CKWCB.12.116b_NHS_Calderdale_Annual_Governance_Statement

NHS Calderdale (Calderdale Primary Care Trust) 5J6 GOVERNANCE STATEMENT 2011/12 1. Scope of Responsibility The Board is accountable for internal control. As Accountable Officer and Chief Executive of this Board, I have responsibility for maintaining a sound system of internal control that supports the achievement of the organisation’s policies, aims and objectives. Patient safety remains our first priority and I take personal responsibility for this along with safeguarding the public funds and the organisation’s assets, as set out in the Accountable Officer Memorandum. I am also responsible for ensuring that the organisation is administered efficiently and effectively within our resources. Internal auditors have throughout the year reviewed governance arrangements and found these to be satisfactory.

NHS Calderdale is part of the local health and social care economy that aims to improve health wellbeing for the people of Calderdale. It supports the development of local services to deliver better health, in partnership with other stakeholders. Our Operating Plan for 2011/12 set out our objectives and targets for the short and medium term. The Board oversees delivery of our Operating Plan, supported by its subcommittee arrangements which maintain the focus on the local priorities. The NHS North of England assesses and monitors performance of the PCT against national and local objectives through the reporting arrangements in place with the SHA. 2. The Governance Framework of the Organisation During 2011/12 the governance arrangements changed significantly for NHS Calderdale in line with national policy to support the NHS reforms.

2.1 Board Committee Structure (April to September 2011) For the period April to September 2011, NHS Calderdale had a Board in place with a committee structure of an Audit Committee, Remuneration and Terms of Service Committee, Finance and Performance Committee, Risk Management Committee, Clinical Commissioning Executive and Health and Social Care Partnership Board.

In March 2011, the three Boards of Calderdale, Kirklees and Wakefield District Primary Care Trusts also agreed to establish the Cluster Partnership as a Sub Committee, with responsibility for overseeing the transition to the new structure of the NHS. This arrangement retained the three Boards as accountable and responsible for the commissioning of safe and effective local health services within the financial resources.

It included the creation of a single executive management structure including one Chief Executive and Accountable Officer for the three organisations and one set of executive directors who sat on the Boards of all three organisations. To ensure clarity of governance for these individuals and the organisations as a whole, Wakefield District’s Standing Orders were adopted by the three Boards.

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As Chief Executive I appointed a Chief Operating Officer for NHS Calderdale from May 2011 with responsibility for operational management of the organisation to ensure a sound governance framework within the organisation on my behalf.

Membership of the Board committees was in line with the Standing Orders of, with three Non Executive Directors as members of the Audit Committee. Good attendance was maintained throughout the governance structure during this period.

Legacy reports for the governance structure were produced on behalf of the NHS Calderdale Board at the end of September 2011 to ensure safe and effective handover to the new governance arrangement implemented from the 1 October 2012.

2.2 Board Committee Structure (October 2011 to March 2012) In July 2011 the Strategic Health Authority wrote to the Chairs and Chief Executive of the Calderdale, Kirklees and Wakefield District Cluster setting out the requirement to move to a single board arrangement. For the period October 2011 to March 2012 the Board membership was amended to reflect this arrangement.

I continued in my role as Accountable Officer, alongside the single Executive Director team and a single set of Non Executive Directors.

The governance structure was redesigned, with the following cluster wide Board Committees being established: Audit Committee Remuneration and Terms of Service Committee Governance Committee Clinical Commissioning Executives Yorkshire and the Humber Specialised Commissioning Group The Clinical Commissioning Executive is supported by three reporting sub-groups covering Audit and Governance, Finance and Performance and Quality.

Since forming, the Cluster Board has undertaken development sessions to develop its effectiveness on strategy (Clinical Services Strategy, Clinical Commissioning Groups, Commissioning Support, QIPP, Urgent Care, Public Health Transition, Service transformation across the health economy).

The Cluster Board has had an independent review of its effectiveness and undertaken development based on this and its responsibilities as set out in the accountability framework for clusters.

Minutes of the Cluster Board meetings demonstrate high levels of attendance by Board members.

Internal Audit has also been asked to carry out a review of the governance Draft 3 NHS Calderdale Governance Statement 23 April 2012

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arrangements to ensure that they are working effectively and have found no significant issues.

2.3 Coverage of work by Board During 2011/12 the Board agendas covered a wide range of work which is outlined below.

The Board considered performance reports against key performance indicators, including the national priorities in the NHS Operating Framework 2011/12, each month following detailed review in Finance and Performance Good levels of performance have been maintained during the year across the majority of areas associated with the headline indicators from the Annual Operating Framework for 2011/12.

During the year NHS Calderdale has consistently achieved the required thresholds for: Planned Care (referral to treatment waiting times) Safety (reducing the incidence of healthcare acquired infection) Urgent Care (including access to A&E and ambulance response times) Cancer (existing and new operational standards for access) There have been notable pressures towards the end of the year associated with sustaining the standards for urgent care and cancer. Specifically this relates to the time spent in A&E where we are working with our local acute partner to understand and improve the indicator. In respect of cancer waiting times we are working with both our acute providers and the Yorkshire Cancer Network to improve performance.

In addition, Patient Experience (minimising the number of breaches associated with mixed sex accommodation) came under pressure in November/ December 2011, as a spate of breaches associated with mixed sex accommodation led to deterioration in the reported position for Calderdale. This related to the actions of an individual and was reported to Clinical Commissioning Executive and Quality Group. Measures have been put in place to prevent future occurrence and improve performance against this indicator.

Other areas of work covered by the Board include: Quality and Patient Safety Reports Finance, and QIPP (quality, innovation, productivity and prevention) Reports (monthly) and Annual Accounts 2010/11 Board Assurance Framework and the high level critical risks Draft 3 NHS Calderdale Governance Statement 23 April 2012

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Governance reports, including the establishment of the Cluster Board, cluster governance arrangements, approval of Board Committee terms of reference, Standing Orders and Standing Financial Instructions amendments and the approval of Schemes of Delegation Chief Executive’s Reports on the context within which we work, current issues, policy initiatives and the NHS reforms Emergency Preparedness Legacy Document on corporate performance, quality and safety, finance and quality, innovation, productivity and performance (QIPP), risk management and governance Safeguarding reports and inquiries Annual reports including the Director of Public Health’s, Senior Information Risk Owner and Infection Control Review of Committee minutes and other reporting groups, e.g. Specialised Commissioning Group.

2.4 Audit Committee The Audit Committee performs the key role of reviewing and monitoring the system of internal control. Following revised governance arrangements from October 2011 and the establishment of a cluster-wide Audit Committee an Audit and Governance group was established within NHS Calderdale which reports to the Clinical Commissioning Executive. The chair of the Audit and Governance group is a Non Executive Director and a member of the Cluster Audit Committee, ensuring linkage between the two groups.

All of these Audit governance arrangements have included regular reports on the work and findings of the internal and external auditors. Minutes of the Audit Committee are reported regularly to the Board and minutes of the Audit and Governance Group are reviewed by the Cluster Audit Committee.

Items highlighted to the Board from Audit Committee minutes included Payment by results audit, audit fees, 2010/11 Annual Accounts process, cluster governance arrangements.

A particular area of focus for Internal Audit has been on the contracting arrangements within the Continuing Care function.

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2.5 Corporate Governance The organisation has in place a corporate governance framework with standing orders, standing financial instructions, a scheme of delegation, and a code of conduct. This has been revised during the year to reflect changed governance arrangements.

Whilst there is no national corporate governance code in place for PCTs (such as the Monitor Code of Governance for Foundation Trusts), the PCT is compliant with principles within this code including: a Board of directors in place meeting monthly to discharge their duties a clear division of responsibilities of the Chair and Chief Executive a balance of Executive and Non-Executive Directors information and professional development – a number of Board Development sessions have been held as described earlier.

2.6 Partnership Governance The Health and Wellbeing Board has been established in shadow form in Calderdale since June 2011. This is supported by the main public sector organisations in Calderdale, alongside the private and voluntary sectors. The Chair is a member of the Board. NHS Calderdale plays a significant part in the collaborative working within the region. This is particularly important in the light of real financial pressures being felt next year and the need to create a system with much lower management costs.

Our partnership with the Local Authority provides opportunities for efficiency and improved impact, with better commissioning around “the Place”. Our Strategic Plan highlights how we will work together to develop a single approach to delivery in Calderdale and will continue to focus on this as we develop the local Clinical Commissioning Group arrangements. We have also been leading the way on integration of health and social care services through the development of the Intermediate Tier work and single point of access, working in partnership to improve services for older people.

3. The Risk and Control Framework The Chief Operating Officer, on my behalf, was responsible for maintaining the corporate risk register for NHS Calderdale. This in turn also populated the cluster-wide risk register. It is NHS Calderdale’s policy that directors, managers and all staff should work together to provide an integrated approach to the management of risk. NHS Calderdale has worked hard to embed a culture that encourages: 

people to work together to recognise and effectively manage risks;

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    

information systems to be developed to increase availability and access to performance data for key areas, e.g. commissioned activity, health and safety; effective incident reporting, complaints and claims handling activities and the coordination of these; better and safer buildings and estates; better maintained and safer equipment; and co-ordinated risks, with information relating to the management of risks to be identified and co-ordinated through the Risk Register, no matter whether the risks are clinical, financial or organisational in nature.

During 2011/12 a cluster-wide Risk Management Strategy was adopted which reflects this. It sets out how the PCT identifies, assesses, manages and controls risks. A key element in the strategy is the maintenance of the Risk Register, including the Assurance Framework.

The PCT has developed a high level set of objectives which cover all the principal activities and deliverables of the organisation. These reflect the Operational Plan locally agreed outcomes.

3.1 Risk Assessment NHS Calderdale’s risk assessment process is identified in the risk management policy and delivered through the use of a bespoke risk register and risk reporting system.

This system is an electronic database that provides quick and easy access to staff at all levels and includes Non Executive directors and Clinical Commissioning group GP’s.

This data base holds all of the organisations risks in a safe and secure medium and allows instant access to live risks which are reviewed and risk rated through a rigorous governance process that is system based and receives group review through scrutiny committee and board sub groups.

The organisations risk profile can be viewed from this system in many ways including Director Portfolio, risk severity, risk category and many other options.

The eight weekly risk review cycle has both local and Cluster review. This starts with the risk owner through sign off by the Senior Management Team before scrutiny at the local Audit and Governance Group. At a Cluster level, the Governance Committee has responsibility for risk management, which is detailed within its terms of reference. A regular report is presented to the Board and Governance Committee on the critical risks within the organisation.

3.2 Management of Risks At a cluster level, the Governance Committee has responsibility for risk management, which is detailed within its terms of reference.

The risks are managed within director portfolios through team meetings and larger directorate reviews. There is an alert system in place for critical risks (risks that score Draft 3 NHS Calderdale Governance Statement 23 April 2012

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20 or 25 on the 5 x 5 risk matrix) to ensure all senior management and staff are aware of these risks and appropriate resource and risk treatment is applied.

The electronic risk data base was chosen because It was a safer and easier way to identify and record risks in comparison to previous spreadsheet systems It allows instant access to timely information It is embedded in a secure NHS informatics environment It is designed to be user friendly and been instrumental in improving the organisations risk identification and management culture.

High level risks scoring 15 or above are identified and reviewed at directorate, director team , Audit and Governance Group and reported separately to the Governance Committee and Board with any critical risks being separately identified and reported on an individual basis.

Separate reports identify new risks and those with increased scores that appear on the high level risk log to ensure these are clear to senior management and Directors.

Risks relating to information governance continue to be monitored closely through the Risk Register. The Senior Information Risk Owner (SIRO) has responsibility for ensuring organisational information risk is properly identified and managed and that appropriate assurance mechanisms exist. They should be familiar with risk management and the organisations response to risk. Any incident reports are thoroughly investigated and the lessons learned shared throughout the organisations.

The Board Assurance Framework captures the organisation’s risks to corporate objectives. This was presented to the Board regularly throughout the year. The format of the Board Assurance Framework changed significantly during the year following the move to cluster arrangements. A cluster wide Board Assurance Framework structured was subsequently developed around the objectives within the cluster accountability framework and was presented to the Governance Committee, Audit Committee and Board.

During 2011/12 the organisation took a range of actions to reduce risk and provide assurance about risk mitigation. This included: Completing the Transfer of Community Services by April 2011, allowing the organisation to focus on commissioning Becoming a member of a cluster - wide organisation in response to national policy, significantly revising governance arrangements and supporting documentation (Establishment Agreement, Standing Orders, Schemes of Delegation and Reservation, Standing Financial Orders) and the Board / Committee structure, with planned evaluation of the effectiveness of revised governance arrangements by Internal Auditors Draft 3 NHS Calderdale Governance Statement 23 April 2012

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Legacy reports (including quality legacy report) to ensure an audit trail of transfer of responsibilities from PCT to cluster Closely monitoring compliance with national and local infection prevention and control targets Ongoing review and testing of emergency preparedness and resilience planning Review of the Information Governance Toolkit Reviewing all contracts and contract documentation to ensure safe handover to successor bodies NHS Calderdale’s new and critical risks during 2011/12 were: Medium term Financial plan and the potential unsustainable business model going forward QIPP programmes fail to identify and deliver required savings These were effectively managed throughout the year with all financial duties being met. 

Transition - the implementation of the Health and Social Care Bill continues to present a number of risks and challenges to the organisation. In particular, the ability to implement the changes with the associated impact on our staff, while ensuring that patients continue to receive safe, high quality care and that we deliver good value for money.

NHS Calderdale will use the project and governance arrangements to oversee and assess the achievement of the transactional elements of the Transition Programme.

The transformational elements of the programme will be taken forward through the QIPP programmes and the associated performance management and reporting arrangements.

3.3 Data Security Risks relating to information governance continue to be monitored closely through the Risk Register. The Senior Information Risk Owner (SIRO) has responsibility for ensuring organisational information risk is properly identified and managed and that appropriate assurance mechanisms exist. They are familiar with risk management and the organisations response to risk. Any incident reports are thoroughly investigated and the lessons learned shared throughout the organisations.

Risks relating to data security appear on the risk register and due to good controls and no serious incidents or security lapses remain at low level. There have been no information security incidents to report to the Information Commissioner.

The organisation continues to work towards improving performance to achieve level “2” compliance against the requirements of the Information Governance Toolkit.

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3.4 Prevention and Deterrence of Risks To provide assurances about the prevention of risk, the organisational governance framework consider any potential risks and their impact by: including an assessment of risk within Board and Committee papers ensuring risk management has an integral role in all major projects and developments within the organisation, keeping a specific risk register, for specific projects and escalating risk on to the corporate risk register.

Risk management policies and procedures were also in place during the year to ensure that risk was managed consistently throughout the organisation.

Counter fraud representatives attended the Audit Committee (until September 2011) and subsequently attended the local Audit and Governance Group. Regular reports on counter fraud are given, with updates on any investigations, raising awareness of fraud amongst staff as a deterrent.

4. Review of the Effectiveness of Risk Management and Internal Control As Accountable Officer, I have responsibility for reviewing the effectiveness of the system of internal control and risk management processes in practice.

The governance arrangements in place within NHS Calderdale during 2011/12 managed risk and provided assurance to the Board as described below: Governance Committee The Governance Committee reviewed the risks identified within the Board Assurance Framework and Corporate Risk Register on a regular basis Audit Committee The Audit Committee reviewed financial issues including the annual accounts. The Committee also sought assurance on the effectiveness of internal control from internal and external audit reports and opinions, counter fraud progress reports and the Board Assurance Framework. Internal and External Auditors actively participate in the Audit Committee.

Remuneration and Terms of Service Committee This Committee ensured that governance arrangements were in place to manage remuneration and terms of service issues on behalf of the Board.

Clinical Commissioning Executive (CCE) This Committee ensured clinical engagement on a broad range of both operational and strategic issues and became responsible for the majority of the commissioning budgets for NHS Calderdale in November 2012. The terms of reference for this Committee contained specific details on managing conflicts of interest.

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Revisions to the scheme of delegation arising from the establishment of the cluster meant that from December 2011 three sub groups supported the CCE in monitoring the system of internal control. These were: Audit and Governance Group Finance and Performance Group Quality Group.

These groups provided assurance in the areas of corporate governance, financial governance and clinical governance.

In addition, I am assured that significant risks to the organisation are being managed by the following: Chief Operating Officer, who has responsibility for risk management within the organisation Senior Management Team Internal Audit - opinions (including the Head of Internal Audit Opinion) and reports by Internal Audit, who work to a risk-based annual plan with topics that cover governance and risk management, financial management and control, procurement, service delivery and performance, operational and other reviews, including the Yorkshire and Humber Specialised Commissioning Group (audit undertaken by the South Yorkshire and North Derbyshire Audit Services).

External Audit - opinion and reports from our external auditors Performance reports Governance and risk reports Investigation reports and action plans following serious incident Safeguarding reports / Serious Case Reviews for Children Emergency Preparedness Annual Report Where any weaknesses are identified a system is in place to manage these.

7. Conclusion In line with the definition of significant issues, Governance Statements - Guidance Update (gateway Reference: 17419) I have not identified any significant issues during the year.

My review confirms that during 2011/12 NHS Calderdale had effective arrangements in place for the stewardship of the organisation.

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Accountable Officer : Mike Potts

Organisation: NHS Calderdale (Calderdale Primary Care Trust)

Signature:

Date:

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