CCG: BOARD ASSURANCE FRAMEWORK
INTRODUCTION
- As a Clinical Commissioning Group (CCG) we have identified various risks. Many of these are low level and are managed at an operational level. This documents highlights the top strategic risks facing us as an organisation therefore the scores for these risks are high, at least at the start of the year.
- The CCG is part of a collaborative arrangement with other CCGs in North West London which comprises Central London, West London, Hammersmith & Fulham and Hounslow CCGs. The CCGs have worked together to identify a common set of risks and to develop common approaches to their management, as appropriate.
- Workshops have taken place with each CCG governing body to identify the key risks to achieving our objectives for the year. The outputs were mapped and discussed with the chairs of the four CCGs to reach a common set of 20 risks. These were reported to and agreed with each governing body in June. The Board Assurance Framework takes those key risks to the delivery of the CCG’s strategic objectives and sets out the controls that have been put in place to manage the risks and the assurances that have been received that show if the controls are having the desired impact. It includes an action plan to further reduce the risks and an assessment of current performance. The table below sets out the strategic objectives and lists the various risks that relate to them.
CCG Objective / Description of risk identified / Initial Score / Current Score / Last Review
Improving patient safety and quality / 1 - Primary care does not have the capacity and capability to deliver new models of care (including the Out of Hospital Strategy) at the desired pace, leading to negative impacts on service quality, financial pressures, and double running. / 20 / 16 / Feb 14
2 - Failure to meet standards in safeguarding adults leading to poor quality care. / 20 / 15 / Feb 14
3 - Failure to meet standards in safeguarding children leading to poor quality care. / 15 / 15 / Feb 14
4 - Migration to a single IT system fails to deliver anticipated returns in a timely and cost effective manner including delays in accessing patient records. / 15 / 9 / Feb 14
5 - Initiatives to help patients take greater control for their care are not effective leading to poor patient experience and greater reliance on unplanned medical care. / 12 / 9 / Feb 14
6 - Lack of good quality patient and public engagement and failure to use patient and public feedback across the system leading to worse patient outcomes than might otherwise have been achieved. / 16 / 8 / Feb 14
7 - Limited quality of care/outcomes data on the quality of services that fall into the ‘jointly commissioned’ category, with particular regard to care homes, leading to poor quality of care. / 25 / 15 / Feb 14
Performance improvement / 8 - Operating within the management budget may lead to:
-insufficient delivery capacity and leadership at governing body;
-Inability to access to appropriately skilled resource to deliver change.
This in turn leads to a reduction in the degree of improvements we can make to quality and performance (including the five outcomes of the NHS mandate) / 16 / 8 / Feb 14
9 - We do not manage information governance risks appropriately leading to breach of statutory duties and inability to deliver new ways of delivering care. / 16 / 8 / Feb 14
10 - Central London Community Healthcare does not deliver the agreed model of community nursing care in line with our Out of Hospital Strategy leading to inefficiencies and improved outcomes not being achieved quickly enough. / 20 / 16 / Feb 14
11 - West London Mental Health Trust’s transformation board does not deliver the required changes in community mental health care services. This will hinder the CCGs’ ability to deliver Out of Hospital Strategies leading to inefficiencies and improved outcomes not being achieved quickly enough. / 16 / 16 / Feb 14
12 - The proposed partnership between West Middlesex and Chelsea & Westminster Hospitals does not proceed as planned causing potential instability to services at West Middlesex leading to a detrimental effect on patient outcomes. / 12 / 20 / Feb 14
Integrating health and social care / 13 - Providers and stakeholders do not share the programme of work (including the timetable) to deliver Shaping a Healthier Future, leading to reduced ability to make improvements to service quality and avoidable financial pressures. / 16 / 8 / Feb 14
14 - The ‘whole systems’ integration programme may not progress as quickly as planned due to changes to funding arrangements as a result if the Comprehensive Spending Review and the new integration fund for 2014/15. This could lead to inadequate links between health and social care. / 20 / 12 / Feb 14
15 - Performance at Imperial College Hospital Trust does not improve leading to less than optimal outcomes. / 20 / 12 / Feb 14
Establishing and developing clinical commissioning / 16 - Challenges in the establishment and development of the Commissioning Support Unit leading to reduced ability to deliver our commissioning objectives. / 20 / 20 / Feb 14
17 - Internal and external pressures mean that a) we are unable to deliver the planned budget in 13/14 and b) we are unable to deliver a sustainable financial position in the medium term, reducing our ability to commission effectively. / 20 / 12 / Feb 14
18 - Insufficient engagement from member practices and localities/networks in responding to change, leading to difficulties in implementing our commissioning plans and not achieving the full ambition of improvements to patient outcomes / 16 / 12 / Feb 14
19 - We do not have access to timely and accurate outcomes based information thus preventing us from effectively managing the quality and performance of our providers. / 15 / 12 / Feb 14
20 – Risk that the proposed Ealing CCG move to the Collaborative leads to reduced ability to deliver our commissioning plans. / 9 / 6 / Feb 14
Objective: Improving patient safety and quality / Director lead: Managing Directors and Director of Strategy & Transformation
Risk: Primary care does not have the capacity and capability to deliver new models of care (including the Out of Hospital Strategy) at the desired pace, leading to negative impacts on service quality, financial pressures, and double running. / Date last reviewed: February 2014
Risk Rating
(likelihood x consequence):
Initial: 5 x 4 = 20
Current: 4 x 4 = 16
Appetite: 2 x 4 = 8 / / Rationale for current score:
It is likely that if new models of care are not delivered, quality of care for patients will be reduced, and savings will not be made. The Out of Hospital Plan has reduced the likelihood of negative impacts.
Rationale for risk appetite:
This relates to three of our four strategic objectives, therefore it is essential to reduce the likelihood of this occurring.
Controls:(What are we currently doing about the risk?)
- Three strand approach being taken to delivery:
- Out of Hospital strategy in place
- Whole Systems integrated care approach being taken to develop GP provider networks
- Utilising existing Network/Locality plans to encourage new ways of working.
- Urgent Care Boards established with a role in improving the overall system.
- Primary Care Transformation Board in place across NW London which has considered the LES review. Project to implement LES review agreed by December Investment committee - additional resource has been sourced to deliver it.
- A partner has been enlisted to help us to develop the estates investment criteria.
Expectations and requirements for primary care clarified in Out of Hospital strategic service delivery plans / Mar 13 / TS
Service models and supporting infrastructure for 7-day access to be developed in response to the Prime Minister’s Challenge Fund / 2014/15 / TS
Assurances:(How do we know if the things we are doing are having an impact?)
- Out of Hospital steering group will monitor progress against agreed commissioning targets and the minutes go to governing body meetings.
- Urgent care board minutes go to governing body meetings
- Shaping a Healthier Future delivery tracker
- Performance report showing progress with delivering local priorities
- Assessment of out of hours provision, including NHS 111, required
- Networks/ Localities are responsible for feedback from and to practices – need a mechanism to report this to governing bodies
- Primary Care workforce development and increasing GP capacity in conjunction with NHSE needs to be developed. Health Education England is also developing training for primary care roles.
- We don’t know how effective education and training programmes are.
Current performance:(With these actions taken, how serious is the problem?)
- Variation in referral management in primary care continues
- Performance of GP out of hours service and 111 remains a concern
West London: Primary Care Strategy Manager in post, multi-disciplinary teams to support Putting Patients First.
H&F: Out of Hospital Programme Board to receive updates. / 1
Objective: Improving patient safety and quality / Director lead:Director of Patient Safety & Quality
Risk: Failure to meet standards in safeguarding adults leading to poor quality care. / Date last reviewed:February 2014
Risk Rating:
(likelihood x consequence)
Initial: 4 x 5 = 20
Current: 3 x 5 = 15
Risk appetite:
2 x 5 = 10 / / Rationale for current score:
Safeguarding Adults became a statutory responsibility of the CCGs on 1st April 2013. We are using the London-wide policy in place and are implementing other governance structures to exercise this function. However risk remains high as systems are largely untested.
Rationale for risk appetite:
We want to reduce the likelihood to low.
Controls:(What are we currently doing about the risk?)
- Clearly defined governance structures/ processes in place: creation of Lead Safeguarding roles within the CWHHE Safeguarding Team; establishment of systems in line with multi-agency working eg Continuing Healthcare Quality Assurance Group, quality Dashboard task group and Director membership of the Local Safeguarding Adults Board.
- Clinical Quality Group terms of reference include role for safeguarding adults.
- Clear relationships with Safeguarding Adults Boards and Local Authorities, including joint reviews, established. Single tri-Borough Safeguarding Board.
- Database set up identifying care homes and monitoring intelligence.
- Regular meetings held with CQC to share quality concerns.
- Policy being developed on when to stop using providers if serious quality issues arise. This has had a legal view and so is being redesigned to reflect that.
- Outcomes framework developed. Sent out to providers to use for Q3/4 data.
Develop learning and improvement framework to underpin the reporting from providers. This should involve collection of data and information / Feb 14 / JW
Review the interface between the two systems for looking at safeguarding cases and Serious Incident process / Feb 14 / JW
Monitor effectiveness of the dashboard for care homes / April 14 / JW
Work with Safeguarding Adult Boards to develop case review groups / April 14 / JW
Influence the Health and Wellbeing Boards to monitor the winterbourne view action plan / Feb 14 / MDs
Outcomes framework (to mirror safeguarding children framework) sent out to providers for submission / Mar 14 / JW
Assurances:(How do we know if the things we are doing are having an impact?)
CCG Quality & Patient Safety Committee minutes showing Quarterly Safeguarding Adults reports; outcome of review following Winterbourne View; Outcome of the self-assessment assurance framework completed for local Safeguarding Board and action plans. / Gaps in assurance: (What additional assurances should we seek?)
Governing Bodies do not yet know if these new systems and processes are sufficiently robust and embedded in multi-agency working.
Current performance:(With these actions taken, how serious is the problem?)
These are new and untested systems but it is anticipated that the mitigating actions will substantially reduce risk
CQC has raised concerns with The Limes care home at which some of our residents are funded.
Process used for Limes (monthly meetings and clinical visits) led to positive outcome of embargo being lifted. / Additional Comments: / 2
Objective: Improving patient safety and quality / Director lead: Director of Patient Safety & Quality
Risk: Failure to meet standards in safeguarding children leading to poor quality care. / Date last reviewed: February 2014
Risk Rating
(likelihood x consequence):
Initial: 3 x 5 = 15
Current: 3 x 5 = 15
Appetite:
2 x 5 = 10 / / Rationale for current score:
Failure in this area would have an impact on vulnerable members of the community and is therefore very serious. Steps have been taken to reduce the likelihood of problems occurring.
Rationale for risk appetite:
While the impact of failures could have a major impact on patients, the aim is to reduce the likelihood of this occurring. Risks can never be completely eliminated.
Controls:(What are we currently doing about the risk?)
- Leadership roles for safeguarding clearly defined within key providers and CCG. Designated Nurses sit on each CCG Quality Committee.
- Established working relationships with the Safeguarding Children’s Boards.
- Reporting systems for serious incidents and framework to CCGs that identifies assurances. Reporting framework has been strengthened for providers via internal review, CQG scrutiny and CCG assurance using the outcomes framework. There are quarterly agenda reports by providers at CQG with exceptions as required monthly.
- Multi Agency Safeguarding Hubs in place
- Review of LAC health services has included discussion with the LA.
- Meetings in place to monitor providers readiness for inspection
‘Looked After Children’ strategy to be strengthened to clearly set out the CCG’s role and how it will discharge its functions. / Jan 14 / JW
Review the Safeguarding Outcomes framework to fit into a learning and improvement framework / March 14 / JW
Influence the Health and wellbeing Boards to consider the child population and link with the LSCBs / Feb 14 / MDs
Highlight local CAMHs tier 4 needs to NHS England / March 14 / JW
Assurances:(How do we know if the things we are doing are having an impact?)
Quarterly written reports to CCG Quality committees with monthly verbal updates for exceptional issues. Minutes presented to governing body meetings. Ofsted have inspected Hounslow LSCB which showed strength of partnership working but also enabled clarity regarding improvements to be made. / Gaps in assurance: (What additional assurances should we seek?)
Risks due to multiple commissioning organisations have not been resolved. Particular risk in relation to CAMHS tier 4 beds – commissioned by NHS England but there are a lack of beds nationally and concerns regarding the quality of the provision. Impact on local children and young people – placed on adult wards or general paediatric wards.
Current performance:(With these actions taken, how serious is the problem?)
Outcomes framework is being used across CWHH.
It is important to track highly mobile families and moving to a single IT system will help. / Additional Comments:
NHS England is reviewing the Named GP role and funding. In Hounslow there are vacancies for the Designated Paediatrician for Unexpected Deaths, Designated Doctor and Nurse for Looked After Children. / 3
Objective: Improving Patient Safety and Quality / Director lead: Strategic IT Lead
Risk: Migration to a single IT system fails to deliver anticipated returns in a timely and cost effective manner including delays in accessing patient records. / Date last reviewed: February 2014
Risk Rating
(likelihood x consequence):
Initial: 5 x 3 = 15
Current: 3 x 3 = 9
Appetite: 2 x 3 = 6 / / Rationale for current score:
Since the start of the year we have agreed to move to a single system and, in the summer, agreed what system to move to. Implementation is underway. These actions have reduced the current risk score.
Rationale for risk appetite:
We want to deliver the expected outcomes.
Controls (What are we currently doing about the risk?)
- Local IT committees in place in each CCG to oversee delivery of implementation plans to migrate to a single system. CollaborativeInformation Strategy and Information Governance committee now in place.
- Business cases for full implementation in all CCGs and for diagnostic cloud formally approved.
- Training has taken place for early implementers.
- Implementation team in place with structured rollout plan.
- Implementation team in place regular operational meetings underway, also regular CCG level IT committee meetings receive updates on progress
Implement single system across West London, Central London and Hammersmith & Fulham / Dec 14 / MDs
Working closely with all providers to integrate information systems / Mar 15 / MDs
Working with Social Care to integrate with their information systems / Mar 15 / PJ
Develop and implement strategy for improving patient record sharing and associated systems, processes and assurance mechanisms / Mar 14 / FF
Assurances (How do we know if the things we are doing are having an impact?)
Formal benefits realisation framework under development for implementation at later stage of programme. / Gaps in assurance (What additional assurances should we seek?)
Current performance (With these actions taken, how serious is the problem?)
- Whole systems IT strategy, benefits realisation framework and assessment mechanism under development.
- H&F: 100% of practices successfully migrated to SystmOne.
- WL CCG: all practices signed up, >5 practices live on SystmOne.
- CL CCG –all practices signed up, >3 practices live on SystmOne.
- HCCG – migration completed and development underway.
Objective: Improving Patient Safety and Quality / Director lead: Managing Directors
Risk: Initiatives to help patients take greater control for their care are not effective leading to poor patient experience and greater reliance on unplanned medical care. / Date last reviewed: February 2014
Risk Rating
(likelihood x consequence):
Initial: 4 x 3 = 12
Current: 3 x 3 = 9
Appetite: 2 x 3 = 6 / / Rationale for current score: