Practices in the

development of the

strategy

- Primary Care

Strategy Draft

Outline

document

- Agendas for

practice Council,

Cluster meetings

etc. include

discussion of

what kind of

providers the

CCG should

develop

Maj

or

(4)

x U

nlik

ely

(2

) =

Me

diu

m R

isk

(8)

Clarity on use on

new national

standard

contracts for

extended

primary are

services from

April 2014.

Maj

or

(4)

x U

nlik

ely

(2

) =

Me

diu

m R

isk

(8)

- The present

Newham CCG

procurement

strategy is out

of date and

not reflective

of the current

NHS position

with respect

to

procurement

New CCG

procurement

strategy


Risk

Rating


Risk

Ref

Linked

to Risk

Areas


Initial

Risk

Rating

25

3.7 Risk Area 6 - To ensure that Newham CCG has transparent and effective corporate and clinical

governance arrangements in place to comply with relevant legislation and mitigate the risk of non-delivery

of strategic objectives


None

identified at

present

- NCCG Business

Continuity Plan

approved by NCCG

Board 09.10.2013

- Winter planning EPR

risks identified though

UC risk register

Target

Risk

Rating

Actions completed

Risk 6.2 NCCG is underprepared for its role in emergency planning procedures Date risk last reviewed: 19-12-2013

6.2 6 Head of

Governance

and

Engagement

(Satbinder

Sanghera)

Uncertainty over

emergency planning

and NCCG's role

Maj

or

(4)

x P

oss

ible

(3

) =

Me

diu

m R

isk

(12

)

None

identified at

present

Business Continuity and

Emergency planning

arrangements require

sign-off from Newham

CCG Board

Assurance around

winter planning and

emergency

preparedness

arrangements to be

picked up and

monitored via Urgent

Care Transformation

programme

Maj

or

(4)

x R

are

(1

) =

Low

Ris

k (4

)

NCCG is working with

colleagues at NHS England,

CSU, other CCGs and LBN to

ensure that robust

emergency planning remains

in place throughout the

transition period and into

the future.

- Desktop emergency

planning exercise facil itated

by NHS England planned for

CCG and key Health

Organisation EPRR leaders

in July 2013

- Attending EPPR/BCP London

quarterly meetings hosted by

NHS England (London office)

to share common concerns

and best practice

- Newham CCG attend as

core members of the BRF

(Borough Resuileience

Forum) - an Local Authority

led forum to facil itate co-

operation and information

sharing at a borough level

between agencies

responsible for co-

ordinating, planning and

endorsing an effective

emergency response and

recovery, enhancing the

resil ience of the London

Borough of Newham

NCCG Business

Continuity Plan

developed

outlining local

business

continuity

arrangements to

feed into wider

emergency

planning

arrangements

- On call rota

established for

EPRR between

senior NCCG

Directors as part

of WELC Pod on-

call

arrangements

CSU specialist

support for EPRR

and surge

management

Maj

or

(4)

x U

nlik

ely

(2

) =

Me

diu

m R

isk

(8)


Risk

Rating


Risk

Ref

Linked

to Risk

Areas


Initial

Risk

Rating

26


Development

of NCCG

specific IG

policies

- IG Policies completed

and submitted to Audit

Committee leads and

Chief Officer for

ratification:

- Information

Governance Strategy

and Framework

- Information Security

Policy

- Information

Management Policy

- Confidentiality and

Disclosure of

Information Policy

- Calendar, Email and

Internet Policy

Target

Risk

Rating

Actions completed

Risk 6.3 Information Governance arrangements for Newham CCG are in an underdeveloped state Date risk last reviewed: 29-11-2013

6.3 6 Head of

Governance

and

Engagement

(Satbinder

Sanghera)

Information

Governance

arrangements for

Newham CCG are

under developed

Mo

de

rate

(3

) x

Ce

rtai

n (

5)

= H

igh

Ris

k (1

5)

Shared folder

resource

between CCG

and CSU IG

support team

developed

with template

policies for

Information

Governance

- Work in progress on

completion of IG Toolkit

in conjunction with

specialist support from

CSU IG team.

- CCG IG lead leading on-

going work to ensure

100% staff compliance

with IG online training

tool assessment

requirements

- Work on-going around

mapping of personal

information data flows

and information asset

identification

Mo

de

rate

(3

) x

Rar

e (

1)

= Lo

w R

isk

(3)

- IG Toolkit to be

completed to ensure

compliance with relevant

IG legislation

- IG development plan

established to monitor

progress against IG

Toolkit completion and

development of

associated IG policies and

procedures

- Procedures are in place

to ensure all NCCG staff

complete mandatory IG

training on an annual

basis

- Corporate incident

reporting procedures

developed to identify

monitor and follow up

risks or incidents which

impact on IG

NCCG has

appointed a

Caldicott

Guardian, Senior

Information Risk

Owner (SIRO)

and Information

Governance

Lead to ensure

the CCG remains

compliant with

relevant IG

legislation and

to promote best

practice IG

arrangements

throughout the

CCG

NCCG has

commissioned

expert

information

governance

support from the

CSU which

includes support

around

completion of

the IG Toolkit

Mo

de

rate

(3

) x

Po

ssib

le (

3)

= M

ed

ium

Ris

k (9

)


Risk

Rating


Risk

Ref

Linked

to Risk

Areas


Initial

Risk

Rating

27

4. How to interpret the Newham CCG BAF

4.1 Risk profile

28

4.2 Full BAF risk entries

29

5. Newham CCG Risk Grading Matrix

item e appendix 1 board assurance framework e... · risk rating director of delivery (scott...

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