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
Internal External Control Assurance
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
Internal External Control Assurance
GapsProposed Actions
Risk
Ref
Linked
to Risk
Areas
Risk Lead Risk Description
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)
ControlsAssurances Current
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
Internal External Control Assurance
Actions completed Target
Risk
Rating
Risk 1.4 Quality of Commissioned Services at Barts Health Date risk last reviewed: 22.11.2013
ControlsAssurances Current
Risk
Rating
GapsProposed Actions
Risk
Ref
Linked
to Risk
Areas
Risk Lead Risk Description
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
Internal External Control Assurance
GapsProposed Actions
Risk
Ref
Linked
to Risk
Areas
Risk Lead Risk Description
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
)
ControlsAssurances Current
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
Internal External Control Assurance
- 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
)
ControlsAssurances Current
Risk
Rating
GapsProposed Actions
Risk
Ref
Linked
to Risk
Areas
Risk Lead Risk Description
Initial
Risk
Rating
12
Internal External Control Assurance
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
Risk Lead Risk Description
Initial
Risk
Rating
ControlsAssurances Current
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
Internal External Control Assurance
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
ControlsAssurances Current
Risk
Rating
GapsActions completed
Risk
Ref
Linked
to Risk
Areas
Risk Lead Risk Description
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
Internal External Control Assurance
- 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
Risk Lead Risk Description
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
GapsActions completed
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
Internal External Control Assurance
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
ControlsAssurances Current
Risk
Rating
GapsActions completed
Risk
Ref
Linked
to Risk
Areas
Risk Lead Risk Description
Initial
Risk
Rating
16
Internal External Control Assurance
- 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
)
ControlsAssurances Current
Risk
Rating
GapsProposed Actions
Risk
Ref
Linked
to Risk
Areas
Risk Lead Risk Description
Initial
Risk
Rating
17
Internal External Control Assurance
- 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)
ControlsAssurances Current
Risk
Rating
GapsProposed Actions
Risk
Ref
Linked
to Risk
Areas
Risk Lead Risk Description
Initial
Risk
Rating
18
Internal External Control Assurance
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
)
ControlsAssurances Current
Risk
Rating
GapsProposed Actions
Risk
Ref
Linked
to Risk
Areas
Risk Lead Risk Description
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
Internal External Control Assurance
- 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
care out of hospital
-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)
ControlsAssurances Current
Risk
Rating
GapsProposed Actions
Risk
Ref
Linked
to Risk
Areas
Risk Lead Risk Description
Initial
Risk
Rating
20
Internal External Control Assurance
- 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)
ControlsAssurances Current
Risk
Rating
GapsProposed Actions
Risk
Ref
Linked
to Risk
Areas
Risk Lead Risk Description
Initial
Risk
Rating
21
Internal External Control Assurance
• 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
ControlsAssurances Current
Risk
Rating
GapsProposed Actions
Risk
Ref
Linked
to Risk
Areas
Risk Lead Risk Description
Initial
Risk
Rating
22
Internal External Control Assurance
- 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
services as a result in
the planned shift in
care out of hospital
- Increased activity
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
ControlsAssurances Current
Risk
Rating
GapsProposed Actions
Risk
Ref
Linked
to Risk
Areas
Risk Lead Risk Description
Initial
Risk
Rating
23
24
Internal External Control Assurance
- 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
services as a result in
the planned shift in
care out of hospital
- Increased activity
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
ControlsAssurances Current
Risk
Rating
GapsProposed Actions
Risk
Ref
Linked
to Risk
Areas
Risk Lead Risk Description
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
Internal External Control Assurance
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)
ControlsAssurances Current
Risk
Rating
GapsProposed Actions
Risk
Ref
Linked
to Risk
Areas
Risk Lead Risk Description
Initial
Risk
Rating
26
Internal External Control Assurance
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
)
ControlsAssurances Current
Risk
Rating
GapsProposed Actions
Risk
Ref
Linked
to Risk
Areas
Risk Lead Risk Description
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
30
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