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					                            ASSURANCE FRAMEWORK


Version   Date                                               Board level
                            Comment
                                                             review
1         April-06                                           Audit             11/22/2006
                            First Draft
                                                             Committee
2         August-06         Second Draft                     Board             11/28/2006
3         September-06                                       Audit              1/22/2007
                            Third Draft
                                                             Committee
4         November-06                                        Audit              4/16/2007
                            Fourth Draft
                                                             Committee
5         January-07                                         Audit              6/25/2007
                            First update
                                                             Committee
6         April-07                                           Audit               8/9/2007
                            Second update
                                                             Committee
7         June-07
                            Third update – end of year
                            2006/07 update
                                                             Audit Committee     9/24/2007
                                                             Board
                            Fourth update - refreshed and
8         Aug - Sept 2007   new risks added                                      1/30/2008

9         Nov-07            Fifth update - new risks added
                                                                                                                                                                                                                                      Priority                         Action Plan to Address Gaps in           Revised Lead       Due
                                                                                                                                                                                                 High level negative                  areas                            Control or Assurance                     Risk               Date
                                          High level risk                      Key controls in place             Assurance on controls         Gaps in controls        Gaps in assurance
                                                                                                                                                                                                     assurance                                                                                                  rating
           Goals -                                                                                                                                                                                                                                                                                              (RAG)
What actions is the             What could prevent the                  What controls/systems we have         Where can we gain              Where are we failing   Where are we failing to   Do we have any evidence                                                                                           after




                                                                                                                                                                                                                                                          Rag Rating
                                                                                                                                                                                                                                                                       These need to be approved by the




                                                                                                                                                                                                                                            Consequence
                                                                                                                                                                                                                         Likelihood
organisation taking to          priority objective from being           in place to assist in securing the    evidence that our              to put                 gain evidence that our    which indicates we are                                                   Board and monitored
deliver priority                met?                                    delivery of our objective?            controls/systems on which      controls/systems in    controls/systems upon     not reasonably managing
objectives?                                                                                                   we are placing reliance are    place? Where are we    which we place reliance   our risks and objectives
                                                                                                              effective?                     failing to make them   are effective?            are not being delivered
                                                                                                                                             effective?




                                                                                     STRATEGIC OBJECTIVE: FIT FOR PURPOSE
Establishing appropriate        Conflict of interest, lack of clearly   Trust Boards monitoring the           Internal and External Audits    None                  None                      None                            3                  3                     Deputy Chief Executive in place to run 2x3
governance structures to        defined accountabilities to each        arrangements, Audit and Governance    opinion. Additional audit time                                                                                                                           the day to day management issues of
support the Chief Executive     PCT Board, lack of capacity and         Committee monitoring the              needs to be purchased. This is                                                                                                                           Haringey and a Deputy Chief
and Director of Finance with    energy to run two organisations,        arrangements, a planned review in     a possible assurance but it has                                                                                                                          Executive for Enfield. With a borough
corporate roles across          affect on finance department if         January 2008, interim arrangements    not been commissioned to                                                                                                                                 Finance Director for Enfield and a
Haringey and Enfield PCTs.      additional support is required for      until March 2008 established.         date.                                                                                                                                                    borough Finance Director for
                                                                                                                                                                                                                                                                       Haringey, with HT corporate FD for
                                EPCT.                                   Committee Responsible for risk:
                                                                                                                                                                                                                                                                       Enfield and Haringey. Regular
                                                                        Audit and Governance
                                                                                                                                                                                                                                                                       updates for both PCTs Boards, and
                                                                                                                                                                                                                                                                       Finance Committee and for Audit and
                                                                                                                                                                                                                                                                       Governance Committees. Clearly
                                                                                                                                                                                                                                                                       identified process for working with
                                                                                                                                                                                                                                                                       each organisation.                                          Decisio
                                                                                                                                                                                                                                                                                                                                   n on
                                                                                                                                                                                                                                                                                                                                   joint
                                                                                                                                                                                                                                                                                                                                   arrange
                                                                                                                                                                                                                                                                                                                       Tracey      ments
                                                                                                                                                                                                                                                                                                                       Baldwin/Har Jan
                                                                                                                                                                                                                                                                                                                       ry Turner   2008



                                                                                                                                                                                                                                                                       We have employed a commissioning
                                                                                                                                                                                                                                                                       project director to steer the GOSH
                               Potential for disruption to services     GOSH working party, OMT and                                                                                                                                                                    negotiations and business case.
                               particularly around ICT, risks           Provider Services Committee.                                                                                                                                                                   Board seminar was held on 31st                              Sept
                               around finance issues which could        Commissioning Team meeting.                                                                                                                                                                    October to debate the issue and                             2007
                               destablised the Business Case            Committee Responsible for risk:                                                                                                                                                                address key risks to the agreement of                       Busines
Robust business case for       particularly infrastructure costs and    Provider Services Committee in the                                                                                                                                                             the Business Case.. There is a                              s case
GOSH/HTPCT integration with commissioner to provider                    transitional phase. Once a                                                                                                                                                                     checklist / transition plan in place with       Jane        and
risks identified and mitigated relationship (corporate, HR finance      commissioned service it will be the   The Business Case is                                                                                                                                     the majority of actions recoreded as            Elias/Liz   March
as far as possible.            and Estates and Faciltiies)              Performance Committee                 submitted to the TPCT Board.   None                   None                      None                            3                  2                     Amber.                                    2x2   Rahim       2008
                                                                                                                                                                                                                                             Priority                         Action Plan to Address Gaps in           Revised Lead    Due
                                                                                                                                                                                                        High level negative                  areas                            Control or Assurance                     Risk            Date
                                       High level risk                    Key controls in place              Assurance on controls            Gaps in controls            Gaps in assurance
                                                                                                                                                                                                            assurance                                                                                                  rating
          Goals -                                                                                                                                                                                                                                                                                                      (RAG)
What actions is the           What could prevent the              What controls/systems we have           Where can we gain                 Where are we failing       Where are we failing to       Do we have any evidence                                                                                           after




                                                                                                                                                                                                                                                                 Rag Rating
                                                                                                                                                                                                                                                                              These need to be approved by the




                                                                                                                                                                                                                                                   Consequence
                                                                                                                                                                                                                                Likelihood
organisation taking to        priority objective from being       in place to assist in securing the      evidence that our                 to put                     gain evidence that our        which indicates we are                                                   Board and monitored
deliver priority              met?                                delivery of our objective?              controls/systems on which         controls/systems in        controls/systems upon         not reasonably managing
objectives?                                                                                               we are placing reliance are       place? Where are we        which we place reliance       our risks and objectives
                                                                                                          effective?                        failing to make them       are effective?                are not being delivered
                                                                                                                                            effective?




                                                                       STRATEGIC OBJECTIVE: FIT FOR PURPOSE
                                                                  STRATEGIC PRIORITY: TACKLING HEALTH INEQUALITIES
Reduce inequalities in life   Risk of not implementing the action Well being Partnership Board, leading Performance indicators .            Life expectancy action     HSP is the overarching        None                            3
expectancy through            plans due to capacity, resources    on the HSPs well being strategic       Refer to performance indicators    plan adopted March         partnership board into
implementation of the life    and cooperation with the Council    framework and a life expectancy plan. in section 6.                       2007 and in train. This    which Well-being
expectancy action plan,                                           Committee Responsible for risk:                                           does not cover all         Partnership Board reports.
including - obesity,                                              Well Being Executive Meeting which                                        elements of Choosing       There is an external audit
physical activity, tobacco,                                       handles the day to day operational                                        Health, which needs        planned for health
access to services and                                            issues and risks to meeting objectives                                    further work.              inequalities during 2007/08.
food and nutrition                                                and targets with regard to health and                                     Resources to support       Better real-time indictors of
                                                                  well being. National performance                                          work in this area to be    performance should be
                                                                  indicators/targets monitored through                                      established, although      established through the
                                                                  Performance Committee and Board                                           proposals made             Joint Strategic Need
                                                                  and commissioning division directors’                                     through CSP. Failure to    Assessment, planned for
                                                                  monthly performance meetings.                                             appoint to Public Health   April 2008.
                                                                                                                                            Strategist (health
                                                                                                                                            inequalities) post has
                                                                                                                                            limited monitoring of                                                                                                                                                                      On-
                                                                                                                                                                                                                                                                                                                                       going-
                                                                                                                                            implementation.
                                                                                                                                                                                                                                                                              Appoinment to Public Health                              review
                                                                                                                                                                                                                                                                              strategist (health inequalities) post,                   in
                                                                                                                                                                                                                                                                              and development of Joint Director of            Public   March
                                                                                                                                                                                                                                                        3                     Public Health role                       3x3    Health   08
Reduce inequalities in life   Risk of not implementing the action Children and Youg People's              Performance Indicators: Refer     Revised Infant mortality   HSP is the overarching                                        2
expectancy through            plans due to capacity, resources    Partnership Board, leading on HSPs      to performance indicators in      action plan adopted        partnership board into
implementation of the         and cooperation with the Council    Children and Young People's Plan.       section 6. New indictaor from     February 2007 and in       which Children and Young
infant mortality action                                           National performance                    2008 include % women booking      train. Resources to        People's Partnership Board
plan including-                                                   indicators/targets monitored through    for ANC by 12 weeks, %            support work in this       reports. New national
breastfeeding, smoking,                                           Performance Committee and Board         women still breastfeding at 6-8   area to be developed,      indicators and real-time
ante and post natal care,                                         and commissioning division directors’   weeks. Health equity audit has    and proposals made         indictors of performance
teenage pregnancy and                                             monthly performance meetings.           started on booking for ante       through CSP. Failure to    should be established
social support                                                                                            natal care.                       appoint to maternity       through the Joint Strategic
                                                                                                                                            cover for Public Health    Need Assessment, planned
                                                                                                                                            Strategist (children and   for April 2008.
                                                                                                                                            young people) post has
                                                                                                                                            limited monitoring of
                                                                                                                                            implementation.
                                                                                                                                                                                                                                                                              Appoinment to Public Health
                                                                                                                                                                                                                                                                              strategist (children and young people)
                                                                                                                                                                                                                                                                              maternity cover, and development of             Public
                                                                                                                                                                                                                                                        2                     Joint Director of Public Health role   2x2      health
Reduce the prevalence of      TB work requires a multi-agency     London TB nurse working at the TPCT, There is no target but NHS     None                             Yes, no performance           none                            2
TB in Haringey                approach and compliance with        work is monitored via the London TB  London might adopt it as a                                      targets or inspection /
                              medication.                         Group.                               performance target for 2008/09
                                                                  Committee Responsible for risk
                                                                  externally London TB group but
                                                                  internally through Commissioning
                                                                                                                                                                                                                                                                              Close monitoring of TB cases and
                                                                  Directors meeting.
                                                                                                                                                                                                                                                                              management and TB Screening unit                Public
                                                                                                                                                                                                                                                        2                     available.                               2x2    Health    Mar-07
To increase t he health and The risk of underachieving the        The Healthy Schools Programme.          LAA target- check with            None                       None                          None                            2
reduce inequalities among target (% of schools achieving          Committee Responible for risk:          Catherine Brown or Kate
children and young people Healthy School Status).                 Children and Young People's             Allardyce
via the healthy schools                                           partnerhip board
programme.

                                                                                                                                                                                                                                                                              Confirming it as a major LAA target to          Public
                                                                                                                                                                                                                                                        2                     ensure that it has the priority required. 1x2   Health   Dec-08
                                                                                                                                                                                                                                                Priority                         Action Plan to Address Gaps in         Revised Lead    Due
                                                                                                                                                                                                           High level negative                  areas                            Control or Assurance                   Risk            Date
                                      High level risk                      Key controls in place               Assurance on controls              Gaps in controls           Gaps in assurance
                                                                                                                                                                                                               assurance                                                                                                rating
          Goals -                                                                                                                                                                                                                                                                                                       (RAG)
What actions is the         What could prevent the                  What controls/systems we have           Where can we gain                  Where are we failing       Where are we failing to       Do we have any evidence                                                                                         after




                                                                                                                                                                                                                                                                    Rag Rating
                                                                                                                                                                                                                                                                                 These need to be approved by the




                                                                                                                                                                                                                                                      Consequence
                                                                                                                                                                                                                                   Likelihood
organisation taking to      priority objective from being           in place to assist in securing the      evidence that our                  to put                     gain evidence that our        which indicates we are                                                   Board and monitored
deliver priority            met?                                    delivery of our objective?              controls/systems on which          controls/systems in        controls/systems upon         not reasonably managing
objectives?                                                                                                 we are placing reliance are        place? Where are we        which we place reliance       our risks and objectives
                                                                                                            effective?                         failing to make them       are effective?                are not being delivered
                                                                                                                                               effective?




Expand the use of health    Failure to use HEA to inform            Well being partnership board has been
equity audit by services    service commissioning and
                                                                                           HEAs completed on smoking
                                                                                STRATEGIC OBJECTIVE: FIT FOR PURPOSENone
                                                                                           cessation services, and initiated
                                                                    re-organised, with life expctancy
                                                                                                                             None                                                                       None                            3

commissioners and           planning will                           target as ket outcome measure.          on booking for ante natal care
providers to identify and   perpetuate/exacerbate health            Health and emotional well-being sub-    and cardiac rehabilittation
respond to inequity         inequalities in Haringey                group to lead on health equity audit.
                                                                    Group not yet in operation.


                                                                                                                                                                                                                                                                                 Appointment of Joint Director of
                                                                                                                                                                                                                                                                                 Public Health, and establishment of
                                                                                                                                                                                                                                                                                 Joint Staregic Needs Assessment will
                                                                                                                                                                                                                                                                                 provide opportuntiies to expand HEA
                                                                                                                                                                                                                                                                                 to other services areas through work
                                                                                                                                                                                                                                                                                 with commissioners and service                Public
                                                                                                                                                                                                                                                           2                     providers.                           2x2      Health   Dec-08
Achievement of Public       Loss of posts and current level of      Public Health core standards and                                            ongoing work to           None                          None                            3
Health developmental        vacancies in Public Health              developmental standards. New DPH to                                        maximise effectiveness
standards, including        Directorate limits ability of team to   be recruited working across the                                            of available resources
development of cost-        support effective commissioning,        Haringey Council and HTPCT better                                          by developing joint
effective proposals for     including prevention and early          able to effect the well being agenda.                                      services and posts.
investment in prevention    intervention.                           Committee Responsible for risk
and early intervention                                              Well being Partnership Board also the
                                                                    targets are monitored via the
                                                                    Performance Committee who will look
                                                                    at risks against achieving targe
                                                                                                                                                                                                                                                                                 Ongoing work is in place to meet the
                                                                                                                                                                                                                                                                                 development standards on public               Public   Ongoin
                                                                                                                                                                                                                                                            2                    health                                 2x2    Health   g work
Increase uptake of          Quality issues with breast           There is a plan agreed with North          Performance Indicators from        Understanding of           Limited in year assurance     None                            5
effective breastscreening   screening service are resolved but   London Breast Screening Service,           breast screening service: round    groups that have low       as annual data for breast
services                    addressing the backlog through as    Quality Assurance Team and Chief           time - revised capacity plan       uptake to facilitate       screening. 3 year cycle for
                            increase in round length time        Executives that is being monitored         ensures most clients will have a   successful targetting of   breast screening means
                            means that Haringey will not be      through monthly performance                maximum of 10 months delay         health promotion           that previous annual
                            able to meet the target of 70% of    meetings with lead commissioner. In        from their original scheduled      efforts                    performance no predictor
                            women screened within 36 months.     addition there are Sector Screening        appointment (ie. a maximum                                    of future performance.
                            There are likely to be a small       (quarterly) meetings and TPCT              roundlength of 46 months) and                                 Issues are faced by all
                            number of interim cancers            Screening (quarterly) meetings where       uptake.                                                       PCTs.
                            identified in women that might       local issues can be addressed.                                                                                                                                                                                  There is close monitoring of breast
                            otherwise have been screened.        Performance is reported to                                                                                                                                                                                      screening services at the Sector
                                                                 Commissioning Division Directors and                                                                                                                                                                            meetings and at the TPCT meeting.
                                                                 Performance Commitee where the                                                                                                                                                                                  Quarter 4's funding was held back to
                                                                 local indicators and actions are                                                                                                                                                                                use as an incentive to increase               Public
                                                                 reviewed                                                                                                                                                                                  4                     performance.                         3x3      Health   Aug-07
Immunisation: ensure the                                         Imm and Vacc Committee in place and        Audit data expected                Becomes a national                                                                       5                                        To be reviewed in light of new
child health surveillance                                        links to pan London IT forum.              beginning of Jan 2008.             target in 2008. Agreed                                                                                                            directorate arrangements, additional
system supports delivery                                         Currentl;y undertaking a                   Routine COVER data                 as a local priority                                                                                                               investment to improve this area
of the child immunisation                                        comprehensice audit of uptake from         expected from CHIA in              through the LAA                                                                                                                   through the top slice is being
programme                                                        GP records of all children up to 11        2008. Member of staff                                                                                                                                                considered. CHIA audit undertaken
                                                                 years, to be reconsiled with CHIA and      seconded from child health                                                                                                                                           December o7/08, funding available
                                                                 produce list of all unimmunised            team to support RIO                                                                                                                                                  for catch up campaign, through
                                                                 children. transfer from CHIA to RIO        transfer.                                                                                                                                                            general practice commencing in Feb
                                                                 planned for Autumn 2008. Committee                                                                                                                                                                              and the majority completed by March
                                                                 responsible for risk: Commissioning                                                                                                                                                                             2008. The TPCT will have a better
                            interim IT system (CHIA) not fully
                            functional since 2004, therefore not Directors meeting from risks                                                                                                                                                                                    picture of the rate of immunisation
                            able to support the call and recall highlighted by Imm and Vaccs                                                                                                                                                                                     and GPs will be paid to ensure that
                            of children or production of uptake Committee.                                                                                                                                                                                                       this work is completed as quickly as          Public
                            and coverage statistics                                                                                                                                                                                                        4                     possible.                            3x3      Health    Apr-08
                                                                                                                                                                                                                                             Priority                         Action Plan to Address Gaps in          Revised Lead     Due
                                                                                                                                                                                                        High level negative                  areas                            Control or Assurance                    Risk             Date
                                      High level risk                    Key controls in place                 Assurance on controls          Gaps in controls              Gaps in assurance
                                                                                                                                                                                                            assurance                                                                                                 rating
          Goals -                                                                                                                                                                                                                                                                                                     (RAG)
What actions is the          What could prevent the               What controls/systems we have             Where can we gain              Where are we failing       Where are we failing to        Do we have any evidence                                                                                          after




                                                                                                                                                                                                                                                                 Rag Rating
                                                                                                                                                                                                                                                                              These need to be approved by the




                                                                                                                                                                                                                                                   Consequence
                                                                                                                                                                                                                                Likelihood
organisation taking to       priority objective from being        in place to assist in securing the        evidence that our              to put                     gain evidence that our         which indicates we are                                                   Board and monitored
deliver priority             met?                                 delivery of our objective?                controls/systems on which      controls/systems in        controls/systems upon          not reasonably managing
objectives?                                                                                                 we are placing reliance are    place? Where are we        which we place reliance        our risks and objectives
                                                                                                            effective?                     failing to make them       are effective?                 are not being delivered
                                                                                                                                           effective?




Immunisation: imporve                                             Imm and Vacc Committee ileads
child immunisation uptake,
                                                                                                         Becomes a national
                                                                               STRATEGIC OBJECTIVE: FIT FOR PURPOSELack of data as to rates of
                                                                  planning for this, with input from NECLtarget in 2008. Agreed immunisation in the
                                                                                                                                                                                                     None                            4

preventing further                                                health protection unit . Currently                                       as a local priority        borough due to CHIA IT
outbreaks of measles and                                          planning a catch up programme for                                        through the LAA            issues. No clear
other preventable diseases                                        children who have not completed their                                                               governance arrangements
                                                                  imms scedule, as identified through                                                                 for Imm & Vacc Committee
                                                                  audit of GP and CHIA records.




                             Measles outbreak in North London                                                                                                                                                                                                                                                                Public
                             (including Haringey) since June                                                                                                                                                                                            4                                                             2x3    Health     Mar-08

                            STRATEGIC PRIORITY:STRENTHENING COMMISSIONING AND MAINTAINING FINANCIAL STABILITY
Develop commissioning        New commissioning framework          Development of Directorate of Clinical    Performance Indicators         Lack of expertise in       Lack of Commissioning       None                               3
strategies and intentions    exposes organisation to additional   Services Procurement and London-          Sarah/Gemma to add             tendering process – a      Board, at present decisions
to provide high quality,     financial risk, new ways of          wide commissioning structures which                                      key process in new         are made at the weekly
value for money services     commissioning could cost more.       also analyses the risks around                                           commissioning              commissioning meeting
for people in Haringey                                            commissioning. We now have a five                                        framework                  through to PEC and then
                                                                  year commissioning strategy and plan                                                                through to Board.
                                                                  finalise October 2007. This strategy
                                                                  details our commissioning plans and
                                                                  how we improve. Committee to
                                                                  managing risk
                                                                  Commissioning Directors meeting                                                                                                                                                                             The CSP has a range of targets which           Helen
                                                                  through to TPCT Board who finally                                                                                                                                                                           will be monitored, it includes financial       Brown
                                                                  approves the CSP.                                                                                                                                                                                           planning to take account of financial          (Gerry
                                                                                                                                                                                                                                                        2                     risks.                                   2x2   Taylor)    Mar-08
                             Practice Based Commissioning does    There are four collaboratives each with   External inspection Therer are N/a                        N/a                            None                            3
                             not achieve appropriate savings      a clinical lead supported by TPCT         two more internal audits this
                             and / or influence commissioning     management, they meet monthly.            year PBC and Demand
                             decisions.                           Feeds into the PEC. Committee             Management                                                                                                                                                                                                       Helen
                                                                  managing ris Commissioning                                                                                                                                                                                                                                 Brown
                                                                  Directors meeting                                                                                                                                                                                           Financial contingencies are in place           (Gerry
                                                                                                                                                                                                                                                        2                     to mitigate financial loss.             2x2    Taylor)    Mar-08
                             Failure to move resources to match The CSP - CDD meeting, PEC and              NHS London will review the     0: Committee will be       Lack of Commissioning       None                               3
                             strategic priorities (ie toward    Board. Within the CSP there are             CSP. NHS London will           established@ May 07        Board, at present decisions
                             primary care)                      targets / indictors. Committee to           performance manage the key     when full results of       are made at the weekly
                                                                managing risk Commissioning                 indicators. IPEC (clinical –   review process available   commissioning meeting
                                                                Directors meeting through to TPCT           demand management and PBC)                                through to PEC and then
                                                                                                                                                                                                                                                                              We have strategies in place seeking            Helen
                                                                Board who finally approves the CSP          Finance Committee                                         through to Board.                                                                                       to achieve this (CSP, Primary Care             Brown
                                                                                                                                                                                                                                                                              Strategy) and the financial modelling          (Gerry
                                                                                                                                                                                                                                                        2                     in place.                               2x2    Taylor)
Achieve financial balance    Short-term financial pressures       Independent audit of mid to long-term Performance Indicators             Annual Healthcheck         Good evidence of controls      None                            4
                             prioritised over strategic plans and financial strategy.                   Financial Balance 07/08 - Green    organised with the LBH     and systems in place,
                             opportunistic innovations.           Committee to managing risk                                               on the Operating Plan      except for activity-based                                                                                                                                        Came
                                                                  Finance committee                                                        (business plan)            costs from providers, for                                                                                                                                        in April
                                                                                                                                           involving patients and     which data can lack                                                                                     We have a large contingency reserve,                     07, risk
                                                                                                                                                                                                                                                                              particularly for demand management,                      rating is
                                                                                                                                           the public February        robustness and be late.
                                                                                                                                                                                                                                                                              built activity profile on outturn and built    Harry     already
                                                                                                                                           2007. (no Gaps in          Continually improving but
                                                                                                                                                                                                                                                        3                     in forecast activity level for 18 weeks. 2x3   Turner    amber
                                                                                                                                           controls)                  still continues to be a gap.
                                                                                                                                                                                                                                            Priority                         Action Plan to Address Gaps in         Revised Lead    Due
                                                                                                                                                                                                    High level negative                     areas                            Control or Assurance                   Risk            Date
                                   High level risk                      Key controls in place              Assurance on controls             Gaps in controls         Gaps in assurance
                                                                                                                                                                                                        assurance                                                                                                   rating
         Goals -                                                                                                                                                                                                                                                                                                    (RAG)
What actions is the      What could prevent the                  What controls/systems we have          Where can we gain                 Where are we failing     Where are we failing to       Do we have any evidence                                                                                            after




                                                                                                                                                                                                                                                                Rag Rating
                                                                                                                                                                                                                                                                             These need to be approved by the




                                                                                                                                                                                                                                                  Consequence
                                                                                                                                                                                                                               Likelihood
organisation taking to   priority objective from being           in place to assist in securing the     evidence that our                 to put                   gain evidence that our        which indicates we are                                                      Board and monitored
deliver priority         met?                                    delivery of our objective?             controls/systems on which         controls/systems in      controls/systems upon         not reasonably managing
objectives?                                                                                             we are placing reliance are       place? Where are we      which we place reliance       our risks and objectives
                                                                                                        effective?                        failing to make them     are effective?                are not being delivered
                                                                                                                                          effective?




                         Financial pressures not acute this      set budgets before the start of the
                         year, so budget managers could
                                                                                        External inspection
                                                                             STRATEGIC OBJECTIVE: reporting NonePURPOSENone
                                                                                        NHS London - formal FIT FOR
                                                                 financial year with CRES for each
                                                                                                                                                                                                 None                               4

                         become complacent.                      budget area. Monthly reporting for     on a quarterly basis and low                                                                                                                                                                                                Came
                                                                                                                                                                                                                                                                                                                                    in May
                                                                 budget managers and follow up          risk rating by NHS London.
                                                                                                                                                                                                                                                                             As reported monthly finance reports                    2007,
                                                                 meetings where required. Monthly       Internal and External Audit
                                                                                                                                                                                                                                                                             to budget managers, half year review                   on track
                                                                 reports to Board and NHS London.       reports
                                                                                                                                                                                                                                                                             of budgets with CE and Dir of                          to
                                                                 Committee to manage risk Finance                                                                                                                                                                            Finance, carrying on with Board and                    deliver
                                                                 Committee                                                                                                                                                                                                   Finance committee reporting and                        revised
                                                                                                                                                                                                                                                                             sending reports monthly to maintain           Harry    risk
                                                                                                                                                                                                                                                       2                     confidence.                          2x2      Turner   rating.
                         Failure to deliver annual financial     Monthly reporting to finance           Internal Audit / external Audit   None                     None                          None                               4                                                                                               Came
                         balance resulting in future funding     committee and Board.                   ALE and KLOE                                                                                                                                                                                                                in May
                         losses and limitation on ability to     Committee to manage risk                                                                                                                                                                                                                                           2007,
                         deliver targets and strategies          Finance Committee                                                                                                                                                                                                                                                  on track
                                                                                                                                                                                                                                                                                                                                    to
                                                                                                                                                                                                                                                                                                                                    deliver
                                                                                                                                                                                                                                                                             Close monitoring of finances, track                    revised
                                                                                                                                                                                                                                                                             record of good scores in ALE and              Harry    risk
                                                                                                                                                                                                                                                       3                     KLOE with rating of 3 in all areas.    2x3    Turner   rating.
                         Unplanned expenditure arising           Monthly reporting to                  Internal review                    Vacancies in             None                          None                               4
                         from activity variance after            finance/PEC/Board with minutes of the Already had an internal audit      commissioning team.
                         implementing PBR and lack of            committee                             report and an External Audit is    Lack of direct control
                         clarity of the costs of non-PBR         Committee to manage risk              planned.                           over providers.
                         activity and Commissioning SLAs         Finance Committee                                                                                                                                                                                           Vacancy out to advert, real push on
                         resulting in considerable unplanned                                                                                                                                                                                                                 recruitment, staff development.
                         expenditure                                                                                                                                                                                                                                         Demand management plans agreed                         Month 9
                                                                                                                                                                                                                                                                             with GPs and providers. Quarterly                      (Decem
                                                                                                                                                                                                                                                                             SLA meetings with Providers and               Harry    ber
                                                                                                                                                                                                                                                       3                     quarterly peformance meetings.         3x2    Turner   2007)
                         Reconfiguration leads to loss of        1:1 meetings with Directors who are    Monthly reports to finance        None                     Internal and External Audit   None                               3
                         staff, inability to recruit permanent   accountable for the directorate        committee and Board.
                         staff and lack of proper resourcing     budgets.
                         of the finance department.              Committee to manage risk                                                                                                                                                                                    High quality temporary staff are in
                                                                 Finance Committe                                                                                                                                                                                            post, recruited to lot of vacancies.                   Month 9
                                                                                                                                                                                                                                                                             Additional effort is being made to                     (Decem
                                                                                                                                                                                                                                                                             recruit high quality staff to senior          Harry    ber
                                                                                                                                                                                                                                                       3                     posts.                                 2x2    Turner   2007)
                         LCFS has a lack of capacity to fufill Audit and Governance Committee,          External Audit                    None                     None                          Reports to Audit and               4
                         proactive and reactive work plans. report to the Board.                                                                                                                 Governance committee
                                                               Committee to manage risk                                                                                                          indicates that they are not
                                                               Audit and Governance Committee at                                                                                                 working to plan.
                                                               present.

                                                                                                                                                                                                                                                                             Close monitoring of counter fraud
                                                                                                                                                                                                                                                                             through Audit and Governance,
                                                                                                                                                                                                                                                                             regular meetings with finance and
                                                                                                                                                                                                                                                                             Counter Fraud, an agreed workplan.            Harry
                                                                                                                                                                                                                                                       3                     Reappraisal of counter fraud service   3x2    Turner    Jan-08

                                                                  STRATEGIC PRIORITY: TRANSFORMING PRIMARY CARE
Primary Care             Depending on the outcome of the         Implementation Plan and recruitment PEC, Commissioning Team              None                     None                          None                               3
Commissioning Strategy   consultation , failure to implement     of Project Lead to implement the new meetings, HTPCT Board.                                                                                                                                                 In the early stages of the
                         a new model of care for Primary         plans starting with Hornsey Central                                                                                                                                                                         implementation plans and need to
                         Care with the establishment of          and Lordship Lane.                                                                                                                                                                                          confirm after the consultation ends if
                         super healthcentres and ensuring        Committee to manage risk                                                                                                                                                                                    this is the model that will be
                         that there is an integration of         Commissioning Directors meeting                                                                                                                                                                             implemented. There are plans for a
                         services to provide patients with a                                                                                                                                                                                                                 'go local' programme management of
                         one stop shop.                                                                                                                                                                                                                                      the implementation of the Primary             James
                                                                                                                                                                                                                                                       3                     Care Stratgegy.                        2x2    Slater    Jun-08
                                                                                                                                                                                                                                           Priority                          Action Plan to Address Gaps in       Revised Lead        Due
                                                                                                                                                                                                  High level negative                      areas                             Control or Assurance                 Risk                Date
                                      High level risk                    Key controls in place                Assurance on controls          Gaps in controls        Gaps in assurance
                                                                                                                                                                                                      assurance                                                                                                   rating
          Goals -                                                                                                                                                                                                                                                                                                 (RAG)
What actions is the          What could prevent the               What controls/systems we have            Where can we gain               Where are we failing   Where are we failing to      Do we have any evidence                                                                                            after




                                                                                                                                                                                                                                                                Rag Rating
                                                                                                                                                                                                                                                                             These need to be approved by the




                                                                                                                                                                                                                                                  Consequence
                                                                                                                                                                                                                              Likelihood
organisation taking to       priority objective from being        in place to assist in securing the       evidence that our               to put                 gain evidence that our       which indicates we are                                                        Board and monitored
deliver priority             met?                                 delivery of our objective?               controls/systems on which       controls/systems in    controls/systems upon        not reasonably managing
objectives?                                                                                                we are placing reliance are     place? Where are we    which we place reliance      our risks and objectives
                                                                                                           effective?                      failing to make them   are effective?               are not being delivered
                                                                                                                                           effective?




                             Failure to performance manage        A full primary care performance team
                             primary care service providers
                                                                                         GP/PCP access (green) Still None
                                                                              STRATEGIC OBJECTIVE:Practice FOR PURPOSENone
                                                                                         Green for 2007/08. FIT
                                                                  are in place (within current resource
                                                                                                                                                                                                                                   2

                             against framework due to limited     constraints). Service Review             Based registers: Diabetes
                             capacity.                            mechanisms developed and to be           (amber) BMI (amber) Blood
                                                                  implemented early 2007 including         pressure current RAG rated
                                                                  contractor visits/action planning and    (TBC), mortality and related
                                                                  monitoring.                              diseases Cholesterol (TBC)
                                                                  Committee to manage risk                 PBRs in place practice based
                                                                  Performance of Independent               registers for CVD, RAG rated
                                                                  contractors - Reference Committee        (TBC) External inspection
                                                                  Targets - Performance Committee          internal audit on PBCPractice
                                                                  Balance Scorecard approach submitted     Service Review mechanisms
                                                                  on a quarterly to Performance            being implemented. To be                                                                                                                                                                                      James
                                                                  Committee and PEC.                       completed early 2007/08                                                                                                                     2                     See controls section.                2x2    Slater        Mar-08
Engaging stakeholders,       Patients, the public and             Consultation Group, Equality Impact      Governance: PEC and
                                                                                                           PPI Forum and CIDA involved     None                   Yes, no external authority   None                                4
patients and the public in   stakeholders feel that there is a    Assessment Panel and Group including     in drawing up the EIA and key                          or mechanism for verifying
the primary care             lack of robust process for the       PPI members                              members on th EIA panel.                               the process meets best
consultation process.        consultation. That the population    Consultation budget agreed, proactive    Overview and Scrutiny                                  practice in terms of
                             of Haringey are not aware of the     work with Enfield Communications         Committee. TPCT Board.                                 consultation, other than
                             PC Strategy and not fully engaged.   team.                                                                                           OSC                                                                                                        Resources have been secured and
                                                                  Committee to manage risk                                                                                                                                                                                   additional support purchased via
                                                                  Equity and Diversity Group                                                                                                                                                                                 Enfield Communications Team. A
                                                                                                                                                                                                                                                                             range of products and processes
                                                                                                                                                                                                                                                                             have been put in place as well as
                                                                                                                                                                                                                                                                             running media campaigns in                  Christina
                                                                                                                                                                                                                                                       3                     September.                           2x3    Gradowski    Nov-07
Review/redesign of walk      Introduction of new provider has     Clearly defined performance indicators   Performance Indicators are      None                   None                         None                                3
in centre at North           potential to create more delivery    and reporting mechanisms developed.      included in the SLA and are
Middlesex Hospital           problems than it resolves            Monthly operational group working to     monitored by Commissioning
                                                                  achieve targets and quarterly            Team.
                                                                  performance group.
                                                                  Committee to manage risk
                                                                  Perfromance Committee - via quarterly                                                                                                                                                                                                                  Helen
                                                                  monitoring meetings with providers.                                                                                                                                                                        Extra attention in monitoring               Brown /
                                                                                                                                                                                                                                                                             governance arrangements and                 Gerry
                                                                                                                                                                                                                                                       3                     performance targets                  2x3    Taylor       Dec-07
                             Lack of robust governance           Quarterly performance review              Performance Committee, PEC,     None                   None                                                    3
                             arrangements in place, particularly meetings with the contractor Chivers      Board. A&E waits (GREEN)
                             around policies and procedures.     McCrea. Performance reports to            Contractor Performance Team
                                                                 Performance Committee (TPCT)              and Performance Committee
                                                                                                                                                                                                                                                                                                                         Helen
                                                                                                                                                                                                                                                                             Extra attention in monitoring               Brown /
                                                                                                                                                                                                                                                                             governance arrangements and                 Gerry
                                                                                                                                                                                               None                                           3                              performance targets                  2x3    Taylor       Dec-07

                           STRATEGIC PRIORITY: IMPROVING THE MENTAL HEALTH AND WELL BEING OF OUR POPULATION
Greater detail in            Failure to progress strategy and     Joint Commissioning framework agreed Performance Indicators                                     None                         None                                3                                         CAMHS performance group is now in
implementation of MH         achieve change in service system     in partnership with LBH (includes    there are some specific LDP                                                                                                                                           place so no longer an issue with
strategy and                                                      CAMHS)                               targets which are on track.                                                                                                                                           controls and feeds into overall MH
commissioning priorities                                          Committee to manage risk                                                                                                                                                                                   Performance Committee.
                                                                  Commissioning Directors meeting                                                                                                                                                                                                                        Helen
                                                                                                                                                                                                                                                                                                                         Brown/Gerr
                                                                                                                                                                                                                                                       3                                                          2x3    y Taylor     Sep-07
                                                                                                                                                                                                                                            Priority                         Action Plan to Address Gaps in         Revised Lead        Due
                                                                                                                                                                                                       High level negative                  areas                            Control or Assurance                   Risk                Date
                                   High level risk                     Key controls in place                Assurance on controls             Gaps in controls           Gaps in assurance
                                                                                                                                                                                                           assurance                                                                                                rating
         Goals -                                                                                                                                                                                                                                                                                                    (RAG)
What actions is the      What could prevent the                 What controls/systems we have            Where can we gain                  Where are we failing      Where are we failing to       Do we have any evidence                                                                                         after




                                                                                                                                                                                                                                                                Rag Rating
                                                                                                                                                                                                                                                                             These need to be approved by the




                                                                                                                                                                                                                                                  Consequence
                                                                                                                                                                                                                               Likelihood
organisation taking to   priority objective from being          in place to assist in securing the       evidence that our                  to put                    gain evidence that our        which indicates we are                                                   Board and monitored
deliver priority         met?                                   delivery of our objective?               controls/systems on which          controls/systems in       controls/systems upon         not reasonably managing
objectives?                                                                                              we are placing reliance are        place? Where are we       which we place reliance       our risks and objectives
                                                                                                         effective?                         failing to make them      are effective?                are not being delivered
                                                                                                                                            effective?




                         Lack of capacity across the joint      Mental Health Executive (joint health,
                         commissioning of mental health
                                                                                        Adult MH targets: update with Partnership
                                                                             STRATEGIC OBJECTIVE: FIT FOR PURPOSEFeeds into the Performance
                                                                social services forum), quarterly
                                                                                        Suicide, Drug misusers,       arrangements are being Committee and reports to
                                                                                                                                                                                                    None                            4

                         services to deliver improvement        performance meetings with MH.            indicators drug users within       reviewed, need to         the Board. The mental
                         across the system .                    Committee to manage risk                 treatment (AMBER) and drug         ensure that gaps do not   health executive feeds into
                                                                Performance Committee through the        users sustained in treatment       emerge. 3 Borough SLA     the Well-being Partnership
                                                                quarterly performance meetings with      (RED) . CAMHs collect once a       management needs          Board and through to HSP.
                                                                MHT                                      year (GREEN), Crisis Resolution    tighter focus
                                                                                                         (AMBER), Older People Mental
                                                                                                         Health collected once a year,
                                                                                                         TBC. We now have quarterly
                                                                                                         performance meetings with the
                                                                                                         mental health trust, in addition
                                                                                                         to the three borough SLA
                                                                                                         meetings.
                                                                                                                                                                                                                                                                             Going to be reviewing commissioning           Helen
                                                                                                                                                                                                                                                                             arrangements and considering                  Brown/Gerr
                                                                                                                                                                                                                                                       3                     alternative providers               3x3       y Taylor     Sep-08
                         Existing resources tied up in          3 borough service agreement in place     CPA 7 day follow-up (green),       None                      None                          None                            3
                         services challenging re-               for 07/08 with specific commissioning    crisis resolution (red)2 Mental
                         commissioning agenda, moving           intentions for HTPCT across all care     Health Executive (joint health,
                         inpatient to community based           groups. There are specific elements in   social services forum),
                         services.                              the SLA for Haringey to achieve these    quarterly performance
                                                                targets.                                 meetings with MH
                                                                Committee to manage risk
                                                                Performance Committee through the                                                                                                                                                                                                                          Helen
                                                                quarterly performance meetings with                                                                                                                                                                          Specific elements within SLA (see             Brown/Gerr
                                                                MHT                                                                                                                                                                                    3                     controls section)                      3x3    y Taylor      Mar-08
                         Failure to deliver key targets         Review of CMHT service system – MHT      Improvement in crisis and CPA None                           None                                                          4
                         relating to MH.                        led consultation process and             F/up (GREEN) . EIP target set
                                                                implementation plan.                     to deliver some outcomes as
                                                                Committee to manage risk                 part of SLA and LDP for
                                                                Performance Committee through the        2007/08. External inspection
                                                                quarterly performance meetings with      Joint Area Review (JAR) – 3
                                                                MHT                                      Governance Haringey
                                                                                                         Strategic Partnership,
                                                                                                         Wellbeing Partnership MH
                                                                                                         Executive, MH Partnership, LIT
                                                                                                         and sub groups. The Joint
                                                                                                         Serious Incident Group is in
                                                                                                         place with MHT, Contract
                                                                                                         monitoring information, waiting
                                                                                                         list/demand for service
                                                                                                         pressures identified, Healthcare                                                                                                                                    With arrangements in place regarding
                                                                                                         Commission Review - MH                                                                                                                                              performance and commissioning                 Helen
                                                                                                         providers in 2007                                                                                                                                                   input into Early Intervention in              Brown/Gerr
                                                                                                                                                                                                                                                       2                     Psychosis risk have been reduced.    3x2      y Taylor     Sep-07
Child and Adolescent     Failure to be effective in managing    CAMHS Priority Action Plan, also a       Performance Committee,             None                      None                          None                            4
Mental Health (CAMH)     contract with MHT to deliver           CAMHS performance meeting feeds          through to PEC and Board.
Commissioning Strategy   strategic aims – to focus service on   into the overall Mental Health
                         early intervention                     Performance meeting.
                                                                Committee to manage risk                                                                                                                                                                                     We are planning to invest additional          Helen
                                                                Performance Committee                                                                                                                                                                                        resources - on tiers one and two of           Brown/Gerr
                                                                                                                                                                                                                                                       3                     CAMHS.                                 3x3    y Taylor     Sep-08
                                                                                                                                                                                                                                          Priority                         Action Plan to Address Gaps in          Revised Lead        Due
                                                                                                                                                                                                     High level negative                  areas                            Control or Assurance                    Risk                Date
                                       High level risk                      Key controls in place                 Assurance on controls            Gaps in controls        Gaps in assurance
                                                                                                                                                                                                         assurance                                                                                                 rating
          Goals -                                                                                                                                                                                                                                                                                                  (RAG)
What actions is the          What could prevent the                 What controls/systems we have              Where can we gain                 Where are we failing   Where are we failing to   Do we have any evidence                                                                                          after




                                                                                                                                                                                                                                                              Rag Rating
                                                                                                                                                                                                                                                                           These need to be approved by the




                                                                                                                                                                                                                                                Consequence
                                                                                                                                                                                                                             Likelihood
organisation taking to       priority objective from being          in place to assist in securing the         evidence that our                 to put                 gain evidence that our    which indicates we are                                                   Board and monitored
deliver priority             met?                                   delivery of our objective?                 controls/systems on which         controls/systems in    controls/systems upon     not reasonably managing
objectives?                                                                                                    we are placing reliance are       place? Where are we    which we place reliance   our risks and objectives
                                                                                                               effective?                        failing to make them   are effective?            are not being delivered
                                                                                                                                                 effective?




Implementation of            Failure to deliver improved capacity    There are now 4 GPs clinical leads -           Further work needed to
                                                                                 STRATEGIC OBJECTIVE: FIT FOR PURPOSENone
                                                                                                               PEC, Commissioning Meetings,                                                                                       3
Primary Care Local           competence/confidence in primary       one for each collaborative.
                                                                                            TPCT Board. The next GP strengthen
Enhanced service             care to manage mental health –         Appointment of 4 clincial leads,           clinical governance group -       performance
                             ongoing level of risk re SUIs and      primary care mental health workers         monitor the joint mental health   management
                             continued high level demand on         apponted. Work programme is now in         action plan.                      arrangements around
                             secondary care.                        place focussing on changes to care                                           CAMHS service
                                                                    pathways, shared care/interface
                                                                    agreement, a review of clinical                                                                                                                                                                        We now have a joint mental health
                                                                    guidelines, use of SMI registers and                                                                                                                                                                   action with the mental health trust that
                                                                    PBC based training.                                                                                                                                                                                    is being implemented and monitor by
                                                                    Committee managing risk                                                                                                                                                                                JSIG. QMAS quality and outcomes
                                                                    SUIs - Joint Clincial Services                                                                                                                                                                         framework information system -
                                                                    Improvement group, performance                                                                                                                                                                         instructio n for every April the
                                                                    issues Performance Committee.                                                                                                                                                                          contractor group provide that
                                                                                                                                                                                                                                                                           information to the Primary Care                James
                                                                                                                                                                                                                                                     3                     Team..                                   2x3   Slater        Mar-08

                                   STRATEGIC PRIORITY: IMPROVING PERFORMANCE BY FOCUSING ON PRIORITY AREAS
Meeting all existing and     Failure to achieve targets.            New Director of Performance and            External Assurance Working None                          None                      None                            4                   3                                                            2x3
new performance targets                                             Primary Care. Head of Performance in       to NHS London's regime;
                                                                    post with overarching responsibility for   monthly written reports and
                                                                    performance against targets. Revised       quarterly meetings Internal
                                                                    focus on managing performance              Assurance Performance
                                                                    targets through bi-monthly                 Committee which meets on a bi-
                                                                    Performance Committee. Monthly             monthly basis. This Committee
                                                                    Performance Focused Commissioning          proactively manages the
                                                                    Division Directors meetings. A regime      progress and work towards
                                                                    of project plans with clear                achieving targets and meeting
                                                                    accountability for delivering targets      NHSL performance regime.
                                                                    and monthly updates provided to NHS        Additionally risks associated                                                                                                                               Awayday to work on key priorities for
                                                                    London and used internally to              with meeting the targets are                                                                                                                                investment in terms of allocating the
                                                                    demonstrate progress.                      managed by the Performance                                                                                                                                  'top slice' monies to those targets
                                                                    Committe responsible for risk              Committee.                                                                                                                                                  where it would make the greatest
                                                                                                                                                                                                                                                                           impact. A renewed focus and drive to
                                                                    Performance Committee
                                                                                                                                                                                                                                                                           achieve targets and clarify areas of           James
                                                                                                                                                                                                                                                                           responsibility.                                Slater        Mar-08
Review options and           Failure to identify appropriate        Business opportunities will be reviewed    Performance Indicators                                   None                      None                           3
implement new model for      partnering agency - as good            by Provider Services Committee.            Access to reproductive health
future delivery of sexual    quality service that needs to be       Committee responsible for risk             target (annual) (anticipate
health and family planning   partnered by the right agency.         Provider Services Committee                green)
services in partnership
                                                                                                                                                                                                                                                                           A business development plan is being
with Enfield PCT
                                                                                                                                                                                                                                                                           put together for sexual health services
                                                                                                                                                                                                                                                                           and will be submitted to the Provider
                                                                                                                                                                                                                                                                           Services Committee as part of the
                                                                                                                                                 None                                                                                                3                     service reviews.                        1x3    Jane Elias   Sep-08
                                                                                                                                                                                                  None                            4
                                                                                                         A system set up with HIS for                                                                                                                                      Invest in new telecommunications
                                                                    Reported to performance committee    PIMS based services to get an                                                                                                                                     software - upgrading phone lines to
                                                                    and reported on STEIS, Also reported early alert for a breach and an                                                                                                                                   improve access to sexual health.
Ensure perforamnce targets Breach of 13 week outpatient time        to OMT.                              access database - reviewing                                                                                                                                       Ensure that close monitoring of
are met in the provider    target in audiology and childrens        Committee Responsible risk           who is breaching the waiting                                                                                                                                      audiology is maintained and targets
services                   services                                 Performance Committee                times.                                  None                   None                                                                         2                     stay on track.                          3x2    JE            Mar-08

                                                                    PATIENT AND PUBLIC INVOLVEMENT
To seek out and respond      Failure to achieve good response       Public response to survey strategy         Performance Indicators          None                     None                      None                           4
to local feedback to         rate to national survey on patient     developed with expertise of company        Substantial increase in 06/07
improve patient              experience indicators leading to       undertaking survey on TPCT behalf          patient survey response rate to
responsive services and      limited picture of patient             using relevant direct marketing            54.5% in relation to HCC
environments                 experience of Haringey services.       techniques. Reports are made to the        Diabetes Survey. This is                                                                                                                                    For the patient survey 2007/08 a
                             The risk is damage to the TPCT's       PEC and Commissioning Team.                reported to the TPCT Board.                                                                                                                                 robust communications plan is in
                             reputation and not being able to       Committee responsible for risk:                                                                                                                                                                        place to advertise t he survey and
                             demonstrate that local servcies        Diversity and Equity Committee                                                                                                                                                                         how the responses inform changes to            Christina
                             meet patient needs.                                                                                                                                                                                                     2                     practice.                           2x2        Gradowski     Jan-08
                                                                                                                                                                                                                                        Priority                         Action Plan to Address Gaps in          Revised Lead          Due
                                                                                                                                                                                                   High level negative                  areas                            Control or Assurance                    Risk                  Date
                                          High level risk                      Key controls in place               Assurance on controls         Gaps in controls        Gaps in assurance
                                                                                                                                                                                                       assurance                                                                                                 rating
           Goals -                                                                                                                                                                                                                                                                                               (RAG)
What actions is the             What could prevent the                  What controls/systems we have           Where can we gain              Where are we failing   Where are we failing to   Do we have any evidence                                                                                          after




                                                                                                                                                                                                                                                            Rag Rating
                                                                                                                                                                                                                                                                         These need to be approved by the




                                                                                                                                                                                                                                              Consequence
                                                                                                                                                                                                                           Likelihood
organisation taking to          priority objective from being           in place to assist in securing the      evidence that our              to put                 gain evidence that our    which indicates we are                                                   Board and monitored
deliver priority                met?                                    delivery of our objective?              controls/systems on which      controls/systems in    controls/systems upon     not reasonably managing
objectives?                                                                                                     we are placing reliance are    place? Where are we    which we place reliance   our risks and objectives
                                                                                                                effective?                     failing to make them   are effective?            are not being delivered
                                                                                                                                               effective?




To engage with patients,        Lack of engagement with the TPCT        Regular meetings with Patient and
public and stakeholders on      about service changes including                      STRATEGIC OBJECTIVE: FIT FOR PURPOSENone
                                                                        Public Involvement Forum, HAVCO,
                                                                                                                                                                                                                                3                   3                    Considerable resources and effort
                                                                                                                                                                                                                                                                         into consulting as widely as possible
changes to health sevices       BEH Clinical Strategy, PC Strategy,     COMPACT and other partnership                                                                                                                                                                    and working across the partnerships
and engage with the             CSP Strategy, thereby damaging          forums. Consultation Strategy and                                                                                                                                                                and groups to engage with patients
public on the                   the TPCT reputation.                    action plan around BEH and PC                                                                                                                                                                    and the public. More work is taking
commissioning of health                                                 Strategy,. Internal Audit report on                                                                                                                                                              place on shaping up the strategy on
services.                                                               Patient and Public Involvement and                                                                                                                                                               Patient and Public involvement not
                                                                                                                                                                                                                                                                         least ensuring that patients are
                                                                        Partnerships.
                                                                                                                                                                                                                                                                         central to decisions around the
                                                                        Committee responsible for risk
                                                                                                                                                                                                                                                                         commissioning of TPCT services. The
                                                                        Equity and Diversity Committee
                                                                                                                                                                                                                                                                         Strategy addresss the Primary Care
                                                                                                                                                                                                                                                                         Implementation Strategy, Practice
                                                                                                                                                                                                                                                                         Based Commissioning and the
                                                                                                                                                                                                                                                                         Commissioning Strategy Plan as well             Christina
                                                                                                                TPCT Board and OSC                                                                                                                                       as joint work with LBH.                   2x3   Gradowski      Mar-08


                                                                        PATIENT AND STAFF SAFETY

                                                                      Estates and Facilties Strategic Board                                                                                                                                                              Minor capital investment of
                                                                      (BEHMHT), E&F Community Group,                                                                                                                                                                     £0.5million in community, robust
                                                                      robust SLA with Barnet PCT, quarterly                                                                                                                                                              SLAs with Barnet PCT, dedicated
                               Due to lack of investment and          monitoring reports                                                                                                                                                                                 Director for E&F. Host of plans and
                               commitment community estates           Committee responsible for risk                                                                                                                                                                     programmes in place to improve the
To provide high quality, fit   and facilities are not fit for purpose Operational Group meeting                                                                                                                                                                          patient environment including working
for purpose patient            and provide poor patient and staff (community / St Ann's) Strategic E&F Internal Audit report on E&F,                                                                                                                                     closely with infection control and              Christina
environment                    experience                             Committee BEHMHT/HTPCT                TPCT Board                         None                   None                                                      3                  4                     facilities management.                1x4       Gradowski      Mar-08
                                                                                                            Audit and Governance                                                                                                                                         Work has been undertaken on
                                                                                                            Committee which will receive                                                                                                                                 establishing a raft of policies and
                               Lack of robust procedures and                                                reports. NHS London with                                                                                                                                     procedures for information
                               processes around the security,                                               respect to Information                                                                                                                                       governance in additon the action plan
To ensure that the TPCT        handling and management of                                                   Governance Action Plans and                                                                                                                                  addresses training needs, data
adheres to the DPA and         patient records. Leading to loss of Information Governance Steering          audits. Information                                                                                                                                          security with the implementation of
good practice on               patient records or mishandling of      Group, action plan created to ensure  Commissioners's IG Toolkit,                                                                                                                                  RIO and active joint management                 Christina
information governance.        records.                               gaps are closed.                      StBH - core standards C9 and       None                   None                      None                            4                  3                     between Head of Corporate             2x3       Gradowski      Mar-08
                                                                      Joint Emergency Planning Committee
                                                                      run by Haringey Council, TPCT                                                                                                                                                                      Work is underway to update the local
                                                                      member, local emergency planning                                                                                                                                                                   Flu Pandemic Plan - significant work
                                                                      group (HTPCT) and Local Resilence                                                                                                                                                                  needs to be undertaken to update the
                                                                      Forum. Integrated Emergency                                                                                                                                                                        plans in line with new guidance from
                                                                      Mnagement Manual and Influenza                                                                                                                                                                     NHS London. Emergency Planning
                                                                      Pandemic Plan (Haringey Council)                                                                                                                                                                   major incident exercises are planned
                                                                      also Haringey TPCT on Local Flu                                                                                                                                                                    with the Council, a major incident              Christina
                                                                      Pandemic Plan and On-call response NHS London will review the                                                                                                                                      exercise is planned for 4th March to            Gradowski/
To ensure that robust          Lack of robust emergency plans in manual. Internal Reporting                 update Flu Pandemic Plan                                                                                                                                     be followed up with an autumn event.            Director of
emergency planning is in       place to deal with a major incident mechanisms - Risk, Health and Safety submitted by HTPCT end Jan                                                                                                                                       Local training for Emergency                    Public
place particularly in relation including flu which could lead to      Group which will monitor the risks    2008. Also NHSL Emergency                                                                                                                                    Preparedness is being developed to              Health for
to a flu pandemic.             the loss of many lives.                around emergency planning.            Planning Group.                    None                   None                      None                            3                  4                     be rolled out in April/May 2008.     2x4        Flu           May-08
                                                                                                                                               None                                             None                            4
                                                                        Bi-monthy Serious Incident Group
                                                                        meets chaired by NED reviews each
                                                                        case. The group ensures that each SUI
                                                                        is reported and managed in a way
                                                                        consistent with the Incident
                                                                        Management Policy - SUIs and action
                                There will always be situations and     plans are produced and closure is
                                circumstances which are out of the      reached on actions. Effective media                                                                                                                                                              We have spent a great deal of time
To ensure that the TPCT         ordinary, that are not expected or      handling is arranged for high profile                                                                                                                                                            and energy getting systems and
has in place robust policies,   planned for that culminate in a         SUIs. Learning is disseminated via      Internal audit inspection on                                                                                                                             processes in place, but we review any
systems and procsses to         serious untoward incident. This is a    internal mechanisms including sharing   governance issues. NHS                                                                                                                                   SUI according to procedures and
avoid SUIs and to undertake     risk to patient safety and reputation   report and findings at clinical         London reporting system                                                                                                                                  review our practices as part of any
robust investigations.          of TPCT.                                governance meetings.                    STEIS, TPCT Board.                                    None                                                                         4                     internal investigation.               3x4       CG, JE        Dec-08
                                                                                                                                                                                                                                       Priority                           Action Plan to Address Gaps in     Revised Lead    Due
                                                                                                                                                                                              High level negative                      areas                              Control or Assurance               Risk            Date
                                      High level risk                   Key controls in place              Assurance on controls            Gaps in controls        Gaps in assurance
                                                                                                                                                                                                  assurance                                                                                                  rating
         Goals -                                                                                                                                                                                                                                                                                             (RAG)
What actions is the          What could prevent the             What controls/systems we have           Where can we gain                 Where are we failing   Where are we failing to   Do we have any evidence                                                                                           after




                                                                                                                                                                                                                                                             Rag Rating
                                                                                                                                                                                                                                                                          These need to be approved by the




                                                                                                                                                                                                                                             Consequence
                                                                                                                                                                                                                          Likelihood
organisation taking to       priority objective from being      in place to assist in securing the      evidence that our                 to put                 gain evidence that our    which indicates we are                                                         Board and monitored
deliver priority             met?                               delivery of our objective?              controls/systems on which         controls/systems in    controls/systems upon     not reasonably managing
objectives?                                                                                             we are placing reliance are       place? Where are we    which we place reliance   our risks and objectives
                                                                                                        effective?                        failing to make them   are effective?            are not being delivered
                                                                                                                                          effective?




                                                                             STRATEGIC OBJECTIVE: FIT FOR PURPOSE
                                                                                        NO LONGER A RISK
Implement electronic staff                                                                                Performance                                                                      None                       3                2                   6    Review of policies post ESR go live,  3x1=3
record –                                                                                                  IndicatorsReadiness for                                                                                                                          ambe restructuring to match finance,       green
                                                                                                          assessment for each stage of                                                                                                                     r    develop business continuity planning,
                                                                                                          project – all flagged                                                                                                                                 ICT strategy implementation. There
                                                                   Project Manager appointed across       greenExternal                                                                                                                                         is a need to ensure that there is a
                                                                   BECF, EPCT, BEHMHT organisations inspectionInternal audit planned      Policies and procedures                                                                                               business continuity plan for ESR and
                                                                                                                                                                                                                                                                this has been requested from Nigel
                             Incorrect or nil payments made to     and form the part of the Joint Project for December 2006Internal       need to be reviewed
                                                                                                                                                                                                                                                                Redmond - Dilo Lalande leads on
                             staff, Inability to access accurate Board.Action plans in place for the      reviewAudit reports, payroll    post go live
                                                                   project.Review and audit of policies   error reports, reconciliation   ESRHierarchy needs to                                                                                                 business continuity planning.
                             workforce information. Failure to
                             meet project milestones leading to and procedures to ensure appropriate between workforce and finance        be re-organised as
                                                                   checks are in place, recording of      reports to Trust                currently does not
                             penalities
                                                                   storage of workforce information,      BoardGovernanceDiversity and    match with financeLack
                             Reduction in budgets for projects.
                                                                   information derived from other         Equity CommitteeOther           of business continuity
                             Staff issues, Business continuity:
                                                                   systems: i.e. finance, development of relevant management              processes for
                             Lack of appropriate ICT network       business continuity processes for      information Audit reports,      alternative payroll
                             infrastructure to support business alternative payroll processing.           payroll error reports,          processingUpdated
                             information      Failure to pay staff Payroll/HR policies and procedures in reconciliation between           action: implement the
                             and access workforce information placeLocal ESR lead in post and ICT workforce and finance reports           aboveICT infrastructure
                             as result of failure to implement     ESR lead in post National Readiness    to Trust Board, BACS            issuesUpdated action:
                             ESR project caused by capacity        Assessments received at each stage of confirmation process able to     as per ICT strategy and                                                                                                                                                   James    COMPL
                             and HR issue                          project                                identify system problems        plan                    NONE                                                                                                                                              Slater   ETED
    Impact/ likelihood matrix            0                     1               2            3            4
                                         Impossible - cannot   Rare - may      Unlikely -   Moderate -   Likely - will
                                         happen in any         happen in       could        Should       occur in
                                         circumstances         exceptional     happen at    happen at    most
                                                               circumstances   some time    some time    circumstanc
                                                                                                         es
0          No injuries/low financial     0                     0               0            0            0
           loss
1          First aid injuries/moderate   0                     1               2            3            4
           financial loss


2          Medical treatment             0                     2               4            6            8
           required. High financial
           loss. Moderate loss of
           reputation, business
           interruption.

3          Excessive injuries. High      0                     3               6            9            12
           environmental
           implications. Major
           financial loss, loss of
           reputation, business
           interruption


4          Single death                  0                     4               8            12           16
5          Multiple deaths               0                     5               10           15           20
5
Certain - will
happen in all
circumstanc
es


0

5


10




15




20
25

				
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