Current Trend in Risk Management

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					      Harrow PCT Assurance Framework                                                                                                   8523253a-cf77-4e42-91d4-21c4f8f0db57.xls




                                                        Trend
                                    Initial   Current           Target                                                                                 Gaps in
 ID        Risk Description                                                    Controls              Assurances           Gaps in Controls                                   Action
                                     risk      risk             risk                                                                                 Assurances
      Lack of continuity of
                                                                         Senior management                                                                             1. Implementation
      leadership due to fast                                                                      Senior management
                                                                         group (state of the                              current low level of                         of VSM.
1.1
      turnover of Executive
      Directors and other senior
                                     16         12      6            8   Nation) estblished to
                                                                         aid succession
                                                                                                  visibility & presence
                                                                                                  at board sub
                                                                                                                          permenant Executive
                                                                                                                          directors
                                                                                                                                                                       2. Appontment of
                                                                                                                                                                       permenat Executive
      managers or multiple                                                                        committees
                                                                         planning.                                                                                     Director
      vacancies

                                                                         A draft joint Adults
                                                                                                                                                                       New structures are
                                                                         and Older People
                                                                                                                                                                       under consultation in
                                                                         Strategy Plan is
                                                                                                                                                                       both organisations to
                                                                         complete. This sets      Monitoring of various   More detailed
                                                                                                                                                  Governance of        enhance capacity for
      ineffective commissioning                                          out the PCT and LA       areas via Partnership   strategic plans
                                                                                                                                                  Harrow Strategic     partnership work and
                                                                         shared workplan for      Board arrangements      required and further
      due to a joint
1.3
      commissioning function with
                                     16         12      6            4   joint commissioning
                                                                         in 08/09 and a
                                                                                                  and monthly
                                                                                                  meetings between
                                                                                                                          work to develop
                                                                                                                          relationships and
                                                                                                                                                  Partnership and
                                                                                                                                                  Partnership Board
                                                                                                                                                                       joint commissioning.
                                                                                                                                                                       External support has
      Local authroity                                                                                                                             arrangements needs   been jointly
                                                                         commitment to            senior PCT and LA       partnership working
                                                                                                                                                  review               commissioned to
                                                                         develop a three year     managers.               skills.
                                                                                                                                                                       focus on partnership
                                                                         plan by 01/04/09.
                                                                                                                                                                       work in learning
                                                                         First draft of JSNA is
                                                                                                                                                                       disabilities.
                                                                         completed.


                                                                         Established Clinical                                                                          1. Quarterly staff
                                                                         leaders forum to                                                                              briefings to ensure
      Failure to achieve clinical                                                                 Provider committee      not all service areas
                                                                         meet quarterly.                                                                               key decisions can be
                                                                                                  to ensure clinical      have well established
      engagement and input of                                            Clinical forums and                                                                           shared and
1.4   clinical leaders to inform
      decision making related to
                                      9         9       1            6   meet meeting where
                                                                         changes and
                                                                                                  engagement and
                                                                                                  impact of quality of
                                                                                                                          area groups where
                                                                                                                          managers and
                                                                                                                                                                       discussed. 2. Senior
                                                                                                                                                                       manager to attend
                                                                                                  care due to service     clinicians interface
      PCT provider services.                                             decisions are                                                                                 team meetings
                                                                                                  changes                 on a regualr basis
                                                                         discussed and                                                                                 quarterly for all
                                                                         inputted into.                                                                                service areas.




                                    1. Be the lead for health in Harrow by working with partners and engaging the public
      Harrow PCT Assurance Framework                                                                                           8523253a-cf77-4e42-91d4-21c4f8f0db57.xls




                                                          Trend
                                      Initial   Current           Target                                                                  Gaps in
 ID        Risk Description                                                     Controls            Assurances   Gaps in Controls                          Action
                                       risk      risk             risk                                                                  Assurances

                                                                           1. Securing extertise
      Poor communication with                                              of external                           1. Internal                         1. Appointment of
      external stakholders,                                                commucations                          communications                      communication

1.6
      including general public,
      due to not having the
                                       12         9       6            3
                                                                           consultant to handle
                                                                           press relations.
                                                                                                                 resource.
                                                                                                                 2. Permenant staff
                                                                                                                                                     officer. 2.
                                                                                                                                                     Appointment of
      appropriate skills, expertise                                        2. Temperary staff in                 in place to ensure                  permenant staff to
      and capacity.                                                        place within PPI/                     continuity.                         PPI team.
                                                                           PALs team.

                                                                           1. Appointment of
                                                                           interim DPH.
                                                                           2. Locum public
      Having an incomplete and                                             health specilialist in
      inaccurate understanding of                                          post      3. Joint
                                                                           Strategic needs
      the health profile and needs
1.7
      of the population due to
                                       12         9       6            4   assessment complete
                                                                           and out for
                                                                                                                 permanent public
                                                                                                                 health staff in post
                                                                                                                                                     Appoint to key PH
                                                                                                                                                     positions
      gaps in Public Health                                                consultation
      capacity.                                                            4. Utilisation of
                                                                           health profiling
                                                                           undertaken by lodon
                                                                           PH observatory




                                      1. Be the lead for health in Harrow by working with partners and engaging the public
      Harrow PCT Assurance Framework                                                                                                    8523253a-cf77-4e42-91d4-21c4f8f0db57.xls




                                                        Trend
                                    Initial   Current           Target                                                                                   Gaps in
 ID        Risk Description                                                   Controls               Assurances           Gaps in Controls                                 Action
                                     risk      risk              risk                                                                                  Assurances
                                                                                                                                                                    1. Establish
                                                                         1. Harrow heights                                                                          quarterly staff
                                                                         2. State of the                                                                            briefing with Director
                                                                                                                          1. Regular face to
                                                                         nation briefings.                                                                          for provider services.
                                                                                                                          face staff briefings.
      Ineffective communication
2.1
      with staff
                                     16         12      6         8
                                                                         3. Clinical leaders
                                                                         forum
                                                                                                                          2. High levels of line
                                                                                                                          manger to staff ratios
                                                                                                                                                                    2. Consider proposal
                                                                                                                                                                    for staff side rep of
                                                                         4. Joint Staff                                                                             provider committee.
                                                                                                                          in some clinical areas
                                                                         consultation                                                                               3. Review service
                                                                         Committee                                                                                  structure in provider
                                                                                                                          1. High levels of line                    services to ensure
                                                                         1. CEO
                                                                                                                          manager to staff
                                                                         communication to all
                                                                                                                          ratio in some parts of
      Staff not having access to                                         line managers to                                                                           1. Audit supervision
                                                                                                  Monitored monthly       organsation.
                                                                         ensure this happens.                                                                       standard
      high quality annual
2.2
      appraisals and professional
                                     16         12      6         4      2. Supervision
                                                                         standard introduced
                                                                                                  by HR.
                                                                                                  2. Quality metric for
                                                                                                                          2. Regular 1:1
                                                                                                                          sessions with all staff
                                                                                                                                                                    2. Training of allline
                                                                                                                                                                    managers of KSF and
      development plans                                                                           provider services.      3. KSF not
                                                                         for all practitioers                                                                       eKSF
                                                                                                                          effectively
                                                                         with provider
                                                                                                                          implemented within
                                                                         services
                                                                                                                          organisation

                                                                         1. Improved
                                                                         financial position of
                                                                         organisation enabling                            1. Actions in 2.2
                                                                         budget holders to                                effective appraisal
      Financial inability to meet
2.3   the professional
      development needs of staff.
                                     16         12      6         4
                                                                         operate within
                                                                         budgets.
                                                                                                                          limiting ability to
                                                                                                                          identify financial cost
                                                                                                                                                                    1. See 2.2
                                                                         2. Utilisation of PD                             of professional
                                                                         activities that do not                           development
                                                                         require direct
                                                                         financial investment

                                                                         1. Staff side
                                                                         engagement through
                                                                         JSCC.                                                                                      Actions implemented
                                                                         2. Improved staff                                                                          through staff
      Stress and uncertainty due
2.4   to structural and
      organisational change
                                     16         12      6         8      comunication see 2.1
                                                                         3. Establishment of
                                                                                                                          see 2.1                   To be set
                                                                                                                                                                    involvement group
                                                                                                                                                                    addressing issues
                                                                         staff involvement                                                                          relating to workplace
                                                                         group to help                                                                              stress
                                                                         address issues
                                                                         identified in staff




                                                                               2. BE A MODEL EMPLOYER
      Harrow PCT Assurance Framework                                                                                                8523253a-cf77-4e42-91d4-21c4f8f0db57.xls




                                                         Trend
                                     Initial   Current           Target                                                                           Gaps in
 ID        Risk Description                                                    Controls            Assurances          Gaps in Controls                            Action
                                      risk      risk              risk                                                                          Assurances

                                                                          1. Higher levels of
                                                                          staff appraisal with
                                                                          mandatroy training
                                                                          needs identified.
                                                                          2. Introduction in
                                                                          elearning packages
                                                                                                                                                             1. Quaterly
                                                                          for mandatory                                1. Autonmated
                                                                                                                                                             moniterly of
      impact on staff and patient                                         training. 3.                                 system for effectively
2.5   safety due to poor attending
      manadatory training
                                      16         16      1         4      Improved availability 1. Training records
                                                                          of safeguarding
                                                                                                                       tracking whois due
                                                                                                                       for mandatory
                                                                                                                                                             mandatory training.
                                                                                                                                                             2. Monthly
                                                                                                                                                             monitoring of
                                                                          adults training                              training.
                                                                                                                                                             safeguarding training
                                                                          4. Mandatory
                                                                          training requirements
                                                                          communicated more
                                                                          effectively to staff
                                                                          through harrow
                                                                          heights



                                                                          1. Staff involvement
                                                                          group establish to
                                                                          look at findings of
                                                                          staff survey.
                                                                          2. Recruitment and monthly monitoring                                              implement staff
      Staff having a poor
2.6
      Work/life balance
                                      12         9       6         3      appointment to all
                                                                          vacant posts
                                                                                               of staff vacancy with
                                                                                               provider sevices
                                                                                                                                                             involvement action
                                                                                                                                                             plan
                                                                          underway, with no
                                                                          posts being held
                                                                          vacant for financial
                                                                          reasons.




                                                                                2. BE A MODEL EMPLOYER
      Harrow PCT Assurance Framework                                                                                               8523253a-cf77-4e42-91d4-21c4f8f0db57.xls




                                                                                                                                                    Gaps in




                                                           Trend
                                       Initial   Current           Target
 ID        Risk Description                                                       Controls              Assurances   Gaps in Controls                                       Action
                                        risk      risk              risk                                                                          Assurances

                                                                            1. Risk
                                                                            management
                                                                            strategy & BAF policy
      Risk management not well                                                                                       1. New committees
                                                                            ratified.
                                                                                                                     need not seen                                   review effectiveness
      bedded within the                                                     2. New committee                                              risk register not yet
3.1   organsation resulting in
      risks not being identified,
                                        15         10      6         5      structure for risk in
                                                                            place                 3.
                                                                                                     risk register
                                                                                                                     through full circle.
                                                                                                                     2. Risk management
                                                                                                                                          reviewed my new
                                                                                                                                          committee
                                                                                                                                                                     of new strategy and
                                                                                                                                                                     committee by Q& G
                                                                                                                     awareness of front                              committee.
      assessed and mitgated.                                                Board and senior
                                                                                                                     line managers
                                                                            manager workshop
                                                                            undertaken in June
                                                                            08.




                                                                            1. Currently
                                                                            updating ESR too                         1. Ensuring ESR                                 1. Develop skills and
                                                                            ensure high data                         properly represent                              knowledge of HR
      Electronic Staff Record                                               quality.                                 organisation                                    staff in use of
      (ESR) not operating to                                                2. Close liason                          structure.                                      capabilities of ESR.

3.2
      maximum potential and
      therefore hampering ability
                                        12         9       6         3
                                                                            between HR and
                                                                            provider services to
                                                                                                                     2. Staff familiarity of regualr reports from
                                                                                                                     ESR.                    ESR being generated
                                                                                                                                                                     2. Progress with ESR
                                                                                                                                                                     self service
      to ulitilise workforce data in                                        identify gaps and                        3. Self service                                 functionality
      timely manner                                                         needs.              3.                   module of ESR                                   3. Update ESR to
                                                                            Local systems being                      (direct use by                                  reflect organisational
                                                                            used to supplement                       managers                                        structure
                                                                            ESR



                                                                                                                                                                      1. Contribute to
                                                                                                                     1. major incident
                                                                                                                                                                      review of major
                                                                                                                     plan requires
      Being unprepared in the                                               1. On call rota                                                    ratified revised major incident paln (GB).
                                                                                                                     reviewing on pan
      event of a major incident or                                          revised and training                                               incident plan          2. Convene multi
                                                                                                                     sector basis.    2. Flu
                                                                            provided for on call                                               2. Ratified flu plan   agency flu planning
      emergency both in terms of
3.3
      directly responding and
                                        15         15      1         5      senior managers and
                                                                            Directors.
                                                                                                                     pandemic plan
                                                                                                                     requires multi
                                                                                                                                               3. Agreed business group to agree plan
                                                                                                                                               continuity plans       3. Review business
      being able to maintain                                                                                         agency coment and
                                                                            2. Flu pandemic                                                    4. Tested major        continuity plans. 4.
      critical business delivery.                                                                                    sign up. 3. Business
                                                                            action plan redrafted                                              incidenet plan         Test major incident
                                                                                                                     continuity plans
                                                                                                                                                                      plan (led by ealing
                                                                                                                     require updating
                                                                                                                                                                      pct)




                                             3. ENSURE OUR SYSTEMS ARE ROBUST AND USED APPROPRAITELY BY OUR STAFF
      Harrow PCT Assurance Framework                                                                                              8523253a-cf77-4e42-91d4-21c4f8f0db57.xls




                                                                                                                                              Gaps in




                                                        Trend
                                    Initial   Current           Target
 ID        Risk Description                                                   Controls               Assurances          Gaps in Controls                       Action
                                     risk      risk              risk                                                                       Assurances

                                                                         1. Key activities
                                                                         covered by Director
                                                                         and other staff.
      Gaps is dedicated                                                  2. Temporary
                                                                         adminisatrative staff
      Goverenance staff reducing
3.4   ability of organisation to
      supports its systems and
                                     15         9       6         6
                                                                         employed until
                                                                         permenant staff in
                                                                                               recruitment timeline
                                                                                                                                                         progress with
                                                                                                                                                         recruitment
                                                                         place.             3.
      processes.                                                         Integrated
                                                                         governance manager
                                                                         post appointed to
                                                                         (start oct 08)


                                                                         1. Project plan to
                                                                         have all policies
                                                                         reviewed by end oct
                                                                         08.                 2.   monthly monitoring
      Reduced quality of service                                         Priority policies        of progress against
      and internal processed due                                         reviewed as fit for      pln by Executive
3.5   to having a high proportion
      of policies not reviewed by
                                     16         12      6         4      purpose
                                                                         System now
                                                                                             3.   committee and
                                                                                                  quarterly by Quality
                                                                                                                                                         follow project plan


      review date.                                                       establised to alert      and Governace
                                                                         responsible              Committee
                                                                         managers of when
                                                                         policies due for
                                                                         review




                                          3. ENSURE OUR SYSTEMS ARE ROBUST AND USED APPROPRAITELY BY OUR STAFF
      Harrow PCT Assurance Framework                                                                                8523253a-cf77-4e42-91d4-21c4f8f0db57.xls




                                                                                                                                          Development of IM&T
                                                                                                       Lack of overall IM&T               Strategy and local
                                                                                                       strategy, disaster                 health community
                                                                                                       recovery plans not in              plan in conjunction
      Information technology                                                                           place. Limited                     with NWLH and Brent

3.6
      systems and infrastructure
      not meeting the needs of
                                   12      12    1         IM&T Steering Group
                                                                                 Reports to Delivery
                                                                                 Committee
                                                                                                       assurance given by
                                                                                                       Internal audit
                                                                                                                             To be set
                                                                                                                                          tPCt. Disaster
                                                                                                                                          Recovery plans to be
      the organisation                                                                                 regarding                          finalised and
                                                                                                       governance and                     implemented.
                                                                                                       reporting                          Remainder of audit
                                                                                                       arrangements.                      recommendations to
                                                                                                                                          be actioned.




                                        3. ENSURE OUR SYSTEMS ARE ROBUST AND USED APPROPRAITELY BY OUR STAFF
      Harrow PCT Assurance Framework                                                                                                  8523253a-cf77-4e42-91d4-21c4f8f0db57.xls




                                              Trend
                                      Risk            Target                                                                           Gaps in
 ID        Risk Description                                          Controls              Assurances         Gaps in Controls                           Action
                                     Status            risk                                                                           Assurances
4.1   Ensure the PCT meets its                                 Policies and             Regular Finance       None - Systems for NA                Change description
      Statutory Financial Duty to                              procedures in place      Reports to the        monitoring &                         to: ensure PCT
      breakeven in 2007/08                                     to influence activity.   Board from the        reporting in place                   achieves its
                                                               Delivery committee       Finance Sub-          and effective.                       control total
                                                               will ensure focus on     committee.                                                 within
                                       G      1                finances continues,
                                                               PCT has contingency
                                                                                        Monitoring by the
                                                                                        SHA
                                                                                                                                                   parameters set
                                                                                                                                                   by NHS London
                                                               reserve.                                                                            in 2008/09




4.2   To ensure the PCT has                                    Realistic operational    Finance Sub-          None - Systems for NA                NA
      sufficient contingency sums                              budgets agreed. No       committee controls    monitoring &
      to meet any reasonably                                   specifc allocation of    use of the            reporting in place
      foreseeable in-year cost                                 contingency but it is    contingency sum,      and effective.
      pressures                                                offsetting cost          ensuring access to
                                       G      1                pressures.               the reserve is
                                                                                        tightly controlled.




4.3   Meet SHA requirement and                                 Policies and             Regular Finance       None - Systems for NA                No longer a risk as
      PCT ambition to achieve an                               procedures in place      Reportsto the Board   monitoring &                         all outstanding
      in-year revenue surplus in                               to influence activity.   from the Finance      reporting in place                   legacy debt repaid
      2007/08 sufficient to repay                              Finance Sub-             Sub-committee.        and effective. SHA                   in 2007/08.
      outstanding legacy debt                                  committee will           Monitoring by the     informed of non-
      plus any deficit incurred in                             ensure focus on          SHA                   recurrent risks to
      2006/07
                                       G      1                finances continues,
                                                               PCT has contingency
                                                                                                              the PCT position
                                                                                                              and assistance
                                                               reserve.PCT could                              requested if
                                                               request further                                available.
                                                               deferment if
                                                               necessary, unlikely
                                                               to be granted.




                                                                      4. BE A HIGHLY PERFORMING ORGANISATION
      Harrow PCT Assurance Framework                                                                                                     8523253a-cf77-4e42-91d4-21c4f8f0db57.xls




                                             Trend
                                     Risk            Target                                                                               Gaps in
 ID        Risk Description                                         Controls              Assurances          Gaps in Controls                             Action
                                    Status            risk                                                                               Assurances
4.4   Review finance department                               Plans for service       Executive team and     None - Finance      NA                   Review completed
      and shared service provider                             changes and             Board proceed with     Director began 10th                      in 2007/08 so no
      to ensure these meet the                                appointmnent of new     service changes and    September. Audit                         longer applicable
      PCTs developing needs and                               Director in progress.   Directors              Contracts in place.
      provide value for money         G      1                Stability of existing
                                                              department
                                                                                      appointment.
                                                                                      Existing department
                                                              enhances curent         respond to Board /
                                                              capacity.               FSC / External
                                                                                      requirements.
4.5   Review finance department                               Engagement of         Outcome of the SBS       None - SBS            NA                 Review completed
      and shared service provider                             existing provider and project reported to      business case has                        in 2007/08 so no
      to ensure these meet the                                SBS project           the FSC.                 been assessed and                        longer applicable
      PCTs developing needs and                               managers.Clear                                 assurances on cost
      provide value for money                                 outcome from the                               and sustainability of

                                      G      1                current SBS project.                           existing Shared
                                                                                                             Service provider
                                                                                                             sought and
                                                                                                             received. Case for
                                                                                                             change unlikely to
                                                                                                             be sufficient.

4.6   Review ALE achievement in                               ALE requirements         ALE ascore at 2, as   Minimal - Changes      NA                Change description
      2006/07 and ensure tasks                                allocated to most       expected. Finance      to HQ structure at                       to: Requirements
      and responsibilities to                                 appropriate             review meetings        the PCT has                              to fulfill the new
      nachieve Level 3 scores,                                managers within         with staff to ensure   delayed agreeing                         Uses of Resources
      where appropriate, are                                  their own objectives.   level 3 planning in    the plan, this will                      assessment (UOR)
      understood and delivered                                Senior Finance Staff    place                  still be be in place                     not fully
                                                              coordinate specific                            in good time.                            embedded within
                                      G      1                areas. Early review                                                                     the organisation
                                                              of level 3
                                                              achievement




                                                                    4. BE A HIGHLY PERFORMING ORGANISATION
      Harrow PCT Assurance Framework                                                                                             8523253a-cf77-4e42-91d4-21c4f8f0db57.xls




                                            Trend
                                    Risk            Target                                                                        Gaps in
 ID       Risk Description                                         Controls             Assurances        Gaps in Controls                          Action
                                   Status            risk                                                                        Assurances
4.7   Review ALE achievement in                              ALE finance leads       Interim ALE         None - Systems for NA                Risk no longer
      2006/07 and ensure tasks                               provide information     assessment          managing the ALE                     applicable
      and responsibilities to                                to individual task      provided by Finance process in place.
      nachieve Level 3 scores,                               leads on                leads, further
      where appropriate, are         G      1                requirements at level   actions identified.
      understood and delivered                               3 and distribute ALE
                                                             updates when issued
                                                             by Dept. Health.

4.8    Not being able to                                   Monthly budget            Regular reports to   Cultural issues as To be set
      implement investment plans                           meetings with             Delivery             PCT emerges from                     Development of a
      and achieve stated                                   CEO/DOF to monitor        Committee.           turnaround,                         further schedule of
      objectives within agreed                             progress. Quarterly       Investment fund      competing workload                  effective, non-
      timescales                                           review by DDOF            identified within    priorities.
                                    12      6            4
                                                           regarding progress in     montly reports.
                                                                                                                                              recurrent but
                                                                                                                                              rapidly deployable
                                                           achieving objectives.                                                              schemes for use in
                                                                                                                                              second half of
                                                                                                                                              2008/09.




                                                                   4. BE A HIGHLY PERFORMING ORGANISATION
      Harrow PCT Assurance Framework                                                                                       8523253a-cf77-4e42-91d4-21c4f8f0db57.xls




                                              Trend
                                      Risk            Target                                                               Gaps in
 ID        Risk Description                                         Controls       Assurances   Gaps in Controls                                     Action
                                     Status            risk                                                               Assurances
4.9    Adherence to agreed
      trajectory for given
                                      12
                                              6            8 SLAs with agreed
                                                               trajectories and
                                                                                                Although SLAs are
                                                                                                in place with clear
                                                                                                                       Imposition of
                                                                                                                       penalties must be
                                                                                                                                               Ensure further
                                                                                                                                               integration of
      availability of timely and                               monitoring of                    trajectories and       undertaken              primary and
      accurate data, available                                 providers with                   associated the         alongside more          secondary care
      capacity and the need for                                agreed penalties                 penalties there is     significant service     pathways. Recent
      significant service redesign                             PBC 18 week group                some variance in       redesign if targets     improvements in
      (demand management)                                      Pathway redesign                 performance at         are to be               data quality and
                                                               and compliance                   NWLHT. Whilst the      achieved.               completeness at
                                                               18 week RTT Local                PCT can apply a        Performance at          the main provider
                                                               Health Community                 financial penalty      other provider          have allowed the
                                                               Board                            this alone will not    hospitals remains       PCT to target
                                                                                                result in improved     a risk as the PCT       additional
                                                                                                access. Up until       has relatively little   resources and
                                                                                                very recently the      control and is          support effectively
                                                                                                quality and            reliant on host         and this must be
                                                                                                completeness of        commissioners to        built upon in the
                                                                                                RTT data has been      lead in monitoring      remainder of the
                                                                                                very poor.             and service             year. Harrow PCT
                                                                                                Therefore the PCTs     redesign process.       is working closely
                                                                                                ability to monitor                             with Brent tPCT
                                                                                                achievement of the                             and NWLHT at a
                                                                                                target and focus                               strategic and
                                                                                                additional resources                           operational level
                                                                                                and support                                    and this has led to
                                                                                                effectively has been                           a better
                                                                                                severely hampered.                             understanding of
                                                                                                                                               the problem
                                                                                                                                               clinical specialities
                                                                                                                                               and ability to
                                                                                                                                               propose solutions
                                                                                                                                               across the local
                                                                                                                                               health economy .




                                                                    4. BE A HIGHLY PERFORMING ORGANISATION
       Harrow PCT Assurance Framework                                                                                              8523253a-cf77-4e42-91d4-21c4f8f0db57.xls




                                              Trend
                                      Risk            Target                                                                        Gaps in
 ID         Risk Description                                       Controls           Assurances         Gaps in Controls                                 Action
                                     Status            risk                                                                        Assurances
4.10   Reduce rates of HAI -                                 Regular internal and Regular monitoring     Clear trajectories     Imposition of any   Continue to
       Current performance is                                external Infection   of infection           and contracts are in   penalty must be     monitor HCAI
       below national standards                              Control meetings are numbers is in place.   place, however the     undertaken          levels and consider
       and requires improvement                              held. The SLA                               penalties              alongside support   performance
       across this year                                      includes HCAI target                        themselves will not    to improve          notification and
                                                             delivery.                                   result in reduced      infection control   request for
                                                             Infection control                           infection levels       policies and        external support if
                                                             team in place to                                                   processes across    significant
                                      12      6            4 support root cause
                                                             analysis and address
                                                                                                                                the Health
                                                                                                                                Community
                                                                                                                                                    variance from
                                                                                                                                                    trajectory
                                                             any actions that
                                                             need to be taken as
                                                             a result of the RCA




4.11   Impact of adverse NWLH                                Close Liaison with   JEG Meetings, Chief    External pressures                         Report to be
       financial position on the                             NWLH,Brent TPCt      Exec forums. Item      on Trust position                          agreed with
       direction/pace of the PCT's                           and NHS London. FD   for monthly            not within PCT's                           NWLH,Brent tPCt
       investment plans/priorities                           Group to reach       performance review     direct control                             showing collective
                                                             collective view of   meetings.                                                         view of Trust's
                                                             Trust's financial                                                                      financial positton
                                                             positions and                                                                          and actions to
                                      16                   8
                                                             actions.                                                                               deliver a break-
                                                                                                                                                    even outturn for
                                                                                                                                                    2008/09.




                                                                   4. BE A HIGHLY PERFORMING ORGANISATION
       Harrow PCT Assurance Framework                                                                                                    8523253a-cf77-4e42-91d4-21c4f8f0db57.xls




                                                 Trend
                                         Risk            Target                                                                          Gaps in
 ID         Risk Description                                           Controls              Assurances        Gaps in Controls                                  Action
                                        Status            risk                                                                          Assurances
4.12    Readiness for IFRS and its                                Initial action plan    Audit Committee       Resource              Lack of clarity       Full action plan
       financial impact and faster                                developed and NHS      oversight of plan     implications          around                with timescales
       closure of annual accounts                                 London checklist       and its                                     guidance/NHS          and resource
       not in place                                               complete               implementation                              timetable             implications to be
                                                                                                                                                           presented to
                                                                                                                                                           October Audit
                                                                                                                                                           Committee
                                          R




4.13   Ability to sustain delivery of                             SLAs with agreed       Weekly                Activity at the       Real time             Monitoring of
       the 4 Hour A&E wait at                                     level of activity      performance           Northwick park A&E    information to        activity and data
       Northwick Park Hospital                                    funded to achieve      meeting with NWLH     department            proactively inform    undertaken o a
       across the year 2008/09 to                                 targets                Weekly                continues to grow     capacity allocation   weekly basis and
       achieve full year target                                   A&E performance        performance review    year on year          (particularly         unscheduled care
                                                                  Local Health           by Executive          Inability of UCC to   relating to           demand
                                                                  Community Board        Committee             reduce attendances    community             management
                                                                  Agreed programme       Regular data review   in A&E to planned     preventative work     overseen by a
                                                                  of demand              UCC and               level                 and delayed           cross directorate
                                                                  management of          Unscheduled Care      Insufficient          discharges)           task force
                                                                  Unscheduled Care       Cost Improvement      intermediate and      Capacity and skills   Operating Plan
                                                                  (via UCC and           Programme             community based       of community          investments to
                                          A                3
                                                                  Unscheduled Care       (monitored on         care to support       teams to case         enhance
                                                                  Action Plans for LHC   monthly basis)        early discharge and   manage                community
                                                                  and for the PCT)                             prevention of                               resources,
                                                                  Urgent Care Network                          admission                                   intermediate care
                                                                  providing strategic                                                                      bed base
                                                                  development and                                                                          Agreed expansion
                                                                  oversight of target                                                                      in the scope of the
                                                                  delivery                                                                                 UCC
                                                                                                                                                           External support
                                                                                                                                                           secured by the
                                                                                                                                                           LHC (Saigai)




                                                                        4. BE A HIGHLY PERFORMING ORGANISATION
       Harrow PCT Assurance Framework                                                                        8523253a-cf77-4e42-91d4-21c4f8f0db57.xls




4.14   The ability to delivery the       SLAs with agreed    Weekly                Availability of real   Imposition of         Monitoring of
       18 week Referral To               trajectories and    performance           time performance       financial penalties   performance
       Treatment Target.                 monitoring of       meeting with NWLH     data                   is retrospective      weekly to provide
       Adhering to agreed                providers with      Weekly                Limited input into     following a period    early warning for
       trajectories for admitted         agreed penalties    performance review    the performance        of failure            remedial action
       and non-admitted                  18 week RTT Local   by Executive          monitoring of          Level of adherence    Financial
       trajectories given the need       Health Community    Committee             providers with         to agreed demand      incentives with
       for significant service           Board               Regular data review   smaller contract       management at all     PBC for practices
       redesign to achieve at            Agreed programme    Regular liaison       values                 referring practices   to adhere to
       specialty level.              4   of demand           meetings with lead                           Potential over        agreed ways of
                                         management of       commissioners                                reliance on lead      working
                                         Outpatients (via    CAS Cost                                     commissioner          Direct contact with
                                         CAS)                Improvement                                  actions               providers (other
                                                             Programme                                                          than NWLH) by he
                                                             (monitored on                                                      Head of
                                                             monthly basis)                                                     Performance and
                                                                                                                                Information to
                                                                                                                                mitigate reliance
                                                                                                                                on lead
                                                                                                                                commissioners




                                              4. BE A HIGHLY PERFORMING ORGANISATION
      Harrow PCT Assurance Framework                                                                                             8523253a-cf77-4e42-91d4-21c4f8f0db57.xls




                                                                                                                                      Gaps in




                                               Trend
                                     Current           Target
ID         Risk Description                                          Controls            Assurances         Gaps in Controls                              Action
                                     Status             risk                                                                        Assurances
5.1   failure to Deliver Smoking                                Identify core team    Quarterly         Data quality from        LDP and LAA        Negotiations with
      Cessation Targets                                         and budget. Work      monitoring of     maternity                submissions        NWLH continue
                                                                with maternity at     targets; Pharmacy                                             assurance given
                                       G       1                NWLHT to improve
                                                                data quality
                                                                                      returns                                                       that new IT
                                                                                                                                                    systems being
                                                                                                                                                    introduced


5.2   failure to implement Obesity                              Identify budget for   Agree budgets         Collection of BMIs   BMI data collected Identify and target
      Strategy                                                  local initiatives     with Board,Train      at GP practices      over last 15       practices
                                                                Work with schools,    various PCT and                            months
                                                                GP practices and      school staff to
                                       G       1                other local
                                                                partners
                                                                                      measure
                                                                                      chilodren's heights
                                                                                      and weights.
                                                                                      Address GP
                                                                                      meetings
5.3   High levels of untreated                                  1. Manage             monitoring of         implementing new                        1. quarterly
      Chlamydia due to low                                      through SLAs and      progress of           programmes                              monitoring
      screening of 15-25 year                                   partnerships          investment plans                                              2. New initiatives
      olds Chlamydia                                            2. Investment                                                                       to improve access
                                       12      1         3      plans agreed                                                                        implemented




                                                  5. IMPROVE HEALTH IN HARROW AND REDUCES HEALTH INEQUALITIES
      Harrow PCT Assurance Framework                                                                      8523253a-cf77-4e42-91d4-21c4f8f0db57.xls




5.4   Deliver LAA targets related               Maintain staff        Partnership group None - staff teams NA            NA
      to Health                                 teams, allocate       meetings, action   work reviewed
                                                individuals to work   plans, LAA returns
                                                on specific targets   and monitoring
                                                and
                                                implementation
                                    G   1       plans.




                                        5. IMPROVE HEALTH IN HARROW AND REDUCES HEALTH INEQUALITIES
      Harrow PCT Assurance Framework                                                                                      8523253a-cf77-4e42-91d4-21c4f8f0db57.xls




                                                                                                                                 Gaps in




                                             Trend
                                   Current           Target
ID         Risk Description                                       Controls            Assurances       Gaps in Controls                              Action
                                   Status             risk                                                                     Assurances
5.5   Health Inequalities remain                              Identification of   Partnership work,    None               NA                   NA
      or worsen in Harrow                                     need through local quarterly
                                                              data analysis       monitoring
                                                              (Annual Public
                                     G       1                Health Report and
                                                              Vitality Profiles).
                                                              TP ( see below)


5.6   Demage to sight of                                      Work with partners   SLA in place;       No apparent gaps. NA                    NA
      diabetics to do low uptake                              to ensure issues     quarterly           LDP targets are
      of retinopathy screening                                identified and       monitoring data     being met
                                     G       1                addressed            shows targets met   consistently.




5.7   aviodable cancer due to                                 Cervical Screening   QA comparative      Awaiting full QA   success of local     Advisory group
      poor cervical screening                                 Advisory Group       and trend data      report             action to increase   meeting to
      uptake                                                  oversees action      shows                                  uptake is in         address QOF and
                                                              plan review to       improvement                            context of changed   practice incentives
                                                              include: smear-                                             practice             taken place to
                                                              taker training;                                             incentives.          promote good
                                                              practice screening                                                               practice with GPs
                                                              lead development;
                                                              implementation of
                                     15      1                QA
                                                              recommendations
                                                              and SpR project
                                                              recommendations




                                                5. IMPROVE HEALTH IN HARROW AND REDUCES HEALTH INEQUALITIES
       Harrow PCT Assurance Framework                                                                                           8523253a-cf77-4e42-91d4-21c4f8f0db57.xls




                                                                                                                                      Gaps in




                                                Trend
                                      Current           Target
ID          Risk Description                                          Controls            Assurances        Gaps in Controls                             Action
                                      Status             risk                                                                       Assurances
5.8    poor health and social                                    To continue to        Improving            TP target set too   target non         Follow multi-
       outcomes of young women                                   reduce the rate by    information,         low for Harrow      negotiable; but TP agency plan to
       and their children due to                                 targeting high        services, access                         action plan in     reduce rates of TP
       teenage pregnancy
                                        R       1                need groups and       and support for                          place
                                                                 deprived              those in higher
                                                                 geographic areas      need
5.9    avoidable disease due to                                  Immunisation          Action plan          data inputters    NA                   investigating
       poor uptake of childhood                                  Advisory Group        implemented; DH      have additional                        resourcing of child
       immunisation (especially 5                                oversee action        dataset shows        workload due to                        health for Hib work
       year olds)                                                plan including:       increase in uptake   new Hib catch-up,
                                                                 data cleaning                              etc
                                        A       1                exercise, practice
                                                                 nurse training,
                                                                 public involvement
                                                                 project, equity
                                                                 audit data analysis



5.10   poor care of people with TB                               Sector                Sector work-plan,    sector review      NA                  Attend sector
       due to inadequate TB                                      commissioning         local health         meeting now                            review meeting.
       services and rising TB rates                              review, continued     promotion actions,   taking place Sept                      And ensure Harrow
                                                                 local health          BCG uptake in 1      10th.                                  represented at
                                                                 promotion action      year olds            Links with Brent                       second Brent and
                                        A       1                                      increased            PCT for prevention
                                                                                                            work initiated.
                                                                                                                                                   Harrow TB
                                                                                                                                                   meeting, for joint
                                                                                                                                                   prevention work
                                                                                                                                                   (1st mtg Sept
                                                                                                                                                   4th).


5.11   undetected cancer due to                                  Sector                Reports from         catch up            shared             continue to
       poor uptake poor breast                                   commissioning         sector               dependent on        commissioning      monitor reports
       screening services and                                    group implements      commissioners        capacity            group remit.       from
       uptake rates                     15      1                findings of
                                                                 feasibility study
                                                                                       group                                                       commissioning
                                                                                                                                                   group and act on
                                                                 (Hudson, 2007)                                                                    recommendations




                                                   5. IMPROVE HEALTH IN HARROW AND REDUCES HEALTH INEQUALITIES
       Harrow PCT Assurance Framework                                                                                    8523253a-cf77-4e42-91d4-21c4f8f0db57.xls




                                                                                                                               Gaps in




                                            Trend
                                  Current           Target
ID          Risk Description                                      Controls            Assurances      Gaps in Controls                         Action
                                  Status             risk                                                                    Assurances
5.12   Ensure provision of cost                              Multi-disciplinary    Financial          No apparent gaps. NA                NA
       effective clinical care                               working via NICE,     comparison and     Initial work plan
                                                             ITP, and Medicines    trends analysis,   being met.
                                    G       1                Management            London NHS
                                                             groups and            review, work
                                                             Priorities Form       group reports

5.13   Harm from Alcohol Abuse                               Agree investment      DAT, Safer Harrow No apparent gaps - NA                Newly funded early
                                                             into the local plan   and PCT Board     However, identify                    intervention post
                                    G       1                at Multi-Agency
                                                             Level
                                                                                   minutes           local targets with
                                                                                                     DAAT
                                                                                                                                          at NPH A&E and a
                                                                                                                                          new community
                                                                                                                                          detox programme.

5.14   High rates of infant                                  Implementation of CYPSP and              Integration of                      Continue work to
       mortality                                             integrated         Safeguarding          plans required                      develop and
                                    R       1                multiagency infant Board minutes
                                                             mortality rate
                                                                                                                                          implement
                                                                                                                                          multicomponent
                                                             reduction strategy                                                           plans




                                               5. IMPROVE HEALTH IN HARROW AND REDUCES HEALTH INEQUALITIES
      Harrow PCT Board Assurance Framework                                                                                                                           BAF August08 V1.xls




                                                          Trend
                                      Initial   Current           Target                                                                           Gaps in
 ID        Risk Description                                                     Controls               Assurances     Gaps in Controls                                     Action
                                       risk      risk              risk                                                                          Assurances
                                                                           1. Joint Nice
                                                                           implementation
                                                                           officer now in post to
      Sub standard practice by                                                                                        governance
                                                                           ensure technology
      failure to implement or                                              appraisals                                 personnel in place to
                                                                                                                                                                     Recruitment of
      monitor the implementation
6.1
      of NICE guidence and
                                       12         9       6         4      implemented.
                                                                           2. System in place
                                                                                                                      support and atrack
                                                                                                                      the implemation of
                                                                                                                                                                     governance
                                                                                                                                                                     practioner
      National Service                                                     ot identify all nice                       NICE guidence &
      Frameworks                                                           guidance and PH                            NSFs
                                                                           guidence
                                                                           3. Lead
                                                                           commissioners
      Less effective care due to
      not implementing or
                                      to be
6.2   monitoring the
      implementation of National
                                       set
                                                  R       1                To be set                To be set         To be set               To be set              To be set


      Service Frameworks

                                                                           1. Administrative
                                                                                                                                                                     review cover
      inability to access essential                                        staff and systems in
                                                                                                                                                                     arrangement for
                                                                           place. 2. Process                          1. Ability to provide
      treatment due to resquests                                                                                                                                     administrative
6.3   for urgent individual
      treatments in a timely and
                                       16         8       6         4
                                                                           overseen by medical
                                                                           director.   3.
                                                                                                    NED sits on ITP
                                                                                                                      cover for annual
                                                                                                                      leave with
                                                                                                                                                                     systems when
                                                                                                                                                                     permenant staff
                                                                           Temporary admin                            permenant staff
      effective manner                                                                                                                                               recruited to
                                                                           support to cover for
                                                                                                                                                                     governance team
                                                                           annual leave



                                                                           1. Supervision
                                                                                                                                                                     1. Document
                                                                           standard agreed with
                                                                                                                                                                     supervision
                                                                           clinical leader.
      Lack of assurance that                                                                                                                                         arrangement for each
                                                                           2. Draft supervision                       1. Documented
                                                                                                                                                                     post in provider
6.4
      effective and regular
      supervision of our
                                       16         12      6         4
                                                                           policy written and
                                                                           available to staff,
                                                                                                                      supervision tree and
                                                                                                                      arrangements for all
                                                                                                                                              audit of supervision
                                                                                                                                              standard
                                                                                                                                                                     services
                                                                                                                                                                     2. audit supervision
      practitioners is in place                                            clinical leaders                           staff.
                                                                                                                                                                     standard
                                                                           working group to
                                                                                                                                                                     3. Agree and ratify
                                                                           further develop
                                                                                                                                                                     supervision policy.
                                                                           policy.




                             6. PROVIDE THE PEOPLE OF HARROW WITH ACCESSIBLE AND EFFIECIENT CARE OF THE HIGHEST QUALITY
      Harrow PCT Board Assurance Framework                                                                                                          BAF August08 V1.xls




                                                     Trend
                                 Initial   Current           Target                                                                      Gaps in
 ID       Risk Description                                                 Controls              Assurances         Gaps in Controls                      Action
                                  risk      risk              risk                                                                     Assurances


                                                                      1. Lead senior
                                                                      manager identified to
      service developments and                                        be responsible for
                                                                                              Progress reviewed
      improvement for PCT                                             each service                                                                  remedial action taken
6.5   community services not
      implemented impacting on
                                  12         8       6         4      development.
                                                                      2. Recruitment plan
                                                                                              monthly at Provider
                                                                                              service SMT and
                                                                                                                                                    where progress is
                                                                                                                                                    behind plan
                                                                                              Provider committee
      patient care                                                    for vacant and new
                                                                      post to provide
                                                                      capacity.




                         6. PROVIDE THE PEOPLE OF HARROW WITH ACCESSIBLE AND EFFIECIENT CARE OF THE HIGHEST QUALITY

				
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