Structured Assessment Public Health Wales NHS Trust

Transcription

1 December 2012 Structured Assessment Public Health Wales NHS Trust Summary of findings Document reference: 631A2012 Gabrielle Smith, Tracy Veale, Anthony Ford and Matthew Coe

2 Structured Assessment Year 3 Does the Trust have sound arrangements to ensure effective governance and board assurance and for the efficient, effective and economical use of resources? Internal Control and Board Assurance Management Information Information Governance, including Caldicott Follow-up of progress against areas for improvement identified in 2010 & 2011 Financial Management Workforce Engagement Slide 2

3 Governing the business The Trust has made good progress over the last three years to put in place key arrangements for governance and assurance but these need to be brought together into a coherent and comprehensive framework. The Trust has made progress to address the areas for development identified in previous years. Key components of internal control are in place but there is scope to strengthen the systems for identifying risks and to provide board assurance. Information needs are being clarified with key measures being developed to strengthen management information and to monitor performance across all aspects of business. Comprehensive arrangements are in place to underpin Caldicott requirements, to ensure compliance with Caldicott principles and provide effective oversight. The Trust engages and manages day-to-day finances well, but financial and workforce planning is not clearly linked to strategic delivery plans. Slide 3

4 Follow-up from 2011 The Trust has made progress to address the areas for development identified in previous years. Strategic delivery plans have been developed to underpin the Trust s objectives but there is a lack of clarity about the timescales for delivery, the resource implications and measures of success. The Trust s risk management strategy was approved in July 2012 and work continues to underpin the strategy with risk management policies and procedures and to improve quality and consistency of reporting to the risk management group. The cycle for reviewing all Trust policies is nearing completion, having inherited many policies from its predecessor bodies; legacy policies not scheduled for review are being branded with the Trust s name/logo. An informatics strategy has been approved with implementation driven by an annual action plan. An integrated planning and performance reporting framework is now ready for implementation. Slide 4

5 Internal control The key components of a governance and assurance framework are in place but some areas still need attention. Organisational structures at tier 1 are now complete ensuring strategic leadership across the whole of the Trust s business and the restructuring of the Public Health Development Directorate is nearing completion. The Trust regularly monitors statutory and mandatory training and is making training more accessible eg, e-learning to improve overall compliance. There are arrangements for Putting Things Right and the Trust is working to strengthen the learning from complaints, incidents and claims, which is scrutinised by the Quality and Safety Committee. Slide 5

6 Internal control There are arrangements in place to comply with legislative requirements. a Health & Safety Policy has been implemented and a Health & Safety professional lead recruited; and draft Asbestos Control Policy approved by the Quality & Safety Committee and an asbestos management plan is being implemented. Organisational policies and procedures are in place with the cycle of review nearing completion. Some aspects of the Trust s business are underpinned by robust quality assurance systems for maintaining high standards of practice and safety e.g. CPA and Quality Manuals. Slide 6

7 Internal control While the Trust has systems to identify risks, these may not be sufficiently robust. The Trust s risk management group oversees corporate and divisional risk registers and regularly notifies the Quality and Safety Committee of changes to corporate risks. However, the Corporate Risk Register could be improved by setting out how the identified risks impact on the delivery of strategic objectives or other priorities agreed by the Board. It is not clear when new risks are added to the Risk Register, which may account for the absence of some planned actions for mitigation. There are different reporting formats in use to capture divisional risks. There are a number of long-standing risks on divisional risk registers with little apparent movement in risk score; although this may be wholly appropriate, it is not clear that the controls and planned actions for mitigation have been reviewed for their effectiveness. Divisional risks that could impact on organisation reputation may not always be captured on the Corporate Risk Register. Slide 7

8 Internal control The Trust needs to demonstrate that the various components of its governance and assurance framework are working effectively. Currently, there is no clearly communicated board assurance framework, which sets out how the Board obtains its assurance, although work is underway to address this. it is sometimes unclear how the board agenda and papers feed across to the corporate risks and priorities; and the format of the Board Secretary s report has changed recently to separate governance issues from operational issues, which should provide better oversight. There is no system which brings together key strands of assurance during the year to provide on-going oversight by the Board, and which would support the timely preparation of the Annual Governance Statement and the new Quality Statement. Slide 8

9 Internal control The standards for health services form an essential element of the Trust s overall framework for internal assurance but the on-going monitoring of progress of improvement plans, by either the Risk Management Group or the Quality & Safety Committee, appears absent. the Trust has moved to strengthen oversight of progress against improvement plans as part of the twice yearly divisional reviews. Until recently, regular reporting against strategic objectives/priorities, with the exception of some screening programmes, has been absent. progress against the numerous PLAs was last reported in 2011; and progress against the Trust s Public Health Strategic Framework was last reported in March Slide 9

10 Internal control The Board and Audit Committee have systems to track actions and recommendations and there is evidence that the Trust is making progress against audit recommendations. the Quality & Safety Committee should consider developing an action log to track agreed actions. Although the functions and membership of the board committees are reviewed regularly, there is no evidence that the Board has undertaken a rigorous assessment of its own performance nor assessed the impact of the new Audit Committee handbook. Slide 10

11 Management information Information needs are being clarified with key measures being developed to strengthen management information and to monitor performance across all aspects of business. The Trust is making progress clarifying its information needs. The volume of management information can be overwhelming yet there are gaps in the information that would enhance board assurance. Slide 11

12 Management information The Trust is making progress clarifying its information needs. The Board and its sub-committees continue to clarify their information needs in relation to quality, safety and performance but members acknowledge that they struggle to get the information they need. in early 2012, the Quality & Safety Committee started work to agree information needs; it now receives and scrutinises performance information in relation to BTW, CSW and BSW and for Stop Smoking Wales. Board members are active users of information, seeking clarification and providing an increasing level of scrutiny and appropriate challenge. the ability to interpret and draw conclusions from the information is generally good with relatively few concerns expressed over the reliability of the information. Board papers are frequently for information than for decision, reflecting the nature of the Trust s business; however, it is not always clear what the Board is being asked to consider or why the information is important. A new performance reporting framework is being implemented to ensure that performance is monitored across all aspects of business using robust measures; a new suite of performance reports will be presented to the Board at its December meeting. Slide 12

13 Management information The volume of management information can be overwhelming yet there are gaps in the information that would enhance board assurance. The Board and its sub-committees regularly deal with a large volume of information, often with limited time for adequate scrutiny. Much of the information is descriptive with few papers underpinned by numerical data. There are gaps in information to assess progress against strategic objectives, value for money or the impact of service/programme delivery but the Trust is working to address these gaps. data on resource inputs (financial and human) are absent from divisional or directorate reports but some progress has been made to link costs with activity e.g. Stop Smoking Wales; and as part of the national review of health improvement programmes, the Trust has worked hard to assess the cost effectiveness of health improvement programmes currently delivered and to incorporate user feedback. Management information is insufficiently integrated to provide a rounded view about organisational performance (absence of inputs, outputs or outcomes). Separate reporting makes triangulation of information with service user experience or stakeholder feedback more difficult. Slide 13

14 Information governance and Caldicott Comprehensive arrangements are in place to underpin Caldicott requirements, to ensure compliance with Caldicott principles and to provide effective oversight. Key staff are in place, supported by a virtual network of local contacts. Key information flows have been identified but there is less clarity on the details of individual data ownership. the Trust is taking action using the local information governance contacts to map what person identifiable information is held and by whom and for what purpose and to identify training needs in relation to sensitive information. Arrangements to inform service users how their information is used are also in place but there is little evaluation of the effectiveness. there is a low number of patient requests for access to their data and guidance about access should be more prominently displayed. There are robust arrangements for on-going monitoring and oversight provided by the Information Governance Committee and thence to the Board. Slide 14

15 Information governance and Caldicott Policies and procedures have been implemented to strengthen information governance and work is underway to assess the level of understanding of these. General training is provided for staff on information governance issues, and while it is included in induction programmes in the screening division it is not part of induction in others. Compliance with mandatory training on information governance is improving; the latest figures indicate that compliance is 70 per cent. There was a marked improvement in the C-PIP self-assessment score with evidence that the C-PIP assessment is being used to drive improvement. Slide 15

16 Managing resources The Trust engages and manages day-to-day finances well, but financial and workforce planning is not clearly linked to strategic delivery plans. The Trust continues to maintain sound financial management and is predicting to break-even but there is scope to increase the level of financial information reported to the Board. Workforce planning arrangements are largely unchanged but organisational development is being strengthened. Public and stakeholder engagement appears to be a key strength. Slide 16

17 Financial management The Trust continues to maintain sound financial management and is predicting to break-even but there is scope to increase the level of financial information reported to the Board. The Trust s approach to financial management is broadly sound. Projected cost savings of 2.3 million are being met and a balanced financial year-end position is forecast. The level of financial information presented to the Board could be improved by integrating financial information with strategic delivery plans. Slide 17

18 Workforce Workforce planning is largely unchanged but organisational development is being strengthened. Strategic workforce planning arrangements are largely unchanged since last year. While demand for public health resource is not fully reflected in the Trust s strategic delivery plans, these plans do highlight the training and development needs for successful delivery. At an operational level, workforce implications are clearly set and, as opportunities arise, resources are realigned to support service change. The Trust has concluded the public health service delivery model project to ensure the resource needs of local teams have been addressed. The Trust has established a training and development function to ensure training and development needs are identified and prioritised, as well as monitoring levels of investment. Progress is being made to finalise and implement the strategic delivery plan to underpin workforce and organisational development. Professional fora are being established to bring together professional/clinical staff from across the organisation to discuss common issues. Slide 18

19 Engagement Public and stakeholder engagement appears to be a key strength. The Public and Stakeholder Engagement Strategy, which sets out the principles for engagement, has been finalised and implemented. there are many examples of on-going engagement activities with service users, particularly within screening services; stakeholder engagement is key to the national review of health improvement programmes; and the Trust actively engages its staff in corporate or directorate developments e.g. the restructuring of the Public Health Development Directorate and workshops with staff to develop performance measures. Slide 19

20 Key issues the Board should consider Setting out a coherent board assurance system linked to strategic objectives and priorities and standards for health services. Reassessing information needs and communicating this clearly once the new suite of performance reports are presented to the Board. How it will ensure on-going oversight of governance and quality throughout the year to better help the Trust to produce a robust annual governance statement and a quality statement. An approach to meeting the requirements of the new Audit Committee handbook. Slide 20