Collaborative governance to effectively deliver NCL-level programmes
LEAD GOVERNING
BODY MEMBER: Martin Machray, Director of Quality and Integrated Governance AUTHOR: Michael Wüstefeld-Gray, Integrated Governance Manager CONTACT
DETAILS:
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SUMMARY:
There are 29 risks on the CCG risk register of which six are rated red pre mitigation and none remain red post-mitigation. Three risks are proposed for deletion (risks 315, 315 and 316 on different elements of Value Based Commissioning) and are replaced by a new proposed risk, 319, as a single overarching risk covering the whole VBC programme.
One risk has its risk rating reduced both pre and post mitigation, risk 215, on succession planning. This is because while the likelihood has increased, the consequence ratings have decreased resulting in a slight net reduction in overall rating. The risk remains red pre-mitigation.
One further risk has had its rating reduced post mitigation, risk 214: Performance at UCLH.
This is because the mitigating strategy is successful but not yet complete, so the risk remains extant.
The Patient and Public Participation Committee has considered the risk register and a series of potential risks that fall within its remit but at the time of writing has not proposed a risk for inclusion, or commented on the existing risks.
To support the effective audit of the CCG’s approach to risk management it is now our practice to ask for evidence supporting mitigation and assurance, which may mean that following a review by Internal Audit some risks may need to be re-evaluated. Some risks require more developed assurance. This has been flagged up to risk leads and will be followed up by risk owners as an action.
This report contributes to:
Ensuring every child has the best start in life,
Preventing and managing long term conditions to extend both length and quality of life and reduce health inequalities,
Improving mental health and wellbeing, and
Delivering high quality, efficient services within the resources available.
Prior consideration by Committees and other partners: the risk register was also considered by the Strategy and Finance Committee on 29 October 2015, and the Quality and Performance Committee on 20 October 2015.
Appendix: 5.1
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Patient & Public Involvement (PPI): This paper is available on the CCG website for consideration by patients and the public.
Equality Impact Assessment: none.
Risks: N/A
RECOMMENDED ACTION:
The Governing Body is asked to consider the risk register and make any comments, amendments or suggested additions that should be taken forward by risk leads including:
the deletion of risks 314, 315 and 316 and the inclusion of risk 319.
encouraging further evidence-based assurance where necessary for risks.
SUPPORTING PAPERS:
5.1.1 Islington CCG corporate risk register
5.1.2 Illustrative heat map
StrategicObjective and BusinessPriorities Risk Clinical Financial Reputational Reference Page Pre-mitigation risk rating Post-mitigation risk rating
Ensure appropriate leadership, systems and processes for child and adult safeguarding Deprivation of liberty safeguards in resedential care or acute settings a a 208 1 16 12
Work effectively with HWB, partners and providers in health and social care in Islington, NCL and nationally Patient Complaints a a 206 1 15 12
Ensure better data and contracting delivers improved outcomes and system-wide working Value based commissioning (contracts) a a 314 4 12 12
Ensure better data and contracting delivers improved outcomes and system-wide working Value based commissioning (outcome masurement) a a 315 4 12 12
Ensure better data and contracting delivers improved outcomes and system-wide working Value based commissioning 319 4 12 12
Ensure better data and contracting delivers improved outcomes and system-wide working Out of Hours/111 a a 317 4 12 12
Secure improvements in quality, and develop capability and capacity in primary care Capacity of Primary Care to Deliver Strategy (workforce development) a a 108b 3 12 12
Ensure the Whittington ICO delivers a programme of transformational change and long-term viability FT Application of Whittington Health a a 101 4 12 12
Ensure commissioning systems and processes are in place to support quality, safety and innovation Integrated Digital Care Record a a 305 3 12 12
Ensure commissioning systems and processes are in place to support quality, safety and innovation Oversight of quality and safety concerns a a 105 1 15 10
Ensure better data and contracting delivers improved outcomes and system-wide working Value based commissioning (diabetes) a a 316 5 10 10
Ensure better data and contracting delivers improved outcomes and system-wide working Mental Health Acute Beds a a 205 3 20 9
Deliver the Operating Plan including performance improvement, savings and investment Workforce and Succession Planning a a 215 1 15 10
Ensure commissioning systems and processes are in place to support quality, safety and innovation Performance at University College London Hospitals a 214 2 12 9
Ensure commissioning systems and processes are in place to support quality, safety and innovation Co-commissioning a a 302 5 9 9
Ensure commissioning systems and processes are in place to support quality, safety and innovation London Ambulance Service a a 313 2 9 9
Ensure better data and contracting delivers improved outcomes and system-wide working Unexpected deaths at Camden and Islington Foundation Trust a a 318 4 12 6
Ensure the Whittington ICO delivers a programme of transformational change and long-term viability Quality Premium a a 107 4 12 6
Secure improvements in quality, and develop capability and capacity in primary care Prime Minister's Challenge Fund a 310 5 6 6
Deliver the Operating Plan including performance improvement, savings and investment Strategic Delivery a a 106 5 8 4
Ensure appropriate leadership, systems and processes for child and adult safeguarding Safeguarding children at risk a a X11 2 6 6
Ensure commissioning systems and processes are in place to support quality, safety and innovation Completing mental capacity assessments and best interests decisions a 212 5 9 4 Ensure commissioning systems and processes are in place to support quality, safety and innovation Delivery of Continuing Healthcare (Domiciliary care framework) a a 119 5 12 6
Ensure appropriate leadership, systems and processes for child and adult safeguarding Care Act a 308 2 12 12
Meeting financial requirements, including balance Forecast Outturn a 210 5 12 12
Ensure appropriate leadership, systems and processes for child and adult safeguarding Prevent a 309 2 10 10
Work effectively with HWB, partners and providers in health and social care in Islington, NCL and nationally QIPP delivery a 307 3 16 9
Continue to develop the CCG to be the best it can be (Governing Body, staff and members) Information Governance a a a 103 1 12 9
Continue to develop the CCG to be the best it can be (Governing Body, staff and members) Business Continuity a a X16 2 9 9
Key
Risk for addition Risk for deletion
Existing risk with substantial amendment for approval Statutory Obligations and Core Business
Ensuring Every Child has the Best Start in Life
Preventing and managing long term conditions to extend both length and quality of life and reduce health inequalities, Improving mental health and wellbeing,
Delivering high quality, efficient services within the resources available.
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Version: 45 Islington CCG risk register Updated 15/10/2015
ID, Category Heading Objective Programme
Principal risk
What could prevent this objective being achieved?
Describe in terms of cause, event, effect.
Risk Approach Proximity Date Old Consequence Old likelihood Current Consequence Current Likelihood Rating
Mitigation
Existing mitigating controls Planned mitigating controls Gaps in mitigation, and action plan
Assurance Existing assurance Planned assurance
Gaps in assurance, and action plan
Old Consequence Old likelihood Post mitigation Consequence Post mitigation Likelihood Rating Date last reviewed Risk lead ( risk owner where blank) Risk owner Committee
208 C, R
Deprivation of Liberty in Residential Care or Acute Care Delivery of high quality, efficient services within available resources Core Business
Following the 'Cheshire West' judgement it may be that patients in residential or acute care e.g.
mental health patients not under section risk being deprived of their liberty without adequate safeguards or reviews put in place. Examples include facilities described by providers as 'locked rehab'. There is a risk that mental capacity assessments and deprivation of liberty assessments are undertaken inconsistently across commissioned services because of insufficient
understanding of what is required. The introduction of the Care Act highlights this area of risk, and a recent serious case review identified a lack of understanding around decision making in key areas.
The consequence of this could be clinical failings in terms of safeguarding vulnerable people and the law may be broken due to unlawful deprivation of liberty.
Mitigate Ongoing
4 4 16
The CCG is working with all providers e.g. Camden and Islington Foundation Trust to seek their assurance that when people are deprived of their liberty it is both lawful and in the person's best interest.
This is through increased training: in organisations, by the safeguarding team at the local authority, across CCGs however unless people understand the framework it is more than likely that it is being applied wrongly.
Existing Assurance
- Increased scrutiny at different levels i.e. CQR, Provider safeguarding committees, LA safeguarding team
Planned Assurance
- CCG Designated professional will have greater links with local providers and the LA safeguarding team and will develop assurance reporting into the Quality and Performance
Committee. 4 3 8
16/10/15 Jen Yousuf/Jennifer Speller Martin Machray Strategy and Finance/Quality andPerformance
215 R, F
Workforce and SuccessionPlanning Delivery of high quality, efficientservices within available resources Core Business
The CCG faces risks relating to recruiting and retaining the right staff to deliver on key projects and the overall strategy, as well as fulfil the CCG's statutory obligations and maintain its position as a leader in the health and social care system in Islington and more widely. Turnover at the CCG is due to increase over the next few months at a number of levels.
These risks are more prominent when considering director level appointments or Governing Body membership
Mitigate 31/03/2016
4 4 3 5 15
Mitigation of the risk comes from a range of sources:
* having clear and robust recruitment processes that where appropriate follow the CCG's constitution
*the CCG has a stable senior management team and a low rate of turnover among Governing Body members.
* the CCGs management team and Governing Body forming close and overlapping professional relationships that diffuse knowledge and expertise across the CCG's functions
* close working with key stakeholders within Islington and with partners in the wider NHS
* keeping roles and portfolios under review with the support of the CCG's Business Support Team and Project Management Office
We are developing mitigation plans with HR and are getting support from subject matter experts at the CSU with the aim of securing continuity of service.
The CCG works closely with other North Central London CCGs, and NHS England to ensure it follows appropriate processes. The CCG's constitution is approved by NHS England and kept under active review in terms of both the role and appointment of Governing Body members and recruitment processes have typically involved both an independent person and a representative from the Local Medical Committee. NHS England also runs recruitment for senior managerial appointments and e.g. the Chief Officer of the CCG and it will have significant experience of exercising this function across England. Under Domain Six of the assurance framework the CCG made a submission on 6 January 2015, including succession planning for GPs staff and
organisational development. A review of 'section 75' agreements with the Local Authority has covered all joint commissioning activity and helped strengthen teams. The CCG continues to monitor staff turnover, and other indicators such as rates of sickness absence. These remain below national averages and below those of other comparable CCGs.
3 3 2 4 8
15/10/15 Martin Machray Quality and Performance
206 R
Patient Complaints Delivery of high quality, efficient serviceswithin available resources Core Business
Each of the organisations involved in commissioning and providing care has their own complaints system and these are not linked or set up to exchange information . The consequences of this are firstly that patients may be reluctant to complain, because of reduced confidence in the system;
and secondly the CCG and wider system may not hear about problems and learn from complaints to improve systems.
Mitigate 3 5 15
Existing Mitigation
The Business Support Team has been handling complaint and feedback to the CCG. They have been trained by the CSU on signposting patients to where they can best raise concerns. The CCG is also exploring other routes by which patients and the public can give feedback. The CCG works closely with Healthwatch to give bi-monthly reports to the Patient and Public Participation (PPP) Committee.
Planned Mitigation
The CCG commissioned a report on complaints from Healthwatch Islington to assess the situation. Actions from this report are now being actioned – including after further community research an Equality Objective on complaints (the focus on the system to complain rather than content of complaints).
The CCG has also put the requirement that providers seek and consider and report on all feedback (not just complaints) in provider contracts.
The PPP Committee oversees patient engagement and complaints while the Quality and
Performance Committee oversees systems and processes with providers. The PPP Committee also receives regular reports from Healthwatch.
Comments and feedback obtained by providers will also be reported to the Quality and
Performance Committee. As highlighted already through research carried out by Healthwatch and further community research how patients complain is now an Equality objective and a series of Healthwatch recommendations will be addressed as part of this.
3 4 12
28/09/15 Elizabeth Stimson Martin Machray
105 C, R
Oversight of quality and safety issues Delivery of high quality, efficient serviceswithin available resources Core Business
The CCG should develop systems to ensure it does not see a significant failure in a commissioned service. The CCG is the lead commissioner for the Whittington, Moorfields, Camden and Islington Foundation Trust (for mental health), Care UK GP out of hours services, and the local NHS 111 service. A failure in a commissioned service could be due to poor performance or quality of services resulting in poor patient experience or potential patient harm.
Mitigate Ongoing
5 3 15
Islington CCG has mechanisms for commissioning and monitoring services that reduce the risk of a failure.
- The CCG holds regular quality review and contract meetings with providers. A forward plan ensures that all key quality metrics are reviewed through the year. Through these meetings the CCG is able to mitigate the risk of failure.
- The CCG is supported by the CSU Contracting and Quality team to provide quality assurance, review provider patient safety incidents, CCG complaint management and performance
management of providers.
- The CCG receives CQC and other alerts with relation to the providers we commission and also receives feedback directly from patients and voluntary organisations such as Healthwatch on the quality of services provided to our residents
- The CCG has strengthened it's quality resource by appointing a Head of Quality in November 2013 and a fixed term Quality Assurance Manager in December 2014.
- The CCG attends bi-monthly NHS England London Quality Surveillance Group where
organisations including NHS England, other CCGs, Health Education England, Monitor and TDA share provider intelligence and risk rating of organisations.
- The CCG mechanisms for addressing a significant failure should one occur is through the CSU Performance Management Framework where issues of concern are escalated against agreed thresholds.
Existing Assurance
- Islington CCG receives regular quality and performance metrics from providers via contract meetings i.e. number of healthcare acquired infections, reporting on referral-to-treatment times, A&E waits, and ambulance handover times .
- Provider reports are taken to the CCG Quality and Performance Committee that provide updates on the key quality and performance issues discussed with providers and actions taken.
- Assurance is provided by minutes of the contract meetings with providers and minutes of the CCG Quality and Performance committee.
- Other forms of assurance currently in place included internal and external audit, and regular assurance provided to NHS England.
- The CCGs internal auditors, Baker Tilley, completed a report on the CCG clinical governance and RAG rated us green with no recommendations for improvement.
- Regular reports of the Quality and Performance Committee are taken to the Governing Body.
- There has been a review of the Terms of Reference of the Quality and Performance Committee and its effectiveness in the last year.
4 2 8
23/07/15 Helen Keynes Martin Machray Quality and Performance
103 F, R,
C
Information Governance Statutory Obligations and Core Business Core Business
There are a number of risks facing the Clinical Commissioning Group (CCG) around information governance. CCGs may generally not access patient identifiable data without explicit consent or where it is not for the purposes of direct care; and we are in an environment there is a lack of knowledge of what the standards for accessing information are and which bodies are responsible for what. The CCG and its stakeholders could be at risk of reputational and financial
consequences if we do not work develop and assure processes for data collection, transmission, analysis and storage. Examples include:
- GPs being asked to provide patient data to third parties without adequate safeguards in place such as clear identification of the legal basis for information sharing and assurance of compliance with data protection and Caldicott principles.
- GPs being unable to answer patient queries relating to activities such as 'care.data' and summary care records.
- Informatics, Primary Care, or other teams being unable to access information for the purposes of risk stratification, or service analysis.
The maximum fine that may be levelled on any organisation or individual for breaches of data protection legislation is £500,000, and information governance has generated significant public and media interest .
See also the risk on business continuity (X16)
Mitigate Ongoing
4 3 12
Existing Mitigation
The CCG has implemented a number of mitigations strategies.
The CCG has consistently achieved the standard to become an Accredited Safe Haven (ASH) Status.
We are working with the Commissioning Support Unit (CSU) and the Public Health Team at the local authority to agree principles of data sharing. The CSU also has ASH status so may legally access data that is then anonymised before being passed on. This will facilitate data sharing within the current set of access rights stakeholders share, and allow e.g. risk stratification (where in the course of analysing aggregate date a patient at potential risk is flagged for follow up by the patient's GP) activity to take place.
CCG staff regularly participate in joint working groups and patient engagement fora to discuss and explain/hear ideas and concerns about information governance, and this work is ongoing. The CCG is also participating in the London Information Governance Forum
During the first two years of the CCG's existence no significant need for patient identifiable data that could not be managed within the existing institutions surrounding data sharing has emerged.
Existing assurance:
The CCG has a comprehensive range of information governance policies and guidance that meet the requirements of the Information Governance Toolkit. The CSU has ASH status and will be able to support the CCG.
The CCG has also developed patient communication materials for patients that have been discussed and approved by the local Medical Committee, Public Health, patient representatives and the Information Commissioner.
Gaps in Assurance
The process to become an Accredited Safe Haven has been up to now an interim process, and how the full process will differ (e.g. what further requirements it will place on the CCG in terms of evidence gathering and audit) is an unknown.
3 3 9
15/10/15 Martin Machray Quality and Performance
Quality and Governance
Version: 45 Islington CCG risk register Updated 15/10/2015
ID, Category Heading Objective Programme
Principal risk
What could prevent this objective being achieved?
Describe in terms of cause, event, effect.
Risk Approach Proximity Date Old Consequence Old likelihood Current Consequence Current Likelihood Rating
Risk Approach Proximity Date Old Consequence Old likelihood Current Consequence Current Likelihood Rating