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Agenda Item 11 Enclosure CKWCB/11/22

NHS Calderdale, Kirklees and Wakefield District Cluster Board Report To:

Cluster Board


Governance and Risk Report

FOI Exemption Category


Lead Director and contact details:

Sue Cannon, Executive Director of Quality and Governance (Nursing) Tel: 01484 464240 email:

Author Name and contact details:

Vicky Pickles, Head of Corporate Affairs, NHS Calderdale Tel: 01422 281418 email:

Key Points to Note:

The paper sets out the work to progress the governance arrangements across the Cluster. It describes the development of the Board Assurance Framework and Assurance Frameworks to support the development of Clinical Commissioning Groups. The paper also sets out the current high level risks across the Cluster.


It is recommended that the Board: i. ii. iii.

Receives the report setting out the proposed governance arrangements for the Cluster. Comments on the proposed arrangements to develop the Board Assurance Framework Receives the high level risks for the Cluster.

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Purpose of Report 1.1.

The report provides an update on the development of the governance arrangements to support the new Cluster Board for NHS Calderdale, NHS Kirklees and NHS Wakefield District and the Clinical Commissioning Executives to support authorisation of the Clinical Commissioning Groups. This follows the national model of governance being implemented, under guidance from the Strategic Health Authority (SHA). The Board is asked to note these arrangements.


The report also provides an update on the progress of development of the Board Assurance Framework for the Cluster alongside the risk management arrangements at a Cluster and local level.


The high level risk log is included to provide the Board with an oversight of the key risks facing the three Cluster Primary Care Trusts at the current time.

Current Position 2.1.

In July 2011 the Strategic Health Authority wrote to the Chairs and Chief Executive of the Calderdale, Kirklees and Wakefield Cluster setting out the requirement to move to a single board arrangement.


At its first meeting last month, the Cluster Board approved its Standing Orders, terms of reference for the sub-committees (Audit, Governance and Remuneration and Terms of Service).


The Board also agreed to form four sub-committees, called Clinical Commissioning Executives (CCEs) to enable the delegation of responsibilities and budgets to the local areas to support the development of the Clinical Commissioning Groups (CCGs).

3. Governance to support the Cluster Board 3.1.

The first meetings of the new Board sub-committees were arranged as follows: -

Audit Committee – 9 November 2011


Governance Committee – 31 October 2011


Remuneration and Terms of Service Committee 18 October 2011


At their first meetings the sub-committees the agenda included the minutes and actions outstanding, along with any appropriate closedown reports, from their predecessor committees.


The Audit Committee will be requesting that Internal Audit undertake a review of the new governance arrangements at both a Cluster and CCCE level early in the new year.

4. Clinical Commissioning Groups, Board sub-committee arrangements 4.1.

As part of the new governance arrangements the Board approved a subcommittee arrangement with the local CCG. This provides a mechanism for having executives and non executives working alongside CCG members and a Page 3 of 6


route for future delegation of responsibilities. More detail on the work done to progress this is included at agenda item 12. 5. Board Assurance Framework and High Level Risk Log 5.1

It was agreed at the last Board meeting that a Board Assurance Framework for the Cluster would need to be developed. Work has been done to look at what this would look like and how it would fit with the Assurance Frameworks at CCE level.


The Board Assurance Framework (BAF) has been developed using the Cluster Objectives of Control, Close, Create Appendix 1 mapped against the Cluster Accountability Framework. These have been amended to create fully worded objectives. It will have an 18 month life span and will identify through which governance arrangements the Board receives its assurance on its objectives. This will provide a framework for the Internal Audit review of governance.


The BAF is being reviewed executive leadership team to identify and agree the long term strategic risks to these objectives. The governance around these will be mapped to the BAF before review by the Audit Committee and Governance Committee in December. It will be presented for approval at the January Board meeting.


Alongside this work, the existing individual board assurance frameworks will be used as the basis for the development of a Risk Assurance Framework for each of the CCEs. This will enable each CCE to identify the long term strategic risks to their quality, safety, performance, finance and developmental responsibilities. It will form part of their authorisation evidence. It is proposed that development of the RAF will be done prior to Audit and Governance Group review and CCE sign off in December / January. The timetable for BAF and RAF review is set out in Appendix 1.


Risk identification and management will continue at a local level using local risk management processes. A process for reporting and escalating risks to the Cluster is being agreed on 26 October and a verbal update on this will be given at the Board meeting. This will also be tested at the Governance Committee.


The current high level risks are attached at Appendix 2.

6. Recommendations It is recommended that the Board: i. ii. iii.

Receives the report providing an update on the governance arrangements for the Cluster and the CCEs. Comments on the proposal for the development of the Board Assurance Framework for the Cluster. Notes the current high level risks.

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Appendix 2 HIGH LEVEL RISK LOG The critical risks identified by the three organisations and their mitigating actions are set out in the table below: Risk

Mitigating action

Lead Director Calderdale Calderdale classes those risks which score 20 or more as critical. There are currently none classified as critical. Next review due 17 November 2011. Delivery of QIPP – short and long term. Short term financial risk in 11/12 of under delivery on secondary care focussed QIPP schemes

Risk mitigated in 11/12 through additional headquarters efficiencies, contingency reserve and specific actions to address slippage. Not expected to impact on achievement of control total in 11/12. Longer term financial risk to recurrent financial position if there is too much reliance on non-recurrent actions. This is being mitigated by ensuring that medium term financial planning takes account of this scenario and sets realistic QIPP targets for future years. Review of Mid Yorkshire programme being undertaken by Chris Dowse. Monitored through Mid Yorkshire FT Programme Board; PCT Boards and in reporting to SHA. This risk and its mitigating actions are covered in detail in the Quality and Safety Paper This is being mitigated by a range of actions, for example, staff briefings, exit surveys and monthly workforce reports being brought to Kirklees SMT. Review of Mid Yorkshire programme being undertaken by Chris Dowse. Monitored through Mid Yorkshire FT Programme Board; PCT Boards and in reporting to SHA.

Carol McKenna

Presentation received by the


Kirklees Mid Yorkshire in terms of performance and finance and ability to become FT

Mid Yorkshire in terms of quality and safety

Wakefield District

Impact of transition on delivery, in particular in relation to impact on workforce eg de-motivation and loss of key staff. Mid Yorkshire Hospitals Trust (MYHT) Performance Targets, including; - 18 Weeks - A&E - Stroke and TIA - Eliminating Mixed Sex Accommodation (EMSA) - MRSA - 62 day cancer target. Delivery of the Mid Yorkshire Page 5 of 6


Anne Ballarini

Sue Cannon Carol Mckenna

Ann Ballarini

Service Strategy

The outcome of the Women’s Service Review. Infection Prevention risk due to the potential failure to meet national targets in relation to community acquired infections and concerns about meeting infection control statutory duties due to resource issues.

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Cluster Partnership at its last meeting. Monitored through Mid Yorkshire FT Programme Board and reports to PCT Board and Cluster Partnership This risk and its mitigating actions are covered in detail in the Quality and Safety Paper Action plans are in place. A mitigating action to address the resource issue is the recent approval for recruitment of additional staffing.



Gill Galdins Andrew Furber