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1

Recommendations

The Governing Body is asked to:

• Review the attached GBAF assuring itself that the document provides adequate information and that the CCG’s corporate objectives and risks to their achievement are accurately reflected and are being effectively managed by accountable officers.

• Note the actions of the Governance Sub-committee and the assurance offered to the Audit and Integrated Governance Committee that operational risks are being effectively managed by officers.

• Identify any additional controls and mitigating actions which members feel should be put into place to address identified risks and the methods by which it would wish to receive assurance of the effectiveness of these controls.

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Thhe reportinng arrranngeemeentts ffor the GGoverninng Boodyy AAsssuraancce Frammewworrk ((GBBAAF) incluudee sccruutinny ffromm both thee GGovverrnaance SSubb-ccommmmitteee (GGScc) aandd thhe Auuditt and Innteggraatedd GGovverrnaancce CCoommmittteee (AAIGGCC) pprioor tto rrepporrting tto GGooveerning Boodyy. A significcannt rolee of thhe GScc iss to ennsuuree thatt iideentifiedd strrateegic risks faacing acchieveemmennt oof tthee orgaanissattionns obbjecctivvess are appprooprriattelyy mmannaggedd inn oorder to reeduucee thhe likeelihoood oor imppacct oof the rissk.

Thhe GBBAAF iis aan immpoortaant doocuumeentt prrovvidi ng exxternaal aasssuraancce to NHHSS Englannd, interrnaal aandd exxteernaal aauddit, sttakeehooldderss aandd mmemmbeerss off thhe publicc thatt thhe CCCG is coognnisaantt off itss riskss aandd haas a rrobbusst systtemm oof innteernaal cconntrool.

Thhiss innitiaal quartterly repporrt wwass ppreeseenteed to thhe Gooveernnannce SSubb-coommittee oon 255 NNovvemmbber offferringg tthee sub-coommittteee tthee ooppporttunnityy too revieww, moonittor and discusss iddenntiffiedd riiskss aandd wwheere appprroppriaate,, too chhalllenngee thhe asssoociaated cconntrools annd asssuranncees. UUltimmatelyy, tthee Sub-coommittteee pprovviddess AIIGCC aandd GGovverninng BBody coonffirmmattionn thhatt thhat it haas ggaiineed suffficciennt aasssurrannce abbouut thee eeffeectivennesss of thhosse cconntrools. TThee reepoort waas ppreeseenteed to AIGGCC on 117 Deeceembberr 200155.

Ass aa rressult off tiimings oof higgh levvell commmitteeess, it hhass bbeeen agreeed that for the reemaainndeer oof 220115/16 the qquaarteerlyy reepoortiingg peeriood will cclosse twoo wweeekss pprioor too the daatee of thhe Goveernnanncee SSubb-coommmiitteee ratther than tthee usual quuartter ennd peeriood. Hopefuullyy thhis will eenssuree mmore timmelyy aandd up-tto-ddatte rrepportingg oof tthee hiighh leevel risk poositionn. Thhe repporrt thherrefooree inncluudees thee ppossitioon ffor Quarte r 22 upp too aandd inncluuding 211 DDeccemmbeer 2015.

Thhe mostt up-tto-ddatte vverrsioon of the QQuartter 2 GBBAFF is aattaachhedd aat AApppenndix 1 ffor inforrmaatioon.

2 Quuarrterr 2 reevieeww too daatee

Att thhe end oof tthee mmonnitorin g pperriodd thherre wweere 144 risskss iddenntifiiedd onn the GBBAAF –– the leevel oof riiskk is seet ooutt beeloow. TTheeree wweree nno new risks adddeed and nno rissks closeed duurinng this pperriodd.

Poositioon at Quuarrteer 22 upp tto aandd inncluddinng 221 Deeceember 22015

Crritical Veryy HHigh Highh MMeddiuum Loow 0 1 4 9 00

3

The following risks have reduced in score:

4.1 Financial Plan with insufficient ability to reflect changes to meet demands – Very High to High

4.2 Risk management and other governance arrangements put in place by CCG and SCC to manage c £270m Better Care Fund to budget prove inadequate – High to Medium

4.3 Budgetary constraints faced by NHS England in particular re specialised services and primary care contracts adversely impact on CCG's ability to implement our plan

NB The above three risks were further reviewed at 21 December resulting in an additional reduction in the level of risk to Risk Ref 4.3 (3 x 2)

Ref Risk Owner Risk Initial

Score Risk current

Score

Risk Target or Appetite

Score

Are there Gaps in control?

Are there Gaps in assurance?

Position at 11th November 2015

1.1 TF 9 (9) 9 6 No No 1.2 RG 15 (15) 15 9 No No 2.1 KC 9 (6) 6 6 No No 2.2 TF 9 (9) 9 6 Yes Yes 3.1 TF 9 (6) 6 3 Yes Yes 4.1 JN 16 (16) 12 6 No No 4.2 JN 12 (12) 9 6 No No 4.3 JN 9 (9) 9 6 No No 4.4 TF 9 (9) 9 6 Yes Yes 4.5 KCl 12 (12) 12 6 Yes Yes 4.6 TF 12 (12) 12 4 Yes No 5.1 RG 12 (9) 9 6 No No 5.2 ZM 12 (12) 12 6 No No 5.3 TF 4 (4) 4 4 No No

Gaps in Assurance and/or Control

Four of the 14 strategic risks showed gaps in both control and assurance, and one a gap in control only. Actions taken to close the gaps can be found at Appendix 2.

Review by Governance Sub-committee

Members reviewed each of the five risks where gaps had been identified. With regard to risk ref 2.2 “CCG unable to influence equality of access to healthcare because insufficient or ineffective mechanisms to change” – It was agreed that this control should be referred to the Equalities Action Group.

4

3

With regard to risk ref 3.1 “CCG is unable to undertake the actions, and deliver the outcomes from them, that are set out in the HWB’s plan for reducing health inequalities, eg due to financial constraints” it was noted that the delivery date of 30 June should have been updated and brought into scope.

Members agreed that dedicated time should be allocated to the agenda of the March meeting of the Governance Sub-committee which would feed into the 2016/17 GBAF refresh in March 2016, followed by sign-off by Governing Body in May 2016.

4 Review by Audit and Integrated Governance Committee

A report was submitted to AIGC for review at its meeting on 17 December 2015. The report provided assurance that NHS Sheffield CCG is sighted on its risks and has a robust system of internal control.

5 Operational Risk Register

The majority of risks were reviewed by risk owners/senior managers/directors during Quarter 2 although a small number of risks were not reviewed.

Owner Owner reviewed

Senior Manager

Senior Manager reviewed

Final Reviewer

Final Reviewer Reviewed

Totals 41 37 41 39 41 39

6 Risk Register Update

6.1 Risks scored 15 +

During the Quarter 2 period four risks were identified as ‘serious’. The following risks have been scored 15 or above:

683 There is a risk of service disruption / loss of system inter-connectivity due to the implementation of the new STH Lorenzo PAS resulting in potential loss of patient details (eg failure in lab results electronically flowing to GP practices via ICE) (4 x 4). The Governance Sub-committee sought a further review of this score and that on balance the score was probably too high.

681 SEND REFORMS: From the assessment of the work to date, the CCG is currently not meeting its statutory duties in having a clear EHC health pathway in place, this is because there is not a proposed new EHC pathway in place or fully developed model worked up by SCC so we are unable to understand our the functions or form of the health pathway at this stage. (4 x 4)

714 Impact of National Minimum Wage/National Living Wage Increase will mean home and nursing care providers may become unviable and therefore be

5

unable to continue. This may result in a shortage of providers to deliver this level of care and may mean an increase in secondary care usage. (5 x 3) The Governance Sub-committee sought a further review of this score and suggested a score of 4 x 3.

146 Impact of outstanding Joint Packages of Care: There are approximately 50 patients who have become eligible for a joint package of care. Some of these were previously having their care solely funded by the LA and others had their care solely funded by the CCG. The funding responsibilities are still being agreed. This could lead to an increase in costs overall, including the backdating of any payments to the LA. Impact definition taken from 'financial' definition (5 x 3)

6.2 Risk movement during Quarter 2

Of the 41 risks on the Register during Quarter 2, 24 remained static in score for four cycles (i.e. over a year); an increase from the previous report. One risk has increased in score and two have decreased.

6.3 Review of static risks

All risks which had been static for more than four cycles were reviewed in quarter by a small sub-group of the GSc. Following the review risk owners/senior managers were approached and asked to review again their risks to identify any additional controls and assurances which might mitigate the level of risk. For some risks, owners were asked to provide additional clarity with regard to detail on specific areas of their risk. Each of the risks identified have now been reviewed and it is likely that a number of risks will be closed during the next quarter review; one risk has been closed in quarter. Future reviews of static risks would be held on a six monthly basis.

6.4 New Risks Identified

Eight new risks were identified during Quarter 2. The Governance Sub-committee reviewed the level of risk of each new risk and asked that the scores of three risks be further reviewed and amended accordingly.

6.5 Risks Closed

The Governance Sub-committee approved the six risks which were marked for closure during Quarter 2.

6.6 Overarching Position

The table below shows the total number of risks by risk score:

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‐ ‐ ‐ ‐ ‐

‐

‐

‐

‐

‐

1

7

LIKELIHOOD

3 Possible TOTALS4 Likely

Low Risks (White) : 5 Almost Certain

1 Rare 2 Unlikely

5 Catastrophic 0 0 0 0 0

4 Major 0 1 2 2 0

3 Serious 0 8 8 2 2

2 Moderate 0 6 1 3 3

1 Insignificant 0 1 0 2 0

Moderate Risks : 17 (Green)

High Risks : 19 (Yellow)

Serious Risks : 4 (Red)

Critical Risks : 0 (Black)

IMPACT

Recommendation

The Governing Body is asked to:

• Review the attached GBAF assuring itself that the document provides adequate information and that the CCG’s corporate objectives and risks to their achievement are accurately reflected and are being effectively managed by accountable officers.

• Note the actions of the Governance Sub-committee and the assurance offered to the Audit and Integrated Governance Committee that operational risks are being effectively managed by officers.

• Identify any additional controls and mitigating actions which members feel should be put into place to address identified risks and the methods by which it would wish to receive assurance of the effectiveness of these controls.

Paper prepared by Sue Laing, Senior Associate: Risk and Governance

On behalf of Tim Furness, Director of Delivery

December 2015

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Introduction GBAF REFRESH 2015/16 The Board Assurance Framework aims to identify the principal or strategic risks to the delivery of the CCG’s strategic objectives. It sets out the controls that are in place to manage the risks and the assurances that show if the controls are having the desired impact. It identifies the gaps in control and hence the key mitigating actions required to reduce the risks towards the target or appetite risk score. It also identifies any gaps in assurance and what actions can be taken to increase assurance to the CCG.

The table below sets out the strategic objectives lists the various principal risks that relate to them and highlights where gaps in control or assurance have been identified. Further details can be found on the supporting pages for each of the Principal Risks.

Strategic Objective Principal Risk identified Risk Owner Risk Initial Score

Risk current Score


Score

Are there GAPS in control?

Are there GAPS in

assurance?

1. To improve patient experience and access to care

1.1 Insufficient communication and engagement with patients and the public on CCG priorities and service developments, leading to loss of confidence in CCG decisions.

TF 9 9 6 No no

1.2 System wide or specific provider capacity problems emerge to prevent delivery of NHS Constitution and/or NHS E required pledges. RG 15 15 9 No No

2. To improve the quality and equality of healthcare in Sheffield

2.1 Providers delivering poor quality care and not meeting quality targets. KC 9 6 6 No No

2.2 CCG unable to influence equality of access to healthcare because insufficient or ineffective mechanisms to change

TF 9 9 6 yes yes

3. To work with Sheffield City Council to continue to reduce health inequalities in Sheffield

3.1 CCG is unable to undertake the actions, and deliver the outcomes from them, that are set out in the HWB's plan for reducing health inequalities, eg due to financial constraints.

TF 9 6 3 yes yes

4. To ensure there is a sustainable, affordable healthcare system in Sheffield.

4.1 Financial Plan with insufficient ability to reflect changes to meet demands. JN 16 12 6 No No

4.2 Risk management and other governance arrangements put in place by CCG and SCC to manage c£270m Better Care Fund to budget prove inadequate

JN 12 9 6 No No

4.3 Budgetary constraints faced by NHS England in particular re specialised services and primary care contracts adversely impact on CCG's ability to implement our plan.

JN 9 6 6 No No

4.4 Inability to secure partnerships with our main providers that help us to deliver our commissioning plans, including QIPP.

TF 9 9 6 Yes Yes

4.5 Contractual and financial constraints facing local practices resulting in an inability of some practices to deliver existing non‐core work and/or expand service provision as envisaged in commissioning plans. KCl 12 12 6 Yes Yes

4.6 Provider development required to deliver new models of care and achieve CCG stated outcomes does not happen. TF 12 12 4 yes yes

1

5. Principal Objective: Organisational

development to ensure the CCG can achieve its

5.1 Unable to secure timely and effective commissioning support to enable us to adequately respond and secure delivery to existing and new emerging requirements. RG 12 9 6 No No 5.2 Inability to secure active participation particularly from Member Practices for delivering CCG priorities. ZM 12 12 6 No No

aims and objectives and meet national requirements.

5.3 Inadequate adherence to principles of good governance and legal framework leading to breach of regulations and consequent reputational or financial damage.

TF 4 4 4 No No

The Risk Ratings used in the Assurance Framework are based on the following risk stratification table:

Risk Matrix

Likelihood ‐1

Rare

‐2

Unlikely

‐3

Possible

‐4

Likely

‐5 Almost certain

Consequen

ce

Negligible ‐1

1 2 3 4 5 1 to 3 Low

Minor ‐2

2 4 6 8 10 4 to 9 Medium 10 to 14 High

Moderate ‐3

3 6 9 12 15 15 to 19 Very High (Serious) 20 to 25 Critical

Major ‐4

4 8 12 16 20

Extreme ‐5

5 10 15 20 25

2

Principal Objective: To improve patient experience and access to care Director Lead: Director of Business Planning & Partnerships: (Tim Furness)

Principal Risk: 1.1 Insufficient communication and engagement with patients and the public on CCG priorities and service developments, leading to decisions that do not fully meet needs.

Date last reviewed: 11 November 2015

Risk Rating:

Initial: 3 x 3 = 9 Current: 3 x 3 = 9 Appetite: 2 x 3 = 6

(likelihood x consequence)

0

2

4

6

8

10

Initial Risk Rating Current Risk Rating

Risk Score

Risk appetite

Rationale for current score:

Rationale for risk appetite: We should have mechanisms in place that make effective engagement routine and therefore the likelihood of failure to engage “unlikely” at worst

As a new organisation with new ways of working, there was initially insufficient engagement. Work in 2013/14 has mitigated this but more can be done.

Existing Controls: (What are we doing about the risk prior to any new mitigating actions?) Communication and engagement strategy and engagement plan approved in 2013/14. Engagement committee, led by GB lay member, established. "Involve me" network established. Engagement group overseeing and monitoring activity.

Existing Gaps in Control: (Where are we failing to put controls in place and what more should be done?) We need to further develop operating models and ensure sufficient capacity to support portfolios

Mitigating actions: (What new controls are to be put in place to address Gaps in Control and by what date?) Action Date Continued development of engagement activity, supporting portfolios so that all CCG decisions are properly informed by the views of patients and the public, including GB OD session on 30/7 to inform revised plan. PEEG developing refreshed engagmeent plan, for disucssion by GB Jan 2016

01/10/2015

31/1/2016 Assurances: (Where should we find the evidence that controls are effective?)

• Business cases and GB papers should describe engagement and result of it

Positive Assurance: (Provide specific evidence of Assurances) • Patient experience and engagement reports received by GB in October 2014 and February 2015

Gaps in assurance: (Where are we failing to gain evidence that our controls are effective?)

Principle Risk Reference: 1.1

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Principal Objective: To improve patient experience and access to care Director Lead: Interim Chief Operating Officer (Rachel Gillott) Principal Risk: 1.2 System wide or specific provider capacity problems emerge to prevent delivery of NHS Constitution and/or NHS E required pledges.


Risk Rating:

Initial: 5 x 3 = 15

Current: 5 x 3 = 15 Appetite: 3 x 3 = 9


0

2

4

6

8

10

12

14

16


Risk Score

Risk appetite


Rationale for risk appetite: Consequences of capacity problems can have significant impact on patient experience and these need to be mitigated with effective planning and partnership work

STHFT continues to experience difficulties in relation to 18 week performance (incompletes), diagnostics and A&E. SCH also performance concerns in respect to diagnostic 6ww. Projected improvements in relation to 18ww have not been achieved for STH. Ongoing performance discussions and contract levers are being employed to address. Ambulance response times require improvement. Recovery plans for areas of concern have been requested and are being implemented through various mechanisms. A review of performance oversight processes is underway.

Existing Controls: (What are we doing about the rist prior to any new mitigating actions?) System Resilience Group exists for Sheffield with all relevant partners as core members. Partnership work established through the Right First Time Programme continue to oversee patient flow at STHFT. Recovery Plans exist for both STHFT and SCHFT on achievement of the 18 week performance measure. Quarterly and monthly performance monitoring and

Existing Gaps in Control: (Where are we failing to put controls in place and what more should be done?) None

Mitigating actions: (What new controls are to be put in place to address Gaps in Control and by what date?) Action Date Formal Performance Escalation process enacted at Director level between CCG and STHFT with remedial action plans requested for 18 weeks and A&E Nov‐15 Winter Plans developed across the Health & Social care system agreed at SRG & by Chief Executves across the system Oct‐15 Ensure membership on Urgent Care Network April 2015 Internal Performance Intelligence Meeting established to oversee provider quality and performance issues April 2015 A&E recovery Plan received from STH May 2015 Commissioner representation on the steering group overseeing the STHFT improvements to A&E provision April 2015 System resilience plans reviewed (14/15) and plans for 15/16 established Sept 2015 Contractual mechanisms enacted with local provider in relation to 18 week performance and action plans received. June 2015 Assurances: (Where should we find the evidence that controls are effective?) • Quality & Outcomes Report to Governing Body, SRG Minutes •Monitored through Performance Intelligence Meeting

Positive Assurance: (Provide specific evidence of Assurances) • Quality & Outcomes Report to Governing Body

Gaps in assurance: (Where are we failing to gain evidence that our controls are effective?) No current gaps – to be reviewed


4

Principal Objective: To improve the quality and equality of healthcare in Sheffield Director Lead: Chief Nurse: (Kevin Clifford)

Principal Risk: 2.1 Providers delivering poor quality care and not meeting quality targets. Date last reviewed: 12 November 2015

Risk Rating: 10 Rationale for current score: (likelihood x The impact of the Francis (2) has been reviewed by Sheffield

Initial: 3 x 3 = 9

consequence)

6

8 Risk Score

providers and the CCG requires assurance that the culture of services that we commission continues to be focused on the safety and wellbeing of patient/service users.

Current: 4 2 x 3 = 6 Risk Rationale for risk appetite: Appetite: 2 appetite To ensure that the consequence is moderate and although there will 2 x 3 = 6

0 Initial Risk Rating Current Risk Rating

always be risks to patient safety and poor quality care, that the impact on patient outcomes and experience is as low as possible.

Existing Controls: (What are we doing about the risk prior to any new mitigating actions?) National and Local Policy/ regulatory standards; CQC regulations, SI, Infection Control, Safeguarding procedures, NICE/Quality Standards, Patient Surveys, Quality standards in Contracts, Contract Quality Review Groups

Existing Gaps in Control: (Where are we failing to put controls in place and what more should be done?)

Mitigating actions: (What new controls are to be put in place to address Gaps in Control and by what date?) Date

Assurances: (Where should we find the evidence that controls are effective?) Positive Assurance: (Provide specific evidence of Assurances) • CQC inspections of providers and provider action plans, provider data and annual • Quality Assurance Committee Minutes, Serious Incident reports, reports SI investigation reports, Serious Case Reviews, Clinical Audit reports, Safeguarding reports, Monthly Governing Body Infection control,Patient Infection Control reports, Internal audit benchmarking data, provider Governance Experience /Complaints reports, data on quality targets, exception reports to Meetings, site visits, CCG Commissioning Groups, CCG quality dashboards. Governing Body Quarterly The CCG commissioning for quality strategy has

now been adopted by Governing Body in April and sets out our controls and action for Quality improvement.

Gaps in assurance: (Where are we failing to gain evidence that our controls are effective?) No


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Principal Objective: To improve the quality and equality of healthcare in Sheffield Director Lead: Tim Furness: Director of Business Planning and Partnerships

Principal Risk: 2.2 CCG unable to influence equality of access to healthcare because insufficient or ineffective mechanisms to change


Risk Rating:



0

2

4

6

8

10


Risk Score

Risk appetite


Rationale for risk appetite:

There are contractual obligations in place and providers have obligations under the Equality Act. However, data to assess equality of access to services is poor and no specific contractual processes have been put in place yet to measure and if necessary remedy shortcomings.

The consequence of the risk cannot be mitigated, but we should be able to improve data and then establish processes for measuring and remedying problems.

Mitigating actions: (What new controls are to be put in place to address Gaps in Control and

Equality of access is discussed with providers through the equality engagement group

Existing Controls: (What are we doing about the risk prior to any new mitigating actions?)

by what date?)

Little contractual discussion. Insufficient data to understand how people with protected characteristics access services


Action Date Develop the collection of equality data across all commissioned services 31/10/2015 Collect patient experience information on barriers to access or inequalities 31/12/2015 Highlight equality of access in contracting intentions, to ensure discussion in 2016/17 negotiations 31/12/2015

Assurances: (Where should we find the evidence that controls are effective?) Equality reporting to GB and published in website

Positive Assurance: (Provide specific evidence of Assurances)


controls are not yet in place to provide assurance on


6

Principal Objective: To work with Sheffield City Council to continue to reduce health inequalities in Sheffield Director Lead: Director of Business Planning & Partnerships: (Tim Furness)

Principal Risk: 3.1 CCG is unable to undertake the actions, and deliver the outcomes from them, that are set out in the HWB's plan for reducing health inequalities, eg due to financial constraints.


Risk Rating:



0

2

4

6

8

10


Risk Score

Risk appetite


Rationale for risk appetite: We should not commit to actions we cannot deliver, especially within the HWB partnership, and therefore need to take steps to ensure we can deliver.

The HWB has developed a plan to reduce health inequalities (which the CCG is party to). Given the scale of the challenge, it is possible that the actions for the CCG will prove difficult to achieve.

Existing Controls: (What are we doing about the risk prior to any new mitigating actions?) HWB Plan considered and agreed by GB CCG specific plan agreed by GB January 2015 and part of overall commissioning plan, and will be reported on alongside other commissioning projects

Existing Gaps in Control: (Where are we failing to put controls in place and what more should be done?) Health Inequalities Action Plan not within scope of the PMO

Mitigating actions: (What new controls are to be put in place to address Gaps in Control and by what date?) Action Date Include health inequalities actions within PMO scope, ensuring effective project management and reporting 30/06/2015 review approach to health inequalities with city council and other partners, asa part of SCC's review of Public Health 28/02/2016

Assurances: (Where should we find the evidence that controls are effective?) Positive Assurance: (Provide specific evidence of Assurances) Delivery reports on the plan to CET as part of programme approach CCG performance reports

Gaps in assurance: (Where are we failing to gain evidence that our controls are effective?) We do not yet have positive assurance as reporting on these actions has not yet started.


7

Principal Objective: To ensure there is a sustainable, affordable healthcare system in Sheffield Director Lead: Director of Finance: (Julia Newton)

Principal Risk: 4.1 Financial Plan with insufficient flexibility to meet changing demands. Date last reviewed: 21 December 2015

Risk Rating:



0 2 4 6 8

10 12 14 16 18


Risk Score

Risk appetite


Rationale for risk appetite: Stress testing of forecast out‐turn in different scenarios with contingency plans should give us the confidence that we can deliver required 1% surplus.

Final Plan to deliver required 1% surplus submitted April. Substantial financial risks and challenges remain based on M8 results ‐ notably volatility in prescribing spend forecasts and uncertainty on both elective and emergency hospital admissions. Various mitigating actions agreed by CET and Gov Body in October and work ongoing to deliver.

Existing Controls: (What are we doing about the rist prior to any new mitigating actions?) Plans scrutinised by Governing Body; detailed monthly financial reports to Governing Body; CCG has SOs, Prime Financial Policies and other detailed financial policies and procedures


Mitigating actions: (What new controls are to be put in place to address Gaps in Control and by what date?) Action Date CET continues to have regular updates on delivery of QIPP and mitigating actions monthly

Assurances: (Where should we find the evidence that controls are effective?) • NHS E review of financial plan and monthly review of in year financial position; reviews on financial systems/processes by internal and external audit; external audit VFM reviews

Positive Assurance: (Provide specific evidence of Assurances) • Monthly reports to Governing Body

Gaps in assurance: (Where are we failing to gain evidence that our controls are effective?) None.


8


Principal Risk: 4.2 Risk management and other governance arrangements put in place by CCG and SCC to manage c£270m Better Care Fund to budget prove inadequate

Date last reviewed: 21 December 2015

Risk Rating: (likelihood x

14 Rationale for current score: SCC and CCG have ambitious integrated commissioning programme,

consequence) 12 but major changes (and savings) will take time to implement. Agreed

Initial: 10 Risk Score

budgets for 15/16 including £9.3m of NR funding and contingency reserves to allow delivery against budget. M8 results show BCF

3 x 4 = 12

4

6

8

Risk

overspends which are not entirely covered by contingency reserves but mitigating actions taking place and in year consequence considered to be no more than moderate . Work continues on medium term financial plan.

Current: 3 x 3 = 9

2 appetite

Rationale for risk appetite: Appetite: 0 CCG needs to get to a position that can press ahead with service 2 x 3 = 6 Initial Risk Rating Current Risk Rating redesign with confidence. Assessed as risk score of 6

Existing Controls: (What are we doing about the risk prior to any new mitigating actions?) Section 75 agreement in place from 1 April with risk management arrangements and monthly meeting of a joint Executive Mgt Group. Montly budget monitoring to this group + Governing Body to allow escalation and resolution of issues.


Mitigating actions: (What new controls are to be put in place to address Gaps in Control and by what date?) Action Date Completion of longer term financial planning and scenario planning by both partners on back of Deloitte report Ongoing

Assurances: (Where should we find the evidence that controls are effective?) HWBB minutes; Minutes of Executive Mgt meetings. Continuation of Governance & Finance working group if required

Positive Assurance: (Provide specific evidence of Assurances) • Updates monthly to Executive Mgt Group and Governing Body.

Gaps in assurance: (Where are we failing to gain evidence that our controls are effective?) N/A


9


Principal Risk: 4.3 Budgetary constraints faced by NHS England in particular re specialised services and primary care contracts adversely impact on CCG's ability to implement our plan.

Date last reviewed: 21 December 2015

Risk Rating:

Initial: 3 x 3 = 9



0

1 2 3 4

5 6 7 8

9 10


Risk Score

Risk appetite



For 15/16 financial risk has been brought down to 6 given our better understanding of impact for current financial year. Risk for 2016/17 will need to be re‐assessed once we have clarity on CCG allocations including "real" allocations for primary care (assuming level 3 co‐commissioning) and indicative for specialised. At Dcember 2015 still looking at implications of PMS premium redsitribution and in particular funding for practices where agreed a "special case" exists.

CCG needs to have a position where we are confident that we can work in partnership with NHS E on these areas to develop local health economy and services appropriately.

Existing Controls: (What are we doing about the rist prior to any new mitigating actions?) Joint contracting processes with NHS England. Joint strategy document on primary care and working together to understand/manage impact of changes to core contract funding. More active joint working. Establishment of Specialised Commissioning Oversight Group from September 2014.

Existing Gaps in Control: (Where are we failing to put controls in place and what more should be done?) None

Mitigating actions: (What new controls are to be put in place to address Gaps in Control and by what date?) Action Date

Implement actions re any agreed "special cases" From December 2015

Assurances: (Where should we find the evidence that controls are effective?) • NHS E led reviews

Positive Assurance: (Provide specific evidence of Assurances) • Monthly finance reports to Governing Body

Gaps in assurance: (Where are we failing to gain evidence that our controls are effective?) None.


10

Principal Objective: To ensure there is a sustainable, affordable healthcare system in Sheffield Director Lead: Director of Business Planning & Partnerships: (Tim Furness)

Principal Risk: 4.4 Inability to secure partnerships with our main providers that help us to deliver our commissioning plans, including QIPP.


Risk Rating:



0

2

4

6

8

10


Risk Score

Risk appetite


Rationale for risk appetite: We should aspire to establish relationships with partners that mean that it is most unlikely that those partnerships do not help us deliver our plans.

The CCG has developed partnerships over the last 12 months, within Sheffield and across SY and Y&H, which have established common priorities and workplans. However, our detailed plans are not yet so aligned that we can be confident our specific commissioning plans will be supported

Existing Controls: (What are we doing about the risk prior to any new mitigating actions?) Partnership structures ‐ HWB, Right First Time & Future Shape Children’s Services, SYCOM & CCGCOM, Integrated Commissioning. Draft 5 year vision for health community. Agreement about future role of RFT, reflecting integrated commissioning. System resilience work.

Existing Gaps in Control: (Where are we failing to put controls in place and what more should be done?) There is no formal process in place to align detailed plans of organisations in the health and social care system.

Mitigating actions: (What new controls are to be put in place to address Gaps in Control and by what date?) Action Date Further development of joint five year vision for healthcare in Sheffield with FTs and publication of the vision through RFT and HWB Sept 15

Dec 15 ‐March 16

Development of whole commnuity plans for 2016/17 planning round

Assurances: (Where should we find the evidence that controls are effective?) Reports on RFT and FSC programmes, reports on integrated commisisonig programme

Positive Assurance: (Provide specific evidence of Assurances) • Monthly performance reports demonstrate progress of partnerships on key QIPP and other priorities

Gaps in assurance: (Where are we failing to gain evidence that our controls are effective?) Currently we do not have confirmation of alignment of detailed plans, or consider FTs' business plans at GB


11

Principal Objective: To ensure there is a sustainable, affordable healthcare system in Sheffield Director Lead: Katrina Cleary

Principal Risk: 4.5 Contractual and financial constraints facing local practices resulting in an inability of some practices to deliver existing non‐core work and/or expand service provision as envisaged in commissioning plans.

Date last reviewed:

11 November 2015

Risk Rating:

Initial: 3 x 4 = 12



0

2

4

6

8

10

12

14


Risk Score

Risk appetite



Decision by Governing Body in July 2015 on way forward re PMS premium but special cases will not be reviewed until September 2015. Level of workload in general practice remains high and business cases such as those under Active Support and Recovery and CASES have still be fully developed to potentially support transfer of resources to primary care.

Delivering more services in community setting is a stated aim of the CCG and General Practice is a key facet of this. The CCG would aspire to see more services delivered by these providers in a way that does not detrimentally impact on the wider system.

Existing Controls: (What are we doing about the rist prior to any new mitigating actions?) Currently control is affected by joint discussions with NHSE in an attempt to influence their contractual decisions. Joint practice visits take place where an immediate and significant risk is identified. In 2014/15 the SY&B CCGs plan to submit an expression of intrest to NHSE to secure formal delegated responsiblities for key aspect of general practice contracts. NHSE, following publication of recent guidance on GMS/PMS finances are now working more closely with local CCGs to understand their preferred strategic approach.

Existing Gaps in Control: (Where are we failing to put controls in place and what more should be done?) The key gap is currently the responsibility for how general practice contracts are managed by NHS England with limited "join up" to the wider implications to services and financial risk within the CCG.

Mitigating actions: (What new controls are to be put in place to address Gaps in Control and by what date?) Action Date Complete review of PMS premium "special cases" Nov 15

Implement contract variations for use of PMS premium Oct 15

Assurances: (Where should we find the evidence that controls are effective?) July GB Paper

Positive Assurance: (Provide specific evidence of Assurances) July GB Paper



12

Principal Objective: To ensure there is a sustainable, affordable healthcare system in Sheffield. Director Lead: Director of Business Planning and Partnerships (Tim Furness)

Principal Risk: 4.6 Provider development required to deliver new models of care and achieve CCG stated outcomes does not happen.


Risk Rating:



0

2

4

6

8

10

12

14


Risk Score

Risk appetite



Although work has started, through development of the "vanguard" new models of care bid, much work is needed, across all organisations, to agree how care should be delivered in future.

If we are to achieve our aims, we must work with providers to ensure they are able to deliver the type of support and care that people will need

Existing Controls: (What are we doing about the risk prior to any new mitigating actions?) Development of the vanguard bid Work with partners to develop 5 year vision

Existing Gaps in Control: (Where are we failing to put controls in place and what more should be done?) We do not yet have a clear and agreed view of the new models of care and therefore do not yet have a development plan to achieve the necessary changes

Mitigating actions: (What new controls are to be put in place to address Gaps in Control and by what date?) Action Date Work with partners to develop the 5 year vision Sept 15

Ensure consideration of provider development is part of that work Sept 15

Work with providers to agree new models of care to deliver Active Support and Recovery service, and plan to establish those 31/12/2015

Assurances: (Where should we find the evidence that controls are effective?) Positive Assurance: (Provide specific evidence of Assurances)

Gaps in assurance: (Where are we failing to gain evidence that our controls are effective?) Because this work is at an early stage we have no reporting mechanism in place yet.


13

Principal Objective: Organisational development to ensure the CCG can achieve its aims and objectives and meet national requirements.

Director Lead: Interim Chief Operating Officer: (Rachel Gillott)

Principal Risk: 5.1 Unable to secure timely and effective commissioning support to enable us to adequately respond and secure delivery to existing and new emerging requirements.


Risk Rating:



0

2

4

6

8

10

12

14


Risk Score

Risk appetite


Rationale for risk appetite: Effective commissioning capacity is essential for effective working of CCG . Suite of business cases which identify future commissioning arrangements has now been completed and approved in principle or fully by NHSE. Draft MoUs have now been developed for all shared delivery models.

Current Commissioning Support Arrangements are under review and going through significant change. The commissioning landscape continues to evolve, including integrated commissioning with the LA and the CCG has adopted ambitious commissioning plans to support service transformation. New and emerging initiatives will also need to be responded to as they develop.

Existing Controls: (What are we doing about the risk prior to any new mitigating actions?) Review of current externally sourced commissioning support arrangements are being reviewed and working with commissioning partners across South Yorkshire & Bassetlaw as well as Yorkshire and Humber to ensure sustainable model of commissioning support. PMO arrangements in place to approve project mandates for internal programme priorities. Specific capacity sourced for current priorties.

Existing Gaps in Control: (Where are we failing to put controls in place and what more should be done?) Further work to identify explicit staff within new support arrangements to support mobilisation of new arrangements.

Mitigating actions: (What new controls are to be put in place to address Gaps in Control and by what date?) Action Date Develop Implementation plans for the range of outcomes of the IT Procurement Process via the LPF Dec‐15 Proposal for new future commissioning support arrangements to be presented to Governing Body May 2015 Implement new arrangements and secure transition from current to future model of provision May onwards Development of a capacity and resourcing approach for internal approvals of commissioning priorities July 2015 Identification of CCG requirements for commissioning support services has been completed with majority of business cases for new support arrangements now approved fully or in principle by NHSE. Ongoing procurement for IT and BI services due to be completed September 2015. Sep‐15 Assurances: (Where should we find the evidence that controls are effective?)

CET Approvals Group and Programme Management Delivery Group via Governing Body papers

Governing Body Paper/Minutes Positive Assurance: (Provide specific evidence of Assurances) Minutes of CET & CET Approvals Group and via Governing Body papers

Gaps in assurance: (Where are we failing to gain evidence that our controls are effective?) Currently working with NHSE to identify alternative commissioning support arrangements.


14


Director Lead: Medical Director (Zak McMurray)

Principal Risk: 5.2 Inability to secure active participation particularly from Member Practices for delivering CCG priorities.


Risk Rating: 14 Rationale for current score: (likelihood x consequence)

12 Active engagement at locality level needed, with clear governance structure into the Clinical Executive Team (CET).

Initial: 10 Risk Score All 88 practices have signed the constitution. Active Clinical Reference Group (CRG).

3 x 4 = 12 8 Comprehensive OD plan in place. Current: 6

3 x 4 = 12 4 Risk Rationale for risk appetite: Appetite:

2 appetite Service transformation requires high take up from clinicians and with mechanisms in 2 x 3 = 6

0 Initial Risk Rating Current Risk Rating

place for engagement, as part of our organisational development strategy, will reflect CCG working practices.

Existing Controls: (What are we doing about the risk prior to any new mitigating actions?) Clinical directors now in place with executive role within CET giving clear clinical direction for the organisation. Regular engagement with practices. OD Strategy includes clinical engagement and member practice engagement at its core. CCG Structure includes GP involvement at Governing Body and its associated Committees, CET, CRG and H&WB Board. Localities also collaborate through the Citywide Locality Group where membership includes links to the commissioning portfolios and CET. Allocation of an Executive Lead for each locality should improve engagement with the senior management team.


Mitigating actions: (What new controls are to be put in place to address Gaps in Control and by what date?) Action Date CCG Head of Governance & Planning to review the City Wide Localities Group (CLG) and Locality Executive Groups (LEG) ToRs and Committee Structure to ensure that it supports active engagement at localtiy level C/w Locality group meetings now attended by Medical Director and Clinical Directors whenever possible

August 2015

Work with Communicaitons and OD teams to develop robust engagement approaches Ongoing Assurances: (Where should we find the evidence that controls are effective?) Positive Assurance: (Provide specific evidence of Assurances) • Governing Body Reports 2) OD Steering Group Minutes 3) OD Evaluation Reports Improving Communications and Engagement with Member Practices (July 15) to OD Steering Group 4) Response to Election Process 5) OD strategy Equalisation of Core General Practice Finances ‐ EOGB meeting 16.07.15

Positive evaluation from October Members Council Meeting Minutes from city‐wide locality group meetings

Gaps in assurance: (Where are we failing to gain evidence that our controls are effective?) none


15


Director Lead: Director of Business Planning and Partnerships (Tim Furness)

Principal Risk: 5.3 Inadequate adherence to principles of good governance and legal framework leading to breach of regulations and consequent reputational or financial damage.


Risk Rating:



0 0.5 1

1.5 2

2.5 3

3.5 4

4.5


Risk Score

Risk appetite



Robust arrangements are now in place.

Authorisation is dependent on robust constitutional arrangement

Existing Controls: (What are we doing about the risk prior to any new mitigating actions?) OD strategy to strengthen governance systems and processes. Stringent policies in place to safeguard against conflict of interest. OD session Jan 14 on GB members' role. Explanatory statement now added to committee agendas and explicit discussion regarding percieved

Existing Gaps in Control: (Where are we failing to put controls in place and what more should be done?) no gaps

Mitigating actions: (What new controls are to be put in place to address Gaps in Control and by what date?) Action Date Continual review of governance arrangements, especially with regard to integrated commissioning, co‐commissioning with NHSE establish primary care committee to ensure appropriate mechansims for decisions that can't be taken at GB 30/9 review of conflicts of interest policy and procedures, following concerns raised by national issues 31/08/2015 Assurances: (Where should we find the evidence that controls are effective?) • Endorsement by NHS E of Constitution • Forward Planners • OD event evaluations • Governance Structure including Members Council and LEGs

Positive Assurance: (Provide specific evidence of Assurances)

• Management of Conflicts of interest noted at all meetings • Review of constitution

Gaps in assurance: (Where are we failing to gain evidence that our controls are effective?) No gaps


16

Gaps in Control and Assurance

as at 21 December 2015

If your risk has a red box it needs filling in, once you have done so it will turn white. Grey boxes don't need filling in.

Strategic Objective Principal Risk identified Risk Owner Risk Initial Score

Risk current Score


Score

Are there GAPS in control?

Reason for Gap in Control Action taken to reduce Gap in Control

Are there Gap in

Assurance?

Reason for Gap in Assurance Action taken to reduce Gap in Assurance

1. To improve patient experience and access to care

1.1 Insufficient communication and engagement with patients and the public on CCG priorities and service developments, leading to loss of confidence in CCG decisions.

TF 9 9 6 No no

1.2 System wide or specific provider capacity problems emerge to prevent delivery of NHS Constitution and/or NHS E required pledges. RG 15 15 9 No No

2. To improve the quality and equality of healthcare in Sheffield

2.1 Providers delivering poor quality care and not meeting quality targets. KC 9 6 6 No No

2.2 CCG unable to influence equality of access to healthcare because insufficient or ineffective mechanisms to change

TF

Current lack of data and contractual levers

Plans in place to improve data collection and ensure equality features in contract negotiations

Controls not yet in place to provide assurance on

Controls being put in place

9 9 6

yes yes

3. To work with Sheffield City Council to continue to reduce health inequalities in Sheffield

3.1 CCG is unable to undertake the actions, and deliver the outcomes from them, that are set out in the HWB's plan for reducing health inequalities, eg due to financial constraints.

TF

Health Inequalities plan not in scope of PMO so not being reported on

To be brought in to scope Control not yet in place to provide assurance on

Controls being put in place

9 6 3 yes yes

4. To ensure there is a sustainable, affordable healthcare system in Sheffield.

4.1 Financial Plan with insufficient ability to reflect changes to meet demands. JN 16 16 6 No No

4.2 Risk management and other governance arrangements put in place by CCG and SCC to manage c£270m Better Care Fund to budget prove inadequate JN 12 12 6 No No

4.3 Budgetary constraints faced by NHS England in particular re specialised services and primary care contracts adversely impact on CCG's ability to implement our plan. JN 9 9 6 No No

4.4 Inability to secure partnerships with our main providers that help us to deliver our commissioning plans, including QIPP. TF

Current lack of formal joint planning process

Joint work on future of health and social care

Need process in place to report upon, to provide assurance

Being put in place

9 9 6 Yes Yes

4.5 Contractual and financial constraints facing local practices resulting in an inability of some practices to deliver existing non‐core work and/or wxpand service provision as envisaged in commissioning plans. KCl

Locally Commissioner Service not yet offered to practices. Special Cases process not yet complete

Develop a Locally Commissioned Service to offer all practices. Complete special cases

Process is ongoing and not yet complete

Once LCS offered and signed up to by practices and oncethere is clarity on outcome of the 12 12 6 Yes Yes

4.6 Provider development required to deliver new models of care and achieve CCG stated outcomes does not happen TF

Have not yet established a clear view of the new model

Being developed through integrated commissioning work12 12 4 yes no

5. Organisational development to ensure

CCG meets organisational health

and capability requirements set out in the 6 domains (Annex C

NHS England CCG Assurance Framework)

5.1 Unable to secure timely and effective commissioning support to enable us to adequately respond and secure delivery to existing and new emerging requirements.

RG 12 9 6 No No 5.2 Inability to secure active participation particularly from Member Practices for delivering CCG priorities. ZM 12 12 6 No No

5.3 Inadequate adherence to principles of good governance and legal framework leading to breach of regulations and consequent reputational or financial damage.

TF 4 4 4 No No

Documents

NHS Sheffield CCG US... · f l r UUppdatee on Goovverningg Bodyy Assurance Frammeework and Risskk Register GGooveerningg Boddy meettingg I . 114 JJannu aryy 22016 Author(s)) Suue