ENCLOSURE: E 121/12 BEXLEY CLINICAL COMMISSIONING GROUP ... Clinical Cabinet/Formal... · BEXLEY...

BEXLEY CLINICAL COMMISSIONING GROUP FORMAL MEETING – 6th September 2012

AQP Update

Action Required - For information BCCC is asked to

1) NOTE the contents of the attached CCG Briefing provided by the AQP Steering Group, specifically Paragraph 1.1.1 sub-section 1 and 2.

2) NOTE progress being made for three services areas which are to be subjected to the AQP process in Bexley, namely Adult Hearing, Anti-coagulation and Termination of Pregnancies .

Executive Summary Commissioners from Bexley BSU in response to the Department of Health mandate for each BSU to deliver 3 service commissioned under the Any Qualified Provider programme are working alongside colleagues from 1. NHS SE London on the procurement of the Adult Hearing services 2. BBG on the procurement of the Tier 1 and Tier 2 Anti-coagulation services, and 3. London-wide on the procurement of Abortion services

The attached papers from the AQP Steering Group on which Bexley BSU is represented is intended to provide CCGs with an update of progress towards the delivery of AQP services across SE London. Following the submission of the Chair’s Action paper in June 2012, Bexley BSU alongside Greenwich BSU, took a decision not to proceed with the commissioning of the Continence service via AQP, as NHS SE London were unable to provide a robust financial modeling of the impact of the service and tariff on which CCG approval was contingent. NHS SE London therefore suggested that Bexley BSU should participate in the London-wide Abortion Services AQP.

Consideration by Other Committees/Groups

Organisational implications

Financial Yes

Equality and Diversity

Risk (governance and/or clinical)

Yes - Governance

Patient impact

NHS constitution

Which objective does this paper support? Improve the health of children and young people

Insert Tick )

Improve choice and access to integrated health services for Bexley patients

Reduce the level of health inequalities across Bexley

Improve care for patients with long term conditions & increase the range of services offered within the community

Improving the health & wellbeing for people in Bexley

Maximizing the opportunities of joint working (A Picture of Health, Joint Strategy Needs Assessment, Wellness agenda etc)

Using our resources in the most efficient & effective manner (organisational & financial)

Author : Alan Luke Contact Details 0208-298-6138

Executive Sponsor Pam Creaven

Date 27th July 2012

ENCLOSURE: E Agenda Item: 121/12

Formal Bexley Clinical Commissioning Group (060912)/E(ii)

1

Any Qualified Provider (AQP) Steering Group Brief: 26 July 2012

1. General

1.1 CCG Briefing

1.1.1 Following the last AQP Steering Group the following recommendations were made within the CCG Briefing:

1. The steering group recommends that each CCG flags up AQP within the proposed Commissioning Support Service (CSS) and BSU structures to ensure that the current implementation of AQP is successfully delivered, awarded contracts are managed effectively and that future appropriate use of AQP as a procurement framework can be utilised by CCGs.

2. The steering group recommends that CCGs nominate a clinician that can represent a local clinical view with no conflict of interest in the provision of adult hearing services on the Local Assessment Team.

3. The Steering Group recommends that CCGs confirm agreement to the Continence Specification and Tariff.

4. The steering group recommend that South East London adopts the nationally delayed timeframe for the Wheelchair AQP project. This will enable further local work to better understand activity and pricing in wheelchair services.

1.1.2 Action: Feedback is sought on the CCG Briefing from CCGs via their BSU

representative

1.2 Risk Register

1.2.1 Action: The Steering Group is asked to discuss and agree the mitigating actions to the risk register (attached)

1.3 Communication and Engagement Strategy/Plan

1.3.1 Action: The Steering Group is asked to review the AQP Communication and

Engagement Strategy/Plan (attached)

2. Adult Hearing Update

2.1 Evidence of CCG sign off/agreement

2.1.1 Evidence of CCG sign off received from Bexley, Lambeth, Lewisham and Southwark. Evidence still to come from Bromley and Greenwich.

2.1.2 Action: Bromley and Greenwich steering group representatives are asked to provide evidence of CCG sign off for the Hearing AQP.

2.2 Local Assessment Team

2.2.1 The Local Assessment Team for SE London has been confirmed:

Any Qualified Provider: Steering Group Brief

2

Lead Assessor Marco Inzani

Lambeth, Southwark and Lewisham Lead Debbie Andrews

Bexley, Bromley and Greenwich Lead Jill Prescott

Acute Commissioning Neil Stevenson

Clinician Dr Chrisanthan Ferdinand

Finance Kim Mazzanti

Contract/Estates Sonia Ennals

2.2.2 There have been 18 applications to provide the Hearing AQP service. Applications

will be assessed between 23 July to 3 August 2012 via the ‘Supply 2 Health’ website.

3. Adult Continence Update

3.1 Specification/Tariff 3.1.1 The cluster variations to the national specification were agreed across London.

3.1.2 London clusters agreed to use the national tariff for the continence AQP. SE

London agreed a different tariff based on an average SE London Market Forces Factor:

Adults Level 2 Face to Face: £158.48 (compared to national tariff £129.42)

3.1.3 Action: Lambeth, Southwark and Lewisham Steering Group representatives are asked to provide evidence that their CCGs have agreed the Continence Specification and Tariff.

3.2 Local Assessment Team

3.2.1 The Local Assessment Team for Continence across SE London needs to be

agreed:

Lead Assessor Marco Inzani

Lambeth, Southwark and Lewisham Lead

Clinician

Finance

Contract/Estates

3.2.2 The dates of Assessment are 20 August to 31 August 2012.

3.2.3 Action: The Steering Group is asked to consider nominations for the Continence

Local Assessment Team

4. Children’s Wheelchairs Update

4.1 Change to Timeframe

Any Qualified Provider: Steering Group Brief

3

4.1.1 The DH have verbally confirmed that the Wheelchairs AQP will not be completed in this financial year but will be deferred to next financial year. There will not be a request to pick another AQP service line for this financial year. PCTs are being asked to feed into the national scheme of work in order to develop a more robust commissioning package. A letter to Chief Executives should follow shortly.

5. Anti-Coagulation Update

5.1 Project Plan

5.1.1 A draft project plan with assigned leads has been identified for Anti-coagulation. An updated briefing was circulated to the Project Board. Bromley have taken the business case to the CCG Board who have agreed to the Tier 1 and 2 procurement of Anti-coagulation. The next stage is to consider some clinical and mobilisation issues before the service advert is loaded to Supply 2 Health.

6. Termination of Pregnancies

6.1 6.1 Working Group

6.1.1 Bexley have now joined the London Termination of Pregnancies (ToPs) AQP working group. The working group are currently consulting on the specification, modelling the tariff and are working on a market analysis.

Formal Bexley Clinical Commissioning Group (060912) / ENC E(iii)

Page 1 of 7

Project ANY QUALIFIED PROVIDER STAKEHOLDER COMMUNICATION AND ENGAGEMENT STRATEGY

AQP Project Sponsor Tony Read

AQP Programme Lead Marco Inzani

Version: 0.2 Date: 16/07/2012

Communication and Engagement Lead

Marco Inzani

Version Date Reviewed by Comment

0.1 27/06/12 Created

0.2 16/07/12 Comms, Eng and BSU leads

Remove 4.3.8; add to 5.1 Stakeholder map; change 7.0; amend 8.1.3; add to 9.0; add new Section 10 Stakeholder Communication and Engagement Plan; amend 11.1

Contents

1. Introduction ................................................................................................................. 2

2. AQP Aims and Objectives ........................................................................................... 2

3. AQP Communication and Engagement Aims and Objectives ..................................... 2

4. Local context ............................................................................................................... 3

5. Stakeholder Mapping .................................................................................................. 3

6. Communication and Engagement Strategy Implementation ....................................... 5

7. Communication and Engagement Messages .............................................................. 5

8. Communication and Engagement Medium ................................................................. 6

9. Communication and Engagement Noise ..................................................................... 6

10. Stakeholder Communication and Engagement Plan ................................................ 6

11. Resources ................................................................................................................ 7

12. Governance ............................................................................................................. 7

13. Risk .......................................................................................................................... 7

AQP Stakeholder Communication And Engagement Strategy

2

1. Introduction

1.1. In 2010, the Government reaffirmed a commitment to increase choice and personalisation in NHS-funded services. Choice for patients can be about the way care is provided, or the ability to control budgets and self-manage conditions. The government has specifically committed to extending patient choice of Any Qualified Provider (AQP) for appropriate services.

1.2. AQP is being implemented following a national listening exercise and is based on

introducing competition in specific services based on quality not price. AQP is intended to improve choice for patients. Patients referred to the new services made available under AQP will be able to choose from a list of ‘qualified’ providers who meet agreed service quality requirements, through a locally agreed specification.

1.3. This document supports the work of NHS South East London (SEL) to engage

stakeholders in the development and implementation of AQP. This is set within the context of national and London wide stakeholder engagement for AQP. This strategy has been developed in consultation with the six Clinical Commissioning Groups (CCGs) that make up South East London (Bexley, Bromley, Greenwich, Lambeth, Lewisham and Southwark).

1.4. The initial introduction of AQP nationally must be delivered by April 2013.

2. AQP Aims and Objectives 2.1. The strategic aims of AQP are to:

2.1.1. Increase choice and access of health service providers for patients 2.1.2. Improve quality and outcomes of health services 2.1.3. Drive innovation and efficiency of health services

2.2. The strategic objectives to deliver the aims are to:

2.2.1. Develop local service specifications and tariffs for AQP services 2.2.2. Qualify and register providers as fit to provide NHS services for AQP 2.2.3. Develop local clinical pathways and referral protocols for AQP 2.2.4. Referring clinicians offer patients a choice of qualified provider 2.2.5. Competition for patients is based on quality not price

3. AQP Communication and Engagement Aims and Objectives 3.1. The strategic aims of effective communication and engagement for AQP are to:

3.1.1. Increase awareness of AQP, service lines and decisions 3.1.2. Increase understanding of AQP, its benefits and how to use it 3.1.3. Increase the empowerment of patients in exercising choice

3.2. The strategic objectives to deliver the aims are to:

3.2.1. Provide leadership and co-ordination of AQP across SE London 3.2.2. Identify local priorities for the delivery and linkage of AQP 3.2.3. Engage stakeholders in the development of AQP service specifications 3.2.4. Address issues and concerns with the development and implementation of


3

AQP 3.2.5. Develop appropriate referral pathways into AQP

4. Local context 4.1. Following an engagement process with Clinicians and stakeholders, five service

lines across South East London were selected: Hearing Services for adults; Level 2 (Specialist) Continence services for adults; Assessment of Complex/Non-complex Wheelchair services for children; Anti-coagulation services; and Termination of Pregnancies. The services that each CCG has chosen across SE London are as follows:

CCG Service Lines No.

Bexley Adult Hearing Termination Of Pregnancy Anti-Coagulation 3

Bromley Adult Hearing Wheelchairs Anti-Coagulation 3

Greenwich Adult Hearing Wheelchairs Anti-Coagulation 3

Lambeth Adult Hearing Wheelchairs Continence 3

Lewisham Adult Hearing Wheelchairs Continence 3

Southwark Adult Hearing Wheelchairs Continence 3

4.2. A recent ‘Temperature Check’ diagnostic with local BSUs identified the following

priorities: 4.2.1. QIPP 4.2.2. Saving money 4.2.3. Improving quality 4.2.4. Reducing admissions 4.2.5. Long Term Conditions 4.2.6. Urgent care 4.2.7. CCG authorisation 4.2.8. CSS/BSU transition

4.3. AQP has the potential to link to CCG priorities by:

4.3.1. Defining what good service delivery and care looks like for specific services 4.3.2. Improving data collection and analysis on services that have been difficult

to measure 4.3.3. Chipping away at block contracts to focus attention on specific services and

provide opportunities to improve quality 4.3.4. Decrease inappropriate admissions by improving service delivery to prevent

problems occurring 4.3.5. Meeting local unmet needs 4.3.6. Improving patient experience 4.3.7. Educate and empower patients/carers to take control of their own health 4.3.8. Providing commissioners with a new set of tools for commissioning

5. Stakeholder Mapping 5.1. The following broad groups of stakeholders have been identified:

Category Stakeholder

Public (Service Use) LINk/Health Watch


4

Category Stakeholder

Patient Groups/Forums Public

Partner (Service Development) CCG CSS/BSUs – Non-Executive/Executive and staff NHS London QCE/DoH GPs - Practice Staff Dentists/Optometrists/Pharmacists Local Authority – Social Services

Provider (Service Provision) Acute Community Health Primary Care Mental Health Private Social Enterprise Voluntary/Community

Opinion Former (Service Influence) Local Pressure Groups MPs Councillors Overview and Scrutiny Committee (OSC) Media

Care Group (Special Attention) Disability Groups Deaf/Hard of Hearing Groups Older People Groups Children and Young People Groups Parents/Parent Forums Carers/Carer Forums BME Groups Women’s Groups Pregnant Women Groups Men’s Groups LGBT Groups Religious Groups

5.2. The current position of stakeholders (figure 1) needs to be maintained in order to

facilitate the implementation of AQP. Figure 1: Impact/Interest Analysis of Stakeholders in AQP


5

6. Communication and Engagement Strategy Implementation 6.1. The Project Management Institute, Body of Knowledge describes considering

stakeholder positions in a project in relation to the: 6.1.1. Message: what you want to communicate

6.1.2. Medium: the way you send the message; and

6.1.3. Noise: things that interfere with comprehension

7. Communication and Engagement Messages

7.1. Key messages within the AQP process are aligned to sections of The Engagement Cycle (2009, Patient and Public Empowerment Division, Department of Health):

Category Purpose/Message

1. Raise awareness of AQP

What is AQP and why is it being done? What will it mean for existing/new patients? Raise issues and concerns with AQP

2. Identify local priorities for AQP

What is the decision making process? What are local health priorities based on local plans and patient feedback? Get information on activity/price of current services

3. Influence AQP service design

Develop service specification Develop referral pathway/process Serve decommissioning notices

4. Influence AQP procurement and contracting

Develop standards/indicators based on local data Apply for AQP services Select AQP providers

5. Mobilise new AQP services

Agree implementation of AQP services Repatriate existing patients into new services

6. Performance management of AQP

Monitor according to standards/indicators Receive feedback on chosen providers

Q2 High Impact/ Low Interest

Opinion Formers

Q1 High Impact/ High Interest

Care Groups

Partners

Providers

Q4 Low Impact/ Low Interest

Public

Q3 Low Impact/ High Interest


6

Category Purpose/Message

contract

8. Communication and Engagement Medium

8.1. At the ‘temperature check’ diagnostic the following engagement and communication methods were highlighted as useful:

8.1.1. Teleconferences 8.1.2. Small, focused face to face meetings 8.1.3. Website - Inter/intranet 8.1.4. Briefings/bulletins/newsletters 8.1.5. Provider events 8.1.6. Patient forums 8.1.7. Existing forums and networks 8.1.8. Referral Management System updates

8.2. These methods will be built on and supplemented, where appropriate, with: 8.2.1. Community Outreach 8.2.2. Service Assessments 8.2.3. Road Shows 8.2.4. Surveys 8.2.5. Publications – leaflets/posters 8.2.6. Media – press releases

9. Communication and Engagement Noise 9.1. Current issues that may interfere with the comprehension of AQP are: 9.2. Political Messages – AQP may be viewed by some stakeholders as the

privatisation of the NHS and create an antagonistic environment for implementation. Careful management of messages will be needed which clearly state the aims and objectives for AQP to avoid any confusion.

9.3. NHS Reform – Changes to the local health landscape may impact on the local implementation of AQP. If plans are underway to review and re-commission services in SE London, outside of AQP, any responses to these have the potential to influence responses to AQP. There will need to be awareness of any local changes in areas where AQP is being implemented.

9.4. Conflict of Interest – There is the potential for issues between various stakeholders to surface due to the involvement of clinicians in various parts of the commissioning cycle. If these clinicians are also providers, or aligned in some way to applying providers, there will be a conflict of interest in them becoming involved. Adherence to the NHS SE London Conflict of Interest policy is vital.

10. Stakeholder Communication and Engagement Plan

10.1. A Stakeholder Plan is attached that aligns different messages to different stakeholders utilising a variety of mediums.


7

11. Resources 11.1. There is no dedicated resource for the communication and engagement of

AQP. Existing communication and engagement resources will need to be used.

12. Governance

12.1. Communication and Engagement will be overseen by the monthly AQP Steering Group and will provide regular updates to the SE London Stakeholder Reference Group.

13. Risk

13.1. All communication and engagement risks will be flagged up as part of the overarching risk register for AQP.

Formal Bexley Clinical Commissioning Group (060912) / Enc E(iv)

1

Any Qualified Provider – Steering Group Action Notes

Date: Thursday 28 June 2012

Time: 10.00-11.15

Venue: Room 118, 1st Floor, 1 Lower Marsh

Chair: Tony Read

Present: Chris Gadney; Marco Inzani; Tamsin Hooton; Moira McGrath;

Geraldine Englard

Apologies: Richard Chapman; Yee Cho; Alan Luke

No. Item Due Date

Lead

1. General

2. 1.1 Action ID: 1.36/1.43 The AQP stakeholder communication and engagement plan will be developed for SE London, in collaboration with NHS London with regards to certain elements e.g. referral forms and mobilisation letters. Action: Ask NHS London for due date for mobilisation letter and referral forms.

06/07/12 MI

3. 1.2 Action ID: 1.41 Service lines have been discussed with all acute commissioners. There may be a cross over between Level 2 community continence services and acute urology/gynaecology services. Data is needed to get a clearer picture. Action: Ask acute providers for data on Level 2 services.

26/07/12 MM/ TH

4. 1.3 Action ID: 1.51 – 1.56 Review risk register and ensure risks feed Board Assurance Framework and CCG risk registers.

26/07/12 MI/TR

5. 1.4 6. Action ID: 1.2.3 The steering group considered the AQP temperature check actions. The steering group agreed to give clear recommendations and rationales which will be recorded in concise and clear briefings for CCGs. Each BSU/CCG will be asked to feed in their thoughts on the future management of AQP in current restructure discussions.

7. Action: Ensure CCG briefing includes statement on the future of AQP

8. 06/07/12 9. MI

1.5 Action: Circulate list of contacts for AQP 06/07/12 MI

1.6 Action ID: 1.3.3 The steering group considered the AQP stock take. Action: GSTT to be split across acute and community contracts. Kings information to be completed. New service line to be completed

06/07/12 MI

1.7 Action 1.4.2 The Steering group agreed the structure of the AQP steering group/working group. Further thought is


2

No. Item Due Date

Lead

needed on AQP programme management going forward e.g. would this fit into the BSU Project Management Office functions?

2. Adult Hearing Update

2.1 MI informed the group that London had made a decision to reinstate the aftercare tariff of £23 for existing patients, to reduce the need to re-refer onto an AQP pathway.

2.2 Action 2.1.2 Lambeth have existing CCG governance arrangements including delegated responsibilities. Action: Provide evidence of Lambeth governance arrangements

26/07/12 MM

2.3 Action: Follow up Bromley and Greenwich sign off of Hearing AQP

26/07/12 MI

2.4 Action 2.2.4 The Steering Group considered the nominations for the Local Assessment Teams. Debbie Andrews was nominated as the delegated lead from Lambeth and Southwark. Action: Determine a BSU delegated lead for Bexley, Bromley and Greenwich

20/07/12 MI

2.5 Action: Determine a clinical lead with specialist interest in ENT.

20/07/12 CG

2.6 Action: Determine a governance lead 20/07/12 TR

3. Adult Continence Update

3.1 Action 3.2.3 The steering group considered the specification and tariff. Action: Determine the London position on Market Forces Factor and transport cost uplift based on Hearing tariff.

28/06/12 MI

3.2 Action: Achieve CCG sign off of specification and tariff 29/06/12 CG/ MM/ TH/

4. Children’s Wheelchairs Update

4.1 Action 4.1.2 The steering group considered the position on Children’s Wheelchairs and agreed to delay progress until there is a clearer steer from the Department of Health. Work will still progress regarding a review of activity and pricing.

5. Date of Next Meeting

5.1 3.30p.m. Thursday 26 July 2012, Harding Room 5, 5th Floor, Oasis Centre, Westminster Bridge Road


3

AQP Steering Group Action List Review: 26 July 2012

ID Assign Date

Service Line

Action Lead Due Date Status Comments

1.1 28/06/2012 All

Ask NHS London for due date for mobilisation letter and referral forms.

MI 06/07/2012 Partial

Complete Communications meeting at NHS London 24 July 2012

1.2 28/06/2012 All

Ask acute providers for data on Level 2 services

MM/TH 26/07/2012 Incomplete

TBC

1.3 28/06/2012 All

Review risk register and feed risks into CCG risk registers

MI/TR 26/07/2012 Partial

Complete Risk Register reviewed and amended 16 July 2012

1.4 28/06/2012 All

Ensure CCG briefing includes statement on the future of AQP

MI 06/07/2012

Complete

Circulated 02 July 2012

1.5 28/06/2012 All

Circulate list of contacts for AQP

MI 06/07/2012 Complete

Circulated 10 July 2012

1.6 28/06/2012 All

GSTT to be split across acute and community contracts. Kings information to be completed. New service line to be completed

MI 06/07/2012

Partial Complete

Summary amended

2.2 28/06/2012 Hearing

Provide evidence of Lambeth governance arrangements

MM 26/07/2012

Incomplete

TBC

2.3 28/06/2012 Hearing

Follow up Bromley and Greenwich sign off of Hearing AQP

MI 26/07/2012 Partial

Complete Email sent 16 July 2012


4

ID Assign Date

Service Line

Action Lead Due Date Status Comments

2.4 28/06/2012 Hearing

Determine a BSU delegated lead for Bexley, Bromley and Greenwich

MI 20/07/2012

Complete Jill Prescott (Greenwich) agreed as BBG lead.

2.5 28/06/2012 Hearing

Determine a clinical lead with specialist interest in ENT.

CG 20/07/2012

Complete Dr Ferdinand Chrisanthan approached

2.6 28/06/2012 Hearing

Determine a governance lead

TR 20/07/2012 Incomplete

TBC

3.1 28/06/2012 Continence

Determine the London position on Market Forces Factor and transport cost uplift based on Hearing tariff.

MI 28/06/2012

Complete SEL decided to opt for a SEL tariff with an average SEL MFF and no transport uplift

3.2 28/06/2012 Continence

Achieve CCG sign off of specification and tariff

CG/MM/TH

29/06/2012 Partial

Complete Signed off in principle. Still need evidence of signature.

Formal Bexley Clinical Commissioning Group (060912) / Enc E(v)

Risk Register AQP Corporate Objectives 1. Improve health, quality and maintain safety of local NHS services. Appendix A

Directorate Strategy 2. Sustain an effective grip on finance, performance and QIPP

Accountable Officer Tony Read 3. Proactively manage the transition to the new commissioning system. Date Created 16/01/12

Last Review Date 16/07/12 v0.7

Risk Identification Risk Description and Assessment Action Plan & Target Status

So

urc

e R

ef

Dir

ec

tora

te

Corporate Objective Work Stream Date RaisedRisk

Category

Risk

Owner

Risk Description

(There is a risk that…caused

by......leading to........)

Inh

ere

nt

Lik

elih

oo

d

Inh

ere

nt

imp

ac

t

Inh

ere

nt

Ris

k EXISTING CONTROLS

ie. actions implemented

where this is evidenced/documented

note evidence of risk being controlled

Re

sid

ua

l L

ike

lih

oo

d

Re

sid

ua

l Im

pa

ct

Cu

rren

t R

esid

ual

Ris

k Acceptance

Decision

Control Gap

What still needs to be put in place

Action Plan Summary

(Ongoing/Planned)

Ta

rge

t L

ike

lih

oo

d

Ta

rge

t Im

pa

ct

Ta

rge

t R

es

idu

al R

isk

Review

Date

Movement

(Point)Status

1.01 Strategy

1. Improve health, quality

and maintain safety of local

NHS services.

AQP 16/01/2012 Financial BSU MDs

There is a risk that Service lines

being implemented result in cost

pressures to BSUs due to the

need to extract exisiting service

prices from block contracts

LikelyModera

te12

For each service line tariffs are being developed

which represent value for money. Notice to be

served in relation to decommissioned services.

Contract values to be identified.

LikelyModerat

e12

Mitigate (See

action plan)

Lack of robust information will hinder

this process. BSU staff are

endeavouring to gather robust

information from existing providers so

that this can be modelled

BSUs to gather robust information

where possible. Information from

across London to be shared to

minimise the gaps in information

Possible Moderate 9 23/08/12

Op

en

1.02 Strategy



NHS services.

AQP 16/01/2012 Operations Tony

Read

There is a risk that the AQP

process does not identify

sufficient accredited providers to

generate choice

Possib

leMajor 12

Engagement with providers has been undertaken

through BSU leads. Existing providers are unlikely to

want to lose business altogether. Providers can also

apply to be provider outside of normal area. Tariff

set at competitive market rate.

Unlikely Major 8 Accept

Op

en

1.03 Strategy



NHS services.

AQP 16/01/2012 Operations BSU MDs

There is a risk that patient

choices are restricted by clinical

referral behaviour

Possib

leMinor 6 Engagement plan for GPs to be developed. Unlikely Minor 4 Accept

Op

en

1.04 Strategy



NHS services.

AQP 16/01/2012

Information

Management

and

Technology

IG Lead

There is a risk that information

exchange between suppliers is

not secure, leading to IG issues

Unlikel

yMajor 8

This is addressed within each national specification.

Information Governance Statement of Compliance

mandatory requirement from providers.


Op

en

1.05 Strategy



NHS services.


There is a risk that no providers

bid due to the service line only

being a small part of overall

delivery leading to a gap in

provision

Possib

leMajor 12

Provision currently occurs in all service lines/CCGs

reducing the risk of a gap in provision. Market

analysis will scope the potential for new providers,

where possible.


Op

en

1.06 Strategy



NHS services.

AQP 16/01/2012 Operations

CCGs

There is a risk of a conflict of

interest for those making

decisions on service lines and

specifications caused by the

same people being able to bid

for service delivery leading to

reduced choice for patients

LikelyModera

te12

QCE are coordinating the procurement process for a

large number of the service lines and will ensure a

balanced panel mitigates against unfair advantage

over decisions. Premise of AQP is to extend choice.

Query Conflict of Interest Policy adhered to in local

decision making.

PossibleModerat

e9 Accept

Op

en

1.07 Strategy



NHS services.


There is a risk relating to the

number of applicants for the

programme being very high

which will result in increased

requirement for resources to

manage contracts and monitor

quality

Possib

le

Modera

te9

A three stage procurement process should reduce

the number of aplicants to a managable number.Possible

Moderat

e9

Mitigate (See

action plan)

Market assessment to assess size of

market. Provider workshops may

manage the number of providers who

apply.

Market assessment completed for

Hearing. Other service lines to be

confirmed.


Op

en

1.08 Strategy



NHS services.


There is a risk of cost pressures

due to undetermined go live

dates leading to

decommissioning notices not

being issued to existing

providers

Possib

le

Modera

te9

Dates to be supplied by QCEs. Go live dates and

related contract variation dates will be able to be

calculated

PossibleModerat

e9

Mitigate (See

action plan)

CCGs and the Steering Group to

determine appropriate dates for the

variation of contracts to commence




Unlikely Moderate 6 23/08/12

Op

en

1.09 Strategy



NHS services.

AQP 14/02/2012 StrategicTony

Read

There is a risk that deadlines are

unachievable in August caused

by decisions not made during

July/August caused by lack of

resources being available during

the Olympic period

LikelyModera

te12

Processes are planned around these dates with

some being web based facilitating remote working.Unlikely

Moderat

e6 Accept

Op

en

1.10 Strategy



NHS services.

AQP 05/04/2012 Operations

Lambeth

and

Southwar

k CCGs

There is a risk in Lambeth and

Southwark that contracts cannot

be terminated before the

commencement of the AQP

contracts due to a 12 month

notice period required for

services over £250k per annum

in GSTT community contract.

Possib

leMajor 12

Modelling completed for all but one service line

which has confirmed likely contract variations to be

less than £250k per annum.

Unlikely Major 8Mitigate (See

action plan)

Commence AQP arrangements to

coincide wih block contract termination

Accredit AQP providers and defer

contract start date Unlikely Major 8 23/08/12

Op

en

1.11 Strategy



NHS services.


There is a risk that the QCEs will

undertake the initial work on

AQP and then not exist to

undertake future refreshes.

Possib

le

Modera

te9

DH and NHS London are developing a response to

this.Possible

Moderat

e9 Accept

Out of Cluster control. DH and QCE to

agree

Clo

se

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1.12 Strategy



NHS services.

AQP 20/04/2012 People BSU MDs

There is a risk of market failure

due to the destabilisation of a

lack of guaranteed contracted

activity leading to provider

withdrawal, provider

restructuring costs, provider

reductons in quality and

reducing choice.

Possib

leMajor 12

Response from the DH is "Any Qualified Provider is

about encouraging an increase in the choices for

patients from a wider range of providers delivering

services. We would not expect to see current

providers simply replaced by new providers, as this

would not lead to an increase in choice for patients.

Whilst each possible TUPE situation has to be

considered on a case by case basis, current legal

advice suggests that there will be no “transfer of

undertaking” to a new provider where referral

patterns change because of the use of the Any

Qualified Provider approach.

Rather than redundancies or TUPE, it is more likely

that staff movement between providers will be in

response to job adverts and recruitment processes."

Unlikely Major 8Mitigate (See

action plan)

Providers should consider their

responses and how to mitigate against

this for their business model. Cluster to

organise provider engagement events

Hold provider engagement events Unlikely Major 8 23/08/12

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1.13 Strategy



NHS services.

AQP 20/04/2012 Strategic BSU MDs

There is a risk that the future

monitoring of contracts is not

defined either by CCGs or by

CSS, thereby leaving a gap post

implementation

Possib

le

Modera

te9 BSU leads requested to discuss with BSU MDs Unlikely

Moderat

e6

Mitigate (See

action plan)

CCGs (and their agents e.g. CSS)

need to understand the implications of

AQP and agree how this will be

monitored and taken forward in the

future. Legacy document will be

developed. Comments on proposed

structures have been made.

CCGs to decide the appropriate place

for contract management to sitUnlikely Moderate 6 23/08/12

Op

en

1.14 Strategy



NHS services.

AQP 26/04/2012 PeopleTony

Read

There is a risk that key staff will

be lost caused by restructuring

leading to a lack of AQP

programme and project

management

Possib

le

Modera

te9 Resources determined and interim appointed. Unlikely

Moderat

e6 Accept

Op

en

1.15 Strategy



NHS services.

AQP 14/05/2012 Financial BSU MDs

There is a risk that an increase in

tariff costs caused by the

inclusion of transport costs will

lead to double payments for

patient transport

Possib

le

Modera

te9

Patient transport cost applied to tariff where

appropriate. Patient transport can be monitored and

the potential for linkage with existing system and sub-

contracting of patient transport with corresponding

reduction in contract payment. Projected numbers

are very small.

Possible Minor 6Mitigate (See

action plan)

Current patient transport specification

requires the identification of service for

each patient transported. AQP should

be able to be flagged and reduce the

risk of double payments.

Confirm that AQP service line could

be flagged in patient transport contract

monitoring.

Unlikely Minor 4 23/08/12

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Risk Register AQP Hearing Corporate Objectives 1. Improve health, quality and maintain safety of local NHS services. Appendix A





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Movement

(Point)Status

2.01 Strategy



NHS services.

AQP Hearing 16/01/2012 Financial BSU MDs

There is a risk that the Hearing

AQP results in cost pressures to

BSUs due to the need to extract

exisiting service prices from

block contracts

LikelyModera

te12

The Hearing tariff was developed to represent value

for money. Notice was served in relation to

decommissioned services. Cost pressures were

identified in one BSU.

LikelyModerat

e12

Mitigate (See

action plan)

Implementation of the service line will

need to be carefully monitored to

reduce the risk of significant cost

pressure.

Review first quarter activity for Hearing

to flag actions to reduce cost

pressures.


Op

en

2.02 Strategy



NHS services.

AQP Hearing 25/01/2012 Operations BSU MDs


number of applicants for Hearing

AQP being very high which will

result in increased requirement

for resources to manage

contracts and monitor quality

Possib

le

Modera

te9

17 providers currently applied which may be reduced

by the three stage procurement processPossible

Moderat

e9

Mitigate (See

action plan)

Simplified contract management may

be needed if the number of applicants

remains high

Develop abbreviated monitoring

process to manage by exception if

number of providers reaches a

specified threshold.


Op

en

2.03 Strategy



NHS services.

AQP Hearing 14/02/2012 Operations BSU MDs



dates leading to



providers

Possib

le

Modera

te9

Hearing Go Live date is 30 September 2012.

Current Hearing providers all issued with

decommissioning notices with planned Go Live Date.

UnlikelyModerat

e6 Accept 23/08/12

Clo

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2.04 Strategy



NHS services.

AQP Hearing 05/04/2012 Operations

Lambeth

and

Southwar

k CCGs




commencement of the Hearing

AQP contracts due to a 12

month notice period required for

services over £250k per annum

in GSTT community contract.

Possib

leMajor 12

Modelling completed for Hearing which has

confirmed likely contract variations to be less than

£250k per annum.

Unlikely Major 8 Accept 23/08/12

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Movement

(Point)Status

3.01 Strategy



NHS services.

AQP

Continence16/01/2012 Financial BSU MDs

There is a risk that the

Continence AQP will result in

cost pressures to BSUs due to

the need to extract exisiting

service prices from block

contracts

LikelyModera

te12

The Continence tariff was developed to represent

value for money. Notice was served in relation to

decommissioned community services. No cost

pressures were identified.

PossibleModerat

e9

Mitigate (See

action plan)

Implications for acute service activity still

needs to be identified. Implementation

of the service line will need to be

carefully monitored to reduce the risk of

significant cost pressure.

Serve notice on relevant acute

services. Review first quarter activity

for Continence to flag actions to

reduce cost pressures.


Op

en

3.02 Strategy



NHS services.

AQP

Continence25/01/2012 Operations BSU MDs


number of applicants for

Continence AQP being very high

which will result in increased



quality

Possib

le

Modera

te9


the number of aplicants to a managable number.

Continence advert currently open.

PossibleModerat

e9

Mitigate (See

action plan)

Simplified contract management may

be needed if the number of applicants

remains high

Develop abbreviated monitoring

process to manage by exception if

number of providers reaches a

specified threshold.


Op

en

3.03 Strategy



NHS services.

AQP

Continence14/02/2012 Operations BSU MDs



dates leading to



providers

Possib

le

Modera

te9

Continence Go Live date identified as 1 October

2012. Current Continence service providers issued

with notices of 30 September 2012 for LHT and 1

Dec 2012 for GSTT and so there will be some

overlap.

PossibleModerat

e9

Mitigate (See

action plan)

Contract start date for GSTT to

coincide with end date of notice period.

Amend Go Live date for Adult

ContinenceUnlikely Moderate 6 23/08/12

Op

en

3.04 Strategy



NHS services.

AQP

Continence05/04/2012 Operations

Lambeth

and

Southwar

k CCGs




commencement of the

Continence AQP contracts due

to a 12 month notice period

required for services over £250k

per annum in GSTT community

contract.

Possib

leMajor 12

Modelling completed for continence with likely

contract value to be less than £250k per annum.Unlikely Major 8 Accept 23/08/12

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4.01 Strategy



NHS services.

AQP

Wheelchairs16/01/2012 Financial BSU MDs

There is a risk that the

Wheelchairs AQP will result in

cost pressures to BSUs due to

the need to extract exisiting

service prices from block

contracts

LikelyModera

te12

The Wheelchairs tariff is being developed to

represent value for money. Notice to be served in

relation to decommissioned services. Contract

values to be identified.

LikelyModerat

e12

Mitigate (See

action plan)











Op

en

4.02 Strategy



NHS services.

AQP

Wheelchairs25/01/2012 Operations BSU MDs


number of applicants for

Wheelchairs AQP being very

high which will result in

increased requirement for

resources to manage contracts

and monitor quality

Possib

le

Modera

te9


the number of applicants to a managable number.Possible

Moderat

e9

Mitigate (See

action plan)




apply.



confirmed.


Op

en

4.03 Strategy



NHS services.

AQP

Wheelchairs14/02/2012 Operations BSU MDs



dates leading to



providers

Possib

le

Modera

te9

Dates to be supplied by DoH following national

review of Wheelchairs AQP. Go live dates and

related contract variation dates will be able to be

calculated

PossibleModerat

e9

Mitigate (See

action plan)








Op

en

4.04 Strategy



NHS services.

AQP

Wheelchairs05/04/2012 Operations

Lambeth

and

Southwar

k CCGs




commencement of the

Wheelchairs AQP contracts due

to a 12 month notice period

required for services over £250k

per annum in GSTT community

contract.

Possib

leMajor 12

Modelling needed to confirm whether contract

variations will be less than £250k per annum.Unlikely Major 8

Mitigate (See

action plan)

Commence AQP arrangements to

coincide wih block contract termination

Accredit AQP providers and defer

contract start date Unlikely Major 8 23/08/12

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(Point)Status

5.01 Strategy



NHS services.

AQP Anti-

coagulation16/01/2012 Financial BSU MDs

There is a risk that Anti-coag

AQP will result in cost pressures

to BSUs due to the need to

extract exisiting service prices

from block contracts

LikelyModera

te12

The anticoag tariff was developed to represent value

for money. Notice served to SLHT in relation to

decommissioned services. Contract values to be

identified.

LikelyModerat

e12

Mitigate (See

action plan)

Cost pressures need to be identified

and notice served to remaining

providers of anti-coag.

Model tariff across BBG and serve

notice to remianing providersPossible Moderate 9 23/08/12

Op

en

5.02 Strategy



NHS services.

AQP Anti-

coagulation25/01/2012 Operations BSU MDs


number of applicants for the Anti-

coag AQP being very high which

will result in increased



quality

Possib

le

Modera

te9



Moderat

e9

Mitigate (See

action plan)




apply.



confirmed.


Op

en

5.03 Strategy



NHS services.

AQP Anti-

coagulation14/02/2012 Operations BSU MDs


for Anti-coag AQP due to

undetermined go live dates

leading to decommissioning

notices not being issued to

existing providers

Possib

le

Modera

te9

Anti-coag Go live date is 1 Nov 2012. SLHT notice

did not specify Go Live Date.Possible

Moderat

e9

Mitigate (See

action plan)

Amended notice letter to be issued to

SLHT. Remaining providers to be

issued with notice letters.

Issue notice letters to current anti-

coag providers.Unlikely Moderate 6 23/08/12

Op

en

5.05 Strategy



NHS services.

AQP Anti-

coagulation29/05/2012 Operations

Tony

Read

There is a risk that the Anti-coag

AQP accreditation process is too

complex and onerous for small

providers leading to a lack of

providers and reduced choice

LikelyModera

te12

Provider events will explain the process to all

providers and offer additional support in order to

make the process as easy as possible.

UnlikelyModerat

e6

Mitigate (See

action plan)

As part of practice/provider

development plans in each BSU review

whether providers require minimal or

intense support and balance the need

within the service line to stimulate the

market.

Explore possibility of providing extra

provider/market development Unlikely Moderate 6 23/08/12

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(Point)Status

6.01 Strategy



NHS services.

AQP ToPs 16/01/2012 Financial BSU MDs

There is a risk that ToPs AQP

will result in cost pressures to

BSUs due to the need to extract

exisiting service prices from

block contracts

LikelyModera

te12

The ToPs tariff is being developed to represent value

for money. Notice to be served in relation to

decommissioned services. Contract values to be

identified.

LikelyModerat

e12

Mitigate (See

action plan)











Op

en

6.02 Strategy



NHS services.

AQP ToPs 25/01/2012 Operations BSU MDs


number of applicants for ToPs

AQP being very high which will

result in increased requirement

for resources to manage

contracts and monitor quality

Possib

le

Modera

te9



Moderat

e9

Mitigate (See

action plan)




apply.



confirmed.


Op

en

6.03 Strategy



NHS services.

AQP ToPs 14/02/2012 Operations BSU MDs



dates for ToPs AQP leading to



providers

Possib

le

Modera

te9

Dates to be supplied by NHS London. Go live dates

and related contract variation dates will be able to be

calculated

PossibleModerat

e9

Mitigate (See

action plan)








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Contents hyperlinked in this TAB

Corporate Objectives

Directorate Objectives

World Class Commissioning

Name of Directorate

Risk Category

Impact Categories

Likelihood Risk Scoring

Adequacy of Existing Controls

Trends

Escalation

DEFINITIONS

TABLE 1

Corporate Objectives1. Improve health, quality and maintain safety of local NHS services.

2. Sustain an effective grip on finance, performance and QIPP

3. Proactively manage the transition to the new commissioning system.

TABLE 4Name of Directorate

Development

Operations

Finance

Performance

Acute Contracting

QIPP & Strategy

Primary Care

Medical Director

Workforce

Lambeth BSU

Southwark BSU

Lewisham BSU

Bromley BSU

Bexley BSU

Greenwich BSU

TABLE 5

Risk Category

Change

Financial

Governance

Legal & Compliance

Operations

Information Management and

Technology

People

These concern risks that programmes and projects do not deliver agreed benefits on

time and within agreed budget and or/introduce new or changed risks that are not

effectively identified and managed.

These concern the effective management and control of the finances of the Trust. The

risk events can range from insufficient funding, poor budget management, mismanage

assets and liabilities and failure to collect due revenues

These concern the day to day issues NHS SEL is confronted with as it strives to deliver

its strategic objectives. They can be anything from loss of data to failure of a key IT

system. It covers risk events such as technological breakdown, loss of hard or soft

copy data, failure by 3rd party vendor to deliver service, breakdown in partnership with

These concern insufficient human capital (capacity and capability), inappropriate staff

behaviour. These risks can have a significant impact to the performance and reputation

of NHS SEL.

These concern the establishment of an effective organisational structure with clear lines

of authorities and accountabilities. The risk events can include inappropriate decision

making and delegation of authorities, lack of appropriate tone set by leadership and

lack of Board cohesiveness. All can result in sub optimal performance and losses for

NHS SEL.

These concern such as H&S, consumer protection, data protection, employment

practices, failing to comply with employment legislation or industrial action, claims

against PCTs or Care Trusts in SEL and regulatory issues

These concern the day to day concerns NHS SEL is confronted with as it strives to

deliver its strategic objectives. They can be anything from loss of key staff to process

failure It covers risk events such as failure by 3rd party vendor to deliver service for the

operation, breakdown in partnership with 3rd party,, failure to manage internal change

etc. Operational risks are largely short to medium term horizon where frequency is

high/medium likelihood and low to high impact.

Strategic

Clinical

TABLE 6 Impact Score ( Severity Levels)

Impact Categories 1 2 3 4 5

Categories Negligible Minor Moderate Major Catastrophic

Business Objectives/Projects

Insignificant cost increase/schedule

slippage.

Barely noticeable reduction in scope or

quality

<5 % over project budget.

Schedule slippage or

minor reduction in

quality/scope

5-10% over project budget.

Schedule slippage or

reduction in scope or

quality

Non-compliance with

national 10-25% over project

budget.

Schdule slippage.

Key objective not met.

Incident leading >25%

over project budget.

Schedule slippage.

Key objectves not met.

Injury (Physical/Psychological)

Minor injury not requiring first aid or no

apparent injury.

No time off work

Minor injury or illness, first

aid treatment needed.

Requriring time off work

for >3 days

Increase in length of

hospital stay by 1-3 days

Moderate injury requiring

professional intervention.

Requiring time off work for

4-14 days


hospital stay by 4-15 days

RIDDOR/Agency

reportable

An event which impacts on

a small number of patients

Major injury leading to long

term incapacity/disability

Requiring time off work for

>14 days


hospital stay by >15 days

Mismanagement of patient

care with long term effects

Incident leading to death.

Multiple permanent

injuries irreversible health

effects

An event which impacts

on a large number of

patients

Service/Business Interruption

Loss interruption of >1 hour

Minimal or no impact on the

environment

Loss interruption of >8

hours

Minor impact on

environment

Loss interruption of >1 day

Moderate impact on

environment

Loss interruption of >1 week

Major impact on

environment

Permanent loss of service

or facility

Catastrophic impact on

environment

Adverse publicity/reputation

Rumours

Potential for public concern

Local media coverage -

short term reduction in

public confidence

Elements of public

expectation not being met

Local media coverage -

long term reduction in

public confidence

National media coverage

with <3 days service well

below reasonable public

expectation

National media coverage

with >3 days service well

below reasonable public

expectation. MP

concerned (questions in

House)

Total loss of public

confidence

Complaints/Claims

Locally resolved complaint

Risk of claim remote

Justified complaint

peripheral to clinical care

Claim less than £10k

Below excess claim.

Justified complaint

involving lack of

appropriate care

Claim(s) between £10k

and £100k

Claim above excess level.

Claim(s) between £100k and

£1 million

Multiple justified complaints

Multiple claims or single

major claim >£1 million

Inspection/Audit

Minor recommendations.

Minor non-compliance with standards

Recommendations

givens.

Non-compliance with

standards

Reduced performance

rating if unresolved

Reduced rating.

Challenging

recommendations.

Non-compliance with core

standards

Enforcement Action. Low

rating.

Critical report. Major non-

compliance with core

standards

Improvement notices

Prosecution. Zero Rating.

Severely critical report.

Complete systems change

required.

HR/Organisational Development

Staffing and Competence

Short term low staffing level that

temporarily reduces service quality (<1

day )

Low staffing level that

reduces the service

quality

Late delivery of key

objective/service due to

lack of staff

Unsafe staffing level or

competence (>1 day)

Low staff morale

Poor staff attendence for

mandatory/key training

Uncertain delivery of key

objective/service due to lack

of staff

Unsafe staffing level or

competence (>5 days)

Loss of key staff

Very low staff morale

No staff attending

mandatory/key training

Non -delivery of key

objective/service due to

lack of staff.

Ongoing unsafe staffing

levels or competence.

Loss of several key staff.

No staff attending

mandatory training/key

training on an ongoing

basis

These concern the long term strategic objectives of the Trust. They can be affected by

external factors such as the economy, changes in the political environment,

technological changes, changes in customer behaviour or needs, legal and regulatory

changes, missing opportunities and mismanagement by the Senior Management Team.

The strategic risks are mainly significant risks that can potentially impact the whole

Trust. They are also in a lot of cases cross cutting risks that impact across the Trust

rather than just one area.

These concern risks that arise directly from the provision and delivery of healthcare to

patients. This includes clinical errors and negligence, healthcare associated infection

and failure to obtain consent.

Financial

Small loss Loss >0.1% of budget Loss >0.25% of budget Loss >0.5% of budget Loss >1% of budget

Loss of contract/payment

by results

TABLE 7a

Risk Matrix ImpactLikelihood Negligible Minor Moderate Major Catastrophic

Rare 1 2 3 4 5

Almost Certain (5) (>80%) - Will undoubtedly

happen/recur, possibly frequently Unlikely 2 4 6 8 10

Likely (4) (61-80%) - Will probably happen/recur,

but is not a persisting

issue/circumstance Possible 3 6 9 12 15

Possible (3) (41-60%) - Might happen or recur

occasionally Likely 4 8 12 16 20

Unlikely (2) (20-40%) - Do not expect it to

happen/recur but it is possible Almost Certain 5 10 15 20 25

Rare (1) (<20%) - This will probably never

happen/recur TOLERANCE THRESHOLD

TABLE 7b TABLE 7c

Key Levels of Risk Management Actions

1-3 Low Risk Low Risk

To be brought to the

attention of the

department/team leader.

4-6 Moderate Risk Moderate Risk

8-12 Significant Risk Significant Risk

15-25 High Risk High Risk

Adequate

Minor weaknesses exist in the

control.

Effective

The control never fails, and achieves

its intended management objectives.

Excessive

The design or operation of the

control is over-engineered / too

resource intensive / too expensive in

relation to the actual risk exposed.

Deficient

The control / mitigation activity has a

fundamental flaw, and does not

achieve the management objectives

intended. In terms of the control

environment there is a control

missing.

Accept Some risks may be minimal or unavoidable and retention acceptable

Mitigate (See action plan) Reducing or controlling the likelihood and consequence of the occurrence

Avoid Not proceeding with the activity to generate the risk

Transfer (See action plan) Arranging for another party to bear or share some part of the risk, through contracts, partnerships, joint ventures, etc

↑ Risk is worsening

↓ Risk is improving

↔ Risk is static

TABLE 8

TABLE 9

TABLE 10

Immediate action required by Executive Director, Heads of Department or Nominated Professional Leads. To be brought to the attention

of the PCT Board and Risk Committee/Clinical Governance Committee. Carry out root cause analysis - review risk assessment. A

Director must be informed and he/she will take responsibility for immediately planning action

Line Manager - immediate control measures in place - review risk assessment - inform Heads of Department and Nominated Professional

Lead. Specific responsibility for risk assessment and action planning must be allocated to a named person. Deadline for completion will

usually be within 6 to 12 months and will depend on the availability of resources.

Urgent attention required. To be brought to the attention of the responsible Director, Heads of Department, Nominated Professional

Lead, Line Manager - immediate control measures in place - review risk assessment - action plan devised. Within one month of

identification appropriate action must be agreed. The deadline for implementation and reassessment will normally be no later than 6

months from identification.

Trends

Adequacy of Existing Controls

Risk Decisions

Qualitative Assessment for

Probability /LikelihoodProbability / Likelihood

Probability/Likelihood scores

TABLE 7

Likelihood Categories

↑ Escalated upwards to next level

↓ De-escalated downwards

↔ Managed at current level

R Poor progress being made

G Completed or on target to achieve by due date

A Target date will not be met but good progress being made

DEFINITIONS NOTES

Risk ID

Unique reference number starting with 3

letter abbreviation for directorate + risk id

number

Directorate - Governance;

Risk ID number is 3 e.g.

GOV/R3. If the risk has been

escalated to the Corporate

Risk Register than it will be

CPT/R4 (GOV/R3). The risk

ID in bracket will indicate its

original location

Business Objective

Underlying corporate/directorate objectives

Identify your key objectives

before identifying your key

risks (See table 5

Ratings_Bandings)

Corporate / Directorate / Service

/ Activity / Process Name of business area/function

Date Raised Date the risk was identified

Risk Category Risks grouped into common themes

See table 4 - Risk

Categories

Risk Assessor Name of person conducting the risk assessment

Risk OwnerName of person responsible for ensuring the management of the risk

Each risk must have an

accountable person

Risk Description



Risk statement

Describe the condition that

could result in a potential

impact to the Trust and its

objectives. Identify possible

causes that may give rise to

this risk occurring.

Impact Category Overall impact to the Trust See table 7 - Impact

Inherent Likelihood

Likelihood of the risk occurring without any controls

Assess the chance of a risk

occurring if there were no

controls or actions in place

(See table 6 - Likelihood)

Inherent impact

Impact to the Trust if the risk occurs

Assess the potential impact

if the risk materialises

without any controls in place

(See table 6 - Impact)

Inherent RiskInherent Likelihood x Inherent Impact =

Inherent Risk - the exposure arising from a

specific risk without any controls or before

any action has been taken to manage it.

See table 1 to 3 - Risk

Matrix to plot the risk against

likelihood and impact and

establish what level of action

is required based on the

matrix

Existing controls in place/actions

implemented

Controls/Actions currently in place to mitigate the risk in question

Describe the controls/actions

currently in place to mitigate

the risk. Consider only

those controls that address

the causes.

Adequacy of Existing Control

Are the controls both design and operationally effective?

Do the controls mitigate the

risk? Are they the right

controls? Are they been

performed as designed?

(See table 7 - Control

Evaluation)

Assurances on Controls

Where can we gain evidence that our

controls/systems on which we placing

reliance are effective?

e.g.Management checks, Internal Audit,

Clinical

Audit, Commission for Health Improvement,

External Audit, Local Counter Fraud

Services,

NHS Litigation Authority, other reviews

What evidence do we have

the controls/actions in place

are in operation and

operating effectively?

Positive AssuranceList evidence that shows we are reasonably

managing our risks and our objectives are

being delivered?

How do we know that the

controls/actions are

mititgating the risks and we

are meeting our objectives?

Action RAG

TABLE 12

Escalation

TABLE 11

Control GapWhere are we failing to put controls/systems

in place? Where are we failing in making

them effective?

If the controls are not

designed or operating

effectively then where are

the weaknesses?

Gaps in Assurance

Where are we failing to gain evidence that

our controls/systems, on which we place

reliance, are effective?

Highlight the gaps in

evidence

Residual Likelihood Likelihood of the risk occurring with existing

controls/actions in place

Assess the chance of a risk

occurring given the existing

controls or actions in place

Residual ImpactImpact to the Trust if the risk occurs given

the existing controls/actions in place

Assess the potential impact

if the risk materialises given

the existing controls in place

Current Residual Risk

Residual Likelihood x Residual Impact =

Residual risk - the exposure arising from a

specific risk after implementing existing

controls and actions have been taken to

manage it.

Acceptance DecisionBased on the residual score, is the risk

acceptable or requires further mitigation? A

score of 9 or above is unacceptable

If the risk requires further

mitigation, describe the

proposed actions under

Action Plan. See table 11

and 12 Ratings_Bandings to

help you decide how the risk

should be treated.

Target LikelihoodLikelihood of the risk occurring with

proposed controls/actions in place

Target ImpactImpact to the Trust if the risk occurs given

the proposed controls/actions in place

Target Residual Risk

Target Residual Likelihood x Target

Residual Impact = Target Residual risk - the

estimated exposure arising from a specific

risk after implementing the proposed

controls and actions

Where do we want the risk

to be once the proposed

actions are in place?

Target Reduction DateEstimated completion date to achieve

Target Residual Risk score

Review Date Date the risk is to be next reviewed

Date removed from register Upon closure the risk is removed from risk register

Status Open or close risk

Monthly Trend Movement To what extent is the exposure been

reduced each month to an acceptable level?

See table 9 - Risk

Monitoring

Escalation

Can the risk be managed at the current or

does it require escalation up the

management chain?

See table 9 - Risk

Monitoring

R

A

G

Likelihood Negligible Minor Moderate Major CatastrophicRare 1 2 3 4 5

Unlikely 2 4 6 8 10

Possible 3 6 9 12 15

Likely 4 8 12 16 20

Almost Certain 5 10 15 20 25

Key Levels of Risk

1-3 Low Risk

4-6 Moderate Risk

8-12 Significant Risk

15-25 High Risk

TOLERANCE THRESHOLD

Risk Matrix Consequence

Formal Bexley Clinical Commissioning Group (060912) / Enc E(vi)

Stakeholder Communication and Engagement PlanSUMMARY

Version 0.2

Date 16/07/2012

Ref. Message Category Medium Stakeholder Start Date End Date Lead

SCE1 1. Raise awareness of AQP Website

Public press release

LINk/HealthWatch

AQP Poster

Patient Participation Groups

GP Briefing

Referral Management System

Briefing

Provider Briefing

Supply 2 Health

OSC

Care Group Contacts

Public

Partner

Provider

Opinion Former

Care Group

01/09/2012 31/03/2013 MI

SCE2 2. Identify local priorities for

AQP

AQP Event

CCG Boards

Care Group Meetings

Provider Correspondence

Partner

Care Group

Provider

01/10/2011 30/12/2011 0

SCE3 3. Influence AQP service

design

National Service Specification

CCG Boards

Care Group Meetings

Decommissioning Notices

Partner

Care Group

Provider

01/04/2012 30/09/2012 0

SCE4 4. Influence AQP procurement

and contracting

Load Advert on Supply 2 Health


Partner

Care Group

Provider

25/05/2012 30/10/2012 0

SCE5 5. Mobilise new AQP services Provider Meetings Provider 30/09/2012 31/12/2012 0

SCE6 6. Performance management

of AQP contract

Quarterly Monitoring Meeting

CCG Board

Care Group Feedback

Provider

Partner

Care Group

01/02/2013 01/05/2012 0

Stakeholder Communication and Engagement Plan

Version 0.2

Date 16/07/2012

Ref. Message Medium Stakeholder Start Date End Date Lead

SCE1 1. Raise awareness of AQP:

What is AQP and why is it being done?

What will it mean for existing/new patients?

Raise issues and concerns with AQP

Website

Public press release

LINk/HealthWatch

AQP Poster

Patient Participation Groups

GP Briefing

Referral Management System Briefing

Provider Briefing

Supply 2 Health

OSC

Care Group Contacts

Public

Partner

Provider

Opinion Former

Care Group

01/09/2012 31/03/2013 MI

Ref. Medium Task Start Date End Date Lead

1.01 Website Develop content for web-page

Post content on relevant websites

Create links to relevant information

1.02 Public press release Write content for public press release

Develop list of relevant publications

Send press release to relevant publications

Publish content in in-house publications

1.03 LINk/HealthWatch Develop a LINk Briefing

Book slots on LINK Meeting

Collate feedback from LINk

Write a 'You Said, We Did' Report

1.04 AQP Poster Write content for AQP poster

Design AQP poster

Sign off proofs

Print AQP Poster

Develop list of appropriate venues

Distribute to venues

1.05 Patient Participation Groups Develop brief AQP presentation

Book slots in PPG agenda

Collate feedback from PPGs


All

Public

1.06 GP Briefing Develop consistent correspondence for GPs

Follow up correspondence with brief call or

visit

1.07 Referral Management System Briefing Develop consistent correspondence for RMS

Follow up correspondence with brief call or

visit

1.08 Provider Briefing Develop AQP provider briefing

Develop list of main commissioning contact

for relevant providers

Deliver AQP provider briefing

1.09 Supply 2 Health Post AQP provider briefing on Supply to

Health

1.1 OSC Develop brief AQP presentation

Book slots in OSC agenda

Collate feedback from OSCs


1.11 Care Group Contacts Develop an AQP Care Group briefing

Develop a list of care group contacts

Deliver AQP Care Group Briefing to care

group contacts

Care Group

Partner

Provider

Opinion Former


Version 0.2

Date 16/07/2012


SCE2 2. Identify local priorities for AQP

What is the decision making process?

What are local health priorities based on local

plans and patient feedback?

Get information on activity/price of current

services

AQP Event

CCG Boards

Care Group Meetings

Provider Correspondence

Partner

Care Group

Provider

01/10/2011 30/12/2011


2.01 AQP Event Develop agenda for AQP Event

Identify Date and Venue

Identify speakers

Develop presentations

Hold Event

Collate Feedback


2.02 CCG Boards Develop a CCG Presentation

Deliver CCG Presentation

Collate feedback from CCGs


2.03 Care Group Meetings Develop a Care Group Presentation

Deliver Care Group Presentation

Collate feedback from Care Groups

All

Partner

Care Group


2.04 Provider Correspondence Write to providers for relevant activity

and price of services

Collate Information

Provider


Version 0.2

Date 16/07/2012


SCE3 3. Influence AQP service design

Develop service specification/Indicators/Tariff

Develop referral pathway/process

Serve decommissioning notices

National Service Specification

CCG Boards

Care Group Meetings

Decommissioning Notices

Partner

Care Group

Provider

01/04/2012 30/09/2012


3.01 National Service Specification Email National Service

Specification/indicators/tariff

Collate Feedback

Consider and amend service

specification

3.02 CCG Boards Develop a CCG Presentation

Deliver CCG Presentation

Collate feedback from CCGs


3.03 Care Group Meetings Develop a Care Group Presentation

Deliver Care Group Presentation

Collate feedback from Care Groups


All

Partner

Care Group

Provider

3.04 Decommissioning Notices Determine an appropriate Go Live

date

Develop a provider

decommissioning notice

Deliver provider decommissioning

notice


Version 0.2

Date 16/07/2012


SCE4 4. Influence AQP procurement and

contracting

Advertise AQP Offer

Apply for AQP services

Select AQP providers

Load Advert on Supply 2 Health


Partner

Care Group

Provider

25/05/2012 30/10/2012


4.01 Load Advert on Supply 2 Health Determine dates for AQP service line

Develop advert for AQP Service Line

Load advert on Supply 2 Health

4.02 Local Assessment Team Nominate appropriate partners for

LAT

Develop briefing for LAT

Train LAT on e-procurement

Assess applications

Hold consensus meeting

Load final decisions on Supply 2

Health

Providers

Partner/Care Group


Version 0.2

Date 16/07/2012


SCE5 5. Mobilise new AQP services

Agree implementation of AQP services

Repatriate existing patients into new services

Provider Meetings Provider 30/09/2012 31/12/2012


5.01 Provider Meetings Develop mobilisation plan

Hold mobilisation meetings with

provider

Agree implementation of AQP

contract

Provider


Version 0.2

Date 16/07/2012


SCE6 6. Performance management of AQP

contract

Monitor according to standards/indicators

Receive feedback on chosen providers

Quarterly Monitoring Meeting

CCG Board

Care Group Feedback

Provider

Partner

Care Group

01/02/2013 01/05/2012


6.01 Quarterly Monitoring Meeting Alert providers to Monitoring Meeting

Hold Monitoring meeting

Agree improvement plan

6.02 CCG Board Book slot on CCG Boards

Collate Feedback regarding AQP

services

Feed recommendations into

improvement plan

6.03 Care Group Feedback Book slot on Care Groups

Collate Feedback regarding AQP

services

Feed recommendations into

improvement plan

Provider

Partner

Care Group

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