meeting: governing body (in public) · 3.10. the governing body has delegated authority to the...

Date:22/01/2020

Governing Body Assurance Framework of 21

Meeting: Governing Body (in public)

Meeting Date 22 January 2020 Action Approve

Item No. 10b Confidential No

Title Governing Body Assurance Framework

Presented By Margaret O’Dwyer, Director of Commissioning and Business Delivery

Author Lynne Byers, Risk Manager

David Hipkiss, Risk Manager

Clinical Lead -

Executive Summary

More than ever before and in context of a culture of decentralisation, increased local autonomy and accountability, the CCG’s Governing Body needs to be confident in the systems, policies and people it has in place to efficiently and effectively drive the delivery of its objectives by focusing on the minimising of risk. The Governing Body Assurance Framework, which sets out the current levels of risk and continued actions to enable the delivery of the CCG’s Strategic Objectives as at 30 November 2019, was reviewed by the Audit Committee at its last meeting on 6th December 2019. The Audit Committee was advised that all 10 risks included in the report had been reviewed since the last presentation of the report in September, however all risks have remained static. The Committee acknowledged that this is in part expected as many of the risks require management over the medium-to-long term. The current profile of the risks within the report is summarised as:

7 remain at a significant level of current risk (level 15 or above) to delivery of the CCG’s Strategic Objectives;

3 remain at a high level of current risk (level 8-12) to delivery of the CCG’s Strategic Objectives.

The Audit Committee was notified that three of the strategic risks had been assigned to the Strategic commissioning Board for oversight, and that any feedback from the review of these risks would be included in future reports, however it was noted that at the SCB meeting of 2nd December, a request had been made to change GBAF_PR_4.1 to reflect that decisions should be informed by all staff and clinicians, rather than influenced. This will be reflected in future reports. The Audit Committee was also advised on the work that has commenced, albeit at an early stage, which aims to integrate Risk Management across the CCG and Council. The Audit Committee recommended the Governing Body Assurance Framework to the

Date:22/01/2020


Governing Body. It should be noted that the risks have been reviewed in January and updates will be presented through the next suite of reports and governance arrangements. This will include recommendation to close the Brexit risk.

Recommendations

It is recommended that the Governing Body:

consider the Governing Body Assurance Framework presented: and

Discuss any concerns arising from the information provided.

Links to CCG Strategic Objectives

SO1 People and Place To enable the people of Bury to live in a place where they can co-create their own

good health and well-being and to provide good quality care when it is needed to help people return to the best possible quality of life

☒

SO2 Inclusive Growth To increase the productivity of Bury’s economy by enabling all Bury people to contribute to and benefit from growth by accessing good jobs with good career prospects and through commissioning for social value

☒

SO3 Budget To deliver a balanced budget

☒

SO4 Staff Wellbeing To increase the involvement and wellbeing of all staff in scope of the OCO ☒

Does this report seek to address any of the risks included on the Governing Body Assurance Framework? If yes, state which risk below:

Yes

All GBAF risks are articulated within the report

Implications

Are there any quality, safeguarding or patient experience implications?

Yes ☒ No ☐ N/A ☐

These will be addressed through management of the risks

Has any engagement (clinical, stakeholder or public/patient) been undertaken in relation to this report?

Yes ☐ No ☐ N/A ☒

Have any departments/organisations who will be affected been consulted ?


Are there any conflicts of interest arising from the proposal or decision being requested?


Date:22/01/2020


Governance and Reporting

Meeting Date Outcome

Audit Committee 06/12/2019 The Audit Committee was assured that the level of detail provided against the GBAF risk is sufficient, demonstrating effective risk management. The Audit Committee recommends the report for presentation and discussion at the Governing Body.

Are there any financial Implications? Yes ☒ No ☐ N/A ☐

These will be addressed through management of the risks

Has a Equality, Privacy or Quality Impact Assessment been completed?


Is a Equality, Privacy or Quality Impact Assessment required?


Are there any associated risks including Conflicts of Interest?


Are the risks on the CCG’s risk register? Yes ☒ No ☐ N/A ☐

The risks are articulated within the report and managed through the respective committees as appropriate

Date:22/01/2020


Governing Body Assurance Framework 1. Introduction 1.1. This paper is presented to provide an overview of the strategic risks which may

threaten the achievement of the Clinical Commissioning Group’s Strategic Objectives.

1.2. More than ever before and in context of a culture of de-centralisation, increased local autonomy and accountability, the CCG Governing Body needs to be confident in the systems, policies and people it has in place to efficiently and effectively drive the delivery of its objectives by focusing on the minimising of risk.

1.3. As part of the signing of the Annual Governance Statement (AGS) by the Accountable

Officer and approval of the Annual Accounts and Annual Report, the need for the Governing Body to demonstrate they have been properly informed of the totality of their risks is paramount.

1.4. The Governing Body needs to be able to evidence that it has systematically identified

its objectives and managed the principal risks to achieving them over the course of the year.

1.5. The Governing Body Assurance Framework (GBAF) formalises the process of

securing assurance and scrutinising risks to the delivery of the CCG’s strategic Objectives and is a key piece of evidence to support and demonstrate the effectiveness of the CCG’s system of internal control.

2. Background 2.1. All NHS organisations are required to develop and maintain an Assurance Framework

in accordance with governance regulations applied to the NHS.

2.2. Developed from and aligned to the 5-year strategy and 2-year operational plan, the GBAF should reflect the strategic objectives of the CCG and provide a simple but comprehensive method for ensuring that the CCG’s objectives are delivered and that the principal risks to meeting those objectives are effectively managed.

2.3. It also provides a structure for providing the evidence to support the Annual

Governance Statement. 3. The Assurance Framework 3.1. Whilst there is no formally prescribed template for presenting the GBAF, there are

specific areas that should be included to provide a comprehensive ‘snap shot’ to tell the story in relation to each risk identified, as detailed in italics below.

3.2. The risks that threaten the achievement of the organisations strategic objectives are defined as principal risks. The Governing Body should proactively manage potential principal risks, rather than reacting to the consequences of risk exposure.

Date:22/01/2020


3.3. These risks are assessed against and an original level of risk is determined on the

basis of no controls being in place. 3.4. Mitigation actions to address the gaps and further control or assure against the risk

are identified, the target risk, which should be achieved once actions are complete and gaps reduced is also reflected.

3.5. The Governing Body needs to assure itself that the controls identified not only

manage the principal risks but are also provided at the right level. These are captured as sources of assurance, and where possible, independent assurance sources should be used.

3.6. Having identified the current level of controls and assurance the current risk level is determined and the level of assurance that the risk is managed is also agreed. There are four levels of assurance: full, significant, limited and none.

3.7. Where assurance mechanisms show that controls are not sufficient to manage the

principal risks, or the assurance is not at a sufficient level, then gaps in controls and gaps in assurance should be recorded.

3.8. Consideration is then given to the key controls that are in place to manage the

principal risks. These risks and the controls should be documented and subject to scrutiny by independent reviewers where possible.

3.9. It is essential that the Governing Body receive an update on the effectiveness of the

GBAF on a regular basis so that it has assurance that principal risks are being effectively controlled and managed. This can then be reflected in the AGS at the end of the year.

3.10. The Governing Body has delegated authority to the Audit Committee to advise on the

establishment and maintenance of the effective system of integrated governance across the whole of the CCG’s activity, which includes receiving, scrutinising, challenging and providing the necessary assurance to the Governing Body on the GBAF.

3.11. The GBAF remains a dynamic document and will be further updated to ensure the

end-of-year position, to inform the Annual Governance Statement and Annual Report, is consolidated.

4. Governing Body Assurance Framework Summary Assessment

4.1. As outlined above the GBAF presented at the current position as reported at 30

November 2019.

4.2. Since last presentation of the GBAF to the Audit Committee in September 2019 a review of all 10 risks have been undertaken and the current risk profile of these is summarised as:

7 remain at a significant level of current risk (level 15 or above) to delivery of the

Date:22/01/2020


CCG’s Strategic Objectives;

3 remain at a high level of current risk (level 8-12) to delivery of the CCG’s Strategic Objectives.

4.3. The following risks have been assessed in respect of their current risk levels and are reported as follows. A summary dashboard is provided at Appendix 1, a detailed report is also provided at Appendix 2 and full narrative is provided at Appendix 3.

Risks that have increased in score: 4.4 No risks have increased in score.

Risks that have decreased in score: 4.5 No risks have decreased in score.

Risks that have remained static: 4.6 The following risks have remained static

GB1920_PR_1.1 Lack of effective engagement with communities (Level 15)

GB1920_PR_1.2 Service re-design processes, innovations and new Approaches (Level 12)

GB1920_PR_1.3 Urgent Care System – Re-design 2019/20 (Level 20)

GB1920_PR_1.4 CQC report: Pennine Acute Hospitals Trust. (Level 8)

GB1920_PR_1.5 CQC report: Pennine Care Foundation Trust (Level 8)

GB1920_PR_2.1 Lack of effective working with key partners which influence the wider determinants of health (Level 20)

GB1920_PR_3.1 Risk of in-year deficit (Level 20)

GB1920_PR 3.2 Risk that the CCG becomes financially unsustainable (Level 25)

GB1920_PR_3.3 Brexit no deal scenario (Level 16)

GB1920_PR_4.1 Assuring decisions are influenced by all staff including decisions (Level 20)

New Risks: 4.7 No new risks have been identified.

5. Recommendations

5.1. The Governing Body is asked to:

Review the Governing Body Assurance Framework presented; and

Discuss any concerns arising from the information provided.

Lynne Byers Risk management November 2019 David Hipkiss Risk Manager January 2020

Date:22/01/2020


Appendix 1: Governing Body Assurance Framework – Summary Dashboard Report

Strategic Objective 1 - To enable the people of Bury to live in a place where they can co-create their own good health and well-being and to provide good quality care when it is needed to help people return to the best possible quality of life Reference

Risk Description Owner Q4 Trend Aug Trend Nov Trend Q3 Trend Mar 20 Trend Target

risk

GB1920_PR_1.1 Because of a lack of effective engagement with communities there is a risk that the public will not access preventative services and make lifestyle changes which supports good health and quality of life

Catherine Jackson 15

15

15

10

GB1920_PR_1.2 Because of a lack of engagement with partners and other key stakeholders at the right time in service re-design processes there is a risk that innovative and new approaches across sector may not be implemented

Catherine Jackson 12

12

12

8

GB1920_PR_1.3 Because of longstanding pressures on urgent care there is a risk that if the urgent care system re-design is not implemented in a timely manner, then the improvements across the wider economy will not materialise, impacting upon patient experience and CCG reputation

Margaret O’Dwyer

New 20

20

12

GB1920_PR_1.4 Because the last CQC judgement identified that improvements are required at PAHT, there is a risk that quality and performance at the local provider does not make the required improvements in the delivery of health care services for the local population as stipulated by the CQC and other regulators and stakeholders

Catherine Jackson

8

8

8

4

GB1920_PR_1.5 Because the last CQC judgement identified that improvements are required at PCFT, there is a risk that quality and performance at the local provider does not make the required improvements in the delivery of health care services for the local population as stipulated by the CQC and other regulators and stakeholders

Catherine Jackson

8

8

8

4

Strategic Objective 2 - To increase the productivity of Bury’s economy by enabling all Bury people to contribute to and benefit from growth by accessing good jobs with good career prospects ant through commissioning for social value Reference


risk

GB1920_PR_2.1 Because of the significant impact that the Public Sector Services has on health, there is a risk that opportunities to reduce health inequalities will be minimised if health does not influence and work in harmony with key partners

Margaret O’Dwyer New 20

20

15

Strategic Objective 3 - To deliver a balanced budget for 2019/20 Reference


risk

GB1920_PR_3.1 Because of the increasing demand for services, risk of underachieving savings targets and other emerging financial pressures, there is a risk that the CCG will be in deficit for the current financial year resulting in failure of Statutory Duty and a depletion of historic surplus.

Mike Woodhead

New 20

20

2

GB1920_PR_3.2 Because of the short-term pressures together with increasing demand and barriers to transformational change, there is a risk that the CCG will be unable to agree a credible and financial sustainable medium term plan resulting in failure of statutory duties and adversely impact upon provision of quality services and patient outcomes

Mike Woodhead

New 25

25

15

GB1920_PR_3.3 If no deal is reached for Brexit by October 2019 there is a risk of disruption across the NHS including but not limited to supply chain, workforce and medicines distribution. This could result in a disruption in the delivery of CCG Strategic Objectives and Provider daily operations.

Margaret O’Dwyer

12

16

16

4

Date:22/01/2020


Strategic Objective 4 - To increase the involvement and wellbeing of all staff in scope of the OCO Reference


risk

GB1920_PR_4.1 Because of the commitment to work as one commissioner there is a risk that the new governance structure fails to recognise the importance of staff and clinicians in shaping the One Commissioning Organisation (OCO) and its decision making

Margaret O’Dwyer 15

20

20

10

Key

Increased Decreased Static

Date:22/01/2020


Appendix 2: Governing Body Assurance Framework – Detailed Report

Strategic Objective 1 - To enable the people of Bury to live in a place where they can co-create their own good health and well-being and to provide good quality care when it is needed to help people return to the best possible quality of life

Risk Description Risk Owner C L Score Controls Assurance Risk Review

Date C L Risk

Level of Assurance

Gaps in Controls/Assurance

Action Progress C L Risk

1.1 - Because of a lack of effective engagement with communities there is a risk that the public will not access preventative services and make lifestyle changes which supports good health and quality of life

Catherine Jackson

5 4 20 1. Close working with Public Health to co-ordinate joint working and messages 2. Communications and Engagement Strategy for CCG activity 3. Patient Cabinet in place to promote active engagement and public voice 4. Self-care has an increased focus in the refreshed locality plan 2017 5. Beginning to mobilise locality plan e.g. integrated neighbourhood teams. 6. Neighbourhood engagement models under development 7. Joint Comms & Engagement Team in place.

1. Patient Cabinet reports to the Governing Body 2. Lay Member for PPI voting member on the Governing Body and Primary Care Commissioning Committee 3. Healthwatch attend PCCC 4. NHSE PPI indicator assessment (an external assessment of the CCG's website/annual reports etc.) 5. Annual 360 Stakeholder Survey 6. New Strategic Commissioning Board in place October 2019.

10-Oct-2019 5 3 15 Significant Gap(s) in controls: 1. Engagement Strategy related to the locality plan not yet in place. 2. Slow pace in respect of the implementation required to deliver the transformation programme Gap(s) in assurances: 1. Unable to monitor the Strategy see as currently being developed.

PPI action plan to be implemented

100% 5 2 10

CCG Engagement Programme to be developed (superseded)

100%

Commence development of an integrated Communications and Engagement Strategy (superseded)

100%

Scrutiny of the Health and Well-being of the local population to be built in to regular reporting

50%

OCO Bury 2030 Survey 50%

OCO Engagement Strategy to be developed following Bury 2030 Survey

0%

1.2 - Because of a lack of engagement with partners and other key stakeholders at the right time in service re-design processes there is a risk that innovative and new approaches across sector may not be implemented and therefore the

Catherine Jackson

4 3 12 1. Key partners engaged through LCO Partnership Board and CCG 2. Internal governance supports engagement and involvement with stakeholders 3. Engagement Framework under review, communications and Engagement Strategy being developed 4. Individual Engagement Strategies when significant service redesign is anticipated

1. OCO established 2. NES governance architecture across health and social care supports alignment where appropriate across sectors 3. Bury System Board 4. GM Joint Commissioning Board refreshed 5. Strategic Commissioning Board established October 2019 6. Clinical Congress established

28-Oct-2019 4 3 12 Limited Gap(s) in controls: 1. Communications and Integrated Engagement Strategy not reflective of the changing landscape 2. Effectiveness of Patient Cabinet Gap(s) in assurances: 1. Joint Commissioning Board Phase 2 refresh outstanding

Review patient engagement to support wider public involvement

100% 4 2 8

GM Joint Commissioning Board phase 2 to be confirmed

20%

Joint Commissioning Board to receive and agree the Theme 3 models of care

33%

New Communications and Engagement Strategy to be implemented

50%

Date:22/01/2020



Date C L Risk

Level of Assurance



opportunities for people to manage their health may not be realised

e.g. urgent care, NES clinical services 5. Locality Care Organisation (LCO)/Partners working together to stimulate new approaches 6. OCO/LCO clinical reference group being explored 7. Patient Cabinet function under review

1.3 - Because of long standing pressures on urgent care there is a risk that If the urgent care system re-design is not implemented in a timely manner, then the improvements across the wider economy will not materialise, impacting upon patient experience and CCG reputation

Margaret O'Dwyer

4 5 20 1. Review of the system wide urgent care facilities 2. Implementation of a suite of initiatives under Transformation Programme 5 ( urgent care treatment centre, NWAS Green Car, same day emergency/ambulatory care established) 3. Implementation of the redesign of intermediate care including the development of integrated neighbourhood teams, rapid response to minimise demand in the system 4. Engagement with GM Urgent and Emergency Care Board to explore system wide solutions to address urgent care demand and capacity

1. Bury System Board 2. Governing Body oversight of performance reports 3. Detailed scrutiny by the Health and Care Recovery Board 4. Primary Care Commissioning Committee oversee the development of the Primary Care Networks and alignment with Neighbourhoods 5. Oversight by the Strategic Commissioning Board (SCB)

23-Oct-2019 4 5 20 Limited Gap(s) in controls:

1. Financial sustainability of the Urgent Care Treatment Centre to be determined as part of the urgent care review 2. Sufficient recruitment to enable Intermediate Care Transformation (LCO remit) 3. Impact of the development of Primary care networks unknown Gap(s) in assurances:

Undertake an evaluation of Phase 1 Urgent Care Treatment Centre

100% 4 3 12

Undertake a specific review of the WICs

100%

Maintain oversight of recruitment through the Bury System Board

100%

Primary Care Committee to ensure the development of Primary Care Networks is aligned with the Neighbourhood Teams

60%

Bury System Board and Strategic Commissioning Board to receive and agree proposals of IMC

50%

Undertake overarching review of urgent care

20%

1.4 - Because the last CQC judgement identified that improvements are required at PAHT, there is a risk that quality and performance at the local provider does not make the required improvements in the delivery of health care

Catherine Jackson

5 4 20 1. Strategic leadership through the Northern Care Alliance 2. Improvement Plan submitted to CQC and approved. Improvement plan monitoring reported to GB on a regular basis. 3. Quality Improvement and Prioritisation meetings lead by CCGs providing greater visibility 4. Key Lines of Enquiry (KLOEs) in place 5. LCA established via

1. Regular reports to the Governing Body on performance and quality 2. Quality and Performance Committee scrutiny of measures 3. CQC assurance of progress against improvement plan 4. CQC re-inspection 5. Collaborative quality

scrutiny with the LA and oversight by the OCO 6. MIAA CCG Audit of

28-Oct-2019 4 2 8 Significant Gap(s) in Controls: Gap(s) in assurances: 1. Awaiting on the CQC report from the Autumn inspection (Nov 19)

Strengthen and scrutinise PAHT's key quality indicators

100% 4 1 4

Review findings from the CQC reassessment 2019/20

0%

New quality assurance process to be established for community services

(NCA)

75%

Implementation of the new quality and assurance workplan

100%

Place based walk-arounds to commence to include

10%

Date:22/01/2020



Date C L Risk

Level of Assurance



services for the local population as stipulated by the CQC and other regulators and stakeholders

the Northern Care Alliance NHS Group 6. Board Assurance Framework in place 7. Targeted work plan in place 8. Launch of new Quality and Improvement Strategy September 2019 9. Community transfer from PCFT to the Northern Care Alliance (NCA) completed July 2019

quality controls (significant assurance received) 7. Bi-monthly reporting to GM Quality Board 8. Audit Committee enhanced scrutiny of GBAF 9. Monthly Clinical Quality Leads meeting with PAHT 10. Stakeholder (HEE, NHSI, NHSE and CQC) engagement via the Quality Risk Profiling Tool (QRP)

PAHT services

1.5 - Because the last CQC judgement identified that improvements are required at PCFT, there is a risk that quality and performance at the local provider does not make the required improvements in the delivery of health care services for the local population as stipulated by the CQC and other regulators and stakeholders

Catherine Jackson

5 4 20 1. Local Level Plans (as part of overall improvement plan) 2. Strategic/Board level focus 3. Local level surveillance through Quality and Performance provider meeting 4. NHS Improvement leading collaborative working across 5 CCGs to drive change 5. CQC 'Moving to Good' Action Plan received and approved 6. Regular reporting to the Strategy Partnership Board 8. Locality based improvement programmes established 9. Quality Assurance Committee in place and chaired by Executive Nurse 10. Increased focus on MH improvement since community services moved to the NCA

1. Regular Reports to CCG Governing Body 2. CCG awareness of where service improvement is required 3. PCFT awareness of CQC findings and improvement expectations 4. Structure approved by NHS Improvement 5. Regular reporting to PCFT Strategy Partnership Board 6. Bi-monthly reporting to GM Quality Board 7. Quality Assurance Committee in place and chaired by Executive Nurse 8. Step down of Quality Improvement Board to be managed by the Quality Assurance Committee 9. Regular discussions with NHS Improvement (NHSI)

29-Oct-2019 4 2 8 Significant Gap(s) in Controls: Gap(s) in assurances: 1. Re-inspection in December 2019 awaited publication report Feb 2020

New quality assurance process to be established for community services (NCA)

75% 4 1 4

Creation of separate risk report to be submitted to key stakeholders driving the transfer of Bury Community Services

100%

Review findings from the CQC reassessment 2019/20

0%

Review and scrutinise local soft intelligence and data reporting

30%

NICHE intelligence through the Strategic Contracting and Commissioning Partnership Board (SCCPB) supporting targeted service reviews

25%

Date:22/01/2020


Strategic Objective 2 - To increase the productivity of Bury’s economy by enabling all Bury people to contribute to and benefit from growth by accessing good jobs with good career prospects and through commissioning for social value


Date C L Risk

Level of Assurance



2.1 Because of the significant impact that the Public Sector Services has on health, there is a risk that opportunities to reduce inequalities will be minimised if health does not influence and work in harmony with key partners

Margaret O'Dwyer

5 4 20 1. Bury Strategy under development, including supporting strategies and delivery plans (e.g. Housing, Industry, Environment ) 2. Development of a Commissioning Strategy which will include commissioning for social value (e.g. maximise the CCG's potential to become an anchor organisation by supporting the local supply chain/local recruitment, being an exemplar organisation, inclusion of social value goals in Provider contracts, support environmental sustainability etc.)

1. Health and Well-Being Board 2. Governing Body 3. Council Cabinet (key partner) 4. Joint Strategic Commissioning Board w.e.f. October 2019

10-Oct-2019 5 4 20 Limited Gap(s) in controls: 1. Bury Strategy including refresh of locality plans is currently under development 2. Potential failure of a systematic process to oversee the implementation of a number of high-level strategies which together could have a major impact in reducing health inequalities/improving health and well-being. Gap(s) in assurances: 1. None identified.

Active participation in the development of the Bury Strategy

30% 5 3 15

Refresh of the Locality Plan 30%

Development of an Integrated Outcome Based Commissioning Strategy

0%

Date:22/01/2020


Strategic Objective 3 - To deliver a balanced budget


Date C L Risk

Level of Assurance



3.1 - Because of the increasing demand for services, risk of underachieving savings targets and other emerging financial pressures, there is a risk that the CCG will be in deficit for the current financial year resulting in a failure of Statutory Duty and a depletion of historic surplus.

Mike Woodhead

5 5 25 1. Savings/pressure process in place 2. Project management arrangements in place 3. Interim capacity identified to deliver the opportunities identified via the savings/pressure and project management controls 4. Budgetary Control Group established and meets weekly 5. Establishment of control pressures tightened 6. Savings control tracker / pipeline scheme reports and regular financial reporting in place and scrutinised by committees

1. Joint Executive Team (JET) 2. Health and Care Recovery Board 3. Finance, Contracting and Procurement Committee (FC&P) 4. Governing Body 5. Greater Manchester Health and Social Care Partnership Board 6. Operational Management Group 7. Budgetary Control Group 8. Strategic Commissioning Board

14-Nov-2019 5 4 20 Significant Gap(s) in controls: 1. Significant development of pipeline savings schemes still required (on-going scrutiny via responsible committees/Boards) 2. Implementation of identified schemes to be strengthened Gap(s) in assurances:

Complete in-year review of the transformation Fund Programme

100% 1 2 2

Continue to work with key stakeholders and partners to identify non-recurrent mitigations and or smooth pressures across financial years

30%

3.2 - Because of the short-term financial pressures together with increasing demand for services and barriers to transformational change, there is a risk that the CCG will be unable to agree a credible and financial sustainable medium-term plan resulting in failure of statutory duties, which would also adversely impact upon the provision and quality of services and

Mike Woodhead

5 5 25 1. Refresh of the Medium-Term Financial Plan and Locality plan 2. Budget setting process in place 3. Review of transformation programmes and associated investment agreements 4. Working jointly with the Northern Care Alliance (NCA) on joint system savings programmes 5. Medium-term financial planning workshops 6. Project management of saving and pipeline schemes

1. Weekly meetings with Senior Executives and Finance Leads 2. Bury System Board 3. Finance, Contracting and Procurement Committee (FC&P) 4. Governing Body 5. Strategic Oversight Group 6. Joint Executive Team meetings (JET) 7. Health and Care Recovery Board 8. Strategic Commissioning Board

14-Nov-2019 5 5 25 Limited Gap(s) in controls: 1. Refreshed Medium-Term Financial Plan and Locality Plan still in development 2. Budget setting not yet finalised 3. Joint work with NCA still being worked through 4. Some Transformation Schemes still being mobilised Gap(s) in assurances:

Complete overarching programme of works

40% 5 3 15

Drivers of the deficit work 5%

Date:22/01/2020



Date C L Risk

Level of Assurance



patient outcomes

3.3 If no deal is reached for Brexit by October 2019 there is a risk of disruption across the NHS including but not limited to supply chain, workforce and medicines distribution. This could result in disruption in the delivery of CCG Strategic Objectives and Provider daily operations.

Margaret O'Dwyer

4 4 16 1. GM’s Local Health Resilience Partnership (LHRP) 2. The European Transition Unit programme aims to ensure that NHS England is prepared for the impact of Brexit and that the interests of the NHS are identified and articulated during the negotiations, the transition period, and beyond. 3. The European Transition Unit has supported the EU Exit Oversight Group to develop a comprehensive understanding of the potential areas of EU Exit exposure across NHS England’s areas of responsibility. 4. Regional workshops have been held to get a clear picture of the regional interactions with the EU and to identify the specific risks and opportunities that Brexit could pose to each region; 5. Brexit operational readiness guidance for the health and care system in England issued in 2018/19 remains relevant which Bury CCG is responding to ensure that the relevant Providers are compliant with the requirements 6. GMSS Resilience Team - Bury Emergency Planning Resilience and Response (EPRR) leads 7. CCG Business Continuity Plans EU Exit Operational Readiness Guidance and Action Plan

1. NHS England is working with PHE and the DHSC to facilitate an EPRR exercise to test the resilience of the health system against specific potential no deal Brexit impacts 2. Bury CCG is well connected locally and regionally via the GM Governance Group, GMHSCP, LHRP, HERG and GMSS Resilience Team 3. Dialogue between the CCG and LA ensure reporting consistency 4. Daily SITREPS re-established October 2019

23-Oct-2019 4 4 16 Significant Gap(s) in controls: 1. Understanding the local position in respect of drugs, devices and staffing in the event of a no deal Brexit 2. Awaiting latest position / whole system GM discussion outcomes Gap(s) in assurances:

On-going management / implementation of the Brexit operational readiness guidance

90% 4 1 4

Date:22/01/2020



Date C L Risk

Level of Assurance



8. Risks associated with specific areas of work have been identified

Date:22/01/2020


Strategic Objective 4 - To increase the involvement and wellbeing of all staff in scope of the OCO


Date C L Risk

Level of Assurance



4.1- Because of the commitment to work as one commissioner there is a risk that the new governance structure fails to recognise the importance of staff and clinicians in shaping the One Commissioning Organisation (OCO) and its decision making

Margaret O'Dwyer

5 4 20 1. Clinical Director and Executive Director involvement in all key decision-making Committees/ Groups / Boards 2. Regular meetings across Health and Social Care to shape the working arrangements for integrated commissioning 3. Staff engagement events ongoing 4. Use of and access to all OD opportunities available to all staff (e.g. Employee Assistance Programme(EAP) , Perform @ Your Peak NHS North West Leadership Academy, Advancing Quality Alliance (AQuA)) 5. External capacity secured to support OCO transformation which has development of a comprehensive OD programme as a priority area which will ensure alignment across CCG and Council offer.

1. Reports to GB on progress and development 2. GB and Clinical Cabinet sessions - stakeholder engagement 3. Joint Executive Team meetings 4. Primary Care Working Together meetings 5. Monthly EMT meetings with Clinical Directors 6. Bury System Board 7. Strategic Commissioning Board

10-Oct-2019 5 4 20 Significant Gap(s) in controls: 1. Clarity regarding support available to staff during the period of restructure Gap(s) in assurances: 1. Different decision-making cultures 2. Clarification of the committee substructure and role of clinicians in future sub-committees to be explored

Roles and responsibilities as commissioners to be explored and made explicit

100% 5 2 10

Continued development, engagement and involvement of all staff

20%

Review the roles and responsibilities of the Clinical Cabinet and Joint Professional Congress with the LCO

0%

Commence meetings between the Chief Officer and Clinical Directors to explore their future roles within integrated commissioning

20%

Bi-lateral conversations between the Chair and individual Clinical Directors

60%

Date:22/01/2020


Appendix 3: Governing Body Assurance Framework

1.0 Risks that have increased in score

1.1. During the reporting period no risks have increased in score.

2.0 Risks that have decreased in score 2.1. During the reporting period no risks have decreased in score.

3.0 Risks that have remained static 3.1. The following ten (10) risks have remained static.

GB1920_PR_1.1 Lack of effective engagement with communities

3.2. This risk remains at its current level of 15, against a target level of 10 to be achieved by March 2020 as the significant engagement work is in its infancy.

3.3. The Bury 2030 public engagement survey is underway and has been promoted via public engagement and social media events. The outcomes will inform the Borough Locality Strategy moving forward.

3.4. Work is progressing to undertake reviews of the health and well-being of the local

population. A recent Public Health Paper has been presented to the Strategic Commissioning Board and Governing Bodies on health inequalities in two of the boroughs. This will now be extended to the whole locality.

3.5. The risk is assigned to the Strategic Commissioning Board for oversight, however as

the new governance arrangements have been emerging, the risk will only be presented at the meeting in December and has therefore not been reviewed at Committee level since September.

GB1920_PR_1.2 Service re-design processes, innovations and new approaches

3.6. The risk remains unchanged (level 12) as local robust and systematic processes for engaging with local people around commissioning for health redesign requires time to develop and embed.

3.7. As part of the revised governance arrangements, a new framework in respect to involvement and engagement is being developed. The key principles have been drafted with an aim to ensure that involvement and engagement become embedded in all that the CCG does, rather than a stand-alone activity. In addition, the Bury 2030 Strategy is also under development and once determined will influence the wider Communications and Engagement Strategy.

3.8. As part of phase 2 discussions, the Greater Manchester Joint Commissioning Board agenda has been identified and work is being delegated to look at localities.

Date:22/01/2020


3.9. Work continues to determine the preferred models of care; however further work is

required to work through implementation barriers (for example breast services).

3.10. The risk is assigned to Bury System Board, however due to recent changes in this Committee, the risk report was not included on the agenda of the last meeting on the 13 November 2019 and therefore has only received risk owner review at this time.

GB1920_PR_1.3 Urgent Care – Re-design 2019/20

3.11. The second assessment of this risk has resulted in no change to the risk score of 20, against a target level of 12 to be achieved by March 2020 as a whole system wide transformation is required to achieve system reform.

3.12. A dedicated Project Manager is now in post to oversee and develop the new model. The implementation plan is currently being worked up with a view for implementation in April 2020.

3.13. Evaluation of phase 1 of the Urgent Care Treatment Centre and specific review of the WICs have now been completed and these will now form part of the wider urgent care review which is taking place.

3.14. The proposed model for Intermediate Care (IC) is under development. The options will be subject to review through the normal governance channels during December and January 2020.

3.15. As previously reported, recruitment is required to enable IC transformation. Arrangements are now in place to ensure safe staffing through working arrangements with the NCA and through agencies when required.

3.16. The Primary Care Commissioning Committee (PCCC) is required to ensure the development of Primary Care Networks (PCNs) is aligned with the Neighbourhood Teams (NTs). A memorandum of understanding has been developed to support the working arrangements and will be presented to the PCCC in November 2019.

3.17. The Quality and Performance Committee reviewed this risk at the 13 November 2019 meeting. The Committee was assured that the risk is being effectively managed.

GB1920_PR_1.4 CQC report: Pennine Acute Hospitals Trust (PAHT)

3.18. This risk remains at its current level of 8, against a target level of 4 to be achieved by January 2020.

3.19. The CQC have completed their latest inspection on targeted services and the CCG is

awaiting the re-inspection report which is expected November 2019. 3.20. The Clinical Quality Leads meeting terms of reference and work-plan has been

refreshed and a new work-plan was developed in July 2019. The implementation agenda has been shared with PAHT in August 2019 and outcome of the discussions is awaited.

Date:22/01/2020


3.21. The new quality assurance process for community services has been established

and further local quality meetings are in place to undertake quality assurance reviews of key information provided.

3.22. Key Clinical Directors have commenced targeted place-based walk-arounds at

PAHT. 3.23. The Quality and Performance Committee reviewed this risk at the 13 November 2019

meeting and was assured that the risk is being effectively managed.

GB1920_PR_1.5 CQC report: Pennine Care Foundation Trust (PCFT)

3.24. This risk remains at its current level of 8, against a target level of 4 to be achieved by February 2020.

3.25. Since the Community Services transfer in July 2019 and through the establishment of

the quality assurance process there has been an increased focus on mental health improvement.

3.26. In addition, NICHE intelligence, through the PCFT Strategic Contracting and

Commissioning Partnership Board, is supporting targeted service reviews. A review of the CCG’s Mental Health expenditure on out of area placements (OAPs) has been undertaken. General benchmarking data is available and being analysed.

3.27. The Quality and Performance Committee reviewed this risk at the 13 November

2019 meeting and was assured that the risk is being effectively managed.

GB1920_PR_2.1 Lack of effective working with key partners which influence the wider determinants of health

3.28. The second assessment resulted in no change to the risk score of 20, against a target level of 15 to be achieved by March 2020 as the CCG and Local Authority are in the early stages in terms of developing a suite of integrated strategies.

3.29. The Bury Strategy is underdevelopment, which will be supported by a range of underpinning strategies and delivery plans. Workshops have been undertaken to ensure joint and active participation in developing these strategies and the output of ‘Bury Big Conversation’ is currently being analysed.

3.30. The risk is assigned to the Strategic Commissioning Board for oversight, however as


GB1920_PR_3.1 Risk of in-year deficit

3.31. The second assessment of this risk saw no change to the risk score of 20, against a target of 2 to be achieved by January 2020 as the current net risk reported for the CCG stands at £7.2M deficit.

Date:22/01/2020


3.32. Pipeline schemes and options were presented to the Extraordinary Governing Body

meeting in August 2019. This has resulted in a package of savings schemes totalling £7.6M being put in to development with a target implementation date of 1st April 2020.

3.33. The Strategic Oversight Group has completed the review of the Transformation Fund

Programme and agreed changes which will ensure costs are kept within the current financial envelope.

3.34. An Informal dialogue with key stakeholders and partners to identify non-recurrent

mitigations and / or smooth pressures across financial years has taken place and proposals are now being firmed up.

3.35. Due to the timeliness of the risk review, the Finance, Contracting and Procurement

Committee has not reviewed this risk at this time.

GB1920_PR_3.2 Risk that the CCG becomes financially unsustainable

3.36. The second assessment resulted in no change to the risk score of 25, against a target of 15 to be achieved by March 2020.

3.37. There has been insufficient progress made in the development of the savings plans. Work is progressing however the risk assessment will remain a level 25 until robust savings plans have been finalised. It is unlikely this will be achieved before March 2020.

3.38. The overarching programme of works is running to timescales. The Long-Term Plan

has been refreshed with financial activity figures and submitted for review to GM and NHSE in November 2019.

3.39. Deloittes have commenced work with the CCG in November 2019 to undertake a

review of the underlying drivers that contribute to the deficit. A descriptive report is expected from Deloittes at the end of December 2019.

3.40. Due to the timeliness of the risk review, the Finance, Contracting and Procurement Committee has not reviewed this risk at this time.

GB1920_PR_3.3 Brexit – No deal scenario

3.41. This risk remains a level 16 risk, against a target of 4 to be achieved by October 2019 as there remains on going uncertainty of the national picture.

3.42. On-going management and implementation of the Brexit operational readiness

guidance issued in 2018/19 remains relevant. The CCG continues to work with the relevant providers to ensure they remain complaint with the requirements.

3.43. The daily SITREPs were reinstated in October 2019 and reported to NHSE, however

were once again stepped down following the additional national changes that have been put into place. Additionally, a review of risks associated with specific areas of

Date:22/01/2020


work across the CCG have been identified and monitored accordingly. Work is also being undertaken collaboratively with the Council to ensure robust preparedness and response.

3.44. This risk will be reviewed and escalated as required through the most appropriate

reporting arrangements.

GB1920_PR_4.1 Assuring decisions are influenced by all staff including clinicians

3.45. This risk remains a level 20 risk, against a target level of 10 to be achieved by March 2020.

3.46. Roles and responsibilities as commissioners have been explored and a high-level restructure has been issued on 03 October 2019 which is subject to a 3-month consultation.

3.47. External capacity has been secured to support OCO transformation which has the

development of a comprehensive Organisation Development Programme as a priority area which will ensure alignment across the CCG and Council offer.

3.48. Regular meetings across Health and Social Care are in place to shape the working arrangements for Integrated Commissioning. A joint meeting has been held in September 2019 between the Chief Officer and Clinical Directors to discuss potential new roles, this will now be explored through more joint meetings.

3.49. Furthermore, bi-lateral conversations between the Chair and individual Clinical

Directors are in situ and on-going. 3.50. The risk is assigned to the Strategic Commissioning Board for oversight, however as


4.0 Risks recommended for closure

4.1. During the reporting period no risks have been recommend for closure.

5.0 New Risks Identified

5.1. During the reporting period no new risks have been identified.

meeting: governing body (in public) · 3.10. the governing body has delegated authority to the...

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