Meeting of Bristol Primary Care Trust
To be held Monday 8 June 2009 at 3:00 pm In the Boardroom, South Plaza, Bristol
Agenda Item: 5.1 Draft Statement of Internal Control
1 Purpose This paper presents to the Board a draft statement of internal control for 2008/09 (appendix 1). 2 Background The statement of internal control is part of the statutory accounts and annual report. It is the way that NHS organisations provide a public assurance that risks to the achievement of an organisation’s objectives are being managed and that controls across the organisation are robust. To meet the statutory duty of quality the non-executives must be assured that systems are in place to support the delivery of patient centred, safe, high quality care. When endorsing the statement of internal control the Non-executives must take into account clinical governance responsibilities, alongside financial governance, corporate governance and risk management issues. The annual declaration of compliance with the core standards for better health integrate all these areas and is a key reference documents for the PCT board when making the statement of internal control. It is important that there is consistency between the statement of internal control and the core standards declaration. The Chief Executive as the Accountable Officer makes the statement on behalf of the Board. 3 The statement of internal control 2008/09 The Department of Health has issued one template for NHS bodies to sign since 2003/04. The pro forma has been reissued for 2008/09 with the requirement for an explicit reference to the risk management of data security, this has been added to the statement at section 4.4. For 2008/09 the PCT is reporting that the system of internal control has been in place for the whole year ended 31 March 2009, and up to the date of the approval of the annual report and accounts.
If you need this document in a different format telephone the PCT on 0117 9002289
D:\Docstoc\Working\pdf\c4268710-4752-4285-b41e-c61226a21752.doc
Audit Committee Paper Page 1 of 3
Meeting of Bristol PCT Board – 8 June 2009 – Draft Statement of Internal Control
4
Gaps in the assurance framework The Department requires organisations to make disclosures where gaps in controls and or assurances have been identified on the assurance framework, including any gaps identified through the declaration of compliance No gaps in assurance or control have been recorded during 2008/09 and the PCT made an overall declaration of compliance with the core standards for better health.
5
Compliance with the NHS Pension Scheme regulations The PCT is required to provide assurance that measures are in place to ensure compliance with obligations under the NHS Pension Scheme regulations. The Department issued guidance on the wording to be used and this has been added to the statement at 4.5.
6
Significant control measures Organisations are required to disclose significant control issues that have been identified during the year. The department is clear that this should be confined to strategic control issues in line with guidance issued and not detailed operational control issues. This may include potential weaknesses that could: Close down a service Seriously prejudice or threaten the achievement of a principal objective Threaten the safety of service users Threaten the reputation of the organisation of the NHS Have significant financial implications
Bristol PCT has made no disclosures of significant control issues. 7 How does this contribute to reducing health inequalities? Reducing health inequalities are a core activity of the PCT and therefore included in the assurance framework that informs the statement. This is an administrative task and does not create inequalities. It is not appropriate to conduct and equality impact assessment for the statement. 8 Financial implications This is part of the risk management process and the statement itself has no financial implications for the PCT. 9 How have service users, carers and local people been involved? Users and carers are not involved in drafting the statement, however the statement gives an overview of the PCT systems of control which include the involvement of the public in our work.
Audit Committee Paper Page 2 of 3
D:\Docstoc\Working\pdf\c4268710-4752-4285-b41e-c61226a21752.doc
Meeting of Bristol PCT Board – 8 June 2009 – Draft Statement of Internal Control
10
Risk assessment The statement is an important part of the monitoring of the efficiency and effectiveness of the internal systems of control and indicates the risk management controls that are in place. Compliance and assurance The statement provides evidence for the process for making the following years declaration of compliance with the core standards. Legal Issues The submission and publication of the statement is a statutory requirement. The statement its self raises no legal concerns. Where significant gaps are raised or a disclosure of a significant control measure is made there may be legal implications. No current legal concerns have been identified relating to the disclosure of insufficient assurance concerning statutory and mandatory training.
11
Recommendations The board is asked to Approve this draft statement
Sarah Carr Head of Corporate Governance 28 May 2009 Deborah Evans Chief Executive 1st June 2009 Glossary of terms and abbreviations Assurance Framework Structure that brings together for the board the assurances that show the organisation has in place the correct policies, and process controlling it’s business. A mechanism to provide accountability for the way an organisation manages itself. Covers all the processes involved in identifying, assessing and judging risks, assigning ownership, taking actions to mitigate or anticipate them, and monitoring and reviewing progress. Yearly statement made by all NHS organisations to the Department of Health. The Statement confirms that the organisation has a complete Assurance Framework.
Governance
Risk Management
Statement of Internal Control
Audit Committee Paper Page 3 of 3
D:\Docstoc\Working\pdf\c4268710-4752-4285-b41e-c61226a21752.doc