HESL Board Assurance Framework (BAF)

Paper 05
Health Education South London: Board
16 September 2014
HESL Board Assurance Framework (BAF)
Paper Author
Lead Director
FOI Status
Vicky Lorimer, Business Support Officer
Julie Screaton, Managing Director
Accessible via FOI
Paper Summary
The HESL risk register was last taken to the Risk Assurance
Committee meeting of 15 July 2014 where it was agreed that a
full Board Assurance Framework (BAF) would be developed
aligning risks with the objectives detailed in the HESL Delivery
Plan.
The BAF is presented to the Board to note.
The HESL Senior Leadership Team (including heads of London
facing functions that sit within HESL) have embedded a BAF
review within usual monthly governance processes which aligns
with Risk Assurance Committee meetings.
As agreed by the Risk Assurance Committee, the BAF shows
risks with a post-mitigation score of 12 or above. The BAF
summary gives oversight of all risks identified, and shows in
matrix format, which HESL objectives they impact.
Purpose
Recommendation
For discussion
The Board is asked to:
• Note the contents of the HESL Board Assurance
Framework
Date paper
completed:
Developing people
for health and
healthcare
10 Sept 2014
The Local Education and Training Board for South London
www.southlondon.hee.nhs.uk
[email protected]
HESL BOARD ASSURANCE FRAMEWORK - SUMMARY
HESL23
HEE BUDGET ALLOCATION METHODOLOGY (15/16)
20
15
HESL29
FINANCIAL OUTTURN 14/15
16
16
HESL22
CEPNs - SILO PROJECT
12
12
HESL28
CEPNs - LINK WITH ACUTE PROVIDERS
12
12
HESL27
CEPNs - VALUE FOR MONEY
12
12
HESL13
FINANCIAL MANAGEMENT & GOVERNANCE
12
12
HESL16
HEE MANDATE
12
12
HESL20
GP TRAINING
12
12
HESL07
PAN-LONDON VOICE
9
9
HESL26
TRANSITION TO EDUCATION TARIFFS
20
16
HESL30
HESL15
BEYOND TRANSITION PROGRAMME - REDUCED LEADERSHIP
FINANCIAL SCENARIO PLANNING 14/15 ONWARDS
16
12
16
12
HESL21
POOR DATA QUALITY/GAPS
12
12
HESL06
STAKEHOLDER ENGAGEMENT AND SUPPORT
12
12
HESL14
SHARED SERVICES REVIEW
12
12
HESL31
BT costs
16
16
HESL32
Resource to ensure delivery on investments
12
12
HESL33
Local delivery of national commitments
12
12
HESL34
Service leads influence on education
9
9
HESL35
Lifelong learning
9
9
HESL36
Workforce Development allocation
12
12
HESL37
Lead Providers alignment
12
12
HESL38
London/KSS geography
9
9
HESL39
Lead Provider maturity
8
8
HESL40
Quality groups
8
8
HESL41
Undergraduate quality management
9
9
HESL42
OPS01
HEE BUDGET ALLOCATION METHODOLOGY (16/17)
Oriel recruitment system
20
20
20
15
HR01
Further organisational change across HEE (Beyond Transition (BT) review)
12
16
FIN03
NIHR
9
9
FIN04
Less than Full Time Trainees (LTFTs)
9
9
FIN01
Procurement
9
9
FIN07
FIN08
GPR Salaries
Beyond Transition - Outflow of Finance expertise
9
12
9
16
Risk# is a unique identifier which includes the source (HESL, Operations, HR, Finance)
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PM Score
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Risk Movement Since Last BAF
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Original Score
DELIVERY PLAN CHAPTER ALIGNMENT
10
12
9
9
8
8
4
4
3
12
12
8
6
4
4
12
8
4
6
6
8
4
4
2
2
2
15
12
12
6
6
4
6
16
11/09/2014
HESL BOARD ASSURANCE FRAMEWORK
HESL BOARD ASSURANCE FRAMEWORK
RR#
Description
DELIVERY PLAN OBJECTIVE # 5
HESL26
TRANSITION TO EDUCATION TARIFFS
The introduction of tariffs for education and training will lead to significant
price-based income losses in some providers, which may then be further
exacerbated through (i) volume reductions as part of a national
redistribution of training and (ii) further price changes as a consequence of
the collection of education reference costs. This may then be sufficiently
destabilising to reduce local training placement capacity and potentially
undermine recruitment to the local workforce.
DELIVERY PLAN OBJECTIVE # 9
Score
This will mean reduced management and clinical leadership support to
the Board as the new leadership structure embeds.
PM
score
Assurance
Gaps in Assurance
Action to Address Gaps in Assurance
Education: The education we commission will be targeted at the needs of our population rather than those of any individual organisation
or profession. This includes needs identified nationally in the HEE Mandate as well as those identified locally.
16
• Regular liaison with providers and presentations to provider
staff to help them fully understand the impact of both tariff and
reference costs.
• Shadow and first cut actual postgraduate medical tariff
circulated to all south London Providers.
• Engagement with wider finance group of stakeholders
through LDA quarterly fora, to be extended through specific
regular finance stakeholder meetings.
• LETB resources allocated to all providers in support of
collection of education reference costs.
12
• Undergraduate medical and non-medical tariffs
implementated commencing 1 April 2013.
• Shadow postgraduate medical tariff impact
provided to all south London Providers during
2013/14 and actual tariff implemented with effect
from 2014/15 Q1 LDA.
• Finance stakeholder group not yet in place, Stakeholder group in process of being
as decision made to delay this until the
formed. First meeting after current
results of the August 2014 reference costs reference costs submission.
collection available.
• Lack of clarity around HEE timescale for
introduction of reference cost based tariffs.
• No firm planning assumptions on tariff
price movements beyond current year.
Leadership: The involvement of a wide range of partners in the planning and commissioning of education and training will ensure that our
work remains relevant to the delivery of healthcare services now and in the future.
Ensuring LETB teams have clear delivery plans and
objectives
Business Continuity planning
Support for senior staff through transition; access to resilience
training etc. and readiness for applying for new roles
BEYOND TRANSITION PROGRAMME - REDUCED LEADERSHIP
There will be a change in staff in the leadership of the LETB. A change in
senior leadership capacity may impact business continuity, delivery of
mandate priorities, implementation of the delivery plan, and compromise
stakeholder engagement.
HESL30
Mitigation Actions
16
Regular staff briefings and team meetings
Ensure senior team personal futures discussions
are prioritised
Seek clarity on senior staff plans to support
managed exits
None
n/a
12
Membership of the Board and stakeholder groups may fall away due to
the uncertainty of leadership.
DELIVERY PLAN OBJECTIVE # 10
FIN08
Beyond Transition - Outflow of Core Business expertise
Risk of stretched resource in core business (i.e. operations, finance), due
to uncertainty regarding Beyond Transition and high vacancy rates (e.g.
25-30% currently in Finance). Further leavers could destabilise operational
delivery. This is historically a particular problem for London
Making It Happen: Together with our partners, we will provide coherent system leadership for workforce development, and education and
training in South London.
16
Oriel recruitment system
The September 14 release of new national e-recruitment system, Oriel,
does not provide the same level of functionality as the legacy system in
London. This means that more costly work arounds and significant
changes to process will be required for London, for example a significant
increase in staffing levels and weekend working.
15
OPS01
DELIVERY PLAN OBJECTIVE # 11
HESL23
HEE BUDGET ALLOCATION METHODOLOGY (2015/16)
Although comprehensive HEE allocation methodology now appears
unlikely to be applied for 2015/16, a resource reduction of £2.2m will be
applied to Workforce Development funding. There is also a risk of
reduced resources based on the outputs of HEE financial modelling/HESL
forecast outturn.
Present powerful cases for staff retention/recruitment to HEE.
Utilise agency staff where possible in interim to maintain
service continuity while awaiting further clarity on BT.
Seek delegation of vacancy controls back to local level, once
new senior management structure in place.
Senior members of the Operations team and HENWL
Infomation team, are actively working with the central HEE
project team and represent London on many Oriel related
groups/boards. The London team have contributed 780+ days
to national testing. There is daily interaction with the HEE
project team and approximately 80 WTE days per week are
spent on the project from within the Operations department
from August. The team has been working with the Oriel
system supplier (HICOM) to identify the functionality gaps in
order to 1. influence system development for September 14
and 2. better understand the impact of the reduced system
functions.
16
12
A London Transition to Oriel Board has been
assembled to meet fortnightly with Julie Screaton
as Senior Responsible Officer. The Deputy Director
of Operations continuously monitors potential
operational risks and where there is no central HEE
remedy provided, will escalate through the London
Transition to Oriel Board, which reports monthly to
LEG, and also the HESL Operations Committee.
The Information Team has also raised a risk
pertaining to Oriel with HE NWL and it is being
escalated via HE NWL to HEE. The national project
team and HICOM are responding positively to
system developments requested by London. The
system went live nationally on schedule on 1
September with no immediate issues and with
additional funding secured from central HEE to
cover additional administrative costs.
The HEE risk register rates the risk
associated with the Oriel implementation
nationally as amber. There is concern that
the impact of the reduced system
functionality across London may not be fully
understood by the central HEE team.
The Deputy Director of Operations in HESL
and the Director of information in HENWL
contacted Patrick Mitchell, Director of
National Programmes for HEE to discuss
the concerns. It was agreed that a member
of Patrick's team would attend future
meetings of the London Transition to Oriel
Board to hear, discuss and advise on
London's concerns. A representative
attended the meetings since 25 June 2014.
Finance: to support the delivery of the action priorities identified in the business plan and HEE Mandate, within the resources available to
the LETB.
20
• Rigorous budget management to ensure that all HESL
resources are deployed effectivelyin the delivery of HESL
objectives.
• Engagement nationally to ensure HEE financial model is fit
for purpose and reflects all costs borne by HESL.
• Representation of London LETBs on national working
groups and the national Resource Steering Group (RSG)
15
• Regular report to Board on progress on allocation
methodology and risks involved.
• Breakeven 2014/15 LETB forecast outturn on
programme spending.
• 2014/15 LETB budget not yet fully
Ongoing analysis to reiteratively review
committed, due to uncertainty around level spending and implement strategic
of flexibility available
investments accordingly.
• 2015/16 LETB budget may include shadow
reductions, although it is uncertain how this
will impact on local spending (if at all)
11/09/2014
HESL BOARD ASSURANCE FRAMEWORK
HESL BOARD ASSURANCE FRAMEWORK
RR#
Description
Score
HEE BUDGET ALLOCATION METHODOLOGY (2016/17)
The revision of the HEE model for allocation of budgets to LETBs for
2016/17 and beyond could potentially result in a London-wide reduction of
approx. £100m-£200m p.a. This would represent a very significant impact
on commissioning and planning for 2016/17 onwards and have significant
implications for HESL capacity to support transformation and
development.
20
HESL42
DELIVERY PLAN OBJECTIVE # 12
HESL30
BEYOND TRANSITION PROGRAMME - REDUCED LEADERSHIP
16
16
Further organisational change across HEE (Beyond Transition (BT)
review)
The phase 2 functions review creates a risk of further structural change
which could increase turnover of staff in business critical operations
HR01
• Engagement with HEE through key national groups (SLT,
HoFs, DEQs).
• Engagement with the London Health Board and more widely
with South London membership to ensure the impact of any
funding reductions are widely understood.
• Representation of London LETBs on national Resource
Steering Group (RSG)
• Representation of London LETBs on national financial
modelling working group and engagement nationally to
ensure HEE financial model is fit for purpose and properly
reflects all costs borne by LETBs.
• Development of a contingency plan to address a range of
possible financial scenarios
• Nationally funded project led by HENWL has demonstrated,
from postgraduate destination information, the degree of
migration currently being experienced across England and the
need to ensure that this is recognised as part of the work on
allocation methodology
PM
score
Assurance
Gaps in Assurance
Action to Address Gaps in Assurance
• Updates on HEE Resource Steering Group in MD
Report
• HEE recognition that further work needed before
implementation, as evidenced by:
* Potential delay in introduction of main changes
until 2016/17
* National funding of further research led by
HENWL
• Formal contingency plan not yet in place
• Evidence to support development of local
case - including detailed financial analysis still to be fully assembled
• Suitability of new national model to support
allocation changes not yet demonstrated
• Scope of likely change not yet established
• Board familiarity on financial planning
issues
• Exec Team to draft contingency plan for
Board approval (informed by previous Board
discussions)
• Nationally funded project to gather
evidence on postgraduate migration broadly
complete
• Regular feedback being submitted on
developing proposals and future
development of financial model
• Board seminar to be scheduled for the
Autumn
15
Supporting/Enabling Delivery: Ensuring organisational form is fit for purpose to maximise delivery potential. Includes governance,
resources, infrastructure, etc..
BEYOND TRANSITION PROGRAMME - COST OF IMPLEMENTATION
TO LETBS
Risk that one-off costs of implementation of Beyond Transition are (as yet)
unknown and may not be fully funded by additional allocation from DH.
HESL31
Mitigation Actions
16
See Objective 9 for details
Reduce current running costs spending through nonrecruitment to vacancies, in order to reduce potential
redundancy costs and generate LETB savings to cover
potential requirement to fund at least a share of the one-off
costs of organisational change.
Develop, consult upon and implement revised structures as
required for Beyond Transition Phase 2.
Clear timetable in place
Regular and consistent staff communication
Consultation and engagement with HEE about the proposed
changes
Visible leadership
HESL SLT to monitor staff engagement
Staff resilience training
Continuing positive engagement with staff and Trade Unions.
Ensure focus on OD plan and 2013 staff attitude survey action
plan
12
Running cost budget £46k underspent as at month
4 and forecast to be £488k underspent by year end.
Vacancy controls in place at both local and national
level.
12
Staff feedback (ongoing)
Monitoring turnover and sickness absence
Performance of delivery reported to the Board
12
Unclear whether DH will fund one-off costs
of Beyond Transition or how costs will be
shared between LETBs, if HEE has to fund
from within existing allocation.
Pace of change to new structures will be
nationally coordinated, and may therefore be
independent of speed of local decision
making.
National HR Framework still being
developed
Final picture is not yet known – phase 2
plans will go out to consultation in October
Monitoring staff suggestion schemes and promoting 2014.
the use of the BT mailbox to allow staff to voice
concerns
Influence through BT advisory group and
national HR meetings

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