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					                                                                         BOARD ASSURANCE FRAMEWORK
                   2008/09                                             COMMISSIONING (As at 09 January 2009)




                                           Delivered by (date)
  Lead Director




                                                                                                                            Control A/I/U
                                                                   Description of risk                                                                                                                                                      Code
                     Strategic Priority
                                                                                             What controls have you                                            Sources of Assurance                                                          Red




                                                                                                                                                                                                                                  SfBH
                    COMMISSIONING
                                                                      Risk rating             put in place to ensure                        Gaps In Control          (indicate                    Action Plan                               Amber
                                                                     Consequence            delivery of this objective?                                             +ve or -ve)                                                             Green
                   strategic objectives
                                                                     x Likelihood                                                                                                                                                          & status

     C1
 SC/ To refresh the PCT‟s Commissioning Strategy Plan reflecting the outcomes of the 2007 consultation exercise, Lambeth‟s Sustainable Community Strategy, A Picture of Health and Healthcare for London and to take forward year two of
 SM the Commissioning Strategy Plan though the development and agreement of an Operating Plan for 2009/10.

                                                                                                                                                                                                                                 C5
     To implement the CSP

                                           31st March 2009
                                                                                                                                                                                                                                 C6
     consultation action plan, including                         Risk of having sufficient
                                                                                           Action plan with timescales                                                                  CSP report to PCT Board in May           C7
     producing a report setting out the                          commissioning capacity                                                                                                                                                      G
 SC/                                                                                        for delivery, monitored by                                                CDC                            2008                        C17
     consultation responses received                               to implement action                                       A              None identified
 SM                                                                                          commissioning strategy                                                 PCT Board            Action plan monitored in June,          C18         ]
     on the PCT‟s Commissioning                                            plan.
                                                                                           group on a quarterly basis                                                                   September and December 2008              C19
     Strategy Plan (CSP) and the                                          3x1=3
                                                                                                                                                                                                                                 C22
     PCT‟s response to consultation
                                                                                                                                                                                                                                 C23
     issues.
                                                                                                                                                                                                                                 C5
                                                                                                                                                                                                                                 C6
                                           31st May 2008




                                                                 Risk of having sufficient
                                                                                                                                                                                                                                 C7
     To provide a revised CSP by May                             commissioning capacity                                                                                                                                                      G
 SC/                                                                                        Board approved revised                                                    CDC               CSP report to PCT Board in May           C17
     2008 that takes due account of the                            to implement action                                       A              None identified
 SM                                                                                        CSP at May Board meeting                                                 PCT Board                        2008                        C18         ]
     consultation responses received.                                      plan.
                                                                                                                                                                                                                                 C19
                                                                          3x1=3
                                                                                                                                                                                                                                 C22
                                                                                                                                                                                                                                 C23
     To develop a CSP „refresh‟ for                                                                                                                                                                                              C5
                                                                  Risk of delayed NHS
     2009/10, that takes due account of                                                                                                                                                                                          C6
                                           28th Nov 2008




                                                                   London guidance on       Development overseen by                                                                   PCT's input into and implementation
     NHSL requirements and guidance,                                                                                                                                                                                             C7
                                                                 content and format; lack    Commissioning Strategy                                                  CDC              of a number of wider strategies (HfL,                  G
 SC/ and the PCT‟s input in to and                                                                                                                                                                                               C17
                                                                 of clear outcomes from     Group, CDC and requiring         A              None identified        PCT Board           APOH, Lambert's SCS) refreshed
 SM implementation of a number of                                                                                                                                                                                                C18         ]
                                                                  and/or delays in other        Board approval                                                     NHS London           CSP 2009/10 onwards - Autumn
     wider strategies (HfL, APOH,                                                                                                                                                                                                C19
                                                                  consultation exercise           SHA review                                                                                          2009
     AHSC, Lambeth SCS) and the                                                                                                                                                                                                  C22
                                                                          3x2=6
     PCT‟s CSP consultation exercise.                                                                                                                                                                                            C23
                                                                    Risk of delayed
                                           31st March 2009




     To update and further develop the                             implementation of                                                                                   CDC
                                                                                                                                                                                      Update provided to PCT Board in
     PCT's Financial Strategy in line                            PCT's commissioning        Development overseen by                                                    CSG                                                                   G
                                                                                                                                                                                      March 2008. Update provided in Nov
     with best practice and to support                                 initiatives          PCT Board and outcome                                                Audit Committee                                                             ]
  AE                                                                                                                         A              None identified                           2008                                       C7
     the PCT Commissioning Strategy                              Resource risks arising       from WCC, CSP and                                                    PCT Board
                                                                                                                                                                                      Reviewed through WCC - full update
     Plan priorities, and the PCT's                               from London-wide          Operating plan processes                                              NHS London
                                                                                                                                                                                      to March 2009 Board
     service and financial objectives.                           Financial Framework                                                                              WCC process
                                                                        4x3=12
                                                                                                                                                                                        Operating Plan process agreed in         C5
                                           31st March 2009




                                                                    Risk of delayed                                                                                                               Autumn 2008                    C6
                                                                 National/NHS London        Development overseen by                                                                   Refreshed Commissioning Intention's        C7
     To oversee the development and                                                                                                                                  CDC
 SC/                                                             guidance on resource        Commissioning Strategy                                                                   agreed in Autumn; 1st draft Operating      C17         G
     agreement of the PCT‟s Operating                                                                                        A              None identified        PCT Board
 SM
     Plan for 2009/10.
                                                                 position, priorities and   Group, CDC and requiring
                                                                                                                                                                   NHS London
                                                                                                                                                                                              Plan - January 2009 .              C18         ]
                                                                    required format             Board approval                                                                         Contracts agreed by February 2009.        C19
                                                                         3x3=9                                                                                                           Operating plan approved by the          C22
                                                                                                                                                                                              Board February 2009                C23




Controls                                                                                                                              Consequences
A - Adequate                                                                                                              1-Insignificant 2-Minor 3-Moderate                                                                                      Likelihood
I - Insufficient                                                                                                                4-Major 5-Catastrophic                                                                        1-Rare 2-Unlikely 3- Moderate
U - Unclear                                                                                                                               1 of 8                                                                                 4-Almost certain 5-Certain
                                           Delivered by (date)
  Lead Director




                                                                                                                          Control A/I/U
                                                                   Description of risk                                                                                                                                                         Code
                     Strategic Priority
                                                                                          What controls have you                                              Sources of Assurance                                                              Red




                                                                                                                                                                                                                                     SfBH
                    COMMISSIONING
                                                                      Risk rating          put in place to ensure                         Gaps In Control           (indicate                        Action Plan                               Amber
                                                                     Consequence         delivery of this objective?                                               +ve or -ve)                                                                 Green
                   strategic objectives
                                                                     x Likelihood                                                                                                                                                             & status

     Deliver a balanced 2009/10




                                           31st March 2009
     Operating Plan financial
     framework within the PCT                                                                                                                         CDC                      Medium term strategy agreed by PCT                    G
                                                Risk of deterioration in Development overseen by
     Financial Strategy and that                                                                                                                      CSG                        Board March 2008. Updated in Nov                    ]
 AE                                             PCT's financial position PCT Board, CDC, Audit            A       None identified                                                                                       C7
     supports effective service                                                                                                                 Audit Committee                                 2008
                                                         4x3=12             Committee and CSG
     investment and efficiency                                                                                                                     PCT Board                       OP to be agreed in March 2009
     proposals and addresses financial
     risk management.
     C2
     To deliver the Operating Plan for 2008/2009 in line with agreed financial and service parameters, 2008/2009 commissioning intentions, national and locally agreed targets (including Local Area Agreement targets) as set out below:
 SC/ * staying healthy      * children and young people * sexual health
 SM * long-term conditions * mental health                  * end of life care
     This will be supported by an effective commissioning, monitoring and performance framework


     To deliver the commissioning
     intentions across key clients
     groups as set out in the PCT‟s                              Risk of having sufficient
                                                                                                                                                                                                                                    C5
     2008/09 operating Plan, in line                             commissioning capacity
                                           31st March 2009




                                                                                                                                                                                                                                    C6
     with agreed action plans, quarterly                            to implement action
                                                                                             Monitoring overseen by                                                                         Implementation plans agreed             C7
     milestones, investment profiles                             plans; implementation of                                                                         Project boards                                                                 G
 SC/                                                                                        Commissioning Strategy                                                                           Quarterly monitoring - June,           C17
 SM
     and year end outcomes.                                       change management -
                                                                                           Group and CDC on quarterly
                                                                                                                           A              None identified              CDC
                                                                                                                                                                                         September, December 08 and March           C18          ]
     Implementation plans to cover :                                    care pathway                                                                               PCT Board
                                                                                                      basis                                                                                             2009                        C19
     * Staying health                                               redesign/workforce
                                                                                                                                                                                                                                    C22
     * Children and young people                                      cultural changes
                                                                                                                                                                                                                                    C23
     * Sexual health                                                       3x3=9
     * Long-term conditions
     * Mental Health
     * End of life care
                                                                                                                                                                                                                                            A
                                                                                                                                                                                                                                            R
                                                                                                                                                                                                                                            G
                                                                                                                                                                                                                                            A
                                                                                                                                                                                                                                            G
                                                                                                                                                                                                                                            G
                                                                      Risk that some                                                                                                                                                        AA
                                                                                                                                                                                                                                             A
                                                                                                                                                                                                                                             R
                                           31st March 2009




     To ensure the delivery of national                               trajectories are
                                                                                                                                                              Performance framework
     and London priorities and                                   ignorantly challenging to Monitoring overseen by MT,                                                                                                               C3
                                                                                                                                                              Performance Committee         Monthly monitoring of high risk                      G
 SC/ requirements (Tier 1 VSA and Tier                           deliver given Lambeth's Performance Committees                                                                                                                     C4
                                                                                                                           A              None identified           PCT Board                          targets                                   ]
 SM 2 VSB) for 2008/09, in line with                               demographics; some      (PCT/H&SCP/C&YP), PCT                                                                                                                    C5
                                                                                                                                                                    NHS London             Quarterly monitoring of all targets
     agreed year end trajectories and                             require effective action    Board, NHS London                                                                                                                     C7
                                                                                                                                                              Healthcare Commission
     in year milestones.                                                by partners
                                                                          4x3=12

                                                                    Failure to deliver
                                           30 th June 2009




    Ensure the delivery of the                                                                                                                                     PCT Board                 Monthly budget monitoring and
                                                                   statutory duty and     Budgetary and reporting
    PCTs statutory financial                                                                                                                                McKinsey's external review            reporting framework.
                                                                      NHS London               framework
    targets and the PCTs planned                                                                                                                                 Audit Committee         Mitigation plans developed to address                   G
 AE                                                                   performance            Audit Committee               A              None identified                                                                           C7
    financial control total, agreed
                                                                      requirement.
                                                                                                                                                             Performance Committee        under and overspending scenarios                       ]
                                                                                            Cash management                                                                              Bid to NHS London for additional CRL
    with NHS London, in line with                                                                                                                                 Internal audit
                                                                    Reputation risk.             strategy
    the 2008/09 Operating plan.                                                                                                                                   NHS London
                                                                         3x3=9
                                                                                                                                                                  External audit
     To monitor and manage effectively
                                           31st March 2009




                                                                    Risk of unplanned
     contract performance across the
                                                                  increase in demand,       main contracts monthly                                                                                                                  C3           A
     PCT‟s commissioning portfolio, to                                                                                                                               CDC                 Monthly monitoring of main contracts
 SC/                                                                particularly acute     monitoring of finance and                                                                                                                C4
     ensure delivery of agreed finance                                                                                     A              None identified          PCT Board                Quarterly monitoring of other                        ]
 SM                                                                     contracts            activity and quarterly                                                                                                                 C5
     and activity plans, quality targets                                                                                                                           NHS London                         contracts
                                                                          4x2=8              monitoring of quality                                                                                                                  C7
     and metrics and agreed service
     outcomes.




Controls                                                                                                                            Consequences
A - Adequate                                                                                                            1-Insignificant 2-Minor 3-Moderate                                                                                           Likelihood
I - Insufficient                                                                                                              4-Major 5-Catastrophic                                                                             1-Rare 2-Unlikely 3- Moderate
U - Unclear                                                                                                                             2 of 8                                                                                      4-Almost certain 5-Certain
                                            Delivered by (date)
  Lead Director




                                                                                                                              Control A/I/U
                                                                     Description of risk                                                                                                                                                     Code
                     Strategic Priority
                                                                                               What controls have you                                            Sources of Assurance                                                         Red




                                                                                                                                                                                                                                   SfBH
                    COMMISSIONING
                                                                         Risk rating            put in place to ensure                        Gaps In Control          (indicate                    Action Plan                              Amber
                                                                        Consequence           delivery of this objective?                                             +ve or -ve)                                                            Green
                   strategic objectives
                                                                        x Likelihood                                                                                                                                                        & status


     C3
 SC/
     To develop the commissioning competencies required to deliver World Class Commissioning (WCC) in Lambeth, including the development of Practice Based commissioning, a joint Strategic Needs Assessment with the Local
 SM
     Authority, and the implementation of the PCT's 2008-2010 World class Commissioning project, which includes the further development of the PCT's community involvement and engagement approached, to underpin our commissioning.

     To establish new structures and                                                                                                                                                    Approval of WCC structures by MT &
                                                                     Risk of lack of active    Development overseen by                                                                                                            C6
                                                                                                                                                                                                                                              G



                                            May-08
     process for taking forward WCC in                                                                                                                                                            CDC April 2008
 SC/                                                                  engagement by all         Commissioning Strategy                                                  CDC                                                       C7
 SM
     Lambeth, including the
                                                                    commissioning partners     Group, CDC and requiring
                                                                                                                               A              None identified
                                                                                                                                                                      PCT Board
                                                                                                                                                                                        WCC structures in place - May 2008
                                                                                                                                                                                                                                  C22
                                                                                                                                                                                                                                              ]
     establishment of a new WCC                                                                                                                                                          Monthly meetings established May
                                                                             3x1=3                 Board approval                                                                                                                 C23
     Steering Group.                                                                                                                                                                               2008 onwards
                                            31st March 2009 - TBC
    To agree and implement an
                                                                       Risk of insufficient
    organisational development plan
                                                                      priority given to OD
    to increase overall awareness and                                                         Overseen by Commissioning
                                                                         agenda; longer                                                                                                       Draft OD plan Nov 08.
 UD
    understanding of commissioning
                                                                     timescale to address
                                                                                              Development Committee on
                                                                                                                               A              None identified
                                                                                                                                                                        CDC
                                                                                                                                                                                        Revised OD Plan to be submitted to
                                                                                                                                                                                                                                  C7          G
    across the PCT and to address
                                                                        competency and
                                                                                               a quarterly basis and the                                              PCT Board
                                                                                                                                                                                                 March 09 Board
                                                                                                                                                                                                                                  C11         ]
    competencies and capability gaps                                                                 PCT Board
                                                                         capacity gaps
    within the PCT, to enable more
                                                                              3x3=9
    effective commissioning

     To assess the PCT‟s delivery of
                                            31st March 2009




                                                                       Risks of delayed                                                                                                   Assurance system finalised - June
     WCC competencies to include
                                                                     notification of national Overseen by Commissioning                                                                                 2008.                     C6          G
     (1) an internally led assessment                                                                                                                                  CDC
 SC/                                                                process for assurance; Development Committee on                                                                     Capacity building in SHA - September      C7
     by End of June 2008,                                                                                                      A              None identified        PCT Board                                                                ]
 SM                                                                 capacity implications for a quarterly basis and the                                                                                 2008.                     C22
     (2) delivery of the national                                                                                                                                    NHSLondon
                                                                               PCT                   PCT Board                                                                           Assurance assessments with PCT -         C23
     assessment/assurance process to
                                                                              3x1=3                                                                                                                      TBC
     take place during 2008/09.
                                                                       Risks of delayed
                                          31st March




                                                                     notification of national Overseen by Commissioning                                                                                                           C6
                                                                                                                                                                       CDC                 TBC - dependent on when the
                                                                                                                                                                                                                                               G
                                            2009




 SC/ To agree a development plan to                                 process for assurance; Development Committee on                                                                                                               C7
                                                                                                                               A              None identified        PCT Board          assurance assessment is undertaken
 SM address key assurance gaps.                                     capacity implications for a quarterly basis and the
                                                                                                                                                                     NHSLondon                     - see above
                                                                                                                                                                                                                                  C22          ]
                                                                               PCT                   PCT Board                                                                                                                    C23
                                                                              3x3=9
     To oversee the effective
                                            31st March 2009




     implementation of the PCT‟s non                                                                                                                                                     Implementation plans agreed - April
                                                                        Risk of recruiting                                                                                                                                        C6
     recurrent WCC project - this                                                             Monitored by WCC steering                                                                                 2008                                   A
 SC/                                                                  staff/tendering work                                                                              CDC                                                       C7
     includes the delivery of a Joint                                                         Group on a monthly basis;        A              None identified                             Quarterly monitoring of milestone,
 SM                                                                  slows implementation                                                                             PCT Board                                                   C22          ]
     Strategic Needs Assessment with                                                           CDC on a quarterly basis                                                                 targets and risks - June, September,
                                                                              3x3=9                                                                                                                                               C23
     the LA and a PBC development                                                                                                                                                              December, March 2009
     programme.




Controls                                                                                                                                Consequences
A - Adequate                                                                                                                1-Insignificant 2-Minor 3-Moderate                                                                                     Likelihood
I - Insufficient                                                                                                                  4-Major 5-Catastrophic                                                                       1-Rare 2-Unlikely 3- Moderate
U - Unclear                                                                                                                                 3 of 8                                                                                4-Almost certain 5-Certain
                                           Delivered by (date)
  Lead Director




                                                                                                                             Control A/I/U
                                                                   Description of risk                                                                                                                                                                   Code
                     Strategic Priority
                                                                                              What controls have you                                                Sources of Assurance                                                                  Red




                                                                                                                                                                                                                                               SfBH
                    COMMISSIONING
                                                                      Risk rating              put in place to ensure                        Gaps In Control              (indicate                            Action Plan                               Amber
                                                                     Consequence             delivery of this objective?                                                 +ve or -ve)                                                                     Green
                   strategic objectives
                                                                     x Likelihood                                                                                                                                                                       & status

     C4
 SC/ To further develop partnership working in Lambeth through continuing to establish effective mechanisms and structures with NHS, Local Authority, voluntary sector and other partners to ensure that we commission seamless, joined up
 SM and responsive services across health and social care, with a clear customer focus. In doing so to continue to develop excellent relationships with both other commissioners and service providers.

                                                                                             Monitoring overseen by                                                                                                                           C5
                                                                 Risk of insufficient PCT/




                                           31st March 2009
     To ensure the development and                                                              JCEGs, H&SCP                                                                 CDC                                                              C6
                                                                 partners commissioning
     effective delivery of agreed                                                           Performance Committee,                                                 H&SCP/C&YPSP Boards                 Implementation plans agreed            C7
                                                                         capacity;
 SC/ strategic commissioning plans                                                             C&YPSP, Sector                                                     Sector Specialised services        Quarterly monitoring of milestone,       C17          G
                                                                    implementation of                                         A              None identified
 SM across areas of joint                                                                     Specialised services,                                                       PCT Board                targets and risks - June, September,       C18          ]
                                                                     complex change
     commissioning through the Joint                                                        Commissioning Strategy                                                            LSP                         December, March 2009                C19
                                                                      management
     Performance Board                                                                     Group and CDC on quarterly                                              Joint Performance Board                                                    C22
                                                                           3x3=9
                                                                                                      basis                                                                                                                                   C23
                                                                                                                                                                                                                                              C5
     To provide commissioning input                                 Lack of clarity of
                                                                                                                                                                  Commissioning Development                                                   C6
     and leadership to the partnership                           medium term priorities
                                                                                                                                                                         Committee                                                            C7
                                           ongoing




     structures and processes in                                   for Lambeth in the        Monitored by H&SCP and                                                                                                                                        G
 SC/                                                                                                                                                                   H&SCP Board                                                            C17
     Lambeth – through the Lambeth                                context of SCS and         C&YPSP Board, LSP, and           A              None identified                                               Specific action - TBC
 SM                                                                                                                                                                   C&YPSP Board                                                            C18          ]
     Strategic Partnership, and its                              partnership processes        CDC on quarterly basis
                                                                                                                                                                         PCT Board                                                            C19
     Theme Partnerships, specifically                            slowing down delivery
                                                                                                                                                                            LSP                                                               C22
     the H&SCP and the C&YPSP.                                           3x3=9
                                                                                                                                                                                                                                              C23
                                                                 Risk of lack of influence                                                                                                         Ensure mapping complete by end of
                                           31st July 2008




     To map and review all existing
                                                                       in partnership                                                                                                                               May                                    A
     partnership relationships with LBL;                                                                                                                                    CE
 SC/
     and take action to ensure we
                                                                   relationships and/or      To be monitored closely by
                                                                                                                              A              None identified                MT
                                                                                                                                                                                                   Inputs from relevant PCT staff, MT,        C6           ]
 SM                                                                  inefficient use of           Chief Executive                                                                                             CE and Chair                    C7
     maximise effectiveness and                                                                                                                                           PCT Chair
                                                                         resources                                                                                                                 Action plan for any changes by 31st
     efficiency
                                                                           3x3=9                                                                                                                                 July 2008
     To contribute to the continued
     implementation of lead                                                                                                                                                                         Sector collaborative commissioning
     commissioning and inter PCT                                                                  monitored by                                                                                      arrangements reviewed - May 2008
                                           ongoing




     commissioning arrangements in                               Risk of having sufficient    Commissioning Strategy                                           Collaborative Commissioning Group        Allocation of revised sector                      G
 SC/                                                                                                                                                                                                                                          C6
 SM
     line with SEL/London                                        commissioning capacity          Group, Sector's              A              None identified     London Chief Executive group      commissioning responsibilities - June
                                                                                                                                                                                                                                              C7          ]
     requirements, including chairing                                     3x3=9                   Collaborative                                                            NHS London                               2008
     SEL Executive Commissioning                                                              Commissioning Group;                                                                                 Co-coordinator commissioner role for
     Group, and co-coordinating                                                                                                                                                                              GSTT - ongoing
     commissioner role for GSTT.
     To contribute from a                                                                                                                                                                                                                     C2
                                                                     Risk of historical                                                                                                            JAR/APA arrangements - established
     commissioning perspective to                                                                                                                                                                                                             C5
                                           autumn 2008




                                                                     challenges to be                                                                                       CDC                                    April
     2008/09 planned external reviews,                                                                                                                                                                                                        C6
 SC/ including the Annual Performance
                                                                   addressed in a tight Monitored by H&SCP and                                                            PCT Board                 Preparation work undertaken up to
                                                                                                                                                                                                                                              C7
                                                                                                                                                                                                                                                          G
 SM Assessment and Joint Area
                                                                    timescale; having   C&YPSP Board, LSP, and                A              None identified                 LSP                                  August
                                                                                                                                                                                                                                              C17         ]
                                                                        sufficient       CDC on quarterly basis                                                             HSCP                     External inspections - September
     Review , CPA and any other                                                                                                                                                                                                               C18
                                                                 commissioning capacity                                                                                    CYPSP                      Action plans to inform 2009/10
     inspections, Corporate                                                                                                                                                                                                                   C22
                                                                          3x2=8                                                                                                                    Operating plan Nov - December 2008
     Performance Assessment                                                                                                                                                                                                                   C23




Controls                                                                                                                               Consequences
A - Adequate                                                                                                               1-Insignificant 2-Minor 3-Moderate                                                                                                  Likelihood
I - Insufficient                                                                                                                 4-Major 5-Catastrophic                                                                                    1-Rare 2-Unlikely 3- Moderate
U - Unclear                                                                                                                                4 of 8                                                                                             4-Almost certain 5-Certain
                                                                           BOARD ASSURANCE FRAMEWORK
                   2008/09                                                 PROVIDER (As at 09 January 2009)
                                                                                                                                                                                                                                                      APPENDIX 2
  Lead Director




                                                                                                                           Control A/I/U
                                            Delivered by
                    Strategic Priority                            Description of risk                                                                                                                                                                      Code
                       PROVIDER                                                             What controls have you                                                 Sources of Assurance                                                                     Red




                                               (date)




                                                                                                                                                                                                                                               SfBH
                                                                      Risk rating            put in place to ensure                        Gaps In Control               (indicate                            Action Plan                                  Amber
                   strategic objectives                              Consequence           delivery of this objective?                                                  +ve or -ve)                                                                        Green
                                                                     x Likelihood                                                                                                                                                                         & status
     P1
                                                                                                                                                                                                                                                        R
                                                                                                                                                                                                                                                        G
                                                                                                                                                                                                                                                        A
                                                                                                                                                                                                                                                        G
                                                                                                                                                                                                                                                        A
                                                                                                                                                                                                                                                        G
                                                                                                                                                                                                                             AA
                                                                                                                                                                                                                              A                          R
  AD Ensure that the provider arm achieves key national and local targets within agreed resources, including a review of the balanced scorecard with a key focus on the development of our systems of involvement and engagement in the
     context of the Commissioning Strategy Plan and Operating Plan.
     Develop and implement plans
     working with GP practices,
     schools and others to meet the                                    Immunisation:                                                                                                                                                                         R
     key childhood targets:                                      Significant improvement       Imms Work plan                                                                                                                                                ]
     a) immunisation trajectory for                                   in performance         Imms Steering Group                                                                                            Action plan agreed
     MMR, Hep B, DPT, HPV, Hib and                                  required. 3x4=12       COVER re Balance Score                                                                                 Immunisation action plan reviewed by                      Imms
                                               March 2009
                                                                                                                                                                      COVER Data
     BCG to include working with GPs,                              BMI: dependent on                 Card                                                                                           PEC Nov 2008 and Performance
                                                                                                                                                                PCT Performance Committee                                                     C22
  AD healthy start teams, schools and                               school attendance    BMI: Additional staff funded       A              Dependant on RIO                                               Committee Jan 2009
                                                                                                                                                                   NHS London returns                                                         C23
     on data quality;                                                      3x2=6          to undertake measurement                                                                                           - BMI target met                              BMI and
                                                                                                                                                                     LAA Monitoring
     b) BMI target for Reception and                               Breastfeeding: new        Breastfeeding: Leads                                                                                 - Breast feeding, review of data flows                Breast Feeding
     Year 6 children including building                              target, new data    agreed. Indicator on balance                                                                                            underway
     relationships with schools                                           systems                 score card                                                                                                                                                 A
                                                                                                                                                                                                                                                             G
     c) breast feeding including                                          3x4=12                                                                                                                                                                             ]
     recording systems and setting a
     baseline
     Develop our children's services
     working in partnership with the
     social services in the following key
     areas:
                                                                                                                                                              Integrated Services workstream of
     embed the TAC approach in our                                                                                                                                                                 Workplans to be developed jointly
                                                                  Staff do not engage.     CAF & TAC Steering Group.                                                Children‟s Trust Board                                                    C2             A
                                               Ongoing




     universal + CWD services and                                                                                                                                                                           with LA CYPS
                                                                    High targets not             CAF Targets                                                      Teenage Pregnancy Board                                                     C6             
  AD ensure use of the CAF                                                                                                  A               None identified                                             and reviewed in year                                 ]
                                                                        achieved                CWD measures                                                                LSCB                                                              C22
     implement the Family Nurse                                                                                                                                                                    FNP action plan agreed with DoH
                                                                         3x2=6                FfP Steering Group                                                   Governance Committee
     Partnership RCT programme                                                                                                                                                                                Dec 2008
                                                                                                                                                                     FNP Steering group
     agree and implement a
     safeguarding children work plan
     for 2008/09 to include Child Death
     Review Panels

     Develop and implement plans                                   Difficulty in meeting
     working with GP practices,                                       targets due to:
                                               January 2009




     community pharmacists and                                     Flu: History of non-
                                                                                                Business Plans                                                 Directorate Business meetings
     community nursing teams to meet                                   achievement                                                                                                                      Flu campaign underway.                C7             R
                                                                                                Steering Groups                                                  MT Performance Meetings
  AD key targets: flu target - 70%; stop                                   3x3=9                                            A               None identified                                       Stop smoking action plan agreed and         C22
                                                                                              Aggregate Scorecard                                              PCT Performance Committee                                                                     ]
     smoking target of 1873 quitters;                                Smoking: High                                                                                                                         reviewed midyear                   C23
                                                                                               PMS review visits                                                       DOHA returns
     LAA BME target of 448 4 week                                 population turnover.
     quitters; 1% reduction in pregnant                           Hard to reach groups
     women not smoking at delivery                                        4x3=12
                                               Ongoing 2008-09




     Deliver 2008/09 IM&T plan
     priorities including embedding use                                                                                                                             IM&T Steering Group                     IM&T Plan
                                                                   Low uptake of RiO
AD/A of Rio with clinicians, develop the                                                      RiO Project Board                                                      RiO Project Board                RiO Implementation plan                                A
                                                                   Delays to Version 5                                      A               None identified                                                                                   C9
 E use of management reports from                                                           Routine reports from RiO                                            Directorate Business meeting       Management reports for balanced                           ]
                                                                         4x2=8
     Rio and prepare for                                                                                                                                        PCT Performance Committee                   scorecard
     implementation of version 5.




Controls                                                                                                                             Consequences
A - Adequate                                                                                                             1-Insignificant 2-Minor 3-Moderate                                                                                                    Likelihood
I - Insufficient                                                                                                               4-Major 5-Catastrophic                                                                                      1-Rare 2-Unlikely 3- Moderate
U - Unclear                                                                                                                              5 of 8                                                                                               4-Almost certain 5-Certain
  Lead Director




                                                                                                                                       Control A/I/U
                                                     Delivered by
                          Strategic Priority                               Description of risk                                                                                                                                                                           Code
                             PROVIDER                                                                 What controls have you                                                    Sources of Assurance                                                                      Red




                                                        (date)




                                                                                                                                                                                                                                                               SfBH
                                                                               Risk rating             put in place to ensure                          Gaps In Control                (indicate                              Action Plan                                 Amber
                        strategic objectives                                  Consequence            delivery of this objective?                                                     +ve or -ve)                                                                         Green
                                                                              x Likelihood                                                                                                                                                                              & status
                                                                                                                                                                                                                                                                      A
                                                                                                                                                                                                                                                                      R
                                                                                                                                                                                                                                                                      G
                                                                                                                                                                                                                                                                      A
                                                                                                                                                                                                                                                                      G
                                                                                                                                                                                                                                                                      G
                                                                                                                                                                                                                                                                      AA
                                                                                                                                                                                                                                                                       A
                                                                                                                                                                                                                                                                       R
                                                                                                                                                                                                                   Focus on SfBH that reflect patient
     Deliver all national, NHS London,
                                                                                                                                                                                                                 safety, clinical effectiveness and the




                                                        31-Mar-09
     Standards for Better Health,                                         Failure to meet targets;         SfBH process                                                           Business meetings
                                                                                                                                                                                                                  patient experience; Action plans in                      A
     Public Health and commissioner                                         non-compliance on        Performance Framework.                                                Provider Development Committee
  AD                                                                                                                                    A              None identified                                           place for all key targets by July 2008;      C7
     targets and trajectories and                                         SfBH; loss of reputation   Directorate Balance Score                                                  Governance Committee                                                                       ]
                                                                                                                                                                                                                  SfBH templates to be completed in
     develop outcome measures for                                                  4x3=12                       Card                                                           Performance Committee
                                                                                                                                                                                                                 year. Review information systems to
     community services
                                                                                                                                                                                                                   support capture of outcome data.

                  P2
                  Complete the Fit for the Future business and transformation plan by July 2008 and develop a strategic plan for consultation and implementation which will include models of service provision and the development of outcome measures
  AD
                  of quality of service, focusing on patient safety, patient experience, infection control and clinically effective care across the range of provided services.

     Implement the Fit for the Future
     work programme in line with
                                                        September 2008


                                                                                                                                                                                Consultation document
     agreed timetable including                                                                                                                                                                                      FfP discussion completed
                                                                                                                                                                           Business and transformation plan
     financial planning, financial                                        NHS London timetable Steering Group Professional                                                                                       Board decision to become an APO                           G
                                                                                                                                                                                      completed.
  AD benchmarking and financial                                            does not fit PCT'S.  Reference Group Project                 A              None identified                                                    taken Nov 2008                      C7
                                                                                                                                                                                      PCT Board                                                                            ]
     controls; undertake strategic                                               3x3=9                    Plan                                                                                                   NHSL APO peer review rated green
                                                                                                                                                                           Provider Development Committee
     planning and prepare business                                                                                                                                                                                APO transformation plan agreed
                                                                                                                                                                                APO Programme Board
     and transformation plan for
     consultation in Summer 2008.
                                                        March 2009




     Agree SLAs with all HR and                                           Corporate services do                                                                                                                   Business and transformation plan
     Corporate Affairs, Quality and                                          not agree with                                                                                           PCT Board                  agreed - Sept PDC and reviewed at                         A
  AD                                                                                                 In all Directorate objectives      A              None identified                                                     each meeting                       C7
     Professional Development,                                                 proposals                                                                                   Provider Development Committee                                                                  ]
     Finance and Public Health.                                                  3x2=6                                                                                                                                  SLA's being drafted

     P3
     By continuing the implementation of the Strategic Services Development Plan vision for a network of neighbourhood resource centres as hubs with local practices as spokes, ensure the premises, through which services will be
  AD delivered, meet the highest standards of patient safety and cleanliness, support effective patient care, are accessible to all sections of the local population and deliver environmental targets, subject to the Healthcare for London
     Consultation.

                                                                             Improvements in
                                                                           premises standards,
                                                                           service development
                                                        31st March 2009




                                                                          and pathway redesign                                                                                                                  Ongoing and overseen by Strategic
     Ensure delivery of Strategic                                                                                                                                              Strategic Capital Group
                                                                          not supported. Capital      Strategic Capital Group                                                                                             Capital Group                                    A
     Capital Development Plan per                                                                                                                                                    PCT Board
  AE                                                                        resource. Staffing             Facilities SUG               A              None identified                                         Plans reviewed in the light of reduced         C21
     Provider arm Development Plan                                                                                                                                       Scheme Project Steering Groups & risk                                                             ]
                                                                                 Capacity            Strategic Partnering Board                                                                                   CRL and bid submitted to NHS
     and review of Estate Strategy                                                                                                                                                    registers
                                                                            Work underway to                                                                                                                                 London
                                                                            update pharmacy
                                                                            development plan.
                                                                                 4x3=12




Controls                                                                                                                                         Consequences
A - Adequate                                                                                                                         1-Insignificant 2-Minor 3-Moderate                                                                                                        Likelihood
I - Insufficient                                                                                                                           4-Major 5-Catastrophic                                                                                          1-Rare 2-Unlikely 3- Moderate
U - Unclear                                                                                                                                          6 of 8                                                                                                   4-Almost certain 5-Certain
  Lead Director




                                                                                                                                                            Control A/I/U
                                                     Delivered by
                          Strategic Priority                                                    Description of risk                                                                                                                                                                          Code
                             PROVIDER                                                                                      What controls have you                                                    Sources of Assurance                                                                     Red




                                                        (date)




                                                                                                                                                                                                                                                                                   SfBH
                                                                                                    Risk rating             put in place to ensure                          Gaps In Control                (indicate                              Action Plan                                Amber
                        strategic objectives                                                       Consequence            delivery of this objective?                                                     +ve or -ve)                                                                        Green
                                                                                                   x Likelihood                                                                                                                                                                             & status
                                                                                                                                                                                                                                                                                          A
                                                                                                                                                                                                                                                                                          R
                                                                                                                                                                                                                                                                                          G
                                                                                                                                                                                                                                                                                          A
                                                                                                                                                                                                                                                                                          G
                                                                                                                                                                                                                                                                                          G
                                                                                                                                                                                                                                                                                          AA
                                                                                                                                                                                                                                                                                           A
                                                                                                                                                                                                                                                                                           R




                                                        In line with each scheme's timetable
     Prepare business cases for the                                                                                                                                                                           SPB
     Capital programme that support                                                                                                                                                                 Strategic Capital Group          Ongoing and overseen by Strategic
                                                                                                  Business plan not                                                                                                                                                                            A
  AD service change: Akerman Road,                                                                                             Steering Groups                                                            PCT Board                  Capital Group and Project Steering           C20
  AE Clapham Park, Crowndale and
                                                                                                     signed off
                                                                                                                           LIFT Management Group
                                                                                                                                                             A              None identified
                                                                                                                                                                                              Scheme Project Steering Groups & risk Groups, LiFT management group and             C21          ]
                                                                                                       4x2=8
     West Norwood, Stockwell,                                                                                                                                                                              registers                                SPB
     Kennington and Waterloo, Brixton.                                                                                                                                                             LiFT Management Group
                                                                                                                                                                                                                                                                                          A
                                                                                                                                                                                                                                                                                          R
                                                                                                                                                                                                                                                                                          G
                                                                                                                                                                                                                                                                                          A
                                                                                                                                                                                                                                                                                          G
                                                                                                                                                                                                                                                                                          G
     Manage the business cases
                                                                                                                                                                                                                                                                                          AA
                                                                                                                                                                                                                                                                                           A
                                                                                                                                                                                                                                                                                           R
     agreed and ensure opening of
  AD new premises: Vassall Medical                                                             Building or other delays        Steering Groups
                                                                                                                                                                                                    Strategic Capital Group           Ongoing and overseen by Strategic
                                                                                                                                                                                                                                                                                  C20
                                                                                                                                                                                                                                                                                               A
  AE Centre, Tulse Hill, Streatham                                                                      3x2=6              LIFT Management Group
                                                                                                                                                             A              None identified   PCT Board. Scheme Project Steering      Capital Group and Project Steering
                                                                                                                                                                                                                                                                                  C21          ]
                                                                                                                                                                                                   Groups and risk registers                       Groups
     Common, Woodgate Drive,
     Clapham.

                  P4
                  Support the delivery of objectives through the recruitment, retention and development of our workforce through effective planning, performance management of workforce targets and the development of existing staff including the
  AD
                  creation of new routes into the clinical workforce e.g. “fledgling programme” and preparation for changes to the regulation and revalidation of healthcare professionals.


                                                                                                                                                                                                                                      Recruitment Action plan in place. Fit
                                                                                                                                                                                                                                       for Future programme plan. Work
                                                                                                                                                                                                                                            with HEIs, job centre plus.
     Improve recruitment, retention and                                                                                                                                                                                                 Development of PCT's website to
                                                        30 March 2009




                                                                                                                           External review of clinical
     sickness absence rates in the                                                                                                                                                                                                             support recruitment.
                                                                                               High vacancy rates will          risk action plan                                                                                                                                               R
     Provider Services through new                                                                                                                                                                    Workforce Committee             Implementation of NHS Professional.
  AD                                                                                            result in clinical risk      NHS London workforce            A              None identified                                                                                       C11
     and innovative approaches                                                                                                                                                                  Provider Development Committee           Master vendor agreement to be                         
                                                                                                       4x3=12             target Balance Score Card
     supported by SLAs with Finance                                                                                                                                                                                                        reviewed with Reed for AHP
                                                                                                                                    targets.
     and HR                                                                                                                                                                                                                                       temporary staff
                                                                                                                                                                                                                                         Professional input from Q&PD
                                                                                                                                                                                                                                        Recruitment and retention premia
                                                                                                                                                                                                                                                 being considered

                                                                                                  PCT will not recruit
    To develop workforce
                                                                                                  sufficient and high
    programmes: a pilot with the local
                                                                                                 calibre staff into it's
    HEIs and PC&CS on a new route
                                                                                                 provided services to                                                                                                                 Develop a fledgling programme work
    into the nursing workforce -
                                                                                                deliver care outside of                                                                                                                programme. Develop competency
    "fledgling programme" providing                                                                                                                                                           Provider Development Committee - bi                                                              A
                                                                                                hospital. PCT will not
                                                        Sep-08




                                                                                                                           Workforce committee.                                                                                       frameworks. Review JDs of PCAPs.
 GB
    opportunities and appropriate
                                                                                                have sufficient staff to Project steering group to be        A              None identified
                                                                                                                                                                                                         annual report
                                                                                                                                                                                                                                        Provide ongoing support to teams
                                                                                                                                                                                                                                                                                 C5c           ]
    preparation and support for newly /                                                                                                                                                       Workforce Committee - regular reports                                              C11c
                                                                                               develop next generation established for this project.                                                                                   regarding appropriate delegation of
    recently qualified nursing staff to                                                                                                                                                             PC&CS Business Meeting
                                                                                                     of skilled and                                                                                                                       work. Introduce the assistant
    work in community settings;
                                                                                                     professionally                                                                                                                     practitioner role in school nursing.
    embed the PCAPs project through
                                                                                                 autonomous senior
    development of competency
                                                                                                practitioners required.
    frameworks.
                                                                                                         3x3=9

    Equalities in Employment -                                                                                                                                                                                                         Development of ESR Systems is
                                                                                                    PCT is unable to
    1) further develop our systems of                                                                                                                                                                                                  critical to the success of this work
                                                                                                   produce effective
    employment reporting to the                                                                                                                                                                                                            -phase 1 development to be                          G
                                                                                                information to support     Workforce Committee and
                                                        Mar-09




    Board                                                                                                                                                                                             Workforce Committee             completed by Dec 2008. System to            C7
 UD                                                                                              business needs and         The Equalities group will        A              None identified                                                                                                    ]
    2) develop a schedule of                                                                                                                                                                           Equalities Group                     ensure that equality Impact          C11,
                                                                                                  fails to comply with    oversee delivery of this work
    workforce policy Impact                                                                                                                                                                                                           Assessments are undertaken on all
                                                                                                   current legislation.
    assessments and                                                                                                                                                                                                                   workforce policies and strategies is
                                                                                                          3x3=9
    3) deliver supporting action plans                                                                                                                                                                                                        underway and ongoing.



Controls                                                                                                                                                              Consequences
A - Adequate                                                                                                                                              1-Insignificant 2-Minor 3-Moderate                                                                                                       Likelihood
I - Insufficient                                                                                                                                                4-Major 5-Catastrophic                                                                                         1-Rare 2-Unlikely 3- Moderate
U - Unclear                                                                                                                                                               7 of 8                                                                                                  4-Almost certain 5-Certain
  Lead Director




                                                                                                                       Control A/I/U
                                          Delivered by
                    Strategic Priority                        Description of risk                                                                                                                                                             Code
                       PROVIDER                                                         What controls have you                                               Sources of Assurance                                                              Red




                                             (date)




                                                                                                                                                                                                                                    SfBH
                                                                  Risk rating            put in place to ensure                        Gaps In Control             (indicate                         Action Plan                              Amber
                   strategic objectives                          Consequence           delivery of this objective?                                                +ve or -ve)                                                                 Green
                                                                 x Likelihood                                                                                                                                                                & status
     P5
                                                                                                                                                                                                                                           R
                                                                                                                                                                                                                                           G
                                                                                                                                                                                                                                           A
                                                                                                                                                                                                                                           G
                                                                                                                                                                                                                                           A
                                                                                                                                                                                                                                           G
                                                                                                                                                                                                                             AA
                                                                                                                                                                                                                              A             R
  AD Support the development of our primary care contractors through the creation of local plans for general practice, dental, optometry and pharmacy services, the implementation of an agreed medicines management strategy and new
     primary care access arrangements.


     Prepare a Primary care
     Development Plan that
                                                                Change in National




                                             December 2008
     encompasses a review of QOF,
                                                              requirements. Lack of GP Contract Steering Group
     Primary Care Performance tool,                                                                                                                                                       Practice performance tool discussed
                                                             interest from GPs. GPs      to agree scope of                                                   Performance Committee                                                              A
     prescribing data and includes a                                                                                                                                                        at Nov Performance Committee           C7
  AD                                                             not able to meet   development plan; Issues of         A              None identified   Provider Development Committee                                                         
     financial plan and a development                                                                                                                                                       Data quality checks ongoing with       C22
                                                                    revalidation        Concern to monitor                                                    Governance Committee
     programme including relaunching                                                                                                                                                                    Practices
                                                                   requirements           appraisal uptake
     the Practice Integrated
                                                                       3x3=9
     Performance Management Tool
     and 90% uptake of GP appraisal.

                                                                                                                                                                                                                                           A
                                                                                                                                                                                                                                           R
                                                                                                                                                                                                                                           G
                                                                                                                                                                                                                                           A
                                                                                                                                                                                                                                           G
                                                                                                                                                                                                                                           G
                                                                                                                                                                                                                                           AA
                                                                                                                                                                                                                                            A
                                             December 2008




                                                              Lack of interest from                                                                                                                                                         R
                                                                 Practitioners         Workshops with Dentists to
     Prepare Dental and Pharmacy                                                                                                                                                               Dental plan in draft form
                                                                    Dentists                debate issues.                                                                                                                         C7           G
  AD Development Plans including                                                                                        A              None identified   Provider Development Committee   Work underway to update pharmacy
     financial plans
                                                                     3x3=9             Pharmacy Contract Steering
                                                                                                                                                                                                 development plan.
                                                                                                                                                                                                                                   C22          ]
                                                                 Pharmacists             Group to agree scope
                                                                     1x3=3
                                          December




     Complete the Optometry baseline                          Lack of interest from
                                                                                                                                                                                                                                                G
                                            2008




                                                                                        Regular discussions with                                                                            Optometry baseline assessment          C7
  AD assessment and begin to prepare                             Optometrists                                           A              None identified   Provider Development Committee
                                                                                                  LOC                                                                                                completed.                    C22          ]
     an Optometry Development Plan                                   1x3=3


     Finalise and agree a Medicines
     Management Strategy and work
                                             April 2008




     plan that is focussed on quality,                                                  Strategy and Workplan                                                                                                                                   G
                                                              Strategy not finalised                                                                     Medicines Management Committee
  AD VFM, CD regulations and
                                                                     3x2 =6
                                                                                       Agreement and delivery of        A              None identified
                                                                                                                                                           PCT Performance Committee
                                                                                                                                                                                                       In place                    C4           ]
     guidance, national targets and                                                       prescribing targets
     that supports the development of
     non-medical prescribing.




Controls                                                                                                                         Consequences
A - Adequate                                                                                                         1-Insignificant 2-Minor 3-Moderate                                                                                             Likelihood
I - Insufficient                                                                                                           4-Major 5-Catastrophic                                                                               1-Rare 2-Unlikely 3- Moderate
U - Unclear                                                                                                                          8 of 8                                                                                        4-Almost certain 5-Certain

				
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