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  • NHS Nottingham North and East CCG NHS Nottingham West CCG NHS Rushcliffe CCG

    Primary Care Quality

    Monitoring

    Final Report

    Internal Audit

    September 2017 1718/NNECCG/03 1718/NWCCG/03 1718/RUSCCG/03

    elstvic Typewritten Text RCCG/PCCC/17/047

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    Table of Contents

    Heading Page

    Executive Summary 1

    Findings & Recommendations 4

    Appendix A – Risk Matrix & Opinion Levels 10

    Distribution

    Name For Action For Information

    Nichola Bramhall , Director of Nursing and Quality (South Nottinghamshire CCGs)

     

    Esther Gaskill, Head of Quality, Patient Safety & Experience (South Nottinghamshire CCGs)

     

    Sam Walters, Chief Officer (Nottingham North and East CCG)  

    Vicky Bailey, Chief Officer (Nottingham West and Rushcliffe CCGs)  

    Jonathan Bemrose, Chief Finance Officer (South Nottinghamshire CCGs)

     

    Key Dates

    Report Stage Date

    Discussion Draft Issued: 22 August 2017

    Exit Meeting: 29 August 2017

    Final Draft Issued: 4 September 2017

    Client Approval Received: 4 September 2017

    Final Report Issued: 5 September 2017

    Contact Information

    Name / Role Contact details

    Tim Thomas, Director, 360 Assurance tim.thomas1@nhs.net  0116 225 6114

    Claire Page, Client Manager claire.page9@nhs.net  0115 883 5311

    Kristina Dickinson, Assistant Specialist Services Manager – Clinical Quality

    kristina.dickinson@nhs.net

     07342 072951

    Michelle Dixon, Audit Principal michelle.dixon3@nhs.net  01709 428714

    Reports prepared by 360 Assurance and addressed to NHS Nottingham North and East CCG, NHS Nottingham West CCG and NHS Rushcliffe CCG directors or officers are prepared for the sole use of the NHS Nottingham North and East CCG, NHS

    Nottingham West CCG and NHS Rushcliffe CCG, and no responsibility is taken by 360 Assurance or the auditors to any director or officer in their individual capacity. No responsibility to any third party is accepted as the report has not been prepared for, and is not

    intended for, any other purpose and a person who is not a party to the agreement for the provision of Internal Audit between NHS Nottingham North and East CCG, NHS Nottingham West CCG and NHS Rushcliffe CCG and 360 Assurance dated 1

    st April 2017

    shall not have any rights under the Contracts (Rights of Third Parties) Act 1999. The appointment of 360 Assurance does not

    mailto:tim.thomas1@nhs.net mailto:claire.page9@nhs.net mailto:kristina.dickinson@nhs.net mailto:michelle.dixon3@nhs.net

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    replace or limit NHS Nottingham North and East CCG, NHS Nottingham West CCG and NHS Rushcliffe CCG’s own responsibility

    for putting in place proper arrangements to ensure that its operations are conducted in accordance with the law, guidance, good governance and any applicable standards, and that public money is safeguarded and properly accounted for, and used

    economically, efficiently and effectively. The matters reported are only those which have come to our attention during the course of our work and that we believe need to be

    brought to the attention of NHS Nottingham North and East CCG, NHS Nottingham West CCG and NHS Rushcliffe CCG. They are

    not a comprehensive record of all matters arising and 360 Assurance is not responsible for reporting all risks or all internal control weaknesses to NHS Nottingham North and East CCG, NHS Nottingham West CCG and NHS Rushcliffe CCG.

    This report has been prepared solely for your use in accordance with the terms of the aforementioned agreement (including the limitations of liability set out therein) and must not be quoted in whole or in part without the prior written consent of 360 Assurance.

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    1

    Executive Summary

    Introduction

    In April 2015 NHS England (NHSE) invited Clinical Commissioning Groups (CCGs) to take on an increased role in the commissioning of GP services through three different co-commissioning models:

     Greater involvement – an invitation to CCGs to collaborate more closely with

    their local NHS England teams in decisions about primary care services to ensure that healthcare services are strategically aligned across the local area;

     Joint commissioning – enabling one or more CCGs to jointly commission general practice services with NHS England through a joint committee; and

     Delegated commissioning – offering an opportunity for CCGs to assume full responsibility for the commissioning of general practice services.

    Each CCG could choose its own approach or nothing at all, and the CCGs took on full delegation of commissioning of general practice services from April 2015.

    Under fully delegated commissioning, CCGs have responsibility for the continuous improvement and assurance of quality and performance from primary medical services providers. However, NHS England does also still have a role in the monitoring of primary care.

    This is still a new and developing area of responsibility for CCGs and, as such, systems and processes by which the quality of primary medical care is monitored and improved upon are not necessarily fully developed at a local level. Therefore, this review has

    provided a baseline assessment/gap analysis of current arrangements and commentary on the direction of travel for planned and developing systems and processes.

    Audit Objectives and Scope

    The overall objective of our review was to provide independent assurance on the

    systems and processes in place for the quality monitoring of primary care medical services (both national and local).

    Specifically, our review focused on three key areas:

     Strategy – Have the CCGs identified and documented their strategic aims in

    relation to Primary Care Quality Monitoring? Does securing quality feature in the strategies and how is it monitored?

     Controls - Do the CCGs have sufficient controls in place to ensure that they achieve their objectives in relation to Primary Care Quality Monitoring?

     Governance - Do the governance structures, through the Primary Care Co-

    Commissioning Committees, ensure:

    o the right groups/committees receive appropriate information about the

    quality of services provided by co-commissioned primary care? o appropriate responses in terms of improvement and action planning? o the Governing Bodies receive the necessary assurance that the systems

    are functioning as expected and appropriate action is being taken to address any risks and ensure achievement of objectives?

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    2

    Executive Summary

    Limitations of scope:

    The review considered systems and processes for quality monitoring of primary care

    only. It did not include a review of GPs’ performance against the Quality Outcomes Framework (QOF) or the extent to which GPs evidence achievement of quality aspects of enhanced services.

    Audit Opinion

    Significant assurance - As a result of this audit engagement we have concluded that,

    except for the specific weaknesses identified by our audit in the areas examined, the risk management activities and controls are suitably designed, and were operating with sufficient effectiveness, to provide reasonable assurance that the control environment was effectively managed during the period under review.

    Our opinion is limited to the controls examined and samples tested as part of this review.

    Summary Findings

    Strategy

    Whilst quality is a key aim of the Sustainability and Transformation Plan there is little in the way of national guidance on how best to monitor primary care quality. In response to

    the need to monitor quality and drive improvement, the South Nottinghamshire CCGs have jointly agreed on the production of a primary care quality dashboard to record and monitor quality indicators.

    The CCGs’ Quality Strategy shows a clear outline of quality priorities and provides a brief overview of performance monitoring including quality schedules and contracts. As

    the Strategy was written prior to the changes in Primary Care Co-commissioning it was found that the Strategy does not fully align to the more recent ‘Transforming General Practice in Greater Nottingham’.

    Controls

    The CCGs have produced a ‘Primary Care Quality Assurance Improvement Framework’

    to aid the quality monitoring process and provide guidance for escalation of concerns.

    The dashboard is manually and electronically populated by CCG staff using a range of data collection methods with results being RAG rated to highlight outliers and provide a useful tool to compare practices.

    Governance

    Primary Care Commissioning Committees are delegated wit