NLG(13)260
DATE
30 July 2013
REPORT FOR
Trust Board of Directors – Part A
REPORT FROM
Wendy Booth, Director of Clinical and Quality Assurance &
Trust Secretary
CONTACT OFFICER
Wendy Booth, Director of Clinical and Quality Assurance &
Trust Secretary
SUBJECT
Protocol for the Development and Submission of the Forward
Plan & Associated Self Certification
BACKGROUND DOCUMENT (IF ANY)
Monitor Compliance Framework 2013/14
KPMG Review of Board Assurance & Self Certification 2013
REPORT PREVIOUSLY CONSIDERED BY & DATE(S)
N/A
EXECUTIVE COMMENT (INCLUDING KEY ISSUES
OF NOTE OR, WHERE RELEVANT, CONCERN AND /
OR NED CHALLENGE THAT THE BOARD NEED TO
BE MADE AWARE OF)
The report provides the revised Protocol for the Development
and Submission of the Forward Plan & Associated Self
Certification following the KPMG review
HAVE THE STAFF SIDE BEEN CONSULTED ON THE
PROPOSALS?
N/A
HAVE THE RELEVANT SERVICE USERS/CARERS
BEEN CONSULTED ON THE PROPOSALS?
N/A
ARE THERE ANY FINANCIAL CONSEQUENCES
ARISING FROM THE RECOMMENDATIONS?
NO
IF YES, HAVE THESE BEEN AGREED WITH THE
RELEVANT BUDGET HOLDER AND DIRECTOR OF
FINANCE, AND HAVE ANY FUNDING ISSUES BEEN
RESOLVED?
N/A
ARE THERE ANY LEGAL IMPLICATIONS ARISING
FROM THIS PAPER THAT THE BOARD NEED TO BE
MADE AWARE OF?
NO
WHERE RELEVANT, HAS PROPER
CONSIDERATION BEEN GIVEN TO THE NHS
CONSTITUTION IN ANY DECISIONS OR ACTIONS
PROPOSED?
YES
ACTION REQUIRED BY THE BOARD
The Board is asked to approve the revised Protocol
Directorate of Finance, Planning & Performance
PROTOCOL FOR THE
DEVELOPMENT AND SUBMISSION
OF THE FORWARD PLAN &
ASSOCIATED
SELF-CERTIFICATION
Reference:
Version:
This version issued:
Result of last review:
Date approved by owner
(if applicable):
Date approved:
Approving body:
Date for review:
Owner:
Document type:
Number of pages:
Author / Contact:
FPM003
Minor changes
Trust Board
Director of Finance, Planning & Performance
Miscellaneous
16 (including front sheet)
Wendy Booth, Director of Clinical and Quality Assurance
& Trust Secretary / Mike Rocke, Director of Finance,
Planning & Performance
Northern Lincolnshire and Goole Hospitals NHS Foundation Trust actively seeks to promote equality of
opportunity. The Trust seeks to ensure that no employee, service user, or member of the public is unlawfully
discriminated against for any reason, including the “protected characteristics” as defined in the Equality Act
2010. These principles will be expected to be upheld by all who act on behalf of the Trust, with respect to all
aspects of Equality.
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Contents
Section ............................................................................................................. Page
1.0
Background & Introduction ........................................................................... 3
2.0
Purpose........................................................................................................ 3
3.0
Area ............................................................................................................. 3
4.0
Duties ........................................................................................................... 3
5.0
Actions ......................................................................................................... 4
6.0
Monitoring Compliance and Effectiveness ................................................... 6
7.0
Associated Documents ................................................................................ 6
8.0
References................................................................................................... 6
9.0
Definitions .................................................................................................... 7
Appendices:
Appendix A - Process & Timetable for the Development and Submission of the
Forward Plan & Associated Self-Certification ................................... 8
Appendix B - Forward Plan Board Declarations And Self-Certifications ................. 9
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1.0
Background & Introduction
1.1
NHS Foundation Trusts are required to submit a forward plan to Monitor which
includes forward planning information for publication by 31st May. Monitor in turn will
assess the risks identified in each NHS Foundation Trust’s forward plan and in-year
submissions and assign a risk rating in three areas – finance, governance and
mandatory services. Monitor will use the risk ratings to guide the intensity of its
monitoring and signal to the NHS Foundation Trust its degree of concern with the
specific issues identified and evaluated. At the completion of the annual risk
assessment and each quarterly review, each NHS Foundation Trust will receive risk
ratings and a summary of key issues to be followed up either by their Board or by
Monitor. Monitor will also publish a summary of the results, together with a
commentary.
1.2
The forward planning and monitoring cycle is set out in Chapter 2 and Appendix C of
Monitor’s Compliance Framework. Further advice on the preparation of forward plan
submissions can also be found on Monitor’s website.
1.3
As part of the forward planning process, Monitor requires NHS Foundation Trust
Boards to self-certify in their forward plans, using the separate template provided,
their anticipated compliance with their Licence. The guidance available to NHS
Foundation Trusts states that: “It is important that Boards of NHS Foundation Trusts
have processes in place to ensure they understand the risks of non-compliance and
thereby accurately self-certify”.
2.0
Purpose
This document sets outs the responsibilities, timetable and arrangements in place for
the development and submission of the Trust’s forward plan & associated selfcertifications and in order to ensure compliance with the requirements set by Monitor.
3.0
Area
This document applies to all staff – including the Trust Board – involved in the
development and approval of the forward plan & associated self-certifications prior to
its submission to Monitor.
4.0
Duties
4.1
The Chief Executive is responsible for ensuring that arrangements are in place for the
development and submission of the forward plan & associated self-certifications by the
deadline set by Monitor.
4.2
The Chief Nurse and Medical Director are responsible for ensuring that all cost
improvement proposals contained within the forward plan have been subject to a quality
impact assessment process and have signed off the final plan to confirm that the
implementation and delivery of the plan does not incur any risk to the quality and safety
of the services provided.
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4.3
The Director of Finance, Planning and Performance is responsible for co-ordinating
the development and submission of the forward plan & associated self-certifications in
accordance with the guidance and timetable produced by Monitor and for engaging
relevant Trust staff in the process including the Council of Governors and the Trust
Board. The Director of Finance, Planning and Performance is also responsible for
the provision of the forecast financial performance information for inclusion in the
forward plan and for ensuring that audit verification of the forward planning and selfcertification process is included as a standing item in the annual Internal Audit
programme.
4.4
The Director of Clinical and Quality Assurance & Trust Secretary is responsible for
compiling the Schedule of Assurances provided to the Trust Board to inform the annual
self-certification process and for ensuring that this schedule is available in advance of
the annual Board event and has been considered by the appropriate forums (Trust
Governance & Assurance Committee, Audit Committee, Council of Governors) prior to
that event.
4.5
The Trust Board is responsible for approving the forward plan & associated selfcertifications prior to submission to Monitor.
4.6
Internal Audit is responsible for providing independent verification of the processes
and assurances which support the development and submission of the forward plan &
associated self-certifications.
4.7
Clinical Audit (Deputy Director of Clinical & Quality Assurance/Head of Quality) is
responsible for contributing to the Schedule of Assurances provided to the Trust Board
in respect of compliance with relevant targets and standards and/or the adequacy of
action plans in order to inform the self-certification process. The information from the
clinical audit process will take the form of an annual ‘assurance statement’. The Deputy
Director of Clinical & Quality Assurance/Head of Quality – who oversees the audit
programme – will also be required to attend the annual Board event.
5.0
Actions
5.1
The Trust’s forward plan will be developed in accordance with the timetable and
processes outlined at Appendices A & B and the actions outlined below.
5.2
Forward Planning
5.2.1
The Trust’s annual business planning process will inform the development of the
forward plan.
5.2.2
In preparing the business/forward planning information, which forms part of the
forward plan, the Board must have regard to the views of the Council of Governors
and a specific event will be arranged for this purpose.
5.3
Preparation of the Annual Plan & Associated Documentation
5.3.1
The Director of Finance, Planning & Performance will lead the preparation of the
forward plan and associated documentation, and will seek relevant information from
Directorates/Groups to inform this process.
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5.3.2
The Director of Finance, Planning & Performance will ensure that the Executive
Team and the Trust Board are kept informed of progress with the development of the
forward plan in accordance with the timetable and processes outlined at Appendix
A.
5.3.3
The forward plan will be prepared using the advice and templates provided by
Monitor.
5.4
Self-Certification
5.4.1
A separate Board event to consider self-certification (including assurances and risks
to self-certification) will be arranged prior to approval and submission of the forward
plan. A Schedule of Assurances pro-forma, which will consider all available
assurances – both internal and external – has been developed for this purpose
(Appendix B). As part of this process and reflecting the prospective nature of the
requirements in respect of self-certification, the Board will:
•
use forecasting and extrapolation of historic trends to help predict future
performance and satisfy themselves that systems and plans in place are
adequately robust to achieve targets and standards going forward
•
ensure consistency with the requirements set out in the Commissioner
Requested Services as agreed with relevant commissioners and stakeholders
•
use scenario analysis, particularly downside scenarios and consider how risks
can be mitigated
•
where performance issues have been identified or are predicted, be satisfied
that actions plans are in place to deliver the required improvement to achieve
targets going forward and that review, monitoring and challenge occurs on an
ongoing basis
•
consider the potential impact of risks/risk ratings on the risk register on the
self-certification process
•
consider risk information from the Trust Assurance Framework
•
consider information on benchmarking against peers
•
ensure that issues that are outside of the Trust’s control but that could have a
potential impact on the Trust’s ability to meet its targets and obligations are
explicitly discussed as part of the self-certification process
•
ensure that the plans in place will be sufficient to maintain a minimum
financial risk rating of three
5.4.2
Prior to the Board event and as part of the overall assurance process, the Director of
Clinical & Quality Assurance will submit the completed ‘Schedule of Assurance’
template for comment to the relevant forums (Trust Governance & Assurance
Committee, Audit Committee and Council of Governors). This process will be
completed prior to review of the assurances by Internal Audit (see 5.5 below).
5.4.3
The timing of the Board event should ensure that there is sufficient time between the
Board event and the submission of the Forward Plan to allow time to collate and
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consider any further evidence and information requested by the Trust Board to inform
the requisite certification.
5.4.4
At the Board event, specific time slots will be allocated for each agenda item, and the
agenda will set out the purpose of each paper or highlight the key messages from
each paper to ensure the effective running of the meeting and to allow sufficient time
to consider the assurances and risks to self-certification.
5.5
Independent Verification of the Self-Certification Process
5.5.1
Internal audit will be engaged to provide assurance over the annual planning and
self-certification process. Review by Internal Audit will consider and include:
•
the adequacy of the Trust’s arrangements for self-certification
•
a review of the evidence provided by the Trust prior to self-certification
5.5.2
The outcome from this review will be considered by the Trust Board at the annual
Board event prior to final sign-off of the forward plan.
5.5.3
Information from the clinical audit process – particularly where this covers compliance
with standards and targets covered by the self-certification declarations – will also
inform the ‘Schedule of Assurance’ provided to the Trust Board at the annual Board
event – see also 4.5 above. The information from the clinical audit process will take
the form of an annual ‘assurance statement’.
6.0
Monitoring Compliance and Effectiveness
6.1
Review and monitoring of performance in respect of the targets and priorities outlined
within the forward plan will be undertaken through:
6.1.1
Internally:
6.1.2
•
the performance management framework in place led by the Director of
Finance, Planning and Performance and Chief Executive
•
the regular performance reports submitted to the Trust Board and
Externally:
•
7.0
Monitor’s Annual ARA review
monitoring/compliance submissions
meeting
and
quarterly
in-year
Associated Documents
NLG Quarterly Compliance Reports to Monitor.
8.0
References
8.1
KPMG. (January 2009). Independent Review of Board Self-Certification 2008/09.
8.2
KPMG (May 2011). Review of Board Assurance and Self-Certification Audit.
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8.3
KPMG (May 2012). Review of Board Assurance and Self-Certification Audit.
8.4
Monitor (April 2009). Annual Plan: Advice for NHS Foundation Trusts.
8.5
Monitor (March 2013). Compliance Framework 2013/14 – Chapter 2 & Appendix C.
8.6
KPMG (May 2013). Review of Board Assurance.
9.0
Definitions
9.1
ARA – Annual Risk Assessment
_________________________________________________________________________
The electronic master copy of this document is held by Document Control, Directorate
of Clinical and Quality Assurance & Trust Secretary, NL&G NHS Foundation Trust.
Printed copies valid only if separately controlled
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Appendix A
Process & Timetable for the Development and Submission of the Annual Plan &
Associated Self-Certification
N.B.
Timescales may be subject to change in the light of any annual changes to Monitor
requirements and annual planning timetable.
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Appendix B
FORWARD PLAN 2013 / 14: CORPORATE GOVERNANCE STATEMENT
[Under NHS Foundation Trust Condition 4 (the governance condition), Boards of Trusts are required to make a Corporate Governance Statement outlining
compliance or otherwise with the governance condition and risks to this. The following schedule of assurances, risks of certification and mitigating actions has
been prepared to support the Board’s deliberations in respect of the required declarations.]
Board Statements
Board Assurances
Risks of Certification
[The Board is required to confirm the
following statements on an annual basis.
No supporting details are required unless
compliance cannot be confirmed.]
Quality:
1 The Board is satisfied that, to
the best of its knowledge and
using its own processes and
having assessed against
Monitor’s Quality Governance
Framework (supported by Care
Quality Commission
information, its own information
on serious incidents, patterns
of complaints and including any
further metrics it chooses to
adopt), its NHS Foundation
Trust has, and will keep in
place, effective arrangements
for the purpose of monitoring
and continually improving the
quality of healthcare provided
to its patients.
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Comments / Mitigating Actions
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Board Statements
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Board Assurances
Risks of Certification
[The Board is required to confirm the
following statements on an annual basis.
No supporting details are required unless
compliance cannot be confirmed.]
2 The Board is satisfied that
plans in place are sufficient to
ensure ongoing compliance
with the Care Quality
Commission’s (CQC)
registration requirements.
3 The Board is satisfied that
processes and procedures are
in place to ensure all medical
practitioners providing care on
behalf of the Trust have met
the relevant registration and
revalidation requirements.
Finance:
4 The Board anticipates that the
Trust will continue to maintain a
financial risk rating of at least 3,
as defined in Monitor’s
Compliance Framework, over
the next 12 months.
5 The Board is satisfied that the
Trust shall at all times remain a
Going Concern, as defined by
relevant accounting standards
in force from time to time.
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Comments / Mitigating Actions
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Board Statements
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Board Assurances
Risks of Certification
[The Board is required to confirm the
following statements on an annual basis.
No supporting details are required unless
compliance cannot be confirmed.]
Governance:
6 The Board will ensure that the
Trust remains at all times
compliant with its Licence and
has regard to the NHS
Constitution.
7
All current key risks to
compliance with the Trust’s
Licence have been identified
(raised either internally or by
external
audit
and
assessment
bodies)
and
addressed – or there are
appropriate action plans in
place to address the issues –
in a timely manner.
8 The Board has considered all
likely future risks to compliance
with its Licence and has
reviewed appropriate evidence
regarding the level of severity,
likelihood of a breach occurring
and the plans for mitigation of
these risks to ensure continued
compliance.
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Comments / Mitigating Actions
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Board Statements
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Board Assurances
Risks of Certification
[The Board is required to confirm the
following statements on an annual basis.
No supporting details are required unless
compliance cannot be confirmed.]
9 The necessary planning,
performance management and
corporate and clinical risk
management processes and
mitigation plans are in place to
deliver the annual plan,
including that all audit
committee recommendations
accepted by the Board are
implemented satisfactorily.
10 An Annual Governance
Statement is in place pursuant
to the requirements of the NHS
Foundation Trust Annual
Reporting Manual, and the
Trust is compliant with the risk
management and assurance
framework requirements that
support the Statement pursuant
to the most up to date guidance
from HM Treasury (www.hmtreasury.gov.uk).
11 The Board is satisfied that
plans in place are sufficient to
ensure: ongoing compliance
with all existing targets (after
the application of thresholds)
as set out in Appendix B of
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Comments / Mitigating Actions
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Board Statements
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Board Assurances
Risks of Certification
[The Board is required to confirm the
following statements on an annual basis.
No supporting details are required unless
compliance cannot be confirmed.]
Monitor’s Compliance
Framework; and a commitment
to comply with all known
targets going forwards.
12 The board is satisfied that its
NHS foundation trust can
operate in an efficient,
economic and effective
manner.
13 The Board will ensure that the
Trust will at all times operate
effectively within its
constitution. This includes:
maintaining its register of
interests, ensuring that there
are no material conflicts of
interests in the Board of
Directors; that all Board
positions are filled, or plans are
in place to fill any vacancies;
and that all elections to the
Board of Governors are held in
accordance with the elections
rules.
14 The Board is satisfied that all
Executive and Non-Executive
Directors have the appropriate
qualifications, experience,
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Comments / Mitigating Actions
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Board Statements
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Board Assurances
Risks of Certification
[The Board is required to confirm the
following statements on an annual basis.
No supporting details are required unless
compliance cannot be confirmed.]
training and skills to discharge
their functions effectively,
including setting strategy,
monitoring and managing
performance and risks, and
ensuring management capacity
and capability.
15 The Board is satisfied that the
management team has the
capacity, capability, training
and experience necessary to
deliver the annual plan; and the
management structure in place
is adequate to deliver the
annual plan.
16 For an NHS Foundation Trust
engaging in a major Joint
Venture, or Academic Health
Science Centre (AHSC), the
Board is satisfied that the Trust
has fulfilled, or continues to
fulfil, the criteria in Appendix C4
(of Monitor’s Compliance
Framework).
17 The board is satisfied that
plans are in place to ensure
that the trust will at all times
comply with its statutory
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Comments / Mitigating Actions
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Board Statements
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Board Assurances
Risks of Certification
[The Board is required to confirm the
following statements on an annual basis.
No supporting details are required unless
compliance cannot be confirmed.]
requirements.
18 The Board is satisfied that
during 2013 the Trust has
provided the necessary training
to its governors as required in
s151(5) of the Health and
Social Care Act, to ensure that
they are equipped with the
skills and knowledge they need
to undertake their role.
19 After making enquiries the
Directors of the Licensee have
a reasonable expectation that
the Licensee will have the
Required Resources available
to it after taking account
distributions which might
reasonably be expected to be
declared or paid for the period
of 12 months referred to in this
certificate. OR
After making enquiries the
Directors of the Licensee have
a reasonable expectation,
subject to what is explained
below, that the Licensee will
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Comments / Mitigating Actions
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Board Statements
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Board Assurances
Risks of Certification
Comments / Mitigating Actions
[The Board is required to confirm the
following statements on an annual basis.
No supporting details are required unless
compliance cannot be confirmed.]
have the Required Resources
available to it after taking into
account in particular (but
without limitation) any
distribution which might
reasonably be expected to be
declared or paid for the period
of 12 months referred to in this
certificate. However, they
would like to draw attention to
the following factors which may
cast doubt on the ability of the
Licensee to provide
Commissioner Requested
Services. OR
In the opinion of the Directors
of the Licensee, the Licensee
will not have the Required
Resources available to it for the
period of 12 months referred to
in this certificate.
[NB.
This template will need to be updated in the light of any annual changes to the relevant Monitor guidance in respect of the development and
submission of the Forward Plan and associated self-certifications.]
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