NHS Calderdale, Kirklees and Wakefield District Cluster
Minutes of the Cluster Governance Committee Meeting held on Wednesday 10 October 2012 at 9.30am in the Stewart Room, Broad Lea House, Huddersfield Present: Roger Grasby Angela Monaghan Sandra Cheseldine In attendance: Gill Galdins Sue Cannon Andrea McCourt Judith Salter Alison Fearnley Andrew Furber Deborah Turner Terry Service Ian Wilkinson
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Non-Executive Director and Chair (until 10.35am) Cluster Chair Non- Executive Director
Director of Corporate Development and Transition Executive Director of Quality (Executive Nurse) Head of Corporate Governance (NHS Wakefield District) Assistant Director of Transition (NHS Calderdale) Corporate Governance Administrator (NHS Kirklees) Executive Director of Public Health (NHS Wakefield District) (Agenda Item GC/12/63) Head of Quality and Patient Safety (NHS North Kirklees CCG) (Agenda Item GC/12/61) Assistant Director of Corporate and Risk (NHS Kirklees) (Agenda Item GC/12/60) Safety and Security Manager (NHS Calderdale) (Agenda Item GC/12/60)
Apologies for Absence Apologies for absence were received from Roy Coldwell, Non Executive Director. It was noted that Roger Grasby had to leave the meeting at approximately 10.35am. It was AGREED that Angela Monaghan would then resume as Chair.
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Declarations of Interest Roger Grasby declared an interest in Agenda item GC/12/63 with regard to the Transfer of Public Health Services – Section 75 Agreement.
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Minutes of the last meeting held on 20 June 2012 and matters arising The Minutes of the Governance Committee meeting held on the 20 June 2012 were AGREED as a true and accurate record. The action log sheet was also reviewed and updated.
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Matters arising •
Minutes of the Governance Committee held 18 April 2012 The Executive Director of Quality reported that the Local Authority had requested the removal of the Governance Committee minutes dated18 April 2012 from the PCT’s website as there was an inaccuracy in the minutes under agenda item GC/12/30 relating to the number of reported Serious Case Reviews. It was noted that concerns were also raised that these minutes could potentially generate a problem with legal proceedings until such a time as the judicial process was complete. It was noted that legal advice had been taken on this issue and it had been agreed to remove the minutes from the website in the interim until the relevant sections of the minutes could be redacted before being uploaded back on the website. It was noted that Serious Case Reviews should in future be considered in private sections of meetings, including the Governance Committee and Audit and Governance Group meetings. Following discussion it was AGREED to: • • •
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SUPPORT the action taken to temporarily remove the minutes from the website until the relevant sections of the minutes are redacted; RAISE awareness of this issue via the Cluster Executive Team; and REMIND Chairs of the facility to record sensitive items in private, given that all minutes are subject to release under the Freedom of Information Act.
Revised Governance Committee Terms of Reference It was noted that following discussion at the June meeting the role of the Governance Committee had been reviewed within the context of changes to the commissioning architecture of the NHS and revised Terms of Reference had been approved at the September Board meeting. It was noted that minor amendments had been made to the Terms of Reference following the Board meeting. It was acknowledged that the Governance Committee would now meet more frequently (on a monthly rather than two monthly basis), with a Non Executive only membership. A discussion ensured regarding the Committee’s role in terms of overseeing the quality agenda. Sue Cannon confirmed that the Quality Handover documents provided a comprehensive overview and assurance to the Board as a vehicle for quality going forward. In addition, it was recognised that the individual Designate Chief Officer reports also provided assurance to the Board. Sue also provided assurance regarding the various reporting Page 2 of 8
mechanisms in place for escalating emerging quality issues throughout the organisation. The Committee was assured that robust arrangements were in place. Following further discussion it was AGREED to: • • • •
Include the Quality Handover Document as a standing item on the Governance Committee agenda; Invite the four lay members from the quality groups to the December Governance Committee meeting; Follow up progress on the Internal Audit report regarding quality governance arrangements; and Follow up the outstanding issue regarding Learning Disabilities and Jointly Commissioned services via the transition plan.
The Committee APPROVED the revised Terms of Reference for the Governance Committee. GC/12/59
Governance Committee Annual Report The Governance Committee received the 2011/12 Governance Committee Annual Report and reviewed its content. The committee AGREED that the report was an accurate reflection of the business conducted during 2011/12. It was noted that this would be presented to the Cluster Board in January 2013.
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Cluster Risk Management Report Terry Service and Ian Wilkinson joined the meeting to provide an overview of the risk management activity across the cluster in order to provide assurances that risks were being identified and appropriately managed within PCTs, CCGs and the Cluster. It was recognised that any risks scoring 15 or above would be reviewed by the Cluster Leadership Team and the Governance Committee. Any critical risks would be reviewed by the Cluster Board. Ian provided a comprehensive overview of the risk register review process confirming that all risks were now recorded on a single risk management system. It was acknowledged that the on-line system was accessible to all staff and it was AGREED a live demonstration would be given at the next meeting. A discussion ensued regarding the different functions of the High Level Risk Log (HLRL) and the Board Assurance Framework (BAF). It was recognised that whilst there should be significant focus on the HLRL, ensuring that risks are relative to the transition closedown, it was emphasised that the Cluster BAF remains a statutory function until 31 March 2013. It was acknowledged Page 3 of 8
that this must remain in place and continue to capture the strategic risks of the three PCTs until closedown. Notwithstanding this, it was recognised that individual BAFs for the four Clinical Commissioning Groups (CCGs) were currently being developed and would run in parallel with the Cluster BAF until CCGs resume statutory responsibility. Discussion then took place regarding the content of the HLRL and how this had been populated. In particular, it was emphasised that consideration needed to be given to how risks are phrased due to Freedom of Information (FOI) requirements. Additionally, concerns were raised regarding the quality of the information provided and whether information was up-to-date. It was therefore AGREED that further work would be undertaken to refine how the HLRL is populated. It was also AGREED risks that score 15 or above would have a summary in bold text added to the key controls section of the risk identifying action since the previous review. This would be used to provide high level assurance on the actions to control risks and should reduce the requirement for the Governance Committee to call directors or senior managers to the meeting to explain risks and actions taken to control them. It was AGREED that comments submitted from Roy Coldwell prior to the meeting would be shared with Ian Wilkinson. Ian AGREED to liaise directly with Roy concerning these. GC/12/61
Quality Handover Document Deborah Turner joined the meeting to present the first draft of the Quality Handover documents to the Governance Committee. She explained these documents had been created to capture the quality information held by the three existing Primary Care Trusts (PCTs) within the Cluster namely; Calderdale, Kirklees and Wakefield District. It was noted these are the Sender organisations who are preparing to transfer quality intelligence and information to Receiver organisations, such as Clinical Commissioning Groups or the National Commissioning Board, Public Health England. It was recognised that the Quality Handover document had been submitted to the Strategic Health Authority at the end of September within agreed timescales and was presented to the Governance Committee to provide assurance it was fit for purpose. It was noted that the final draft of the Quality Handover documents would be taken to the final Board meeting of the sending organisations in March 2013 and receiving organisations should receive the document formally at its first public Board meeting in April 2013. It was acknowledged that all documents were working documents and contain confidential information. These were therefore currently exempt from FOI requests. It was highlighted that there remained some areas of development and that there was a robust audit control in place. It was acknowledged that the Cluster Board had delegated authority to Governance Committee to scrutinise these documents on behalf of the Page 4 of 8
Board. The Cluster Board would therefore receive this formally for the first time in January 2013. Overall the committee agreed the documents were comprehensive and a good check list. Some comments were made in terms of accuracy and inconsistencies in the way that the different PCTs were reporting legacy issues. In addition there were some comments from Roy Coldwell which would be shared with Deborah following the meeting. All these issues would be addressed accordingly. It was emphasised that the Quality Handover documentation needed to be aligned to the transition and closedown arrangements. It was AGREED that Gill Galdins would liaise with Sue Cannon regarding this following the meeting. It was acknowledged that arrangements were in place to present these documents to the local Audit and Governance Groups. Assurance was also provided that relevant discussions had taken place with CCG Chairs to ensure they are sighted on this as Receivers. It was noted that the documentation would be disaggregated into the four CCG areas in the future. The Governance Committee RECEIVED the Quality Handover Documentation. GC/12/62
Performance Advice Group Minutes The Governance Committee RECEIVED and NOTED minutes from the Performance Advice Group (PAG) held on 9 August 2012. It was highlighted that these minutes should be accompanied by a cover sheet confirming the FOI exemption, given the confidential nature of the content of these minutes. It was highlighted that there should be a long term record of poor performers as part of the handover on performance. It was recognised that this was captured in the Quality Handover documentation. The Governance Committee received assurance that the PAG was working effectively.
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Transfer of Public Health Services – Section 75 Agreement Andrew Furber joined the meeting to present the report which sought approval for the transfer of lead commissioning responsibility for Public Health Services from NHS Wakefield District to Wakefield Council from 1 October 2012 through a Section 75 Agreement. The committee sought clarity on why the public health service in Wakefield was seeking to transfer services six months ahead. It was acknowledged that the Public Health Transformation Steering Group in Wakefield was Page 5 of 8
further advanced than Calderdale and Kirklees due to its local situation and capacity. Assurance was provided that Andrew’s appointment as Director of Public Health remained a joint one between the Cluster and the Local Authority. Andrew also confirmed that the Section 75 agreement related to contracts and budgets, not the transfer of staff and that there was a separate Memorandum of Understanding pertaining to staff arrangements. Andrew also highlighted the financial benefits of these arrangements and provided assurance that there were no significant risks. It was acknowledged that the financial implications for the Clinical Commissioning Executive and NHS Wakefield Clinical Commissioning Group had been considered and discussed. The Committee sought assurance on the legalities of the Section 75 agreement and novation of contracts. It was acknowledged that the council’s legal department was aware of this and perceives this as low risk for either party. The Head of Contracting in Wakefield had confirmed that the novation of contracts was permissible under Department of Health guidance. Committee members requested written legal advice be sought by the cluster regarding its authority to novate contracts as proposed under the Section 75 agreement. The Governance Committee gave APPROVAL in principle for NHS Wakefield District to enter into a Section 75 agreement for the identified public health services, for the shadow period up until the 1 April 2013 with Wakefield Council, SUBJECT to written legal advice that this was appropriate. GC/12/64
CKW Transition and Closedown: Governance arrangements The Governance Committee received assurance on the governance arrangements in place to support the CKW transition and closedown arrangements. Judith Salter provided an overview of the Transition and Closedown Programme that had been established to date. She explained that a programme approach had been adopted to support the senior managers who are leading the work across the three PCTs and she described the governance arrangements, the structure and shared the draft programme plan. It was acknowledged that a Steering Group had been established to oversee the delivery of the programme which currently meets monthly with the function leads. It was AGREED to include Deborah Turner as a separate member of the Steering Group to ensure linkage with the quality legacy work. The Committee noted that consideration was also being given to extending the membership to include a Non Executive Director. Page 6 of 8
Ian Wilkinson explained how the High Level Risk Log (HLRL) was being further populated to capture risks related to transition. The committee reviewed the Terms of Reference of the Steering Group. It was suggested that these needed to reflect the need to seek best practice, guidance and legal advice. It was therefore agreed that additional narrative would be incorporated into the role and function section to capture this point. In addition, it was highlighted that the Steering Group should maximise the use of public resources by sharing legal advice on a regional basis with the Bradford, Airedale and Leeds Cluster. The committee scrutinised the draft programme plan attached at Appendix 3 of the report. It was acknowledged that this was continuing to be populated daily. It was noted that the committee would be able to view this document live at future meetings along with the HLRL. A discussion ensued regarding task reference 4.1.4 concerning the staff award ceremonies. It was suggested that in addition to the individual staff award ceremonies arranged during November and December, consideration should be given to organising a collective closedown ceremony during the last week in March. Furthermore it was recognised that arrangements need to be made to issue thank you letters to staff as well as induction/welcome letters from receiver organisations. The committee AGREED that future reporting to the Governance Committee would be via a RAG rated highlight report to include narrative on items scored RED. The Governance Committee AGREED to: • • • • GC/12/65
RECEIVE the update report; APPROVE the Steering Group Terms of Reference, subject to the suggested amendments; NOTE the first draft of the Programme Plan; and NOTE the risks and actions being taken to mitigate against them.
Governance Committee Meeting Schedule The committee noted the date and time of future meetings as outlined in the attached meeting schedule. It was AGREED to cancel the April meeting, given the CKW Cluster would no longer be a statutory organisation. It was acknowledged that the programme plan would address the issue of follow up post April 2013.
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Any Other Business None.
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GC/12/67
Date and time of next meeting It was noted that the next meeting would take place on 23 November 2012 at 9am in Interview Room 9, Broad Lea House, Huddersfield. It was noted that Sandra Cheseldine would attend on behalf of Roger Grasby.
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