Board Assurance Framework - Newham CCG October 2013... · Board Assurance Framework 3.1 Risk profile Risk Identifier Linked to Risk Areas Risk Summary Risk Owner Initial Risk rating

1

Board Assurance Framework

Document information

Version Version 3.0

Reported to To be reported to Newham CCG Board meeting – 09.09.2013

Next review October 2013

Author Luke Moore – Governance and Risk Manager

Chair: Dr Zuhair Zarifa Accountable Officer: Steve Gilvin

2

Contents

2. Purpose and Scope ........................................................................................................... 3

2.1 Board Assurance Framework ...................................................................................... 3

2.2 Risk Management Governance ................................................................................... 3

2.3 Risk Areas ................................................................................................................... 4

2.4 Risk Identifiers ............................................................................................................. 4

3. Board Assurance Framework ............................................................................................ 5

3.1 Risk profile ................................................................................................................... 5

3.2 Risk Area 1- To reduce health inequalities, improve access and reduce variation ........... 6

3.3 Risk Area 2 - To develop Integrated Care, in particular to support improved management

of long term conditions ........................................................................................................ 12

3.4 Risk Area 3 - To ensure robust patient and public engagement is embedded in the

operations of Newham CCG and at all stages of the commissioning cycle .......................... 13

3.5 Risk Area 4 -To ensure that Newham CCG achieves robust financial stability and

balance to supporting effective working and implementation of our plans ........................... 14

3.6 Risk Area 5 - To support quality improvements in primary care services to ensure they

are fit for purpose and able to support the shift in care out of hospital ................................. 18

3.7 Risk Area 6 - To ensure that Newham CCG has transparent and effective corporate and

clinical governance arrangements in place to comply with relevant legislation and mitigate

the risk of non-delivery of strategic objectives ..................................................................... 23

4. How to interpret the Newham CCG BAF ......................................................................... 26

4.1 Risk profile ................................................................................................................. 26

4.2 Full BAF risk entries ...................................................................................................... 27

5. Newham CCG Risk Grading Matrix ................................................................................. 28

3

2. Purpose and Scope

2.1 Board Assurance Framework

The primary purpose of the Newham CCG Board Assurance Framework (BAF) is to:

1) Act as a mechanism for alerting and appraising the Board of the main risks to

achieving to the CCG in terms of achieving strategic objectives as set out in

the Operating Plan

2) List, evaluate and provide assurance to the Board regarding the mitigations in

place to the reduce the likelihood or impact of the risk

3) Summarise to the Board the remedial or proposed actions that further

mitigate the likelihood or impact of the risk

The BAF is also an important document for providing external assurance (to NHS England,

Internal Audit and patients and public) that the CCG is sighted on its risks and has a robust

system of internal control.

A guide to interpreting individual BAF entries is shown at 4. How to interpret the Newham

CCG BAF

The risk scoring matrix to establish initial risk ratings is shown at 5. Newham CCG Risk

Grading Matrix

2.2 Risk Management Governance

Risk Management is embedded in Newham CCG’s Governance Structure:-

The Audit Committee is responsible for scrutinising the group’s Risk Management policies

and procedures. Accountable to the group’s Board, the Committee provides the Board with

an independent and objective view of the group’s financial systems, financial information and

compliance with laws, regulations and directions governing the group in so far as they relate

to finance.

The Executive Committee is responsible for approving internal control arrangements, risk

sharing and pooling agreements.

The Chief Officer is responsible for approving the group’s arrangements for business

continuity and emergency planning.

The Chief Finance Officer is responsible for approving the group’s Counter Fraud, Security

Management and Risk Management arrangements.

The Governing Board is responsible for approving and monitoring the Board Assurance

Framework.

4

2.3 Risk Areas

BAF risks have been categorised into six main risk areas. Five of these risks areas link to

the core strategic objectives of Newham CCG, as outlined in the Newham CCG Operating

Plan. These are:

1. To reduce health inequalities, improve access and reduce quality variation

2. To develop Integrated Care, in particular to support improved management of long

term conditions

3. To ensure robust patient and public engagement is embedded in the operations of

Newham CCG and at all stages of the commissioning cycle

4. To ensure that Newham CCG achieves robust financial stability and balance to

supporting effective working and implementation of our plans

5. To support quality improvements in primary care services to ensure they are fit for

purpose and able to support the shift in care out of hospital

The Board has taken the view to include a sixth risk area to highlight the importance of

establishing and maintaining good governance practices to enable the CCG to effectively

deliver against its core strategic objectives:

6. To ensure that Newham CCG has transparent and effective corporate and clinical

governance arrangements in place to comply with relevant legislation and mitigate

the risk of non-delivery of strategic objectives

It is recognised that a number of BAF risks will be linked to one or more of the above risk

areas. This will be noted where applicable on the risk profile template (section 3.1).

2.4 Risk Identifiers

Each BAF risk will be assigned a unique risk identifier (number). This will be based upon the

primary area of risk identified from the five designed risk areas and subsequently the order in

which the risk is added to the BAF. For example, the first risk added to the BAF with a

primary risk area of category 1 (to reduce health inequalities… etc.) would be assigned a risk

identifier of 1.1.

5

3. Board Assurance Framework

3.1 Risk profile

Risk

Identifier

Linked to

Risk AreasRisk Summary Risk Owner

Initial Risk

rating (April

2013)

October

2013

forecast

Trend

End of

Year

Target

Difference

between

target and

forecast

1.1 1,2,4,5 Failure to deliver QIPP Plans within target Scott Hamilton 15 12 8 4

1.2 1,2,4,5Failure to develop future QIPP plans appropriate to the evolving needs of the CCG

in a timely and robust mannerScott Hamilton 12 12 8 4

1.3 1,2 CSU ability to deliver on contracted services due to capability / capacity. Scott Hamilton 20 10 5 5

1.4 1 Quality of Commissioned Services at Barts Health Chetan Vyas 15 15 5 10

1.5 1,2Failure to establish and/or maintain effective enagement and collaborative working

arrangements with the Local AuthoritySatbinder Sanghera 9 9 3 6

1.6 1,2,4,5,6 Failure to recruit develop and retain key staff Steve Gilvin 20 9 6 3

2.1 1,2Failing to develop models of integrated care and robust cost and savings

assumptions to support the shift to care out of hospitalScott Hamilton 15 15 10 5

3.1 1,2,3Failing to embed meaningful patient and public engagement at all levels of the

CCGSatbinder Sanghera 10 10 10 0

4.1 4Monitoring and planning for the possible impact to CCG from Barts Health financial

performanceChad Whitton 20 15 10 5

4.2 4 Failure to monitor performance and activity at Barts Health Chad Whitton 15 15 10 5

4.3 4 Financial management of the CCG Chad Whitton 16 8 4 4

4.4 4Transfer of a proportion of the specialised commissioning budget from NCCG to

NHS EnglandScott Hamilton 20 15 10 5

5.1 5 Failing to build appropriate capacity and support for Primary Care Jane Lindo 12 12 4 8

5.2 5,6 Staff skills and competencies within the CCG Chetan Vyas 16 12 4 8

5.3 5,6 Board skills and competencies within NCCG Chetan Vyas 12 12 8 4

5.4 4,5Failure to develop practices as the "power house" of commissioning through

development of Clusters as CommissionersMargaret Chirgwin 12 12 8 4

5.5 5Failing to develop new and functional Extended Primary Care Providers/Shared

Services ProvidersMargaret Chirgwin 12 12 8 4

6.1 6 CCG has outstanding conditions for authorisation Satbinder Sanghera 12 1 1 0

6.2 6 NCCG is underpreared for its role in emergency planning procedures Satbinder Sanghera 12 8 2 6

6.3 6 Information Governance arrangements for NCCG are in an undeveloped state. Satbinder Sanghera 15 9 3 6

Risks last reviewed: September to October 2013 (for October 2013 update to Newham CCG Board)

6

3.2 Risk Area 1- To reduce health inequalities, improve access and reduce variation

Internal External Control Assurance

Actions completed

since last review

(Date)

- Revise QIPP plans to

ensure they contain

high level strategic

intentions and delivery

plans until 2014/15

- CCG Governance

revised to enable

broader oversight of

QIPP initiatives - *

Review completed and

revised CCG Governance

structure in place from

August 2013

- NHS England

sign-off of

CCG QIPP

initiatives by

March 2013

- QIPP tracker

regularly

reviewed by

SMT

- Prepare and submit

detailed QIPP plans with

a focus on low level

implementation for

2013/14/15/16.

- Revise QIPP plans to

ensure they contain

high level strategic

intentions and delivery

plans until 2014-15

- Focus on stakeholder

and PPE strategy to

ensure patients and

public are effectively

engaged in the detail of

QIPP initiatives

Maj

or

(4)

x U

nlik

ely

(2

) =

Me

diu

m R

isk

(8)

Failure to deliver QIPP

plans could result in:

- A reduced ability to

deliver local service

improvements for

patients (this year and

beyond)

- An increase in the

likelihood of

performance

management

measures from NHS

England

- Adverse media

coverage

- Failure to meet

national QIPP financial

targets and a

deterioration in the

CCG financial position

which impact the

CCG's ability to

implement service re-

design and invest to

save initiatives to

support

improvements in

commissioned care

and the shift in care

out of hospital

Seve

re (

5)

x P

oss

ible

(3

) =

Hig

h R

isk

(15

)

Programme Boards

(*Commissioning

Committees from Aug

2013) have responsibility

for managing/monitoring

QIPP schemes with

oversight from Quality

and Delivery PG and

Executive Committee

- QIPP trackers

developed for each

initiative to monitor

progress against

objective - led by Carl

Edmonds for CSU and

Scott Hamilton for CCG

- QIPP trackers are

reported to NCCG Quality

Committee and fed back

to CCG Board as part of

Activity and Finance

report

- QIPP trackers also

scrutinised at NCCG

Executive with input

from QIPP leads to report

on mitigations to keep

trackers on target

- Senior management

meeting between CCG

and CSU relating to

finance activity and

performance

- Terms of

reference,

agendas,

minutes of

Commissioning

Committee

meetings, Q&D

PB and CCG

Executive

Committee (for

oversight)

demonstrate

CCG focus on

delivery

- Service level

agreement

between NCCG

and NEL CSU

demonstrates

CSU support in

development

and monitoring

of QIPP

initiatives

- management

leads are in post

working with

CSU teams (e.g.

Borough Team

and Health

Intelligence) to

ensure delivery

within financial

envelope.

Maj

or

(4)

x P

oss

ible

(3

) =

Me

diu

m R

isk

(12

)

- McKinsey

Consulting were

commissioned

by NHS England

to undertake a

review and

report on the

robustness of

NCCG QIPP Plans

and identify

scope for further

initiatives and

savings.

Risk Description

Risk 1.1. Failure to deliver QIPP Plans within target

Risk Lead

1.1 1,2,4,5

Proposed Actions

Target

Risk

Rating

Assurances GapsRisk

Ref

Linked

to Risk

Areas

Initial

Risk

Rating

Controls

Current

Risk

Rating

Director of

Delivery

(Scott

Hamilton)

No formal

process (i.e.

threshold) in

place for

exception

reporting to

Board as

trackers are

reviewed in

the context of

individuals

schemes (it is

expected that

this would be

picked up

through

Quality /

Executive

Committees

and reported

to Board via

special

discussion

paper as and

when

required)

7


Risk 1.2 Failure to develop future QIPP plans appropriate to the evolving needs of the CCG in a timely and robust manner

Risk

Ref

Linked

to Risk

Areas

Risk Lead Risk Description

Initial

Risk

Rating

ControlsAssurances Current

Risk

Rating

GapsProposed Actions

Actions completed

since last review

(Date)

Target

Risk

Rating

1.2 1,2,4,5 Director of

Delivery

(Scott

Hamilton)

Failing to develop

future QIPP plans in a

timely and/or robust

manner could result

in:

- Failure to reach

savings targets due to

inaccuracies in

underlying savings

assumptions

- Reputational damage

to CCG

- The possibility of

performance

measures

Seve

re (

5)

x P

oss

ible

(3

) =

Hig

h R

isk

(15

)

- 13/14 QIPP process fully

mapped with QIPP

identified, Lead Senior

Officers appointed, risk

assessed plans and KPIs,

and summarised in

trackers.

- Trackers updated and

reviewed monthly at

H6Executive Committee.

- Outcomes and QIPP

progress reported

monthly to Board.

- Quarterly QIPP review

meetings with input form

CCG QIPP leads, finance

and CSU to look in-depth

at in-year delivery of

QIPP to date, forward

assessment for 2014/15

with assessment of need

to carry over QIPP plans +

gap identification for

additional savings

requirements (Outputs

form QIPP review

meetings to be cascaded

through CCG Practice

Member Council and

clusters in parallel with

14/15 commissioning

round

Monthly update

and review of

trackers inc

financial and KPI

delivery.

Monthly review

by Executive

Committee.

Monthly update

in A&F report to

Board. Remedial

process

available to

ensure targets

are met. On-

going review to

identify further

QIPP. 14/15

target and early

development

programme core

to CSP.

Maj

or

(4)

x U

nlik

ely

(2

) =

Me

diu

m R

isk

(8)

QIPP identified

at scheme level

and risk rated in

Operation Plan

financial

template.

Monthly report

to NHSE.

McKinsey

assessment

provided to CCG

and NHSE and

NHSE assurance

provided

through a deep

dive assessment

in July 2013.

Maj

or

(4)

x P

oss

ible

(3

) =

Me

diu

m R

isk

(12

)

Detailed

remedial

process to be

identified.

N/A Internal audit review of

QIPP - results to be

reviewed and process

adjusted to reflect

recommendations.

Development of

remedial process to be

agreed by Quality

Committee and

Executive Committee.

Development of source

and apps financial

model to determine

2014/15 and 2015/16

QIPP requirements.

Development of

detailed plan for QIPP

identification, scheme

development and risk

rating as integral part of

CSP planning.

8


Risk 1.3 NEL CSU ability to deliver on contracted services due to capability or capacity

Risk

Ref

Linked

to Risk

Areas


Initial

Risk

Rating


Risk

Rating


Target

Risk

Rating

Actions completed

since last review

(Date)

1.3 1,2 Director of

Delivery

(Scott

Hamilton)

NEL CSU failing in

capability/capacity to

deliver on contracted

services could result

in:

- the increased

likelihood of failure to

deliver CCG strategic

objectives, including:

- Delivering QIPP plans

on time and on target

- Monitoring and

resolution of quality

issues with service

providers

Seve

re (

5)

x Li

kely

(4

) =

Hig

h R

isk

(20

)

- Documented

process for

escalation and

contract levers

to manage

performance

- Market test exercise to

be undertaken

- Service line price list

from CSU

Seve

re (

5)

x R

are

(1

) =

Low

Ris

k (5

)

- Monthly SLA review

meetings between

Senior CCG and CSU

teams

- Quarterly review

meeting with CSU Chief

Executive

- Annual review to test

services provided under

SLA are fit for purpose

with marketing testing

- SLA between

NCCG and NEL

CSU sets out

agreed service

areas and

performance

requirements

covered under

the contract

- CSU KPI's and

meeting

schedules

WELC POD

meeting every

two weeks to

review

performance

- Monthly CSU

Executive

Meeting for

escalation

Seve

re (

5)

x U

nlik

ely

(2

) =

Me

diu

m R

isk

(10

)

- Finalise KPIs

for CSU

including local

Newham KPIs

- Establish a

CCG network

for

performance

management

of CSU

- Develop

contingency

plans for

alternative

commissionin

g support

arrangements

- Embed CSU

into the CCG

governance

structure

- Quarterly SLA review

conducted with CSU

- Restructure agreed of

the CSU team internal

process

- CCG Governance

restructure

- Developed KPIs and

performance

management process

for CSU

- Established an

escalation process for

the resolution of issues

9


• Barts Health CQRM and

SPR meetings which

include trend analysis

and assurance reports

across key quality

indicators

• WELC POD Quality

Leads meetings to

commence in July 13

• Quality Leads of WELC

CCGs routinely share

information and

intelligence regarding

Barts Health

• CSU Quality and

Contracting Team

working with DD of

Quality

• Refreshed Amber Alerts

mechanism rolled out

across Member Practices

July 2013

• CCG Quality and

Delivery Programme

Board (*Quality

Committee from August

2013) where quality of

services at Barts Health is

discussed

- ToRs in place

for routine

meetings

- Agenda and

papers for 1st

Quality Leads

meeting

- Amber Alerts

received and

responded to by

Barts Health

- Quality reports

that indicate the

quality of

services at Barts

Health

- Minutes from

Quality and

Delivery

Programme

Board (*Quality

Committee from

August 2013)

Seve

re (

5)

x R

are

(1

) =

Low

Ris

k (5

)

- SLA with CSU to

support contract

and

performance

monitoring

arrangements

- Agendas and

minutes of Barts

health CQRM

and SPR

meetings

Seve

re (

5)

x P

oss

ible

(3

) =

Hig

h R

isk

(15

)

- Embedded

quality

monitoring of

Barts Health

- Robust

recovery

action plans

from provider

to remedy

quality

concerns

- CCG capacity

to fully

understand

the quality of

services across

Barts Health

upon

commenceme

nt of Lead

Commissioner

Role

- None

identified at

present

• Review quality

management processes

with CSU

• Agree ways of working

with WELC CCG Quality

Leads

• Review Amber Alerts

process after one

quarter and provide a

report to the Quality

and Delivery

Programme Board and

CCG Board

- NCCG Board

Development session

on 25/07 with specific

focus on Barts quality,

performance and

finance

- Barts Health Summit

meeting scheduled for

02/08 to involve key

stakeholders: TDA,

WELC CCGs, NHSE and

NELCSU

• Explore the possibility

of securing extra

resources to support the

quality management of

Barts Health upon

commencement of Lead

Commissioner role

- NCCG Governance

review completed and

revised governance

structure (inc. remit of

Quality Committee)

agreed and in place

from August 2013

1.4 1,2 Deputy

Director of

Quality

(Chetan

Vyas)

Failure to manage and

effectively monitor

the quality of

commissioned care

providers could result

in:

- Failure to meet

contractual targets

which will negatively

impact upon the

healthcare of the local

population, CCG

finances and

reputation.

- Poor value for money

for the CCG and the

taxpayer

- Potential risk in

falling to adequately

identify, monitor and

manage quality

performance issues

which could result in

unacceptable

standards of care and

the possibility of

serious incidents

occurring

Seve

re (

5)

x P

oss

ible

(3

) =

Hig

h R

isk

(15

)

Risk 1.4 Quality of Commissioned Services at Barts Health

Risk

Ref

Linked

to Risk

Areas


Initial

Risk

Rating


Risk

Rating


Actions completed

since last review

(Date)

Target

Risk

Rating

10


Risk 1.5 Failure to establish and/or maintain effective engagement and collaborative working arrangements with the local authority

Risk

Ref

Linked

to Risk

Areas


Initial

Risk

Rating


Risk

Rating


Target

Risk

Rating

Actions completed

since last review

(Date)

1.5 1,2 Head of

Governance

and

Engagement

(Satbinder

Sanghera)

Failure to establish

effective engagement

and collaborative

working with the Local

Authority could result

in:

- Reputational damage

and/or increased

complaints/ adverse

media coverage

- Duplication of effort

e.g. around jointly

commissioned care

areas

- Services which fail to

meet population

needs

- Poor value for money

through missed

opportunities

Mo

de

rate

(5

) x

Po

ssib

le (

3)

= M

ed

ium

Ris

k (9

)

- None

identified at

present

- Development of a

communications and

engagement strategy to

highlight the range of

communication

mediums used to

engage and collaborate

with stakeholders.

- Further clarification on

the role of LBN

representation on CCG

Board and the working

partnership on the

Health and Wellbeing

Board.

- Identify CCG

representation on other

LBN Partnership Boards

such as Children's Trust

Mo

de

rate

(3

) x

Rar

e (

1)

= Lo

w R

isk

(3)

- Joint Commissioning

Programme Board

(*Partnership

Commissioning

Committee from August

2013) meets monthly

with LA input with a focus

on jointly commissioned

areas of care.

- Monthly joint ops

meeting with LA to

discuss areas of

commonality to ensure

VFM and to identify

further joint working

opportunities

-Section 75/256 contracts

agreed with LBN

- Health and Well Being

Board

- Integrated Care

Transformation

Programme

- Work plan and

membership of

Partnership

Commissioning

Committee

established with

LBN Senior Team

and CCG GP

Chair.

- S75/256

agreements and

MOUs in place

for joint working

and joint

services to

continue.

- H&W strategy

and

implementation

plan that both

organisations

have agreed and

are jointly

implementing

- Clarity on

governance

arrangements

for the

Integrated Care

Transformation

Board

- Joint agenda

and work

programme

agreed for

Partnerships

Committee,

Health and

Wellbeing and

Integrated Care

Mo

de

rate

(3

) x

Po

ssib

le (

3)

= M

ed

ium

Ris

k (9

)

- Awaiting

NHS England

monitoring /

performance

management

process for

novated

services such

as Health

Visiting,

School

Nursing etc.

- NCCG Governance

review completed and

revised governance

structure (inc. remit of

Partnerships

Commissioning

Committee) agreed and

in place from August

2013

11


Risk 1.6 Failure to recruit develop and retain key staff

Risk

Ref

Linked

to Risk

Areas


Initial

Risk

Rating


Risk

Rating


Target

Risk

Rating

Actions completed

since last review

(Date)

1.6 1,2,4,5,6 Chief

Executive

Officer

(Steve Gilvin)

Failure to recruit and

or retain key staff

across the

organisation could

result in:

- loss of organisation

memory

- Increased difficulty

in monitoring and

meeting QIPP targets

and strategic

objectives

- Negative financial

implications as a result

of increased

recruitment costs

Seve

re (

5)

x Li

kely

(4

) =

Hig

h R

isk

(20

)

- All staff to undertake

an appraisal process

with PDPs to support

career and skills

development

- Initial appraisals and

agreed 2013/14 PDPs for

all staff to be finalised

and signed-off by end

September 2013

Min

or

(2)

x P

oss

ible

(3

) =

Me

diu

m R

isk

(6)

- Nearly all permanent

posts now recruited to

- External recruitment

being undertaken if no

suitable candidates in

internal redeployment

pool

- Temporary staff

recruited if business

need is agreed

- Training and

skills

development

programme in

place for all staff

to support

succession

planning and the

development of

future

organisational

leaders.

- NEL CSU

support for

temporary/short

term

recruitment and

substantive

recruitment

processes

Mo

de

rate

(3

) x

Po

ssib

le (

3)

= M

ed

ium

Ris

k (9

)

- One

substantive

post in CCG

structure

currently

vacant

(Performance

Manager)

- CCG Head of

Informatics post

appointed as at 21/07/13

12

3.3 Risk Area 2 - To develop Integrated Care, in particular to support improved management of long term

conditions


2x Project management

support roles appointed

to support the overall

delivery of the

Integrated Care

programme

Proposed Actions

Target

Risk

Rating

2.1 1,2 Bob Arora,

Integrated

Care Project

Lead

- Increased activity

levels in acute and

increased cost under

PBR arrangements

- Fragmentation of

care pathways and a

lack of joined up

services

- Lack of clarity around

national IG guidelines

for risk stratification

and integrated care

could impede linking

of patient data across

providers

- Failure to work

collaboratively with

providers to ensure

flows of money

effectively follow the

patient journey could

lead to cost

duplication, i.e. an

increase in costs for

community provision

without subsequent

reduction in acute

capacity

Seve

re (

5)

x Li

kely

(4

) =

Hig

h R

isk

(20

)

3 dedicated integrated

care work streams

established: -

1. Rapid Response

2. Discharge support -

including Mental Health

liaison and discharge

support (RAID model)

3. Coordination

- CCG and local authority

leads for IC appointed to

lead development of IC

in Newham

- IC Programme

Board (* IC

Transformation

Board from

August 2013) and

delivery work

streams (ToR,

Minutes)

- WELC

Integrated Care

Board to look at

elements of IC

that can be

effectively

developed and

delivered across

WELC

- NCCG IC

Programme

Board receives

regular reports

and integrates

with WELC IC

Board. _

Monthly reports

from NCCG IC

Transformation

Board to NCCG

Board to track

and monitor

progress of the

development of

Integrated Care

UC streamer

model supports

appropriate A&E

admissions

avoidance

Seve

re (

5)

x P

oss

ible

(3

) =

Hig

h R

isk

(15

)

- IC

Management

lead post to

be re-

advertised

- One

Integrated

Care project

management

support post

remains

vacant

awaiting

recruitment

LBN

advertising for

a Band 7 IC

Transformatio

n Manager to

support the

delivery of

Integrated

Care

Work closely with

providers to develop

appropriate

reimbursements models

aimed at ensuring the

money follows the

patients and where

appropriate releasing

capacity savings in acute

(recognition that savings

may not be only

financial but also

possibility in freeing up

Consultant time to

provide step down

support to Community

and Primary Care).

Seve

re (

5)

x U

nlik

ely

(2

) =

Me

diu

m R

isk

(10

)

Risk 2.1. Failing to develop models of integrated care and robust cost and savings assumptions to support the shift of care out of hospital

Risk

Ref

Linked

to Risk

Areas


Initial

Risk

Rating


Risk

Rating

Gaps Actions completed

since last review

(Date)

13

3.4 Risk Area 3 - To ensure robust patient and public engagement is embedded in the operations of Newham

CCG and at all stages of the commissioning cycle


Proposed Actions

Target

Risk

Rating

Current

Risk

Rating

Gaps

Seve

re (

5)

x U

nlik

ely

(2

) =

Me

diu

m R

isk

(10

)

-

Development

of a CCG

Comms. and

Engagement

Strategy

- More detail

required

around

processes in

place to

monitor the

effectiveness

of patient

engagement

activities

- PPE Manager

leading on

engagement

strategy with

support from

CSU on

comms.

element

Development of a

communications and

engagement strategy

and action plan to build

on existing engagement

platforms and develop

new platforms to

increase borough wide

participation and

strengthen inclusion of

hard to reach groups

- Conduct a scoping

exercise to potentially

further develop the role

of PPGs at cluster level

- Develop a forward plan

to track and coordinate

PPE needs across the

CCG and ensure the CCG

is delivering on its duty

to involve

- Increase promotion of

how to get people

involved through

community outreach

and CCG communication

channels

Seve

re (

5)

x U

nlik

ely

(2

) =

Me

diu

m R

isk

(10

)

Actions completed

since last review

(Date)

- Appointment

of Board Lay-

Member

responsible for

PPE

- Head of

Governance and

Engagement and

PPE Manager

posts in place

- PPE Strategy

and action plan-

Complaints

monitoring

process adds

additional level

of assurance

around capturing

patient feedback

- PPE Manager to

build capacity of

CCG staff to

deliver effective

PPE and embed

across all levels

of the CCG

- CCG website

- PPE support

commissioned

through Forum

for Health and

Wellbeing

- Patient forums

and PPGs act as

mediums to

capture

feedback

Risk 3.1 Failing to embed meaningful and measurable patient engagement at all levels of the CCG structure and throughout the commissioning cycle

Risk

Ref

Linked

to Risk

Areas


Initial

Risk

Rating

ControlsAssurances

3.1 1,2,3 Head of

Governance

and

Engagement

(Satbinder

Sanghera)

Failure to implement

meaningful PPE

strategies could result

in:

1. CCG unable to

deliver on Section 242

of the NHS Act 2006,

which mandates NHS

organisations to

involve patients in the

planning,

development of

proposals and

commissioning of

healthcare services.

2. Reputational

damage and / or

increased complaints /

adverse media

coverage

3. Services which fail

to meet population

needs (and

consequently offer

poor value)

Seve

re (

5)

x P

oss

ible

(3

) =

Hig

h R

isk

(15

)

Established PPE

platforms:

- Newham Patient Forum,

Community Reference

Group, Health and Social

Care Network and PPGs

14

3.5 Risk Area 4 -To ensure that Newham CCG achieves robust financial stability and balance to supporting

effective working and implementation of our plans


Risk 4.1 Monitoring and planning for the possible impact to NCCG arising from the financial performance of Barts Health

Risk

Ref

Linked

to Risk

Areas


Initial

Risk

Rating


Risk

Rating


Target

Risk

Rating

4.1 4 Chief Finance

Officer

(Chad Whitton)

Failure to monitor and

plan for the impact on

the CCG arising from

the financial

performance at Barts

Health could result in:

- Reduced ability to

plan for/shift care out

of hospital

- reduction in local

acute services

Requirements for

allocation of

contingency funding

to support Barts

Health which could

reduce CCGs

bargaining power in

other provider

contract negotiations

Seve

re (

5)

x :L

ikel

y (4

) =

Hig

h R

isk

(20

)

- Co-ordination

of monitoring

and control -

triangulation

with Specialised

commissioning

activity

- Clarification of

commitment to

WELC CCGs

through risk

share on impact

of turnaround

- Input and

agreement

required with

Commissioning

Lead to Barts

Health

Turnaround Plan

- Board development

session to focus on

mitigation strategies for

Barts financial risk.

Development of BH

Productivity

Improvement Plan - CSU

dedicated team to

monitor contract

Seve

re (

5)

x U

nlik

ely

(2

) =

Me

diu

m R

isk

(10

)

- WELC Mgt and

Collaborative

Commissioning

Governance Structure

overseeing

implementation of

contract including in-

depth analytics, claim

management.

- CCG Acute

Commissioning

Committee overseeing

CCG specific analysis.

- Dedicated CCG/CSU

capacity to ensure

effective monitoring and

contract control

- Updates on Barts

financial performance

picked up through

discussions with

collaborative leads

through the WELC Clinical

Strategy Groups

- Barts Health provide an

update on the CIP

programme to the WELC

Clinical Strategy group

attended by COs, Chair's,

and CFOs of all WELC

CCGs - pertinent updates

will be fed back via

reporting to NCCG Board

CCG Acute

Commissioning

Committee

WELC Mgt and

Collaborative

review, Monthly

contract

meetings,

monitoring

against

projected

activity including

agreed BH

Productivity

Improvement

Plan

- CCG review of

Barts CIP plan to

sign-off that CCG

are happy there

are no material

quality

implications as a

result of

proposed

savings

Seve

re (

5)

x P

oss

ible

(3

) =

Hig

h R

isk

(15

)

- In depth

analysis of Barts

Health Cost

Improvement

Programme (CIP)

- Formal access

and input to

Barts Health

Turnaround and

other associated

plans

- Timely access

to Barts Health

financial

reporting

15


Risk 4.2 Failure to monitor performance and activity levels at Barts Health

Risk

Ref

Linked

to Risk

Areas


Initial

Risk

Rating


Risk

Rating


Target

Risk

Rating

Actions completed

since last review

(Date)

4.2 4 Chief Finance

Officer

(Chad

Whitton)

Failure to monitor

performance and

activity at Barts Health

could result in:

- Increased risk of over

performance due to

loss of 5% cap and

collar arrangement

and move to PBR

contract for 2013/14

with associate risk of

uplift in contract

value.

- Reduced bargaining

position in contract

negotiations with

other providers

- Reduction in the

CCG's budget to

support the shift in

care out of hospital

and integrated care

work streams

- Disaggregation of

specialised

commissioned

services could lead to

duplication of charge

Seve

re (

5)

x Li

kely

(4

) =

Hig

h R

isk

(20

)

- Strong well

established

collaborative

working

arrangements

with other

significant

commissioners

(WELC)

- Robust

alignment with

specialised

commissioning

- Development of

demand management

targets at cluster level

- Triangulation with

specialised

commissioning contract

and monitoring teams

- Continuation of regular

update via weekly

CFO/WELC Collaborative

Telcons with Lead

Commisioner CFO

- Triangulation with

TDA/NHSE on

turnaround to ensure

limited liability

- Recruitment of

informatics/analytics

capacity to work with

CSU to enhance

effectiveness of

monitoring

Seve

re (

5)

x U

nlik

ely

(2

) =

Me

diu

m R

isk

(10

)

- Focus on demand

management initiatives

at cluster level

- Contractual levers

including KPIs and

CQUINS

- Monthly CQRM and SPR

meetings to review

quality and performance

issues at the Trust

- Urgent Care re-

procurement and service

re-design to support the

management of patients

in non acute setting and

appropriate streaming of

patients to non-urgent

community care settings

- Development of virtual

ward to reduce

admissions and LOS

- Clinical engagement in

Barts Health productivity

agreement

- Regular update via

weekly CFO/WELC

Collaborative Telcons

with Lead Commisioner

CFO

- Minutes of

cluster meetings

to demonstrate

work around

demand

management

- Clinical

engagement

into CQRM and

SPR processes

- Monthly high

level service

review meetings

between NCCG

and Barts Health

SLA with CSU for

contract and

finance activity

monitoring

arrangements

- NHS England

performance

management

processes would

ensure that a

development

plan is initiated

upon major

slippages

- Tripartite

formal

agreement

between NHS

London, DH and

Barts Health (on

Merger FBC and

Barts CIP)

Seve

re (

5)

x P

oss

ible

(3

) =

Hig

h R

isk

(15

)

- NCCG

Informatics /

information

analyst post

remains

vacant

- Emerging

national IG

regulations

may prohibit

CCGs from

accessing PID

data around

financial

activity which

could prevent

clinical

challenge

- CCG Head of

Informatics post


16


Risk 4.3 Financial management of Newham CCG

Risk

Ref

Linked

to Risk

Areas


Initial

Risk

Rating


Risk

Rating


Target

Risk

Rating

Actions completed

since last review

(Date)

4.3 4 Chief Finance

Officer

(Chad

Whitton)

Failure to plan for a

sustainable financial

future could result in:

- Major impact on the

CCG's ability to deliver

its strategic objectives

and QIPP targets

- Severe impact on

CCG finances and the

likelihood of a

deterioration in the

budget position with

the possibility of a

deficit budget at year

end

- Severe damage to

CCG reputation

- The possibility of

performance

management

measures being

imposed by NHS

England Maj

or

(4)

x Li

kely

(4

) =

Hig

h R

isk

(16

)

- Final

financial plan

- Scheme of

delegation

- Review of core

governance policies

including prime

financial policies in

Sept/Oct 2013 agreed

with NCCG Audit

Committee

- Internal audit review

agreed for the following

areas: Continuing Care;

Clinical Governance &

Quality;

Governance Framework -

Phase One & Two;

Budgetary Control,

Financial Reporting &

QIPP;

Commissioning &

Contract Management ;

Contract Monitoring –

Commissioning Support

Unit ;

Payroll & Financial

Feeders;

Risk Management /

Board Assurance Part

Two;

Remuneration of

Members.

Maj

or

(4)

x R

are

(1

) =

Low

Ris

k (4

)

- Finance plan for 2013/14

has a 1% surplus target

and will provide 2% non-

recurrent headroom and

1% contingency, 50% of

which is to cover acute

contracting risk. There

will be a risk reserve of

£2.3 million and plans to

commit the balance of

£3.8m brought forward

12/13 surplus on non-

recurrent pump-priming

initiatives.

- Detailed monthly

reporting to NCCG Board

and Q&D Programme

Board

- Monthly FIMS return to

NHS England

- Substantive

CFO in post

- Documented

NCCG Board

approval of

Financial Plan

- Audit

Committee TOR,

agenda and

minutes

- CCG Board and

Q&D PG minutes

- Financial

reports process

to Board

provides

indicative

position at

ledger close

- NHS England

approval of

financial plan as

part of the

authorisation

process

Maj

or

(4)

x U

nlik

ely

(2

) =

Me

diu

m R

isk

(8)

- Review of

standing

financial

instructions

and scheme of

delegation

17


Risk 4.4 Transfer of a proportion of the specialised commissioning budget from NCCG to NHS England

Risk

Ref

Linked

to Risk

Areas


Initial

Risk

Rating


Risk

Rating


Target

Risk

Rating

Actions completed

since last review

(Date)

4.4 4 Director of

Delivery

(Scott

Hamilton)

There is a risk that the

CCG will not be able to

fully recover funding

transferred pro-rata to

NHS England to enable

the Londonwide costs

of specialised

commissioning to be

met. As a result:

- This could impact the

CCG's ability to reach

acceptable Heads of

Terms with providers

(* though outline HoT

have been agreed

with major Acute and

Community providers

for 2013/14)

Seve

re (

5)

x Li

kely

(4

) =

Hig

h R

isk

(20

)

- Detailed work to be

undertaken by

NCL/NELC CCG in

conjunction with the

CSU contracting team to

monitor and challenge

the contract value of

specialist

commissioning services

transferred to NHS

England

- Capturing and coding

of CCG specialist

commissioning activity

to be established with

activity flows linked to

established pathways

and protocols

- CCG to define and

referral activity and

guidelines for

specialised

commissioning

Seve

re (

5)

x U

nlik

ely

(2

) =

Me

diu

m R

isk

(10

)

- The NCCG Board holds

overall responsibility for

commissioning services

within budget

- Programme Boards

(*Commissioning

Committees from August

2013) hold devolved

budgets for their defined

areas of commissioning

- CCG providers are

engaged through

Programme Boards and

contract negotiation

meetings.

Director of

Delivery holds

overall

responsibility

for acute

commissioning

- A technical

group led by the

London area DoF

and including

CCG

representatives

is working with

the SCG to

ensure CCGs

contributions

are matched to

commitments

throughout the

year with

appropriate

repatriation of

excess funding

Seve

re (

5)

x M

od

era

te (

3)

= H

igh

Ris

k (1

5)

Deep dive into

the detail of

the main areas

of specialist

commissionin

g to be

undertaken

jointly

between CCG

Informatics

Lead and

NELCSU team.

- CGG Head of

Informatics post


18

3.6 Risk Area 5 - To support quality improvements in primary care services to ensure they are fit for

purpose and able to support the shift in care out of hospital


Risk 5.1 Failing to build appropriate capacity and support for the development of Primary Care

Risk

Ref

Linked

to Risk

Areas


Initial

Risk

Rating


Risk

Rating


Target

Risk

Rating

Actions completed

since last review

(Date)

5.1 5 Deputy

Director of

Delivery

(Jane Lindo)

Failure to build

appropriate skills,

capacity and support

for primary care

providers could result

in:

- Adverse

media/reputational

risk

- An under-resourced

workforce

- Primary Care

Facilities not fit for

purpose

- Lack of capacity to

manage expected

increase in demand

for Primary Care

services as a result in

the planned shift in


-Unnecessary

unscheduled

admissions

- Failure to meet

outcome framework

indicators

Maj

or

(4)

x Li

kely

(4

) =

Hig

h R

isk

(16

)

- Monthly

cluster reports

Development of a

primary care strategy

that incorporates a

workforce skills and

education mapping

exercise to be

undertaken to identify

gaps and plan

contingencies

Development of a

Performance framework

to monitor cluster plans

Strongly performance

manage CSU data

reporting function. At

present NELIE and other

reports not meeting

basic requirements.

Development of

integrated care

programme including

extended Primary Care

Team to support

practices to keep

patients out of hospital -

extended district nurse

pilot covering 6

practices will become

fully operational end of

September

Maj

or

(4)

x R

are

(2

) =

Low

Ris

k (4

)

- Development of Primary

Care Strategy to include

development of Performance

Management Support to

clusters and practices and

development of future

models of primary care

providers e.g. federated

models/networks.

Development of Cluster

plans to support primary

care targets and demand

management initiatives.

- Prescribing team

supporting practices

- Monthly cluster meeting to

review activity and quality

data and other reports,

discuss ideas, share

concerns and share best

practice between practices

and other clusters

- Monthly cluster leads

meeting to coordinate ideas,

share concerns and share

best practice between

clusters to feed up through

the CCG structure

- educational curriculum

with monthly GP educational

meetings reflecting key

priorities

- Introduction of EMIS web

and training to support use

-Monthly MDTs in place for

Diabetes.

- Each NCCG

cluster has

dedicated

Practice

Facilitator

support

- Project Director

for Primary Care

Strategy

appointed to

lead the

development of

a primary care

strategy for

Newham

- Agendas and

papers from

cluster and

cluster leads

meetings

- Cluster Plans

- Extended hours

schemes help to

support

improved access

- Working

collaboratively

with NHS

England to

identify and

mitigate against

risks in primary

care skills and

capacity gaps

- Working

collaboratively

NBC to ensure

the primary care

role in

prevention is

not reduced or

lost

Maj

or

(4)

x P

oss

ible

(3

) =

Me

diu

m R

isk

(12

)

- Statistically

valid analytics

to support

clusters and

practices to

understand

where there is

true quality

variation with

national and

other useful

benchmarks

Development

of the CHN

services

focussed on

supporting

practices and

patients to

avoid

emergency

admissions

(Virtual Ward,

Rapid

Response,

Extended

Primary Care

Team)

19


Risk

Ref

Linked

to Risk

Areas


Initial

Risk

Rating


Risk

Rating


Actions completed

since last review

(Date)

5.2 5,6 Deputy

Director of

Quality

(Chetan

Vyas)

Failure to bridge skills

and competency gaps

throughout the

organisation could

lead to:

- Errors or significant

incidents resulting in

financial and/or

reputational loss

- Difficulty with

succession planning

-Failure to deliver

objectives on time and

on-targetM

ajo

r (4

) x

Like

ly (

4)

= H

igh

Ris

k (1

6)

Analysis of

Gaps to be

undertaken

subsequent to

the

completion of

the Training

Needs

Analysis

- Training Needs

Assessment (TNA) of

CCG staff to understand

their requirements

- Continue Staff

Development sessions

- Roll-out of Personal

Development Review

process to ensure all

staff have objectives

and PDPs

- Initial appraisals and

2013/14 PDPs for all staff

to be finalised and

signed-off by end Sept

2013

- Roll-out of Learning

and Development policy

to access CCG funds

- Understand what

learning and

development

opportunities CCG staff

can access via the CSU

- Staff Development

Sessions have

commenced

- Staff meetings are being

re-shaped to encourage

collective development

in meetings

- SMT development day

held to develop the SMT

SMT Devt Day

agenda

None identified

at present

Maj

or

(4)

x P

oss

ible

(3

) =

Me

diu

m R

isk

(12

)

20


Risk 5.3 Board skills and competencies within NCCG

Risk

Ref

Linked

to Risk

Areas


Initial

Risk

Rating


Risk

Rating


Actions completed

since last review

(Date)

Target

Risk

Rating

5.3 5,6 Deputy

Director of

Quality

(Chetan

Vyas)

Failure to bridge skills

and competency gaps

in the Board of NCCG

could lead to:

- Errors or significant

incidents resulting in

financial and/or

reputational loss

- Significant

reputational damage

and/or adverse media

interest

- Difficulty with

succession planning

-Failure to deliver

objectives on time and

on-target

- Potential for

enforced performance

management

conditions from NHSE

Maj

or

(4)

x P

oss

ible

(3

) =

Me

diu

m R

isk

(12

)

- Board Development

Plan in place signed off

via the authorisation

process

- Board Development

schedule in place

- Board

Development

Plan

- Board

Development

Meetings

- Agendas of

Board

Development

Meetings

Maj

or

(4)

x U

nlik

ely

(2

) =

Me

diu

m R

isk

(8)

Maj

or

(4)

x P

oss

ible

(3

) =

Me

diu

m R

isk

(12

)

Review of the

effectiveness

of the Board

Development

Plan to

understand

progress made

by the Board

development

• Board Code of Conduct

to be drafted

• Board Conflicts of

Policy to be reviewed

and amended

• Review of how the

Board has collectively

performed

21


5.4 Failure to develop practices as the "power house" of GP commissioning through development of Clusters as Commissioners

Risk

Ref

Linked

to Risk

Areas


Initial

Risk

Rating


Risk

Rating


Actions completed

since last review

(Date)

Target

Risk

Rating

5.4 4,5 Project

Director for

Primary Care

Strategy

(Margaret

Chirgwin)

Failure to build

appropriate skills,

capacity and support

for clusters as

commissioners could

result in:

- CCG failure to live

within budget

- Lack of provision for

expected increase in

demand for PC





and therefore cost

under Barts PBR

- Failure to meet

outcome framework

indicators

Maj

or

(4)

x P

oss

ible

(3

) =

Me

diu

m R

isk

(12

)

- Development of

Primary Care Strategy to

include development of

Commissioning role of

clusters

- Monthly cluster

meeting to discuss ideas,

share concerns and share

best practice between

practices and other

clusters

- Monthly cluster leads

meeting to coordinate

ideas, share concerns and

share best practice

between clusters to feed

up through the CCG

structure

- CCG engagement LES

requiring attendance at

cluster and CCG wide

events

- Monthly Practice

Member Council

Meetings

- Each NCCG

locality

(covering 2

clusters)has

dedicated

Practice

Facilitator

support

- Programme

Director for

Primary Care

Strategy

appointed to

lead the

development of

a primary care

strategy for

Newham

Maj

or

(4)

x U

nlik

ely

(2

) =

Me

diu

m R

isk

(8)

Maj

or

(4)

x P

oss

ible

(3

) =

Me

diu

m R

isk

(12

)

- CCG

constitution

clearly defines

the Clusters as

Committees of

the Board and

their

commissioning

roles and

responsibil ities

- Agreement on

budget

allocation

methodology to

practices and

clusters

- Agreement on

risk sharing

between

practices and

clusters

- Agreement on

management of

cluster under

and overspends

at the end of

year

- Financial

reporting at

cluster and

practice level

- Financial and

commissioning

support to

clusters

-Board papers

- Changes to

constitution

- Review relevant

sections of the

constitution

-Take paper to the Board

on budget allocation

formula to practices and

clusters for 2013/14 for

shadow budget and

process for 14/15 budget

allocations

-Take paper to the Board

on risk sharing proposals

within and between

clusters

- Take paper to the

Board on how propose

to manage cluster under

and over spends at end

of 2013/14

- Agree CCG

Management and

finance support

required to develop

clusters as

commissioners

(recommend an 8D

supporting 2 clusters +

finance to attend cluster

meetings)

22


Risk 5.5 Failing to develop new and functional Extended Primary Care Providers/Shared Services Providers

Risk

Ref

Linked

to Risk

Areas


Initial

Risk

Rating


Risk

Rating


Actions completed

since last review

(Date)

Target

Risk

Rating

5.5 5 Project

Director for

Primary Care

Strategy

(Margaret

Chirgwin)

Failing to develop new

Extended Primary Care

Providers/Shared

Services Providers

could result in:

- Adverse

media/reputational

risk

- An under-resourced

workforce

- Lack of provision for

expected increase in

demand for PC





under Barts PBR

- Unnecessary

unscheduled

admissions

- Failure to meet

outcome framework

indicators

- Widening gap in life

expectancy between

best and worst off

decile of the Newham

population and

between Newham and

England average

Maj

or

(4)

x P

oss

ible

(3

) =

Me

diu

m R

isk

(12

)

- Development of

Primary Care Strategy to

include development of

Extended Primary Care

Providers including how

this market should be

developed and how the

CCG will commission

these kinds of services

and service

developments

- Engagement with

Member Practices in the

development of the

strategy

- Primary Care

Strategy Draft

Outline

document

- Agendas for

practice Council,

Cluster meetings

etc. include

discussion of

what kind of

providers the

CCG should

develop

Maj

or

(4)

x U

nlik

ely

(2

) =

Me

diu

m R

isk

(8)

Maj

or

(4)

x P

oss

ible

(3

) =

Me

diu

m R

isk

(12

)

- The present

Newham CCG

procurement

strategy is out

of date and

not reflective

of the current

NHS position

with respect

to

procurement

New CCG

procurement

strategy

- NELCSU in discussion

with NCCG to develop a

new draft procurement

strategy for discussion

and approval by NCCG

Board

23

3.7 Risk Area 6 - To ensure that Newham CCG has transparent and effective corporate and clinical

governance arrangements in place to comply with relevant legislation and mitigate the risk of non-delivery

of strategic objectives


None

identified at

present

Insi

gnif

ican

t (1

) x

Rar

e (

1)

= Lo

w R

isk

(1)

- Evidence to support the

removal of the remaining

conditions was submitted

to NHS England in the

June evidence window

- Working with NHS

England to clarify

expecttaions on the

WELC conditions,

particularly risk share

Mitigation plan

developed and

regularly

submitted to

NHS England for

review

Authorisation

feedback and

feedback on

evidence

submissions

from NHS

England to

identify areas

where further

detail is

required

Insi

gnif

ican

t (1

) x

Rar

e (

1)

= Lo

w R

isk

(1)

- Awaiting

guidance on

how end of

year 1

assessment

will be

undertaken

Confirmation received

from NHSE on 23/07 that

all 8 outstanding

conditions have been

removed.

6.1 6 Head of

Governance

and

Engagement

(Satbinder

Sanghera)

NCCG has been

authorised by NHS

England (With 8

remaining conditions

as at the June 2013

evidence window).

In order to fully

discharge its

commissioning duties

the CCG must remove

the remaining

conditions as soon as

possible.

Maj

or

(4)

x P

oss

ible

(3

) =

Me

diu

m R

isk

(12

)

Risk 6.1 NCCG has outstanding authorisation conditions

Risk

Ref

Linked

to Risk

Areas


Initial

Risk

Rating


Risk

Rating


Target

Risk

Rating

Actions completed

since last review

(Date)

24


Risk

Ref

Linked

to Risk

Areas


Initial

Risk

Rating


Risk

Rating


Actions completed

since last review

(Date)

6.2 6 Head of

Governance

and

Engagement

(Satbinder

Sanghera)

Uncertainty over

emergency planning

and NCCG's role

Maj

or

(4)

x P

oss

ible

(3

) =

Me

diu

m R

isk

(12

)

None

identified at

present

Business Continuity and

Emergency planning

arrangements require

sign-off from Executive

Committee

NCCG is working with

colleagues at NHS

England, CSU, other CCGs

and LBN to ensure that

robust emergency

planning remains in place

throughout the transition

period and into the

future.

- Desktop emergency

planning exercise

facilitated by NHS

England planned for CCG

and key Health

Organisation EPRR

leaders in July 2013

- Attending EPPR/BCP

London quarterly

meetings hosted by NHS

England (London office)

to share common

concerns and best

practice

NCCG Business

Continuity Plan

developed

outlining local

business

continuity

arrangements to

feed into wider

emergency

planning

arrangements

- On call rota

established for

EPRR between

senior NCCG

Directors as part

of WELC Pod on-

call

arrangements

CSU specialist

support for EPRR

and surge

management

Maj

or

(4)

x U

nlik

ely

(2

) =

Me

diu

m R

isk

(8)

None

identified at

present

25


Risk 6.3 Information Governance arrangements for Newham CCG are in an underdeveloped state

Risk

Ref

Linked

to Risk

Areas


Initial

Risk

Rating


Risk

Rating


Target

Risk

Rating

Actions completed

since last review

(Date)

6.3 6 Head of

Governance

and

Engagement

(Satbinder

Sanghera)

Information

Governance

arrangements for

Newham CCG are

under developed

Mo

de

rate

(3

) x

Ce

rtai

n (

5)

= H

igh

Ris

k (1

5)

Shared folder

resource

between CCG

and CSU IG

support team

developed

with template

policies for

Information

Governance

Work in progress on

completion of IG Toolkit

in conjunction with

specialist support from

CSU IG team.

Mo

de

rate

(3

) x

Rar

e (

1)

= Lo

w R

isk

(3)

- IG Toolkit to be

completed to ensure

compliance with relevant

IG legislation

- IG development plan

established to monitor

progress against IG

Toolkit completion and

development of

associated IG policies and

procedures

- Procedures are in place

to ensure all NCCG staff

complete mandatory IG

training on an annual

basis

- Corporate incident

reporting procedures

developed to identify

monitor and follow up

risks or incidents which

impact on IG

NCCG has

appointed a

Caldicott

Guardian, Senior

Information Risk

Owner (SIRO)

and Information

Governance

Lead to ensure

the CCG remains

compliant with

relevant IG

legislation and

to promote best

practice IG

arrangements

throughout the

CCG

NCCG has

commissioned

expert

information

governance

support from the

CSU which

includes support

around

completion of

the IG Toolkit

Mo

de

rate

(3

) x

Like

ly (

4)

= M

ed

ium

Ris

k (1

2)

Development

of NCCG

specific IG

policies

- Appointments of CG,

SIRO and IG leads for

NCCG recognised by

Audit Committee

- All NCCG staff

registered on IG online

training tool for 2013/14

26

4. How to interpret the Newham CCG BAF

4.1 Risk profile

27

4.2 Full BAF risk entries

28

5. Newham CCG Risk Grading Matrix

29

Documents

Board Assurance Framework - Newham CCG October 2013... · Board Assurance Framework 3.1 Risk profile Risk Identifier Linked to Risk Areas Risk Summary Risk Owner Initial Risk rating