North East Essex Clinical Commissioning Group

Governance Assurance Framework

Document Information

Reference: / NEE/CCG/2013/049
Version: / 3.0
Approved by: / Audit Committee
Date Approved: / 13 January 2018
Name of Original Author: / P Lansdown
Review Frequency: / Bi-Annually
Review Date: / November 2019

Amendment History

Version / Date / Reviewer Name(s) / Comments
1.0 / 2013 / P Lansdown / Document produced
1.2 / 16/09/2014 / P Lansdown / Policy reviewed.
1.3 / 20/02/2015 / P Lansdown / Comments from Audit Committee reflected within and paragraph added to 8.1.4 re Board responsibilities and use of checklist within Appendix 1.
1.4 / 05/03/2015 / P Lansdown/ Corporate Support / Amendments made to Appendices/Appendix 5 updated. Version amended to 1.5
2.0 / November 2015 / CorporateChief Finance Office, Business Manager & Corporate Services Officer / Policy review undertaken.
Role of Lay Member added under section 19.
2.1 / April 2017 / Corporate Services Officer / Appendix 4 updated
3.0 / January 2018 / Director of Resources / Review undertaken and updated
Section: / Description / Page number
1 / The NEE CCG Our Vision & Values / 4
2 / Introduction
2.1 Why we need Good Governance / 5
3 / The NEE CCG Governance Assurance Framework / 6
4 / Accountability / 7
5 / Transparency / 9
6 / Probity / 10
7 / Governance Arrangements within the NEE CCG 7.1 The NEE CCG Constitution / 11
11
8 / Delivery of Good Governance Assurance within the NEE CCG
8.1 Corporate Governance
8.1.1 The Governing Body (Board)
8.1.2 The Operation of the Governing Body
8.1.3 The Governing Body Decision Making Process
8.1.4 Governing Body Training & Development
8.1.5 Committees of the Governing Body / 12
12
12
13
14
15
15
9 / The Monitoring & Management of Risks to Quality / 16
10 / Performance Reporting, Analysis & Management
10.1 Performance management / 17
18
11 / The Reporting Process / 19
12 / Clinical Governance
12.1 Clinical Performance & Monitoring / 19
19
13 / Patient Experience & Patient & Public Engagement
13.1 Patient & Public Communication / 21
22
14 / Financial Governance
14.1 Internal & External Audit / 23
23
15 / Information Governance / 23
16 / Research Governance / 24
17 / Policies & Procedures / 25
18 / The NEE CCG Standards of Business Conduct & Conflicts of Interest
18.1 Managing Conflicts of Interest, Gifts, Hospitality and Sponsorship Policy
18.2 Anti-Fraud & Anti-Bribery / 25
26
26
19 / Responsibilities of Key CCG Roles
19.1 Chair
19.2 Accountable Officer
19.3 Chief Finance Officer
19.4 Lay Members / 27
Appendices
Appendix 1 Governance Check List
Appendix 2 Board Challenges & Prompts
Appendix 3 References & Links for Further Reading
Appendix 4 The NEE CCG Governance Structure
Appendix 5 The NEE CCG Performance Management Process Framework / 30
37
40
41
42

CONTENTS PAGE

1.THE NORTH EAST ESSEX CLINICAL COMMISSIONING GROUP (THE NEE CCG) - OURVISION AND VALUES

Our vision is “Embracing better health and wellbeing for all.” Even though we will focus on priority groups within North East Essex, everybody should be able to expect an improved level of health and wellbeing from the services we commission.

We want to work in partnership with public, patients and carers in North East Essex to help them have greater choice, control and responsibility for health and wellbeing services: -

People will be encouraged and supported to look after their own health and social care needs
Carers will receive the support they need
Patients, public and community groups will take up opportunities to be involved in planning and developing services
Services will be centred around the patient and will be high quality, evidence-based, cost effective and sustainable
People will receive seamless and joined up services across their health and social care needs.

We are committed to commissioning services which are equitable, inclusive and sustainable.

The values that lie at the heart of the work of the CCG are: -

Integrity – We will work in the spirit of public service, professionalism and selflessness to serve our local population
Inclusiveness - Our commissioning will be driven by the health needs of the whole population. We will prioritise our commissioning towards work which delivers the greatest improvements in health and the best possible experience for all people throughout their care and treatment
Improvement - Our communities require high-quality services. This means services which are safe, personalised and deliver good clinical outcomes. We will seek to continually improve quality wherever possible and to embrace innovation to achieve this
Patient-centred – We will ensure that services respond to people as individuals, involving them in their individual care decisions and also in the planning of services

We are committed to delivering the pledges of the NHS Constitution and upholding its values.

2.INTRODUCTION

2.1 Why we need good governance

Over the past few years, a number of high profile events have resulted in an increased focus on quality and the way we do things; the Francis Inquiryand the Keogh Review findings have resulted in recommendations for improving earlier detection and faster response to poor performance and potential risks to quality and safety. The reports also stressed the importance of listening to, and heeding, the patient voiceand being open when things go wrong.

The NEE CCG is a statutory organisation and as such must discharge the following duties:

To demonstrate value for money and adhere to procurement regulations
To adhere to equality legislation
To stay within set revenue and capital resource limits set for the financial year and break even each financial year.

The importance of good governance

Good governance is important:

To patients – because they depend on the quality of judgements that the NEE CCG takes

To the public – as it will give them confidence that the best decisions are being taken for the right reasons, that the quality of healthcare services is protected and that public money is being spent wisely

To clinicians – because it supports them to make the best possible decisions, reduces the likelihood of things going wrong and protects them in the event that things do go wrong.

The core components of good governance are:

CorporateGovernance

Is the principal mechanism through which the NEE CCG will bring together all the requirements of how we need to work and will provide the Governing Body(Board) with assurance that we are meeting all of our obligations and managing risk appropriatelyand effectively. It provides a system for overseeing all the elements of the integrated governance framework and ensures the CCG discharges all of its statutory and accountability requirements in a co-ordinated way

Clinical Governance

Is the statutory duty to secure continuous improvement in the quality and outcomes of the services the NEE CCG commissions and safeguarding high standards of care. Effective governance will create an environment in which excellence in clinical care and care quality will flourish

Financial Governance

Is the day-to-day financial control of the organisation and the effective stewardship of public funds required for the delivery of high quality healthcare services

Information Governance

Supports the provision of high quality care through the effective and appropriate use of information. It provides a set of rules with which the NEE CCG must comply in order to maintain comprehensive and accurate records and includes keeping those records confidential and secure

Research Governance

Research and development is a core function of the NHS and leads to benefits for health, public health and the national economy. The Department for Health expects NHS organisations who are considering giving permission for research to take place to manage any significant risks to patients, users and all relevant stakeholders

3.THE NEE CCG GOVERNANCE ASSURANCE FRAMEWORK

The NEE CCG Governance Assurance Framework defines arrangements intended to provide a foundation of excellent governance to enable the NEE CCG to lead changes in the way NHS services are planned, delivered and experienced.

The Framework sets out the principles and methods the NEE CCG will adhere to in delivering its roles and functions. It also sets out the procedures by which the Board will operate, be governed and held to account on how we conduct our business. The Framework describes how we embed our commitment to openness and how we make ourselves accountable to the people and communities we serve.

The function of good governance is to ensure that an organisation fulfils its overall purpose, achieves its intended outcomes and operates in an effective, efficient and ethical manner.

The underlying principles of all good governance are:

Accountability
Transparency
Probity
Focus on the sustainable success of an entity over the longer term

Some of the most notable governance and organisational failures can be linked to a failure to adopt these principles – for example at Mid Staffordshire NHS Foundation Trust a lack of accountability and transparency led to a failure of care to their patients, a culture of tolerance to poor standards and consequently undermined public trust.

These core principles represent the ‘spirit’ of good governance. While codes of governance can set out good practice in critical areas, the lessons from those organisation that have failed is that following the spirit of the guidance is just as important.

Within the NEE CCG Constitution, it states in clause 3.4 that the group will at all times observe “such generally accepted principles of good governance” in the way it conducts its business. These include:

The highest standards of propriety involving impartiality, integrity and objectivity in relation to the stewardship of public funds, the management of the clinical commissioning group and the conduct of its business
The good governance standards for public services
The seven key principles of the NHS Constitution
The standards of behaviour published by the Committee of Standards in Public Life (1995) known as the ‘Nolan Principles’
The Equality Act 2010

4.Accountability

The CCG has stated in its Constitution that it will demonstrate its accountability to its members, local people, stakeholders and NHS Englandin a number of ways including:

Publishing its Constitution, Standing Orders and Standing Financial Instructions
Appointing independent lay members and non-GP clinicians to its Governing Body
Holding meetings of its Governing Body in public
Complying with local authority health overview and scrutiny committee requirements
Publishing an annual report, annual accounts, annual commissioning plan and holdings the Annual General Meeting in public
Having a published and clear complaints process which complies with the NHS Complaints Regulations
Complying with the Freedom of Information Act 2000
Providing information to NHSEngland as required
Publishing its principal commissioning and operational policies
Tasking the Governing Body to have an on-going role in reviewing the Group’s governance arrangements to ensure that it continues to reflect the principles of good governance.

The CCG is held to account in a variety of ways, both formally and informally.

The primary, formal line of accountability is toNHS England. NHS England has recently published its CCG Improvement and Assessment Framework (IAF) for 2017/18.It builds on the IAF introduced in April 2016, which replaced both the CCG assurance assessment and CCG performance dashboard and provides a greater focus on assisting improvement, alongside NHS England’s statutory assessment function. The IAF is intended as a focal point for joint work, support and dialogue between NHS England, CCGs, and Sustainability and Transformation Partnerships (STPs).It aligns key objectives and priorities, and informs the way NHS England managesits relationships with CCGs. It has been designed to supply indicators for adoption in STPs as markers of success.

NHS England has a statutory duty to conduct an annual performance assessment of every CCG.The annual assessment will be a judgement, reached by taking into account the CCG’s performance in a set of indicator areas over the full year and balanced against the financial management and qualitative assessment of the leadership of the CCG.

Leadership will be assessedon the extent to which a CCG demonstrates:

- probity and good corporate governance;

-workforce engagement;

- effective of working relationships in the local system;

- patient and community engagement;

- quality of leadership.

As a public body the CCG is accountable to our local population and community.

There is a strategic alignment with the Essex Health and Wellbeing Board.

There is mutual accountability between the CCG Governing Body and our member practices. This arrangement is detailed in the Memorandum of Agreement (set out in the Constitution, Appendix 9).

There is a commissioning relationship between the CCG and the North-East London Commissioning Support Unit (NEL CSU). This arrangement is detailed in the Service Level Agreement.

Board to Board meetings will take place with key partners in the wider health system, for example, with Colchester Hospital University NHS Foundation Trust (CHUFT) and Essex Partnership University NHS Foundation Trust (EPUT), to scrutinise on-going work and to build strong relationships.

5.Transparency

North East Essex CCG has made a commitment through its Constitution to promote an open and transparent approach.

All communications issued by the group, including the commissioning plan, annual report, notices of procurements, public consultations, reports, Governing Body meeting dates, times, venues and papers are published on the NEE CCG website:

The terms of reference of the CCG Board and sub-committees have been published and are appendices to the Constitution.

As part of the Constitutionthe CCG has published its:

Standing Orders – which set out the arrangements for meeting, the appointment processes to elect the group’s representatives and appoint to the group’s committees, including Governing Body
Scheme of Reservations and Delegation – which sets out those decisions that are reserved for the membership as a whole and those decisions that are responsibilities of the Governing Body, its committees and sub-committees, individual members and employees
Standing Financial Instructions – which set out the arrangement for managing the group’s financial affairs.

Meetings of the Governing Body will be held in public and will meet at least 6 times per year. Every board member will be given at least 14 days’ notice to attend.

Employees, members, committee and sub-committee members of the group and members of the Governing Body (and its committees) will at all times be fully conversant and aware ofthe Constitution and the group’s policies on Business Conduct, Conflicts of Interest, Hospitality, Gifts and Sponsorship, andthe requirements of Managing Conflicts of Interest in the NHS – Guidance for staff and organisations and Managing Conflicts of Interest: Revised statutory guidance for CCGs (2017). They should act in good faith and in the interests of the group and should follow the Seven Principles of Public Life (Nolan Principles).

As stated in the Constitution the group recognises the importance in making decisions about the services it procures in a way that does not call into question the motives behind the procurement decision that has been made. Procurement guidance and legislation calls for all commissioning organisations to procure services in a manner that is open, transparent, non-discriminatory and fair to all potential providers. All employees, members, committee and sub-committee members of the group and members of the Governing Body (and its committees) are expected to comply with the Constitution and the group’s policies on Procurement and Competition Disputes.

6.Probity

Probity is the principle of having strong moral standards and leadership based on honesty and decency. It is the responsibility of the NEE CCG Governing Body to make sure that probity is maintained. The Managing Conflicts of Interest, Gifts, Hospitality and Sponsorship Policy has been approved and adopted by the NEE Governing Body which clearly states the group’s standards of conduct in such matters for all members of staff, members, committee and sub-committee members of the group and members of the Governing Body (and its committees).

The Nolan Principles have been adopted by the NEE CCG as part of its Constitution which clearly states that the group will work within the standards of behaviour published by the Committee on Standards in Public Life (1995) known as the ‘Nolan Principles’:

Nolan Principles

Selflessness Holders of public office should act solely in terms of the public interest. They should not do so in order to gain financial or other benefits for themselves, their family or their friends
Integrity Holders of public office should not place themselves under any financial or other obligation to outside individuals or organisations that might seek to influence them in the performance of their official duties
Objectivity In carrying out public business, including making public appointments, awarding contracts, or recommending individuals for rewards and benefits, holders of public office should make choices on merit
Accountability Holders of public office are accountable for their decisions and actions to the public and must submit themselves to whatever scrutiny is appropriate to their office
Openness Holders of public office should be as open as possible about all the decisions and actions that they take. They should give reasons for their decisions and restrict information only when the wider public interest clearly demands
Honesty Holders of public office have a duty to declare any private interests relating to their public duties and to take steps to resolve any conflicts arising in a way that protects the public interest
Leadership Holders of public office should promote and support these principles by leadership and example.

The CCG Governing Body and its committees have all adopted the key principles of:

Clinical Commissioning must be focused on individual needs and promote the health and wellbeing of communities, as well as addressing health inequalities
Clinical Commissioning must work in the spirit of public service, professionalism and selflessness to serve our local population
Clinical Commissioning should be driven by the health needs of the population, prioritising our commissioning towards work which delivers the greatest improvements in health and the best possible experience for all
Clinical Commissioning will seek to continually improve quality wherever possible and to embrace innovation to achieve this, within available resources and ensuring value for money
Clinical Commissioners must be drivers of strong clinical leadership and enablers of clinical empowerment.

In summary, good governance flows from a shared approach or culture as well as systems and structures. It cannot be reduced to a set of rules or achieved by compliance with a set of requirements. The spirit and ethos of good governance must be expressed as values and demonstrated as behaviours.