APPROVED

NHS Grampian (NHSG)

Minute of the Audit Committee Meeting

Thursday 6 May, 1000-1300

Conference Room, Summerfield House

Present

Cllr Bill Howatson, Chair

Mr Charles Muir, Non Executive Director, NHSG

Mr David Anderson, Non Executive Director, NHSG

Dr David Cameron, Chairman, NHSG

Mr Gordon Stephen, Employee Director, NHSG

In Attendance

Mr Richard Carey, Chief Executive, NHSG

Mr Alan Gall, Finance Director, NHSG

Mr Garry Kidd, Interim Assistant Director of Finance, NHSG

Mr Alan Gray, Director, PricewaterhouseCoopers (Chief Internal Auditor)

Mr Stuart Sands, PricewaterhouseCoopers

Mr David McConnell, Audit Scotland (External Auditor)

Ms Helen Cobb, Audit Scotland (External Auditor)

Mr Gary Mortimer, Acting Director of Facilities, NHSG - Item 6

Mr Andrew Jackson, Legal Adviser, NHSG – Item 7.1

Mr Graeme Smith, Head of Service Development, NHSG - Item 7.2

Mr Andrew Fairhead, Medical Physics, NHSG - Item 7.3

Mr Steve Glass, Head of Procurement, NHSG - Item 8

Ms Helen Robbins, Head of Clinical Governance/Risk Management , NHSG - Item 11

Miss Anne-Marie Meconi, Minuting

Item / Subject / Action /
1 / Apologies and Welcome
Cllr Howatson welcomed Mr Garry Kidd, Interim Assistant Director of Finance, NHSG, who had taken over from Mr Barry Jenkins.
Apologies were received from:
Mr Terry Mackie, Non Executive Director, NHSG
2 / Minute of Meeting held on 3 March 10
The Committee approved the Minute.
3 / Matters Arising
3.1 / Action Log of 3 March 10
The Committee noted the Action Sheet and closed off items apart from the following:
09 09 09 - Item 8 - Backlog Maintenance: Mr Mortimer to continue to attend meetings at six monthly intervals.
26 06 09 - Item 5.2 - SFR 18.0 Loss Statement: Mr Kidd to provide a covering note with the purpose of SFR 18.0 and 18.1c for the June 2010 Committee meeting.
09 09 09 - Item 4.2 - Information Management - Best Value: Review of Resources: Mr Gall to arrange for the development of an action plan to be considered at the next meeting of the Operational Management Team.
02 12 09 - Item 5.4 - Efficiency and Productivity Project Management Office (EPPMO) Mr Gall to update the Committee at every meeting.
02 12 09 - Item 6.1 - Single Tender Register - Estates Update on Woodend Fire Precautions Work Mr Gall to seek clarification on the legislative issues from Aberdeen City Council and update the Committee at the June 2010 meeting.
The Committee noted the Action Sheet.
4 / External Audit Update – Audit Scotland
4.1 / Internal Control Letter
Mr McConnell said that Audit Scotland were required to report disclosures made in the Statement on Internal Control and make an assessment on whether they meet the requirements of the Scottish Government Health Directorates, were misleading or inconsistent with the information which Audit Scotland had available from normal audit work. Mr McConnell said that from the audit work to date, Audit Scotland had not identified any potential issues for management to consider for disclosure in 2009/10. Mr McConnell explained that a number of control issues arose during the course of the testing on the Boards financial systems. These issues together with the management response were detailed in the copy letter circulated with the agenda.
Mr Anderson asked if there had been further investigation into each of the specific instances identified for example, where the batch header for a debtor request form was not signed.
Ms Cobb replied that more substantive testing was carried out in each instance and although the control check in these instances had not been carried out the actual transaction was found to be valid.
Mr Kidd said that clearly the control checks were there to provide assurance and should be consistently applied. Management in payroll, procurement and finance have provided their responses to the issues and will take appropriate action in their areas to tighten these controls. As a secondary issue, a review of the control issues raised had identified that in several instances managers had signed off amendments to payroll or authorised expenditure believing they had authority within the scheme of delegation when none existed. These issues were arising for example when a manager leaves and was replaced or promoted and the change was not notified to the Finance Department.
Mr Gall said it was important to ensure that we had good liaison between different departments to ensure that the Scheme of Delegation was up to date.
Cllr Howatson asked about "item 9 - a member of staff authorising his own timesheet". Ms Cobb said that that had been followed through and was found to have only been a single instance.
Mr Kidd and Mr Gall to review current arrangements for maintenance and update of the Scheme of Delegation.
The Committee noted the Report. /
GK/AG
5 / Internal Audit
5.1 / Internal Audit Progress Report
Mr Gray went through the report which was to highlight key findings arising from the Internal Audit reports completed and issued since the last Committee meeting in March.
Review of VS/VERS update - Mr Gray said that the findings were presented at the last Committee meeting and since then MrMarkSinclair, Head of HR, NHSG, had presented the report to the HR community across Scotland. The Scottish Government had not agreed to an extension to the variation order that applied in 2009/10.
Mr Gall said that the VERS scheme was no longer acceptable to the Scottish Government as it was slightly outside national conditions and they were nervous about taking this forward even though they had thought it was value for money and they were happy with the way it was handled.
Mr Gray to keep in touch with Mr Sinclair as national discussions progress.
Vaccinations and immunisations - Mr Gray provided an update on the audit ongoing in relation to the processes and oversight arrangements in respect of payments made to GPs by NHSG (under a Directed Enhanced Service contract) to deliver the pre-school vaccinations and immunisations programme. Mr Gray reported that the initial audit work had focused on considering the extent to which a sample of NHSG health visiting teams is involved in supporting GP practices deliver pre-school vaccinations and immunisations programme.
Mr Kidd highlighted that the guidance on implementation of HALL 4 (Health For All Children) the most recent report from the Royal College of Paediatrics and Child Health suggests that vaccinations and immunisations should be co-ordinated by health visiting staff.
The Committee considered the update from Mr Gray who commented that the next phase of work would be extended to a further sample of health visiting teams. Mr Carey said that the complexities around the payments for and resourcing of the pre-school vaccinations and immunisations programme was a matter for all NHS Boards.
After due discussion the Committee supported the ongoing audit review and agreed that they would await the outcome of the final audit before deciding whether this matter required to be reported as a significant audit issue to the Scottish Government Health Directorate.
Mr Kidd confirmed that he had arranged to meet with DrPaulineStrachan, Chief Operating Officer, NHSG and Mrs Elinor Smith, Nursing Director, NHSG, in order to agree a way forward. The outcome of this meeting would inform the next phase of the audit.
Mr Kidd to liaise with Dr Strachan, Mrs Smith and Mr Gray to agree a way forward
Pharmacy dispensing - Woodend Hospital - A review of the controls around the dispensing of drugs had taken place at the request of management. The findings had now been reported to pharmacy staff at Woodend and an initial management action plan had been agreed.
Mr Gray to report back to the next Committee meeting.
Information technology general controls - Mr Sands went over
this part of the paper which detailed the review which was to assess the controls in place over the use of information technology systems. Page 5 stated the high priority recommendations which management were considering and a draft action plan was being developed to address them.
Dr Cameron said that at 2.08 he was concerned about the 13 instances where the users (Consultants) had self-authorised the request and accessed sensitive information.
Mr Gray said that the people were not inappropriate users and they needed the information for clinical care. This system was widely used and tighter controls were needed to ensure staff were authorised through an access request form or in the Consultants cases a peer's signature. Alison Hawkins, General Manager for e-Health had developed an action plan.
Mr Gray to report back to the next Committee meeting on progress
Internal communications - NHSG employs 17,000 staff in different locations across Grampian and it was essential that an effective way to communicate key messages to them was in place.
The conclusion was that NHSG was well organised and structured although the Team Brief could work better and be used more effectively.
Mr Stephen said that the staff survey indicated that staff welcomed the face to face meetings. But we needed to improve on team brief. Face to face roadshows were well attended particularly the one on pension choice. Team Brief was the right way to communicate some of the more difficult messages to staff.
Mr Muir asked if there were particular groups of staff because of their hours or locations more difficult to reach. Mr Stephen said that there were management structures in place which could be built upon for improvement for this not to occur.
The Committee noted the Report. / PWC/MS
GK/PS/
ES/PWC
PWC
PWC
5.2 / Internal Audit High Priority Recommendations
Mr Gray outlined the report which was to provide a summary of progress made in relation to the implementation of high priority internal audit recommendations.
Nurse bank arrangements - There was a lot of work ongoing in this area ie the Safe Affordable Nursing Establishment (SANE) project to review nursing establishments.
Dr Cameron asked if the deadline set for completing the amalgamating of all the individual nursing bank arrangements into a single nurse bank was still 30 April.
Mr Gray said he would confirm and communicate the deadline to Committee members.
Mr Carey said that there had been continuing significant reductions in using bank and agency nursing staff due to the enhanced controls now in place.
Waiting time payments - Mr Gray said that the recommendation that additional payments to certain Consultants would be discontinued until appropriate controls and processes were in place had been implemented within the Maxillo Facial service. He reported that action had been effective and he had been pleased with the response from management.
Dr Cameron said that he was pleased with progress in this specific area and in the work to introduce similar controls across the whole service.
Mr Carey said that this had improved and that he was taking a personal interest in this.
Mr Gall said that a recent report from the Access Unit had commended NHSG for the local approach to the delivery of waiting targets as a component of core service delivery without the use of specific targeted waiting times initiatives. NHSG had received additional funding as a result of this.
The Committee noted the Report. / PWC
6 / Back-log Maintenance Update
Mr Mortimer went through his summary report relating to the backlog position which was assessed using relevant historical data, asset surveys and professional judgements. As at 1 March 2010 the assessed backlog across the three surveyed facets (physical condition, statutory standards and energy performance) totalled £118m. This compared favourably to the backlog level in previous years.
The HEI inspection at ARI had highlighted significant issues and challenges with the physical environment that are not within the current backlog plan. An HAI risk based approach had been taken and this had identified high priority categories. The approach had been welcomed by the HEI inspectors. These priorities will now be included in future backlog investment plans. Currently an investment of approx £12m was needed to address the findings of the initial acute sector audits. £2.5m was needed to address the elemental priorities assessed by Senior Charge Nurses.
Mr Carey thanked Mr Mortimer for his update and asked is it is possible to quantify the impact of the planned major capital investment in for example the Emergency Care Centre (ECC) on the assessed backlog. Mr Mortimer said that if all planned schemes progress to implementation this will reduce the backlog by circa £70m.
Mr Mortimer to be invited back to the December meeting to give a further update to the Committee. / GM/GK
7 / Single Tender Register
7.1 / Review of Single Tender Register
Mr Jackson said that there were four new additions to the register since the last meeting. The two most significant items had been selected for review and the responsible manager requested to attend this meeting.
There followed some discussion on the process and the following actions were agreed:
- For future meetings, in addition to a copy of the Register, the Committee required to see all of the relevant backing papers to each single tender authorised in that period.