Report to the Audit & Risk Committee on 20 June 2014

NHS FIFE

Report to the Audit & Risk Committee on 20 June 2014

SUMMARY OF BOARD STANDING COMMITTEES’ ANNUAL REPORTS

1.INTRODUCTION

1.1All Board Standing Committees have now submitted their Annual Reports, which have been placed on the agenda for the Board meeting on 24 June.

1.2Attached as appendix 1 is a collation of the “Conclusion” sections of the reports. These provide the assurance by Committee Chairpersons that adequate and effective governance arrangements are in place. As the full Annual Reports of the main governance committees have also been submitted, the Chief Internal Auditor is happy that these summaries fulfil the Audit & Risk Committee’s duty in this respect.

1.3I confirm that I have seen signed copies of all reports and confirm these reports have been signed by the Chairs of the respective Committees.

2.BEST VALUE

2.1 For 2013/14 and future years, the Board is required to provide overt assurance on Best Value. Appendix 2 provides evidence of where and when the Board considered the relevant characteristics during 2013/14.

3.RECOMMENDATION

3.1The Audit & Risk Committee is asked to

note the summary reports.

NORMA WILSON

Head of Corporate Services

Appendix 1

1.DUNFERMLINE and WEST FIFE CHP COMMITTEE

CONCLUSION

“As Chair of the Dunfermline & West Fife CHP Committee during financial year 2013/2014, I am satisfied that the integrated approach, the frequency of meetings, the breadth of the business undertaken and the range of attendees at meetings of the Committee has allowed us to fulfil our remit as detailed in the Code of Corporate Governance. As a result of the work undertaken during this year, I can confirm that adequate financial and management governance arrangements were in place across Dunfermline & West Fife CHP during the year.

2.GLENROTHES and NORTH EAST FIFE

CONCLUSION

“As the Chair of the Glenrothes and North East Fife Committee during financial year 2013/14,I am satisfiedthat the integrated approach, thefrequency of meetings, the breadth of the business undertaken and the range of attendees at meetings of the Committee has allowed us to fulfil our remit as detailed in the Code of Corporate Governance. As a result of the work undertaken during the year, I can confirm that adequate planningand monitoring arrangements were in place throughout Glenrothes and North East Fife CHPduring the year.

I wouldpay tribute to the dedication and commitment of fellow members of the Committee and all attendees. I would also thank those members of staff who have prepared reports and attended meetings of the Committee”.

3.HEALTH and SAFETY GOVERNANCE

CONCLUSION

As the Chair of the Health and Safety Governance Committee during financial year 2013/14, I am satisfied that the integrated approach, the frequency of meetings, the breadth of the business undertaken and the range of attendees at meetings of the Committee has allowed us to fulfil our remit as detailed in the Code of Corporate Governance. As a result of the work undertaken during the year, I can confirm that adequate and effective Health and Safety Governance planning and monitoring arrangements were in place throughout NHS Fife during the year.

4.HEALTH and SOCIAL CARE PARTNERSHIP GROUP (NHS FIFE COMMITTEE)

CONCLUSION

As Chair of the Fife Health and Social Care Partnership Group during financial year 2013-2014, I am satisfied that the integrated approach, the frequency of meetings, the breadth of the business undertaken, and the range of attendees at meetings of the Group has allowed us to fulfil our remit as detailed in the Code of Corporate Governance

As a result of the work undertaken during the year I can confirm that adequate and effective governance arrangements were in place throughout the Partnership during the year.

5.KIRKCALDY and LEVENMOUTH CHP COMMITTEE

CONCLUSION

As Chair of the Kirkcaldy & Levenmouth CHP Committee during financial year 2013/14, I am satisfied that the integrated approach, the frequency of meetings, the breadth of the business undertaken and the range of attendees at meetings of the CHP Committee has allowed us to fulfil our remit as detailed in the Code of Corporate Governance. As a result of the work undertaken during the year, I can confirm that adequate financial and management governance arrangements were in place across Kirkcaldy & Levenmouth CHP during the year.

6.ACUTE SERVICES DIVISIONAL COMMITTEE

CONCLUSION

As Chair of NHS Fife Operational Divisional Committee during financial year 2013-2014, I am satisfied that the integrated approach, the frequency of meetings, the breadth of the business undertaken and the range of attendees at meetings of the Committee has allowed us to fulfil our remit as detailed in the Code of Corporate Governance. As a result of the work undertaken during the year I can confirm that adequate and effective planning and monitoring arrangements were in place during the year.

I would again pay tribute to the dedication and commitment of fellow members of the Committee and to all attendees. I would thank those members of staff who have prepared reports and attended meetings of the Committee.

7.PATIENT FOCUS PUBLIC INVOLVEMENT COMMITTEE

CONCLUSION

“As Chair of the Patient Focus Public Involvement Standing Committeeduring financial year 2013/14, I am satisfied that the integrated approach, the frequency of meetings, the breadth of the business undertaken and the range of attendees at meetings of the Committee have allowed us to fulfil our remit as detailed in the Code of Corporate Governance. As a result of the work undertaken during this year, I can confirm that adequate system and processes in respect of public involvement and equality and diversity were in place throughout NHS Fife during the year.

8.SERVICE REDESIGN COMMITTEE

CONCLUSION

As Chair of the Redesign Committee during financial year 2013/14, I am satisfied that the integrated approach, the frequency of meetings, the breadth of the business undertaken and the range of attendees at meetings of the Committee have allowed us to fulfil our remit as detailed in the Code of Corporate Governance. As a result of the work undertaken during this year, I can confirm that adequate and effective arrangements were in place throughout NHS Fife during the year.

I would pay tribute to the dedication and commitment of fellow members of the Committee and to all attendees. I would thank all those members of staff who have prepared reports and attended meetings of the Committee. I would particularly like to acknowledge the contributions of Mrs. McGovern, Mr. Winton and Mrs. Archibald and their active participation at the Committee during 2013.

9.PRIMARY MEDICAL SERVICES COMMITTEE

As Chair of the PMSC during the final quarter of the financial year 2013/14, I amsatisfied that the integrated approach, the frequency of meetings, the breadth of thebusiness undertaken and the range of attendees at meetings of the Committee hasallowed us to fulfil our remit as detailed in the Code of Corporate Governance.

Appendix 2

Executive and Non-Executive leadership are involved in setting clear direction and organisational strategy. / Strategic context included within introduction to LDP which feeds into Balanced Scorecard.
Approval of Balanced Scorecard predicated on confirmation of strategic direction / Board
Board / Annual
Annual / LDP for 2013/14 approved by Board on 26.03.13.
SMT reviewed Balanced Scorecard (BSc) and agreed key elements of its development at end January. Noted development of 2013/14 BSc by Board 26.02.13, and approved by Board 30.04.13. Included in Board Executive Performance Report.
Strategic priorities are agreed, reviewed and updated on a regular basis and leaders communicate the strategy to all staff and stakeholders and ensure that it is translated into meaningful actions and outcomes. / Approval of Balanced Scorecard encapsulates strategic priorities
Corporate Communications Framework and Action Plan / Board
Board / Annual
Annual / Approved by Board 30.04.13. Reported bi-monthly in Board Executive Performance Report.
Executive and Non-Executive leadership and senior managers have developed a vision of how Best Value contributes to achieving effective outcomes for the organisation and that this is communicated clearly in relevant corporate and operational documents. / Inclusion of specific reference to Best Value, including targets showing continuous improvement within:
 LDP
Regional Plans
Single Outcome Agreements (SOAs)
Annual Report (outcomes) / Board / Annual / Reported bi-monthly in Board Executive Performance Report.
Both the setting of priorities and the assessment of performance are undertaken transparently and openly. / Balanced scorecard taken in open session at Board meetings / Board / Annual / Reported bi-monthly in Board Executive Performance Report.
Executive and Non-Executive leadership ensure accountability and transparency through effective performance reporting for both internal and external stakeholders and that there is a willingness to be open to external scrutiny, for example, through formal external accreditation tools. / Consideration of relevant external reports included within remit and workplans of relevant committees.
Formal consideration/mapping by Committees and Board of independent sources of assurance
Board effectiveness review updates
External review reports i.e. HIS, HEI etc. / Board/Committees
Board/Committees
Board
Relevant Committee / Annual
Biennial
Biennial
Ongoing / Internal and External reports considered on an adhoc basis.
Board considers all Committee’s assurance statements annually.
Executive and Non-Executive leadership demonstrate a commitment to high standards of probity and propriety and the organisation has, and implements, appropriate codes of conduct for all staff, directors and trustees. / Code of conduct for members / Code of conduct for staff
Board Register of Interests included in annual report / Audit & Risk Committee Committee/Board
Board / Annual
Annual / Standards of Business Conduct for Board and Staff included at Section G of Code of Corporate Governance approved by Board 25.02.14.
Included in Annual Accounts adopted by Board 25.06.13
The organisation has a strategy with realistic and achievable objectives and targets which are matched to their financial, asset base and other resources and which is explicitly translated into clear responsibilities for implementation. / Approval of full LDP by Board
Approval of Balanced Scorecard encapsulates strategic priorities
Approval of Financial Plan / Board
Board
F&R Committee /Board / Annual
Annual
Board / Approved by Special Board 26.03.13.
Approved by Board 30.04.13.
Approved by Special Board 26.03.13.
Statements, strategies and plans clearly show a systematic approach by the organisation towards risk management. / RM Strategy
Risk Management included in all relevant Board/Committee reports
RM annual report and assurance statement
Corporate Risk Register / Board Clinical Governance/Audit & Risk Committee
Board/Committees
Board Clinical Governance/Audit & Risk Committee
Audit & Risk Committee / Board / Annual
Ongoing
Annual
Bi-annual / Strategy considered by Audit & Risk Committee 19.09.13. Workshop held on 28.11.13 to consider further iteration and development of Risk Management Framework.
Risk Management included on template to be followed for all Board Reports.
Work underway in 2013/14 resulting in new Audit and Risk Committee. Audit and Risk Annual Report and Assurance Statement to be submitted to Board on 24.06.14. Code of Corporate Governance (CoCG) altered to reflect change and approved by Board on 25.02.14.
Governance committees responsible for risks on Corporate Risk Register most associated to that committee. Executive lead for each risk provides update in terms of management actions undertaken to minimise risk where possible. Full Corporate Risk Register submitted to Audit & Risk Committee 16.05.13 & 19.09.13.
There is an explicit and systematic approach to integrating continuous improvement into everyday working practices and involving all staff in developing the organisation’s approach to Best Value. / Board Annual Directors Report outlines approach to continuous improvement and Best Value
Best Value Toolkits / Board / Audit & Risk Committee
Relevant Committee / Annual
Ongoing / Included in Annual Accounts adopted by Board 25.06.13.
An organisational culture which recognises the value of working with wider stakeholders and partners to achieve more effective and sustainable policy development, better services and customer-focused outcomes. / SOA
Fife HSCP annual report
SEAT annual report, workplan and Priority Framework / Board
Board
Board / Annual
Annual
Annual / Considered at various governance committees, principally H&SCP and FHWBA. Update to Board on Community Plan 27.08.13.
Noted by Board 25.06.13
Noted by Board 27.08.13.
Leaders and senior managers actively encourage opportunities for formal and informal partnerships, including through joint use of resources and joint funding options, where this will offer scope for improvement in outcomes, as well as continuous improvement in organisational performance. / Reference to appropriate partner input/consultation in relevant business cases, strategies etc. / Board /Acute Services Division /CHPs/F&R / Ongoing / Business cases considered on an adhoc basis.
The organisation is clear about the intended outcomes and likely impacts of partnership working and that it has identified, and is sensitive to, the needs of the potentially different communities it and its partners serve. / Fife HSCP minutes / Board/CHPs / Ongoing / H&SCP minutes submitted to the Board.
Where the partnership is involved in joint delivery, governance arrangements include:
(a) agreeing appropriate respective roles and commitments and
areas of collective responsibility;
(b) integrated management of resources where appropriate;
(c) effective monitoring of collective performance; and
(d) joint problem-solving and learning. / SOA
Fife HSCP Annual Report
SEAT annual report, workplan and priority Framework / Board
Board
Board / Annual
Annual
Annual / Considered at various governance committees, principally H&SCP and FHWBA. Update to Board on Community Plan 27.08.13.
Noted by Board 25.06.13
Noted by Board 27.08.13.
Where appropriate, the organisation participates effectively in Community Planning Partnerships and other joint working initiatives, working openly to agreed objectives, performance management and reporting mechanisms and integrating these into local planning mechanisms to deliver outcomes. / Fife HSCP Annual Report
SEAT Annual Report / Board/CHPs
Board / Annual
Annual / H&SCP minutes submitted to the Board. Annual Report Noted by Board 25.06.13
SEAT minutes submitted to the Board and Annual Report noted by Board 27.08.13.
Leaders address impediments and barriers which inhibit integrated approaches to joint funding and joint management of activities with internal and external partners and undertake appropriate engagement (including with the Scottish Government) where this would help promote more effective use of resources and better value for money. / Reference to consideration of joint working in relevant business cases, strategies etc. / Board / Acute Services Division /CHPs/F&R / Ongoing / Business cases considered on an adhoc basis.
The organisation has developed a corporate plan which is focussed on the successful delivery of outcomes, takes account of statutory responsibilities and is translated into specific actions to be carried out at both corporate and operational levels to achieve those outcomes. / LDP
Approval of Balanced Scorecard / Board
Board / Annual
Annual / Approved by Board on 26.03.13.
Approved by Board 30.04.13.
Plans, priorities and actions are informed by an understanding of the needs of its stakeholders, citizens, customers and employees. / Specific reference within LDP / Board / Annual / Approved by Board on 26.03.13.
Decision-making processes are open, transparent and clearly based on evidence that can show clear links between the activities and the outcomes to be delivered to customers and stakeholders. / Approval of LDP in open Board session
Approval of Balanced Scorecard in open session / Board
Board / Annual
Annual / Approved by Board on 26.03.13.
Approved by Board 30.04.13.
The approach to Public Performance Reporting is balanced, enabling the discharge of statutory requirements together with provision of concise, relevant and accessible reporting of information that is useful for the public and other stakeholders, including information on use of financial resources. / Annual Report from Director of Public Health
Corporate Communications Framework and Action Plan
Annual Accounts Directors Report / Board
Board
Board / Biennial
Annual
Annual / Submitted to Board on 26.02.13.
Work underway in Comms Dept to define Comms Strategy and Head of Corporate Services now attends PFPI Standing Committee to report on Comms issues. Draft Strategy submitted to PFPI Standing Committee in June 2013 and amended Strategy to be submitted on 4.06.14. Minutes of the PFPI Standing Committee are submitted to the Board.
Included in Annual Accounts adopted by Board 25.06.13.
Where delivery is through others, a robust framework of corporate governance is in place to manage that delivery which sets out roles and responsibilities, objectives and outcomes and a process for performance and risk management and reporting. / Risk Management Report includes specific reference to joint working / Board Clinical Governance/Audit & Risk Committee / Annual / Governance Committees responsible for risks on Corporate Risk Register most associated to that committee. Minutes submitted to the Board.
The organisation has a framework for planning and budgeting that includes detailed and realistic plans linked to available resources together with an effective system for financial stewardship and reporting in order to achieve the organisation’s goals, ensure appropriate financial governance, deliver high-quality and efficient services and ensuring continuous improvement in both performance and delivery of outcomes / LDP