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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
