Quarter /19 Diane Sankey, Governance, Risk & Complaints Manager

Transcription

1 NHS BOLTON CLINICAL COMMISSIONING GROUP Public Board Meeting AGENDA ITEM NO: 12 Date of Meeting: 27 July 2018 TITLE OF REPORT: AUTHOR: PRESENTED BY: PURPOSE OF PAPER: (Linking to Strategic Objectives) LINKS TO CORPORATE OBJECTIVES (tick relevant boxes): RECOMMENDATION TO THE BOARD: (Please be clear if decision required, or for noting) COMMITTEES/GROUPS PREVIOUSLY CONSULTED: REVIEW OF CONFLICTS OF INTEREST: VIEW OF THE PATIENTS, CARERS OR THE PUBLIC, AND THE EXTENT OF THEIR INVOLVEMENT: OUTCOME OF EQUALITY IMPACT ASSESSMENT (EIA) AND ANY ASSOCIATED RISKS: Board Assurance Framework Quarter /19 Diane Sankey, Governance, & Complaints Manager Su Long, Chief Officer This paper provides details of the strategic, financial and operational risks associated with achieving Bolton CCG s 2018/19 objectives and provides assurance to the governing body that risks are effectively identified and monitored. Corporate risks assessed as High (15 or above) are routinely reported to the Board and these are referred to in Q1 report. Deliver Year 3 of the Bolton Locality Plan. Ensure compliance with the NHS statutory duties and NHS Constitution. Deliver financial balance. Regulatory Requirement. Standing Item. The Board is asked to accept the Board Assurance Framework and the assessment of strategic and high level corporate risks for Q1 (1 st April to 30 th June 2018) Clinical & Associate Directors Chief Officer and Chief Finance Officer Executive Committee Conflicts of interest reviewed throughout the review process s identified as a result of patient complaints, incidents or service user feedback are added to the Register if necessary and managed as part of the Assurance Framework as appropriate. This standard report relates to risks identified by the CCG and has been considered against the criteria of EIA. EIAs may be necessary for some objectives/risks and these will be considered on an individual basis 1

2 Board Assurance Framework and s Quarter /19 1 Executive Summary 1.1 There were 16 risks included in the CCG Board Assurance Framework for 2018/19. These have been assessed by Executive leads/risk owners and reviewed by the Executive Committee. 1.2 There were 6 high risks included in Q1 BAF and these are highlighted in the BAF dashboard attached. 1.3 Full details of each risk and mitigations in place are attached. 1.4 Other risks included in the corporate risk register on Q1 with a risk score of 15 or above are also outlined in this report /19 Bolton CCG Objectives 2.2 BAF s for 2018/19 are summarised in the BAF dashboard below. 2.2 BAF s for 2018/19 are summarised in the BAF dashboard below. 2

3 3 Other key issues from corporate risk register Quarter / There were 4 high risks on the corporate risk register in Q1 outlined below. They do not relate to the Clinical Commissioning Group s operational issues but are external risks. Ref Description Score 240 Potential closure or suspension of care homes due to Regulator concerns/financial sustainability Failure to meet infection control targets (Cdiff and MRSA targets) A&E resilience and failure to meet 4 hour 95% target NWAS response times and ambulance handover targets not met for 2018/ Recommendations 3

4 4.1 NHS Bolton Clinical Commissioning Group Governing Body Board is asked to: Accept the Board Assurance Framework and note the high level corporate risks for Q1/Year end. Name of person presenting the paper: Title: Su Long, Chief Officer Date: 27 July

5 Number: R1 Owner: Ian Boyle Failure to meet NHS Financial balance in 2018/19 Current 12 Quarter: Q1 April - June Last Review Date: 26/06/2018 Financial Plan submitted and signed off by CCG Board Detailed monthly reports and presentations to Executive Cttee, Finance & QIPP Committee and monthly monitoring reports to Board Joint Bolton System Financial Position report to F&Q Cttee IBCF spending plans monitored via Joint Commissioning Board Bolton FT DoF and LA Treasurer attendance at F&Q Cttee and Bolton Finance Leads meeting monthly Summary QIPP reporting to NHS England Area Team CCG CFO attendance at BFT Finance and Investment Committee Finance and QIPP reports to Board Detailed monthly reports and presentations to Executive Cttee Further NHS England decisions impacting on CCG allocations Unexpected overperformance in Independent sector and non-bolton FT Acute Providers Detailed analysis and review of contract position and action plan to be reported through Finance, Activity and QIPP group Financial position of whole Bolton system reported through individual governance structure and with system wide senior committee oversight with partners from key organisations

6 Number: R2 Owner: Melissa Laskey Failure to consistently meet NHS Constitutional targets Current 16 Quarter: Q1 April - June 18/19 Last Review Date: 28/06/2018 Quarterly assurance process with GM Health and Social Care Partnership (GMHSCP) CCG Improvement and Assessment Framework (IAF), with quarterly reporting to aid benchmarking and identifying areas for improvement System Sustainability and Transformation Board (SSTB) - meeting of senior leaders from system partners to discuss system transformation and performance Monitoring of performance against Locality Plan and Investment Agreement monthly through SSTB Performance against NHS Constitutional targets reported monthly through Corporate Performance Report to CCG Board Additional deep dives at Board on areas of performance concern Ongoing monitoring through Quality and Performance Groups with providers, with deep dives where required Bolton Quality Contract in place 2018/19 operating plans agreed and aligned to Investment Agreement and Bolton FT and GMMH plans to support achievement of Constitutional targets Joint QIPP plans across Bolton FT and CCG to encourage service re-design Quality and Safety Committee Collaborative Capacity and Demand Programme overseen by Planned Care Strategy and Planning Group Urgent and Emergency Care Board Service re-design projects in Urgent and Emergency Care to reduce demand and improve patient experience e.g. ED streaming Monthly Corporate Performance Report to Board with deep dive into key areas when required for assurance System performance dashboard presented to SSTB CCG IAF reported quarterly Lack of consistent assurance on data quality and robust data intelligence to monitor variance from plan Lack of detailed trajectories for performance improvement and activity changes at speciality level Locality Plan and Transformation Fund projects are required to demonstrate impact in Investment Agreement Development of detailed trajectories and action plans as part of CCG/FT capacity and demand work In depth monitoring of Bolton Locality Plan including actual activity against plan, financial impact and health and wellbeing outcomes Fully implement robust contractual management (including counting and coding) for all GM providers, including independent sector Quarterly assurance process with GMHSCP Quarterly CCG IAF reports Monthly Corporate Performance Report Monthly monitoring of QIPP plans jointly across FT and CCG Performance dashboards at Strategy and Planning Group level reviewed monthly Monthly tracking of capacity and demand, including backlog through Planned Care Strategy and Planning Group

7 Number: R3 Owner: Melissa Laskey Locality Plan Transformation Fund schemes do not deliver planned outcomes Current 12 27/06/2018 Joint governance for monitoring system activtiy vs plan and health and wellbeing outcomes Monthly monitoring in place at scheme level and reported via Locality PMO to System Sustainability and Transformation Board (SSTB) Joint governance in place for reporting via Strategy and Planning Groups with senior committee oversight with partners from key organisations Detailed evaluations completed for majority of TF schemes, with emphasis on benefits realisation and demonstrating outcomes 2018/19 operating plans aligned with Investment Agreement for streamlined reporting and monitoring Shadow Partnership Board bringing together senior leaders from across system partners Monthly programme update to SSTB Monthly system dashboard to SSTB, detailing health and wellbeing outcomes and activity Regular reporting to Finance and QIPP Committee Bi-monthly highlight reporting to GM Health and Social Care Partnership (GMHSCP) Regular updates on TF projects via relevant Strategy and Planning Group Sustainability of projects post-tf regarding recurrent funding Lack of clear and measurable health and wellbeing outcomes and activity plans for all schemes Lack of robust evaluation for all schemes Complete evaluations to required standard for remaining schemes - meeting between system leaders in July to review submissions and agree next steps Decision regarding future of TF schemes - which ones to commission recurrently and decommission Strengthen KPI reporting - discussions underway between Locality PMO and BI to use outputs from evaluations to inform this and revise dashboards Refresh Investment Agreement for 2018/19 - underway following Exec to Exec with GMHSCP and will be completed by August Reconstitute Strategy and Planning Groups for Primary Care, Care Homes and Integrated Care and Community into a single group, recognising the joint working required in these areas - proposal agreed and terms of reference drafted Monthly dashboard, programme and finance reports to SSTB Bi-monthly highlight reports to GMHSCP TF scheme evaluations

8 Number: R4 Owner: Su Long Reputational: CCG loses trust of Bolton people Current 8 06/07/2018 Lets Make it... Better Bolton campaign ongoing 2018/19 Comprehensive communication and engagement work with public, GPs and stakeholders. Patient engagement and experience reports monitored by Quality and Safety Committee Use of social websites, twitter by CCG and website BQC monitored by Joint Commissioning Cttee Community Engagement (E&D and ETAG) Roadshows and other public events jointly with Bolton Council Good GP Member Practice engagement, GP Events at The Bridge and Clinical Leads meetings Staff briefings throughout 2018/19 CCG Executive oversight System Sustainability & Transformation Board reporting to Health & Wellbeing Exec Patient Engagement reports and updates to Board Monthly patient story to Board CCG rated as 'Good' CCG from Review of CCG gave assurance that stakeholders feel engaged and involved in Locality Plan development Joint communication & engagement strategies to be developed Ongoing public engagement/consultation with staff/gp member practices Joint Communication & Engagement strategies to be developed Ongoing joint stakeholder engagment events, campaigns and Locality Plan Toolkit

9 Number: R5 Owner: Su Long / Stephen Liversedge Lack of engagement from CCG workforce and GP membership Current 6 28/06/2018 Primary Care Joint Commissioning Group Population Health Strategy & Planning Group Co-Design Strategy & Planning Group S&P Groups reporting to System Sustainability & Transformation Board and have operational risk logs in place Patient engagement events and Comms & Engagement roadshows Primary Care Communications & Engagement Strategy in place Joint meeting held CCG & Alliance (CVS & Healthwatch) to agree messages/engagement with patients in neighbourhoods System Sustainability & Transformation Board reporting to Health & Wellbeing Board and Exec Committee oversight and minutes to CCG Board Feedback from Engagement Events to Board None Patient engagement events to be continued throughout 2018 Further develop Comms & Engagement Plan Continue development of staff engagement and support to Locality Plan

10 Number: R6 Owner: Barry Silvert Failure to organise services to meet planned demand Current 16 27/06/2018 System Sustainability and Transformation Board (SSTB) Corporate Performance Report to CCG Board Activity monitoring of performance against Locality Plan and Investment Agreement Robust delivery plans for 2018/19 outlining plans to shift activity from acute to community and reduce demand Bolton Quality Contract in place Joint QIPP plans across Trust and CCG to reduce demand CCG/FT Collaborative Capacity and Demand Programme overseen by Planned Care Strategy and Planning Group Service re-design projects in Urgent and Emergency Care to reduce demand e.g. ED streaming TF projects monitored through relevant Strategy and Planning Group to review shift in activity from acute to community Urgent and Emergency Care Board System performance dashboard presented to SSTB Monthly Corporate Performance Report to Board with deep dive into key areas Quarterly Locality Plan update to Board Lack of consistent assurance on data quality and robust data intelligence to monitor variance from plan Lack of detailed trajectories for performance improvement and activity changes at speciality level Locality Plan and Transformation Fund projects are required to demonstrate impact in Investment Agreement Development of detailed trajectories and action plans as part of CCG/FT capacity and demand work In depth monitoring of Bolton Locality Plan including actual activity against plan and joint demand management plans Non Bolton FT contractual performance management Strengthen KPI reporting for Transformation Fund projects - discussions underway between Locality PMO and BI to use outputs from evaluations to inform this and revise dashboards Transformation Fund Investment Agreement - monitoring of actual activity against plan Corporate Performance Report with high level activity monitoring (actual against plan) Transformation Fund Investment Agreement Monthly monitoring of QIPP plans jointly across FT and CCG Contract performance dashboard reviewed each month jointly by Commissioning and Finance Directorates Performance dashboards at Strategy and Planning Group level reviewed monthly

11 Number: R7 Owner: Stephen Liversedge Lack of resilience and capacity within community services and general practice Current 16 06/07/2018 Primary Care Workforce reform monitored through System Sustainabilty & Transformation Board - includes enhanced Primary Care Workforce i.e. Pharmacists, MSK, Mental Health, Health Improvement Practitioners Primary Care Commissioning Committee Population Health & Prevention Strategy Group Strategic Workforce Board Planned Care Strategy (Demand Management) Recruitment progressing as per Primary Care Strategy & Planning Group Final recruitment phase completed Mental Health practiioners now in post MSK recruited Phased recruitment of HIPs in progess - next planned recruitment Sept 2018 CCG Exec oversight Primary Care workforce monitoring reports to Board System Sustainability & Transformation Board reporting to Health & Wellbeing Exec and Board Shanti Medical Centre - CQC rated inadequate, approx 6000 patients will be affected by potential closure Primary Care MSK to commence Q2 2018/19 Implementation of Primary Care Programme as per Strategy & Planning Group Action Plan Scoping of community services & support requirements at neighbourhood level wrapped around GP Practices to be undertaken (April - Sept 2018) Increase in primary care workforce Pharmacists, Mental Health, MSK and Health Improvement Practitioners in GP Practices by July 2018

12 Number: R8 Owner: Su Long Loss of local services due to system wide workforce shortages Current 12 06/07/2018 Local, national and international recruitment drives for recruitment and retention of doctors, nurses & AHPs in Bolton including return to work and retirement opportunities Strategic Workforce Board overseeing re-designed roles and workforce Care Home & Home Care S&P Group reviewing workforce Joint Leadership Group Safeguarding Intelligence Forum - subgroup of Adult Safeguarding Board Workforce Engagement Forum (system wide) North West Sector working and GM working to develop sustainable service models Task and finish goup focussing on filling difficult gaps, growing our own and Bolton's Employers brand Exploring new health and care roles including generic workers Work underway to map existing workforce and skills and capabilities GM working on developing common terms and conditions of employment System Sustainability & Transformation Board reporting to senior committee oversight with partners from key organisations Strategic Workforce Board CCG Executive oversight Delays in recruitment and upskilling workforce for re-designed roles Lack of joined up working across system on workforce re-design and lack of information sharing Challenges in recruiting from overseas Monitoring of Primary Care Workforce Ongoing recruitment and retention of doctors, nurses & AHPs within the Bolton system Ongoing monitoring of vacant posts Reduction in overseas registrants HR Lead at BFT to provide detailed actions to contain agency use and spend Reduced agency spend/premium spend and number of vacancies Reduced staff turnover and staff sickness

13 Number: R9 Owner: Melissa Laskey Failure of main provider to deliver effective capacity to meet contracted demand 28/06/2018 Current 16 System Sustainability and Transformation Board (SSTB) Corporate Performance Report to CCG Board Executive level contract performance monitoring meeting between CCG and Bolton FT Contract for 2018/19 for Bolton FT based on robust planning and included increased commissioned (and funded) capacity for demographic growth, cancer and other projected activity increases 2018/19 operating plans agreed and aligned across CCG and Bolton FT Joint QIPP plans across Trust and CCG to reduce demand CCG/FT Collaborative Capacity and Demand Programme overseen by Planned Care Strategy and Planning Group with senior leadership from both CCG and FT Joint service re-design projects to reduce demand e.g. ED streaming, advice and guidance Ongoing monitoring through Quality and Performance Group Monthly joint Commissioning and Finance Contract and QIPP meeting to review performance against contract and identify issues to be addressed with Bolton FT Urgent and Emergency Care Board North West Sector working Strategic Workforce Board to address workforce issues posing a risk to service stability and sustainability System performance dashboard presented to SSTB Monthly Corporate Performance Report to Board with deep dive into key areas Monthly Finance Report to Board Additional performance updates to Board when required Lack of consistent assurance on data quality and robust data intelligence to monitor variance from plan Lack of detailed trajectories for performance improvement and activity changes at speciality level Lack of forward planning for future changes in workforce (e.g. retirement), impacting on sustainability of local services Development of detailed trajectories and action plans as part of CCG/FT capacity and demand work In depth monitoring of Bolton Locality Plan including actual activity against plan and joint demand management plans Assurance from Bolton FT on resolving workforce issues with potential to impact on service sustainability Transformation Fund Investment Agreement - monitoring of actual activity against plan Corporate Performance Report with high level activity monitoring (actual against plan) Transformation Fund Investment Agreement Monthly monitoring of QIPP plans jointly across FT and CCG Contract performance dashboard reviewed each month jointly by Commissioning and Finance Directorates Performance dashboards at Strategy and Planning Group level reviewed monthly

14 Number: R10 Owner: Jane Bradford Increase in quality & safety concerns and patient complaints due to deteriortating performance Current 16 06/07/2018 Quality and Safety Committee Quality & Performance Meetings with providers and minutes of these to Quality & Safety Cttee Corporate Performance Report - monthly Incident reporting systems embedded across health economy Significant Incident Review Group and SI Policy in place Compliments, PALS & Complaints Policy Quality & Safety Cttee minutes to Board Corporate Performance and specific quality reports to Board with focus on clinical specialty areas Monthly Patient Experience story to Board Performance data for Q shows continued slippage in several key targets and potential patient safety incidents continue to be received from member practices Quality & Performance concerns identified for Bolton locality include -A&E resilience and targets -NWAS response times and handover targets -Diagnostics -18 RTT -GMMH performance -Potential closure or suspension of nursing and care homes due to regulator concerns or financial stability Continued monitoring via regular Contract & Performance meetings and oversight by Quality & Safety Cttee. Review by Quality & Safety Cttee of performance targets slippage at May 2018 meeting Continued monitoring by Contract, Quality & Performance meetings with Providers. Quality issues included in Quality Matrix and escalated to Q&S Cttee where appropriate. Key quality risks scored 12 or above included on Corporate Register

15 Number: R11 Owner: Su Long Lack of alignment and clarity between GM and local responsibilities Current 12 18/07/2018 Quarterly assurance meetings with GM Health and Social Care Partnership (GMHSCP) Locality engagement with GM level meetings and forums Locality representation on GM work programmes Transformation Fund Investment Agreement Bi-monthly highlight reports to GMHSCP Quarterly Locality Plan and Transformation Fund update GM devolution agreement Lack of clarity from GMHSCP on impact of GM level work programmes on locality activity, demand and performance Impact on locality of GM work programmes to be provided by GMHSCP Review of operating model for GM commenced - opportunity to clarify accountabilities

16 Number: R12 Owner: Su Long Lack of system governance and assurance Current 12 28/06/2018 Bolton Locality Plan Updates and improved reporting from all Locality Plan work programmes to System Sustainability and Transformation Board (SSTB) Transformation Fund Investment Agreement Consistent documentation and monitoring via Locality PMO Joint QIPP work streams agreed with Bolton FT Quality and Performance meetings with providers Health and Wellbeing Board (HWB) and Executive Board development sessions HWB governance review Locality Plan governance via System Sustainability and Transformation Board and Health and Wellbeing Executive Commissioning Partnership Board - Integration Quarterly Locality Plan update to Board Monthly Corporate Performance report to Board - including Locality Plan performance reporting Clear system accountability for Bolton performance Compliance with monitoring processes Complete the review of system governance Establish Shadow Partnership Board for integrated system Regular and transparent system reporting Internal audits of monitoring processes

17 Number: R13 Owner: Su Long Failure to meet expected timescales for ICO delivery Current 12 28/06/2018 Bolton Locality Plan Locality Plan system governance Joint Leadership Group External support and facilitation from The King's Fund Health and Wellbeing Board development sessions and governance review System Sustainability and Transformation Board (SSTB) Executive and Board development sessions and ongoing discussion relating to future direction Development of neighbourhoods LCO peer to peer workshop with other localities Monthly updates to CCG Executive Health and Wellbeing Executive Updates to Board development sessions Quarterly Locality Plan update to Board Reports to Health and Wellbeing Board Quarterly assurance meetings with GMHSCP Proposals for creation of Integrated Care Partnership (ICP) formally taken through CCG and FT Boards and Council Cabinet Formal agreement to ICP - expected early July 2018 subject to Board and Cabinet approval Programme plan and further timescales for implementation of ICP Staff and public engagement Formal agreement to ICP - expected early July 2018 subject to Board and Cabinet approval Programme plan and further timescales for implementation of ICP Ongoing staff and public engagement - comms and engagement plan developed Bi-monthly highlight reports to GMHSCP Quarterly assurance meetings with GMHSCP Regular reports to Board and Health and Wellbeing Executive

18 Number: R14 Owner: Melissa Laskey Failure to meet expected timescales for delivery of joint strategic commissioning function Current 12 28/06/2018 Bolton Locality Plan Shadow Partnership Board System Sustainability and Transformation Board (SSTB) Primary Care Commissioning Committee with MoU in place with NHS England for full delegated commissioning arrangements Commissioning Partnership Board Strategy and Planning Groups for all programme areas, bringing together providers and commissioners across system (includes Council, CCG, Public Health Commissioners) Programme team of senior leaders to progress Strategic Commissioning Function (SCF) Draft terms of reference developed for Shadow Partnership Board and Joint Commissioning Board over time Proposals for creation of SCF approved through CCG and FT Boards and Council Cabinet Budget alignment exercise undertaken to identify areas for expansion of pooled budgets SCF self-assessment undertaken with partners from GM Health and Social Care Partnership (GMHSCP) Bi-monthly highlight reports submitted to GMHSCP including updates on SCF progress Shadow Partnership Board CCG Executive and Board oversight Commissioning Partnership Board Quarterly Locality Plan updates to Board, including the SCF Quarterly assurance meetings with GMHSCP Proposals for creation of SCF approved through CCG and FT Boards and Council Cabinet Programme plan and further timescales for implementation of SCF Expansion of pooled budgets Staff and public engagement Development of programme plan for implementation of SCF Expand formal budget arrangements, supported by a legal framework Ongoing staff and public engagement - comms and engagement plan developed Regular reports via Shadow Partnership Board Bi-monthly highlight reports to GMHSCP Quarterly assurance meetings with GMHSCP

19 Number: R15 Owner: Ian Boyle Estates configuration does not support new models of care Current 16 26/06/2018 Sustainable Development Strategy included in Bolton Locality Plan. Bolton Estates Strategy Bolton Strategic Estates Group - Chairs meet monthly to review operational matters CFO and Bolton FT Senior Estates Lead attend the GM Health & Social Care Partnership monthly Strategic Estates Board meetings Two Memorandum of Understanding between National and GM Bodies GM Bodies to enable GM to work with local partners and Central Government to support delivery of the Estates Strategy CCG Health & Safety Cttee includes rep from NHS Property Services CCG Executive oversight Bolton Strategic Estates Group and update reports to Board Estates concerns escalated to NHS England Funding agreement to Locality Estates requirement by GMH&SCP Funding the revenue consequences of capital CCG Estates oversight group Bolton Estates Strategy now out of date Bolton memorandum of understanding for delivery of services using public sector buildings Building capacity in neighbourhood working model GMH&SCP Capital Finance Strategy implementation Notification of Estates funding from GMH&SCP Team Establish CCG Estates group with GP membership to report into CCG Executive and SEG Review and update Bolton Estates Strategy Develop Bolton MOU through SEG Review all assets within each neighbourhood Long term capital funding to be agreed for the Bolton health economy Improved utilisation of buildings

20 Number: R16 Owner: Ian Boyle Fragmented IT Infrastructure across the Locality 28/06/2018 Current 16 CCG Executive oversight of GMSS delivery IM&T Operational Board GM IM&T Operations board and programme board maintain oversight of performance GM IM&T Assurance group maintain oversight of both groups and of finances NHS Digital national issue, ensure all funding is secured for GM wide system CFO/IMT Leads meeting taken place SIP created Finance & QIPP Cttee - all IT funding now received Regular IT project tracker report to CCG Executive Minutes from GMSS Ops Board & Programme Board submitted to Bolton IM&T Ops Board Monthly Finance reports to CCG Board CCG Executive oversight Bolton Locaility Digital Strategy Lack of Senior Leadership and assurance with implementation of new GP IT Operating Model Locality work underway for long term IT solution Regular IT project tracker oversight by Executive Cttee Monthly Finance reports to Board