Internal Audit Engagement Letter Template - Excel

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					                                                                                                                                                                                                                    Corporate Risk Assurance Framework                                                                                                                                                                                               Quarter 4
                                                                                                                                                                                                                                                                                                                                                                                                                                                  Version 0.42




                        ISP or Core Business




                                                                                                                                                                                                                                                                                                                                                                                                                             Date Last Reviewed
                                                                                                                                                                                                                                                                                 Mitigating Control
                                                 London-wide/




                                                                                                                                                                                                                                                                                                                                                                                                          EMT Sponsor
                                                                 Reputational/




                                                                                                                                                                                              Org. Impact




                                                                                                                                                                                                                          Risk Rating
                                                                                                                                                                                                            Likeli-hood




                                                                                                                                                                                                                                                                                                                                                                    Assurance
                                                                                                                                                                                  Proximity




                                                                                                                                                                                                                                                                                      (Actions)
                                                                  Financial
       Identifier




                                                                   Clinical/




                                                                                                                                                                                    Date
                                                     SHA




                                                                                                                             Risk
ISP-D001            Delivery                   London           All              Organisational Capacity and Capability                                                       June 2010        5             4            20            Building on the current system, developing transition arrangements to strengthen           Via PDG, SSG and NHS London Board - TBC as part of review of       Ruth              3/4/2010
(previously         of the                     wide                              There is a risk that commissioners and providers will not be able to implement                                                                         sector commissioning for 1 April - AK                                                      ISP governance.                                                    Carnall
ISP002)             ISP                                                          Healthcare for London, at the pace required.                                                                                                           Reviewing which functions should be performed 1:6:31 times, to ensure we
                                                                                                                                                                                                                                        understand resourcing requirements -AK                                                     The Challenged Trust Board will review plans to ensure long term
                                                                                 This is due to capability and capacity issues. On the commissioner side, there is a                                                                    Reviewing resourcing options across the system to identify where resource should           sustainability for organisations with historic deficits.
                                                                                 risk that the Strengthening Commissioning enabler will not be delivered fast                                                                           be placed, and where it can be removed -AK
                                                                                 enough. On the provider side, there is a risk that parties are unable to meet the                                                                      Decisions on the end-state development will be taken in Spring/Summer 2010-AK              World Class Commissioning Panels will assess strategic and
                                                                                 timetable for achieving clinical and financial sustainability and good governance                                                                      Gap analysis and needs assessment for all providers with Organisational                    financial plans for sectors and PCTs
                                                                                 due to organisational capacity/capability issues, agreement among stakeholders                                                                         Development plans agreed with the SHA (Feb 2010) -MH
                                                                                 etc.                                                                                                                                                   Development of overall strategic plan for the provider landscape to inform approval        As part of the delivery of Workforce for London Programme:
                                                                                                                                                                                                                                        of ongoing end state and Mergers and Acquisition (M&A) proposals (June 2010) -
                                                                                 The consequence will be further delay in the creation of a sustainable provider                                                                        MH                                                                                         Workforce for London Delivery Board
                                                                                 landscape that can deliver the Healthcare for London clinical vision in an affordable                                                                  Ongoing management and co-ordination of development and support programmes                 Workforce Advisory Forum
                                                                                 way.                                                                                                                                                   (Feb 2010 to March 2013) - MH                                                              DWT monthly meetings
                                                                                                                                                                                                                                        Challenged Trust Board work programme to rigorously scrutinising the capacity and          Governance of the Operating Model
                                                                                                                                                                                                                                        capability of challenged organisations and recommending remedial action - ongoing          CSL involvement/governance arrangements being finalised
                                                                                                                                                                                                                                        -MH                                                                                        OGC Programme Review commissioned September 2009
                                                                                                                                                                                                                                        Continuing development of the performance management of providers i.e. sector              SHA Assurance
                                                                                                                                                                                                                                        acute commissioning units, community provider performance regime (ongoing) -               Internal & External Challenge Events
                                                                                                                                                                                                                                        JD/JB
                                                                                                                                                                                                                                        Directors of Workforce Transformation appointed to support sector capacity and
                                                                                                                                                                                                                                        capability development - SA
                                                                                                                                                                                                                                        Board Development – priority project -SA
                                                                                                                                                                                                                                        Support for commissioning workforce development in CSL through CPPD
                                                                                                                                                                                                                                        funding - SA
ISP-D002            Delivery                   London           F, C             Quality of plans                                                                             April 2010       5             4            20            Commissioner plans are being interrogated through the World Class                          Via PDG, SSG and NHS London Board - TBC as part of review of       Ruth              3/4/2010
(previously         of the                     wide                              There is a risk that the system will not deliver on the affordability challenge.                                                                       Commissioning Assurance process both for strategic implementation and financial            ISP governance                                                     Carnall
ISP001)             ISP                                                                                                                                                                                                                 probity and plans not agreed by NHS London until the quality and financial gains
                                                                                 This is due to commissioner and provider plans lacking identifiable actions and                                                                        are demonstrable and deliverable (April 10) – AF/AM                                        NHS London Executive and teams will review the sector models to
                                                                                 being of insufficient quality. This includes investment business cases being                                                                           The planning cycle for next year (and beyond) is being accelerated so that                 ensure consistency with the Healthcare for London strategy and
                                                                                 submitted but lacking the quality required for approval.                                                                                               guidance to commissioners will be agreed by June 2010 -AF                                  affordability of plans on a sector and pan London basis.
                                                                                                                                                                                                                                        Financial benefits will be tracked through performance against plans submitted to
                                                                                 The consequence of this is that the quality and financial benefits of Healthcare for                                                                   NHS London to validate assumptions of affordability study and assure progress to           The Executive Team and the Board will receive regular updates
                                                                                 London are delayed or not realised at all.                                                                                                             delivery. -AM                                                                              throughout the 2010/11 planning process so that they can assess
                                                                                                                                                                                                                                        Contingency plans for fast paced implementation of the affordability levers were           the medium term financial outlook for organisations in London.
                                                                                                                                                                                                                                        developed in summer 2009 and these will be kept under review. - AM
                                                                                                                                                                                                                                        Contribution of all providers to delivery of plans will be built into work on the London   World Class Commissioning Panels will assess strategic and
                                                                                                                                                                                                                                        delivery chain (April 10) -SH                                                              financial plans for sectors and PCTs
                                                                                                                                                                                                                                        Ongoing management and co-ordination of provider development and support
                                                                                                                                                                                                                                        programmes including financial/ productivity capacity/ capability building (Feb 2010       For capital business cases, standing agenda item for Capital
                                                                                                                                                                                                                                        to March 2014) - MH                                                                        Management Group and escalated as necessary to Capital
                                                                                                                                                                                                                                                                                                                                   Investment Committee.

ISP-D003            Delivery                   London           C, F             Capital Reorganisation and Realisation                                                       2011/2012        4             4            16            Following comprehensive inventory, ongoing engagement on estates strategy will             Via SSG and NHS London Board - TBC as part of review of ISP        Paul              3/4/2010
(previously         of the                     wide                              There is a risk that:                                                                                                                                  aim to ensure that:                                                                        governance                                                         Baumann
ISP007)             ISP                                                          a) Timing and amount of capital capable of release from surplus/underutilised                                                                          a) within sectors future needs are identified, prioritised, minimised and reflected in
                                                                                 estate falls short of the desk top based opportunity cost evaluation review;                                                                           PCT/Trust estates strategies (August 2010)                                                 Standing agenda item on the Capital Management Group, and
                                                                                 b) released capital cannot be invested where it is needed, and;                                                                                        b) sector leadership maximises the value generated from existing NHS assets On-            escalated as necessary to the Capital Investment Committee.
                                                                                 c) there is insufficient capital available either nationally and/or locally to deliver the                                                             going
                                                                                 priorities                                                                                                                                             c) levers and incentives are in place to ensure that estates value can be maximised
                                                                                                                                                                                                                                        and applied per strategic priorities May 2010
                                                                                 This is due to actual site limitations and validation assumptions inherent in the                                                                      d) estates management capabilities across London are adequate for this task On-
                                                                                 review; the fact that spare capacity in estate does not match the current needs the                                                                    going
                                                                                 economic downturn and market conditions; and the NHS finance regime as it                                                                              e) alternative models for estates provision/financing are explored On-going
                                                                                 relates to the treatment of surplus estate sale proceeds.                                                                                              f) a consistent approach to prioritisation across London is developed May 2010

                                                                                 The consequence is that we do not realise sufficient capital to support delivery of
                                                                                 Healthcare for London




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                                                                                                                                                                                                             Corporate Risk Assurance Framework                                                                                                                                                                                         Quarter 4
                                                                                                                                                                                                                                                                                                                                                                                                                                     Version 0.42




                        ISP or Core Business




                                                                                                                                                                                                                                                                                                                                                                                                                Date Last Reviewed
                                                                                                                                                                                                                                                                         Mitigating Control
                                                 London-wide/




                                                                                                                                                                                                                                                                                                                                                                                             EMT Sponsor
                                                                 Reputational/




                                                                                                                                                                                       Org. Impact




                                                                                                                                                                                                                   Risk Rating
                                                                                                                                                                                                     Likeli-hood




                                                                                                                                                                                                                                                                                                                                                          Assurance
                                                                                                                                                                           Proximity




                                                                                                                                                                                                                                                                              (Actions)
                                                                  Financial
       Identifier




                                                                   Clinical/




                                                                                                                                                                             Date
                                                     SHA




                                                                                                                             Risk
ISP-D004            Delivery                   London           All              Clinical Leadership                                                                   2010/2011        4             4            16            Workforce Advisory Forum - SA                                                            As part of the delivery of Workforce for London Programme:     Anne         3/4/2010
(previously         of the                     wide                              There is a risk that change is not clinically led.                                                                                              Sector Clinical Leadership Arrangements being explored - SA                                                                                             Rainsberry
ISP012)             ISP                                                                                                                                                                                                          Integration with National professional advisory bodies and MEE - SA                      Workforce for London Delivery Board                            Andy
                                                                                 This is due to lack of involvement and engagement with clinicians.                                                                              Education commissioning functions being established with clinical leadership as a        Workforce Advisory Forum                                       Mitchell
                                                                                                                                                                                                                                 priority – SA                                                                            DWT monthly meetings                                           Trish Morris
                                                                                 The consequence of this is reduced confidence from the public, key stakeholders                                                                 Event being held in April to collect and shape clinical leadership requirements - SA     Governance of the Operating Model                              Thompson
                                                                                 and NHS staff that change is being made for the right reason, i.e. to improve the                                                               Leading for Health established to address specific sector and London-wide issues,        CSL involvement/governance arrangements being finalised        Lindsay
                                                                                 quality of services.                                                                                                                            including bespoke development for the clinical leadership groups in the sectors and      OGC Programme Review commissioned September 2009               Davies
                                                                                                                                                                                                                                 targeted development for existing medical directors to lead the creation of              SHA Assurance
                                                                                                                                                                                                                                 polysystems – SA                                                                         Internal & External Challenge Events
                                                                                                                                                                                                                                 Established the Clinical Leadership Steering Group, which will bring together senior
                                                                                                                                                                                                                                 SHA clinicians to support the SHA in furthering its strategic objectives, and act as a   Via PDG, SSG and NHS London Board - TBC as part of review of
                                                                                                                                                                                                                                 bridge with the Clinical Leadership Group (CLG) to align the CLG priorities with         ISP governance
                                                                                                                                                                                                                                 SHA priorities - JY
                                                                                                                                                                                                                                 Develop regional networks of clinicians, eg Medical Directors, PEC Chairs, PBC
                                                                                                                                                                                                                                 cluster leads etc and provide regional leadership to support implementation of
                                                                                                                                                                                                                                 Healthcare for London strategy and the QIPP agenda; Programme of Events
                                                                                                                                                                                                                                 developed for 2010-11
                                                                                                                                                                                                                                 clinical engagement activities - JY
                                                                                                                                                                                                                                 Support a programme of work to support lead clinicians to equip
                                                                                                                                                                                                                                 clinical leaders with the
                                                                                                                                                                                                                                 knowledge and skills to support implementation of clinical change across the
                                                                                                                                                                                                                                 London landscape - JY
                                                                                                                                                                                                                                 Working with the Strategy and Communications Directorates to develop a
                                                                                                                                                                                                                                 broad programme of clinical engagement around
                                                                                                                                                                                                                                 implementing the HfL strategy - JY

ISP-D005            Delivery                   London           C, F             Disruption Due to Change                                                                June 2010      4             4            16            To minimise disruption, building on current arrangements, NHS London and sectors         Via PDG, SSG and NHS London Board - TBC as part of review of   Hannah     3/4/2010
(previously         of the                     wide                              There is a risk that there will be disruption to service delivery and transformation by                                                         will develop transition plans for delivering the transitional arrangements to            ISP governance                                                 Farrar
ISP003)             ISP                                                          sectors and PCTs.                                                                                                                               strengthen sector accountability and resourcing - AK                                     Monthly and quarterly reporting                                Sara Coles
                                                                                                                                                                                                                                 The introduction of sector CEs as full time positions, with the delegation and           Escalation actions monitored and reviewed monthly
                                                                                 This is due to the planned changes to commissioning arrangements                                                                                authority of the SHA, will strengthen leadership at sector level to ensure
                                                                                                                                                                                                                                 organisations are held to account for delivery - AK
                                                                                 The consequence of this would be a delay in service delivery and transformation                                                                 Annual plans from commissioners and providers subject to in-depth scrutiny and
                                                                                                                                                                                                                                 monitored regularly in-year to ensure planned service and transformation delivered.
                                                                                                                                                                                                                                 – JD/JB
                                                                                                                                                                                                                                 Established escalation process in place to manage organisations in-year that
                                                                                                                                                                                                                                 deviate from agreed plans – JD/JB

ISP-D013            Delivery                   London           All              External challenge                                                                    May 2010         4             4            16            Maintain active dialogue with the Department (ongoing) - AF                        Via PDG, SSG and NHS London Board - TBC as part of review of         Hannah            3/4/2010
(previously         of the                     wide                              There is a risk that ineffective consultation and/or external challenge affects                                                                 Support sector and PCTs in maintaining active dialogue with local stakeholders and ISP governance                                                       Farrar
ISP009)             ISP                                                          implementation of Healthcare for London.                                                                                                        the public, including local councils (ongoing) - AF                                                                                                     Stephen
                                                                                                                                                                                                                                 Quality assuring commissioner plans for consultation on major service change                                                                            Webb
                                                                                 This is due to our failure to persuade the public and national and local government                                                             (ongoing) - AF
                                                                                 of the benefits of the change and/or individuals presenting legal challenges.                                                                   Maintain clear audit trail of decision making to defend any formal challenge
                                                                                                                                                                                                                                 (ongoing) - AF
                                                                                 The consequence of this is that proposed activity may be delayed as a result, and                                                               Development and implementation of a detailed Stakeholder Strategy and
                                                                                 in extreme circumstances, stopped altogether.                                                                                                   Stakeholder Management -SG
                                                                                 .


ISP-D006            Delivery                   London           F                Financial Incentives                                                                  2010/2011        4             4            16            In parallel to introducing new tariffs etc, support providers in becoming more cost      Via PDG, SSG and NHS London Board - TBC as part of review of   Paul              3/4/2010
(previously         of the                     wide                              There is a risk that the current payment mechanisms and contractual                                                                             effective (e.g. facilitate best-practice sharing)                                        ISP governance                                                 Baumann
ISP005)             ISP                                                          arrangements do not incentivise delivery of healthcare in the Healthcare for                                                                    Extensive stakeholder management and close liaison with DH                               Regular monthly review by Project Manager and SMT and EMT
                                                                                 London settings                                                                                                                                 Work closely with Competition and Cooperation Panel to identify potential issues         representatives
                                                                                                                                                                                                                                 and resolve early
                                                                                 This is due to provider and primary care contracts being based on volume rather                                                                 Pilot incentives thoroughly to understand all implications, and adapt proposals
                                                                                 than quality outcomes                                                                                                                           accordingly Incentivise GPs with capitated budgets
                                                                                                                                                                                                                                 Work closely with pilot health economies on communication and stakeholder
                                                                                 The consequence of this is that providers will not change their behaviour as this                                                               management
                                                                                 will lead to reductions in income without incentives and the savings needed are not                                                             Involve clinicians in key decisions around the design concepts of new tariffs and
                                                                                 realised                                                                                                                                        incentives linked to quality of care incentives and financial risk management




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                                                                                                                                                                                                             Corporate Risk Assurance Framework                                                                                                                                                                                            Quarter 4
                                                                                                                                                                                                                                                                                                                                                                                                                                        Version 0.42




                        ISP or Core Business




                                                                                                                                                                                                                                                                                                                                                                                                                   Date Last Reviewed
                                                                                                                                                                                                                                                                          Mitigating Control
                                                 London-wide/




                                                                                                                                                                                                                                                                                                                                                                                                EMT Sponsor
                                                                 Reputational/




                                                                                                                                                                                       Org. Impact




                                                                                                                                                                                                                   Risk Rating
                                                                                                                                                                                                     Likeli-hood




                                                                                                                                                                                                                                                                                                                                                         Assurance
                                                                                                                                                                           Proximity




                                                                                                                                                                                                                                                                               (Actions)
                                                                  Financial
       Identifier




                                                                   Clinical/




                                                                                                                                                                             Date
                                                     SHA




                                                                                                                           Risk
ISP-D007            Delivery                   London           C, F             Influencing Public Behaviour                                                           2010/2011       4             4            16            NHS London will support the capacity and capability of PCTs and sectors to deliver Via PDG, SSG and NHS London Board - TBC as part of review of           Stephen            3/4/2010
(previously         of the                     wide                              There is a risk that we are unable to change public behaviour in line with                                                                      these messages around use of urgent care and healthy behaviours throughout the ISP governance                                                             Webb
ISP008)             ISP                                                          Healthcare for London (staying healthy, use of polyclinics, managing long term                                                                  reconfiguration process, from April 2010.
                                                                                 conditions).                                                                                                                                    Running of the 'Choose Well' campaign - ongoing
                                                                                                                                                                                                                                 Better coordination of research, evaluation and social marketing activity to drive
                                                                                 This is due to lack of information about their own health and how to access the                                                                 behaviour change
                                                                                 best services to meet their needs.

                                                                                 The consequence of this will mean they do not get the best care, in the right place
                                                                                 and the right time.
                                                                                 .




ISP-D008            Delivery                   London           F, C             Polysystem IT Integration                                                              2010/2011       4             4            16            Working with Sectors to support them in developing IT capability                    IT-IM Working Group reporting to Sector Programme Board               Kevin              3/4/2010
(previously         of the                     wide                              There is a risk that polysystems are unable to effectively share information (both                                                              Action -Joint-working with Provider Transformation, CSL, Sectors and „lead PCTs‟ –                                                                        Jarrold
ISP006)             ISP                                                          inside the system and with other partners)                                                                                                      ongoing                                                                             Via SSG and NHS London Board - TBC as part of review of ISP
                                                                                                                                                                                                                                                                                                                     governance
                                                                                 This is due to the IT systems not being in place to support the flow of patients to                                                             Clarifying the strategic approach to IT delivery around what gets delivered at each
                                                                                 community settings                                                                                                                              of the following levels:
                                                                                                                                                                                                                                 National
                                                                                 The consequence of this is that affordability savings and improvements in patient                                                               London-wide
                                                                                 care are not realised, and there is potential for IT systems to deteriorate.                                                                    Sector
                                                                                                                                                                                                                                 Local
                                                                                                                                                                                                                                 Action -Joint-working with Provider Transformation, CSL, Sectors and „lead PCTs‟ –
                                                                                                                                                                                                                                 ongoing
                                                                                                                                                                                                                                 Action - Work with sectors through the production of IM&T Strategy to ensure
                                                                                                                                                                                                                                 priority requirements are identified - Q1 2010/11
                                                                                                                                                                                                                                 Action - Ensure IT programmes are correctly prioritised at Sector and local NHS
                                                                                                                                                                                                                                 organisations - ongoing

                                                                                                                                                                                                                                 Supporting the development and delivery of solutions via pilots, joint working, and
                                                                                                                                                                                                                                 exploring what can be delivered from the BT contract
                                                                                                                                                                                                                                  Action - Ensure IT programmes are correctly prioritised at Sector and local NHS
                                                                                                                                                                                                                                 organisations - ongoing
                                                                                                                                                                                                                                  Action - Early clarification of IT requirements on a project by project basis - Sept
                                                                                                                                                                                                                                 2010
                                                                                                                                                                                                                                  Action - Ensure close alignment to sector project plans and local service plans –
                                                                                                                                                                                                                                 ongoing
                                                                                                                                                                                                                                  Action - Investigate interim solutions on a project by project basis - ongoing

ISP-D009            Delivery                   London           F                Polysytem Business Modelling Implementation                                            2010/2011       4             4            16            Identification of possible provider delivery models and contractual arrangements to     High level assurance via ISP programme management controls i.e.   Mark               3/4/2010
(previously         of the                     wide                              There is a risk that the polysystems are not delivered to the required specification                                                            inform 2011/12 contracting round (Jan-June 2010)                                        PDG, SSG and NHS London Board                                     Davies
ISP004)             ISP                                                          and PCTs are not able to shift demand to the community sector                                                                                   Piloting and evaluation of new provider delivery models and contractual
                                                                                                                                                                                                                                 arrangements (July 2010-Mar 2011)                                                       Provider Transformation – (PT011-013)
                                                                                 This is due to a lack of contractual arrangements to deliver the new business                                                                   Establish a multi-disciplinary core project team and expert panel to guide
                                                                                 models and new ways of staff working across traditional acute/community                                                                         development of the workstream designed to mitigate against risk of blockages and        Regular Provider Delivery Models core project team and expert
                                                                                 boundaries required not being sufficiently developed, as a result of issues relating                                                            resolve issues as they arise (Jan 2010) – MH                                            panel meetings (monthly)
                                                                                 to workforce, IT, estates, joint working between organisations and stakeholder buy-                                                             Support rollout of delivery models and contractual changes across London (Apr
                                                                                 in                                                                                                                                              2011-Mar 2013) - MH

                                                                                 The consequence of this will be that new models cannot be implemented from
                                                                                 2010/11 onwards, polysystems will not function and make the quality and                                                                         Also see
                                                                                 affordability improvements identified                                                                                                           - ISP002 Organisational capacity and capability
                                                                                                                                                                                                                                 - ISP006 Financial incentives
                                                                                                                                                                                                                                 - ISP010 Workforce
                                                                                                                                                                                                                                 - ISP006 IT
                                                                                                                                                                                                                                 - ISP007 Capital realisation




1b7d89b2-263e-4368-b996-f38811672b8f.xls                                                                                                                                                                                                                                                                                                                                                                                                      3 of 6
                                                                                                                                                                                                             Corporate Risk Assurance Framework                                                                                                                                                                                           Quarter 4
                                                                                                                                                                                                                                                                                                                                                                                                                                       Version 0.42




                        ISP or Core Business




                                                                                                                                                                                                                                                                                                                                                                                                                  Date Last Reviewed
                                                                                                                                                                                                                                                                          Mitigating Control
                                                 London-wide/




                                                                                                                                                                                                                                                                                                                                                                                               EMT Sponsor
                                                                 Reputational/




                                                                                                                                                                                       Org. Impact




                                                                                                                                                                                                                   Risk Rating
                                                                                                                                                                                                     Likeli-hood




                                                                                                                                                                                                                                                                                                                                                         Assurance
                                                                                                                                                                           Proximity




                                                                                                                                                                                                                                                                               (Actions)
                                                                  Financial
       Identifier




                                                                   Clinical/




                                                                                                                                                                             Date
                                                     SHA




                                                                                                                             Risk
ISP-D010            Delivery                   London           F                Provider Productivity                                                                  2010/2011       4             4            16            SHA productivity lead to be recruitment and resource requirements identified            High level assurance via ISP programme management controls i.e.   Mark              3/4/2010
(Previously         of the                     wide                              There is a risk that providers fail to deliver productivity gains outlined in the                                                                                                                                                       PDG, SSG and NHS London Board                                     Davies
ISP013)             ISP                                                          affordability analysis                                                                                                                          Work programme of productivity initiatives to be developed and agreed, led by
                                                                                                                                                                                                                                 Provider Transformation, so as to ensure that delivery precedes the full scale          Assurance measures to be established: productivity programme
                                                                                 This is due to insufficient planning and delivery of the providers to meet that                                                                 impact of the funding squeeze                                                           board comprising key stakeholders to monitor delivery of the
                                                                                 challenge                                                                                                                                                                                                                               programme (frequency tba)
                                                                                                                                                                                                                                 Identification of initiatives for inclusion in the programme, where possible, to draw
                                                                                 The result is that affordability is compromised and as a result quality of care also                                                            on robust and adaptable examples of best practice, built on a firm evidence base,       Robust performance management of sectors‟, PCTs‟ and providers‟
                                                                                 suffers                                                                                                                                         where the resources/ support required from other enablers i.e. workforce, IT is         implementation of the agreed programme of initiatives (ongoing)
                                                                                                                                                                                                                                 already in place

                                                                                                                                                                                                                                 Identification of key enablers and partners required to deliver work programme

                                                                                                                                                                                                                                 Programme to link in with work being done by nationally on productivity to ensure
                                                                                                                                                                                                                                 all possible opportunities are identified, reviewed and implemented as appropriate


ISP-D011            Delivery                   London           All              Synchronisation                                                                        2010/2011       4             4            16             - Initial priorities for implementation have been identified and agreed in the First Via PDG, SSG and NHS London Board - TBC as part of review of        Hannah            3/4/2010
(previously         of the                     wide                              There is a risk that the commissioning of Healthcare for London delivery models                                                                 Stage Report - JS                                                                     ISP governance                                                      Farrar
ISP011)             ISP                                                          will not synchronise with the decommissioning of existing models of care resulting                                                              - NHS London will focus piloting activity on some of the 30 polysystems which are                                                                         Mark
                                                                                 in extended periods of double running costs.                                                                                                    being completed in 2010/11 - AF                                                                                                                           Davies
                                                                                                                                                                                                                                 - Developing speedier approach to reconfiguring services needs to be developed,
                                                                                                                                                                                                                                 where necessary in partnership with the Department of Health and the Cooperation
                                                                                                                                                                                                                                 and Competition Panel - JS
                                                                                                                                                                                                                                 - Full testing and evaluation of possible new delivery models for polysystems prior
                                                                                                                                                                                                                                 to roll out (Apr-July 2010) -MH




ISP-D012            Delivery                   London           C, F             Workforce                                                                              2010/2011       4             4            16            Actions sit within Workforce for London as a coherent programme of work,                As part of the delivery of Workforce for London Programme:        Anne       3/4/2010
(previously         of the                     wide                              There is a risk that the workforce will not transition to support implementation of                                                             established in 2008:                                                                                                                                      Rainsberry
ISP010)             ISP                                                          new models of care in line with Healthcare for London                                                                                                                                                                                   Workforce for London Delivery Board
                                                                                                                                                                                                                                 Appoint sector based Directors of Workforce Transformation (January 2010) to lead       Workforce Advisory Forum
                                                                                 This is partly due to the quality of sector workforce strategies and planning, and                                                              on sector workforce transformation                                                      DWT monthly meetings
                                                                                 partly due to the workforce not being aligned to delivery models. It may also be due                                                            Develop sector workforce transformation plans, tested and ratified through              Governance of the Operating Model
                                                                                 to lack of staff buy-in                                                                                                                         Workforce Advisory Forum, to support workforce transformation                           CSL involvement/governance arrangements being finalised
                                                                                                                                                                                                                                 Design and implement operating model for Directors of Workforce Transformation          OGC Programme Review commissioned September 2009
                                                                                 The consequence of this would be staff are not in the right place, with the right                                                               (Summer 2010) to ensure maximum support in the implementation of the workforce          SHA Assurance
                                                                                 skills, at the right time to support Healthcare for London                                                                                      transformation plans                                                                    Internal & External Challenge Events
                                                                                                                                                                                                                                 Link in with new sector models emerging from strengthening commissioning
                                                                                                                                                                                                                                 enabler (April 2010)                                                                    Via PDG, SSG and NHS London Board - TBC as part of review of
                                                                                                                                                                                                                                 Ensure the integration of sector workforce transformation plans with new workforce      ISP governance
                                                                                                                                                                                                                                 planning and education commissioning arrangements
                                                                                                                                                                                                                                 Improve relationship and alignment with CSL, in particular increase focus on
                                                                                                                                                                                                                                 workforce implications arising from pathway reviews and the development of
                                                                                                                                                                                                                                 polysystems
                                                                                                                                                                                                                                 “Leading Workforce Transformation” development programme – additional
                                                                                                                                                                                                                                 investment in 2010 to support diffusion and implementation of “Breakthrough
                                                                                                                                                                                                                                 Projects”
                                                                                                                                                                                                                                 Leading Workforce Transformation– building transformational capability and
                                                                                                                                                                                                                                 capacity in the system
                                                                                                                                                                                                                                 Continue to work in partnership with employers and unions including
                                                                                                                                                                                                                                 development of staff redeployment strategies
                                                                                                                                                                                                                                 Strategic management of additional CPPD investment to reflect
                                                                                                                                                                                                                                 changing workforce needs.




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                                                                                                                                                                                                                 Corporate Risk Assurance Framework                                                                                                                                                                                           Quarter 4
                                                                                                                                                                                                                                                                                                                                                                                                                                           Version 0.42




                        ISP or Core Business




                                                                                                                                                                                                                                                                                                                                                                                                                      Date Last Reviewed
                                                                                                                                                                                                                                                                            Mitigating Control
                                               London-wide/




                                                                                                                                                                                                                                                                                                                                                                                                   EMT Sponsor
                                                               Reputational/




                                                                                                                                                                                           Org. Impact




                                                                                                                                                                                                                       Risk Rating
                                                                                                                                                                                                         Likeli-hood




                                                                                                                                                                                                                                                                                                                                                           Assurance
                                                                                                                                                                               Proximity




                                                                                                                                                                                                                                                                                 (Actions)
                                                                Financial
        Identifier




                                                                 Clinical/




                                                                                                                                                                                 Date
                                                   SHA




                                                                                                                           Risk
F&I015               Core     London                          F                London Financial Control Total                                                              Ongoing          5             4            20            The annual and operating plans of PCTs and Trusts have been reviewed to              All organisations have been risk rated after final plans were         Paul             3/4/2010
                     Business wide                                             There is a risk that the NHS in London will fail to deliver its overall financial control                                                             determine the impact on the financial performance for 2009/10 and 2010/11 in         submitted and assessed and the frequency of monitoring has been Baumann
                                                                               total and/ or will have more organisations going into deficit than originally planned                                                                 particular (completed June 2009).                                                    based on those risk ratings.
                                                                               due to acute contract overperformance and lack of delivery of cost improvement                                                                        Feedback has been provided to both trusts and PCTs based on their final plans        Final triangulation to ensure where possible that PCT and Trust
                                                                               programmes and demand management schemes etc.                                                                                                         (completed June 2009).                                                               plans are consistent took place after the final plans were submitted
                                                                                                                                                                                                                                     Triangulation of activity, income and expenditure plans of Trusts and PCTs has       in June.
                                                                               The consequence of this is that the SHA will fail to meet its financial targets set by                                                                been carried out to determine the impact of Payment by Result tariff changes and     Achievement of CIPs, demand management, ongoing impact of tariff
                                                                               the DH as well as a number of organisations in London failing to meet their                                                                           Market Forces Factor (completed June 2009).                                          and IFRS will be monitored regularly as part of the review of central
                                                                               financial targets.                                                                                                                                    All PCT and trust plans have been signed off as agreed (completed July 2009).        finance returns and financial performance management.
                                                                                                                                                                                                                                     All trusts and PCTs submit returns on a monthly basis. Organisations at risk are     A finance governance self assessment checklist has been sent out
                                                                                                                                                                                                                                     met with on a monthly basis with escalation meetings where they are significantly    which is to be completed on a quarterly basis. This covers the key
                                                                                                                                                                                                                                     off plan (ongoing as necessary). In all other cases meetings will be held at least   areas of financial governance and risk.
                                                                                                                                                                                                                                     quarterly (ongoing every quarter). Initial meetings are with the SHA financial       In addition to the FIMS returns, a template requiring a progress
                                                                                                                                                                                                                                     performance teams and the organisations' Finance Directors and Chief Execs.          report on CIPs and Demand Management schemes has been
                                                                                                                                                                                                                                     Escalation meetings involve the SHA Director of Finance & Invesment, SHA Chief       developed for PCTs and Trusts to return completed on a monthly
                                                                                                                                                                                                                                     Executive and DH representatives.                                                    basis.
                                                                                                                                                                                                                                     Individual financial control totals have been issued to PCTs and Trusts              Regular monthly meetings are undertaken by the Finance and
                                                                                                                                                                                                                                     with a covering letter explaining the need to manage to these fixed amounts          Investment Directorate and the SHA Chief Executive.
                                                                                                                                                                                                                                     before impairments.                                                                  Reports are taken to the Trust Executive Management Team every
                                                                                                                                                                                                                                                                                                                          month and to the SHA Board every quarter.
                                                                                                                                                                                                                                                                                                                           Internal Audit to review processes for effectively
                                                                                                                                                                                                                                                                                                                          monitoring performance and report findings to
                                                                                                                                                                                                                                                                                                                          the Audit Committee.

CN007                Core     London                          R, C             Safeguarding Children                                                               On-going                 5             3            15            Establish Safeguarding Children Improvement Visits to review and support local       Briefings to Safeguarding Children's Review Group and DH on all     Trish    3/4/2010
                     Business wide                                             The risk to children in London is that there may be a breach of compliance with the                                                                   health economies' safeguarding practice - complete November 10.                      highly sensitive Serious Case Reviews.                              Morris-
                              & SHA                                            policy for safeguarding children.                                                                                                                     Share learning on emerging themes and issues arising from SIT visits - Ongoing.      Serious Case Review numbers and location by PCT reported bi-        Thompson
                                                                                                                                                                                                                                     Audit all of the Serious Case Reviews reported by Trusts to the SHA including        monthly to SMT.
                                                                               This would damage the reputation and cause a loss of public confidence in NHS                                                                         tracking of all action plans until full implementation- Ongoing                      Regular audit findings on quality of SCR reports are submitted to
                                                                               London due to significant adverse publicity.                                                                                                          Improve the quality of NHS Trusts Internal Reports and SCR processes by issuing      Safeguarding Children Review Group and further discussed with
                                                                                                                                                                                                                                     guidance to NHS Trusts - February 2010.                                              Trust Designated Leads and safeguarding partners.
                                                                                                                                                                                                                                                                                                                          Designated Professional Safeguarding Leads meet quarterly for
                                                                                                                                                                                                                                     Establish and maintain partnership working as a member of the multi-agency           supervision and updating.
                                                                                                                                                                                                                                     London Safeguarding Board and Government Office London - ongoing.                    Safeguarding Children Review Group held every two months
                                                                                                                                                                                                                                     Support the leadership development programme for Designated Professional             reports to the Quarterly Quality and Clinical
                                                                                                                                                                                                                                     Safeguarding Leads                                                                   Governance Committee.
                                                                                                                                                                                                                                                                                                                          Safeguarding Improvement Programme - peer group
                                                                                                                                                                                                                                                                                                                          reviews.
                                                                                                                                                                                                                                                                                                                          Review and monitor Trust declarations against
                                                                                                                                                                                                                                                                                                                          David Nicholson letter re: minimal safeguarding standards.
                                                                                                                                                                                                                                                                                                                          CQC review of standard C2 in all provider organisations
                                                                                                                                                                                                                                                                                                                          CQC registration process

LPFIT006             Core     SHA                             R                Contract Negotiations                                                                       April 2010       5             3            15            A Programme of work has been initiated to monitor and control CCN3.                   Review of progress against plan is reported to the CCN3 Senior     Kevin              3/4/2010
                     Business                                                  There is a risk that the London Programme for IT (LPfIT) and BT fail to reach                                                                         A high-level plan has been developed against which progress is monitored on a         Review Group [Director level], which meets weekly.                 Jarrold
                                                                               agreement in the current re-negotiations of the contract (called CCN3). Failure to                                                                    regular basis. Current Memorandum of Understanding has been extended until end
                                                                               agree CCN3 could result in the non-delivery of the Programme.                                                                                         of March 2010.                                                                        Each care setting workstream reports into the appropriate care
                                                                                                                                                                                                                                                                                                                           setting programme board [NHS Exec level] the progress against
                                                                               This would have significant reputational impact on NHS London and IT systems                                                                          BT have submitted a series of draft business proposals, the most recent of which      plan. This also ensures NHS involvement in the CCN3 - meets
                                                                               would not be delivered to support corporate objectives.                                                                                               has been reviewed and broadly approved by the care-setting boards and then by         monthly.
                                                                                                                                                                                                                                     the London Programme Board on 25th Februray. The proposal will be finalised by
                                                                                                                                                                                                                                     5th March. It will then be reviewed alongside the financial model with target date of London Programme Board [SHA CEO] - Meets every 6 weeks.
                                                                                                                                                                                                                                     19th March to finalise the overall solution.

                                                                                                                                                                                                                                     The National Programme Board, consisting of the SROs of the three programmes
                                                                                                                                                                                                                                     (Ruth Carnall for London) as well as senior representatives from the Department of
                                                                                                                                                                                                                                     Health, will meet on 24th March to sign-off the solution.




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                                                                                                                                                                                                          Corporate Risk Assurance Framework                                                                                                                                                                                             Quarter 4
                                                                                                                                                                                                                                                                                                                                                                                                                                      Version 0.42




                       ISP or Core Business




                                                                                                                                                                                                                                                                                                                                                                                                                 Date Last Reviewed
                                                                                                                                                                                                                                                                    Mitigating Control
                                              London-wide/




                                                                                                                                                                                                                                                                                                                                                                                              EMT Sponsor
                                                             Reputational/




                                                                                                                                                                                    Org. Impact




                                                                                                                                                                                                                Risk Rating
                                                                                                                                                                                                  Likeli-hood




                                                                                                                                                                                                                                                                                                                                                    Assurance
                                                                                                                                                                        Proximity




                                                                                                                                                                                                                                                                         (Actions)
                                                              Financial
       Identifier




                                                               Clinical/




                                                                                                                                                                          Date
                                                  SHA




                                                                                                                       Risk
MD001               Core     SHA                             R               Clinical Quality & Patient Safety                                                       Ongoing         5             3            15            1. Sentinel indicators that best correlate with poor quality services identified.    NHS London Quality and Clinical Governance Committee reviews          Andy               3/4/2010
                    Business                                                 There is a risk of failing to identify seriously under-performing organisations at an                                                            2. Cumulative acute trust score card being developed to be used by EMT, Quality      early alerts and interventions and reports to SHA Board. Joint Risk   Mitchell
                                                                             early stage, if a sufficient assessment & escalation framework is not embedded in                                                                and Clinical Governance Committee and NHS London Board to highlight potential        Summits with CQC.
                                                                             NHS London.                                                                                                                                      risks in system.                                                                     Monitoring of SUI's, Patient Survey and Staff survey results, and
                                                                                                                                                                                                                              3. Process for managing potential risks being developed, including whole system      triangulation of wider information.
                                                                             The consequence of this would be an impact on the ability of the SHA to initiate                                                                 escalation framework.                                                                Trusts compliance with CQC, Health and Social Care Act 2008
                                                                             early and proactive interventions.                                                                                                               4. Actions taken by SHA to review organisations flagged by CQC with high mortality   registration requirements (from April 2010).
                                                                                                                                                                                                                              rates.
                                                                                                                                                                                                                              5. SHA-wide health intelligence gathering mechanism will be designed by end of
                                                                                                                                                                                                                              March 2010




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