Enclosure 23 - Audit Committee Minutes
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Enclosure 23 SUNDERLAND TEACHING PRIMARY CARE TRUST Audit Committee thNotes of the meeting held on Friday 12 March 2004 at 9.30 am in the Board Room, Armstrong House, Washington Present: - Mr P Watson, Non-Executive Member, STPCT (Chair) Mr M Greenfield, Non-Executive Member, STPCT GK Lloyd-Williams, Non-Executive Member, STPCT In attendance: Mrs K Straughair, Chief Executive, STPCT Mr C Macklin, Director of Finance, STPCT Mrs N Harris, Head of Corporate Affairs, STPCT Mr J Connolly, Audit Manager, Audit Commission Mrs A Oswald, Internal Auditor, CHS Mrs V Peacock, Internal Auditor, CHS Mrs J Anthony, Corporate Affairs Administrator Mr Glen Gregory, Audit Commission 1. Apologies: Mrs Sheila Rooney, Non-Executive Member, STPCT Welcome The Chair welcomed everyone to the Audit Committee. 2. Minutes of Previous Meeting (Enclosure 1) Page 7 - Progress Report on Tactical Audit Plan (Enclosure 7) The Chair pointed out that in paragraph 4 “Newcastle PCT” should read as “new Acute Trust”. Subject to this amendment the minutes were received as a true and accurate record. 1 Sunderland TPCT Audit Committee th12 March 2004 3. Matters Arising Page 3 - Annual Audit Letter (Enclosure 2) - Mr Macklin stated that the Main stAccounting System went live on 1 January 2004 and that the team was still undergoing a transitional period. Page 5 – Financial Aspects of Corporate Governance (Enclosure 4) – ...
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1
Sunderland TPCT
Audit Committee
12
th
March 2004
Enclosure 23
SUNDERLAND TEACHING PRIMARY CARE TRUST
Audit Committee
Notes of the meeting held on Friday 12
th
March 2004 at 9.30 am in the Board
Room, Armstrong House, Washington
Present: -
Mr P Watson, Non-Executive Member, STPCT (Chair)
Mr M Greenfield, Non-Executive Member, STPCT
Mr GK Lloyd-Williams, Non-Executive Member, STPCT
In attendance:
Mrs K Straughair, Chief Executive, STPCT
Mr C Macklin, Director of Finance, STPCT
Mrs N Harris, Head of Corporate Affairs, STPCT
Mr J Connolly, Audit Manager, Audit Commission
Mrs A Oswald, Internal Auditor, CHS
Mrs V Peacock, Internal Auditor, CHS
Mrs J Anthony, Corporate Affairs Administrator
Mr Glen Gregory, Audit Commission
1.
Apologies:
Mrs Sheila Rooney, Non-Executive Member, STPCT
Welcome
The Chair welcomed everyone to the Audit Committee.
2.
Minutes of Previous Meeting (Enclosure 1)
Page 7 - Progress Report on Tactical Audit Plan (Enclosure 7)
The Chair pointed out that in paragraph 4 “Newcastle PCT” should read as “new
Acute Trust”.
Subject to this amendment the minutes were received as a true and accurate
record.
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Audit Committee
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3.
Matters Arising
Page 3 - Annual Audit Letter (Enclosure 2) -
Mr Macklin stated that the Main
Accounting System went live on 1
st
January 2004 and that the team was still
undergoing a transitional period.
Page 5 – Financial Aspects of Corporate Governance (Enclosure 4)
– Mrs
Harris explained that the Board considered the paper in January 2004 and would
outline further details in agenda item 6.1. Mrs Harris explained that she was still
trying to find details regarding an “legality protocol”. Mr Connelly agreed to provide
Mrs Harris with some helpful suggestions.
Mr Macklin stated that the TPCT was in partnership with CHS in developing the
NHS Foundation model which is based on a non-NHS contract. He mentioned that
he, Mrs Straughair and Mr Bremner, (CHS), had met to discuss the document
further. He explained that it was a very detailed and complex contract. The TPCT
has entered into a risk sharing agreement with STW, CHS and SS.
Page 8 – Losses and Compensations Register (02/03)
– Mr Macklin explained
that the piece of work looking at trends had not been completed as yet, but would
concentrate on the number of claims made against lease cars. He stated that a
note on safe parking had been issued to all users. Mrs Peacock mentioned that
STW had raised the same issues of safe parking etc.
Mrs Harris mentioned
problems occurred not only due to drivers but also due to the physical parking
facilities around Health Centres and other sites.
Page 8 – Controls Assurance Statement (03/04)
– Mrs Harris stated that the
TPCT was on target to deliver this document. She stated that the SHA had not
mentioned a prescribed format and therefore our information was presented to the
SHA in the wrong format. This has now been corrected and will be presented to
the Board in March.
4
Audit Commission Issues / Reports
4.1
Annual Audit Letter (Enclosure 2)
Mr Connolly gave the background to this paper and stated that work was
progressing in line with the planned timetable and highlighted that the risk
assessment was an ongoing process and changes to the Plan may be necessary if
significant risk emerged. Mr Connolly stated that the audit would be completed
earlier than usual this year to fall in line with the TPCT’s financial year.
Mr
Connelly stated that he was anxious to start the survey for the IM&T arrangements
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Audit Committee
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th
March 2004
part 2. Mr Macklin suggested that he view the CHI questionnaires to see what
information can be gained from this existing source.
4.2
Reference Costs / H.R.G.S. (Enclosure 3)
Mr Gregory presented this paper and highlighted that the NHS Plan have signalled
investment of significant extra resources in the NHS to deliver improved patient
care. In October 2002, the DOH have issued “Reforming NHS Financial Flows:
Introducing Payments by Results which sets out the changes to the way funds are
flowed through the NHS. Mr Gregory stated that the new funding arrangements
would be phased in over the next five years with a national tariff for each HRG.
He went onto explain that due the TPCT being a new PCT it was the first time it
had made a reference costs submission and highlighted that many positive aspects
were found. Mr Gregory pointed out that due to the incorrectly excluded costs and
unsupported activity data, there was a risk that the Trust’s reference costs may be
materially inaccurate and stated that the TPCT needed to address any weakness
identified. Mr Gregory explained the main findings and highlighted the key areas
for action.
Mr Macklin explained that reference costs submission guidelines were followed but
unfortunately there were incorrect guidelines.
He highlighted that this was a
learning curve for the TPCT and for 03/04 these would be presented correctly.
The Chair acknowledged Mr Macklin’s comments. Mr Greenfield asked what type
of evidence the TPCT wasn’t collecting.
In reply, Mr Macklin explained that
national returns should have been used instead of the local nursing information.
Mr Connelly pointed out that lessons had been learnt. Mr Macklin explained that
the DOH had laid on training sessions which the TPCT had attended.
4.3
NHS Plan Implementation Review (Enclosure 4)
Mr Connolly presented the background to this paper and highlighted that this was a
national piece of work and that this was the final year that this work would be
carried out. He explained that a review was undertaken during November and
December 2003 and covered key themes; LDP process, PPF targets, patient
experience and perspective, working in partnership and sustainability.
Mrs Straughair stated that nationally this was not a popular review but at least the
findings locally were consistent with PCT views and it is good to receive this
feedback.
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Audit Committee
12
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March 2004
LDP Process
Mr Connolly explained that an assessment had been taken of how well the new
planning processes were implemented for the LDP and how robustness of the
resulting plans. He went onto state that the assessment was based on a rating
scale.
PPF Targets
Mr Connolly explained that the PPF targets were assessed on whether or not the
PCT was likely to achieve key targets and whether current performance was
sustainable and likely to improve.
Mr Connolly explained the way in which
assessments were rated.
Mr Connolly highlighted the main findings and explained that the PCT continues to
make solid progress towards the NHS Plan implementation. He explained that the
LDP process was relatively robust and that delivery against PPF targets was
generally sound. He explained that the indications were that the PCT was able to
sustain and improve on performance.
Mr Connolly pointed out a number of areas where progress needed to be made to
meet targets and highlighted that the TPCT had recognised these and actions had
been taken to address them. One of these areas was in Workforce Planning where
relationships have now been established with the Workforce Development
Confederation and a Workforce MARG established. The PCT needs to build on
this start and develop a medium to long-term Workforce Plan.
Mr Connolly
explained that this was an important process for the TPCT in terms of its
performance. Mr Connolly also mentioned some areas where PPF targets could
be improved.
Patient Experience and Perspective
Mr Connolly explained that they would wait until the CHI review results were in
place.
Working in Partnership
Mr Connolly went onto highlight that working partnership with Social Services was
a very positive sign and that there was a strong public sector community
developing. He explained that the PCT benefited from a stable top management
team which had contributed to the rating of “fairly strong” in terms of management
capacity with only one or two gaps in the structure. He highlighted that the TPCT
needed to draw up robust plans to develop, recruit and sustain the skilled
workforce it needed to meet the challenges of modernisation.
Mrs Straughair explained that this had not been a popular review. It had been a
difficult start but that Mr Connolly and his team had highlighted areas that other
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organisation had already highlighted so at least it was good that feedback was
being received albeit weaknesses or strengths.
Mr Greenfield thanked Mrs Straughair for her reflection and asked when the
vacancies within the structure would be filled as Primary Care, Partnerships and
Commissioning was a huge directorate with major areas of work. In reply, Mrs
Straughair stated that the breadth of the directorate was indeed massive and
highlighted that work was being undertaken to try to take some work out of the
directorate. The TPCT does recognise this issue and changes will be seen within
the structure.
5.
Internal Audit Issues
5.1
Progress Report (Enclosure 5)
Mrs Oswald gave the background to this paper which detailed the findings arising
since that last Audit Committee Meeting relating to STPCT and the CSA and asked
the Audit Committee to receive the progress report.
Mrs Oswald went onto
highlight one high priority issue and a few medium concerns.
Sunderland Teaching Primary Care Trust
Nurse Bank Staff
Mrs Oswald highlighted that there were five medium priority issues in relation to
appropriate authorisation before staff are requested to work. Actions have been
agreed with management and have now been implemented.
Procurement – Proactive Fraud Review
Mrs Oswald explained that a review was carried out in accordance with the
proactive fraud plan to detect possible fraudulent activity in respect of procurement
arrangements. No evidence of fraud was found, however, one high priority issue
was identified in relation to the failure to advertise tenders in accordance with
European Union regulations. All action was agreed with management and now
been implemented.
Mr Macklin explained that the high priority at CSA could easily have occurred at
STPCT and therefore a decision was made to move supplies from 3N’s to CHS
supplies. The TPCT would be able to take advantage of CHS’s experience and
knowledge in doing so.
St Benedict’s Hospice
Mrs Oswald explained that the purpose of this audit was to review aspects of
internal control arrangements.
She highlighted that four medium priority issues
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Audit Committee
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th
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relating to; recording and charging for training provided to third parties;
establishment of formal SLAs with other PCTs; the necessity for a robust
mechanism to ensure that all costs are recovered for out of area patients; and
improvement required in the production and monitoring of performance data.
Actions have been agreed with management and recommendations will be
reviewed within agreed timescales.
Service Maintenance Contracts
Mrs Oswald explained that the purpose of the audit was to review the control
arrangements in place for service maintenance contracts.
There were three
medium priorities identified relating to the responsibility for contract monitoring not
being clearly assigned and the rollover of contracts without formal contract
monitoring or review. This could be improved to ensure that value for money is
being attained.
Mr Macklin stated that an advert for the Head of Estates post had been placed and
the candidate would assist in maintaining the TPCT’s SLAs.
Tyne and Wear Contractor Services Agency
IM&T Organisation, Management and Development
Mrs Oswald highlighted that 2 medium priority issues relating to; workload of the
department and an insufficient staff complement; and the lack of target dates and
performance indicators in the department’s business plan. Mrs Oswald highlighted
that the outcome of the review was a significant improvement on the previous
review. All action was agreed with management and been implemented.
Spectacle Vouchers
Mrs Oswald explained that no evidence of fraud was found although the review
identified that a third of the claims submitted were incorrectly completed which
could result in inaccurate payments. All actions were agreed by management and
implemented.
5.2
Follow up of Internal Audit Recommendations (Enclosure 6)
Mrs Peacock presented this paper and explained the purpose of the report. She
explained that all recommendations had been actioned except for Financial
Control. The outstanding recommendation was considered as a medium risk.
Mrs Harris stated that a paper had been developed describing what a risk register
was and what tools would be used to access risk. She went onto report that a draft
copy had gone to the Board and that the risk register would be presented to the
Board in March.
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Audit Committee
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th
March 2004
5.3
Local Counter Fraud Specialist Update (Enclosure 7)
Mrs Peacock stated that there were no ongoing investigations of suspected cases
of fraud and that the TPCT had no fraudulent activity has been detected.
Mrs Peacock highlighted the National Fraud Initiative Data Matching Exercise
which had involved matching data on the TPCT’s payroll system to data held by
other public sector bodies on payroll, national insurance and benefits systems.
She went onto highlight that nothing untoward had been identified. She explained
that this year’s report will be concentrating on registration of patients with GPs and
this would be reported back to the Audit Committee at a later date.
5.4
Appraising Internal Audit / Working with Internal Audit (Enclosures 8
and 9)
These briefing papers were presented for information only.
6.
Controls Assurance / Risk Management
6.1
TPCT Update (Enclosure 9)
Mrs Harris formally apologised for tabling this report and went onto give the
background to the document explaining that the document was being presented to
the Audit Committee on behalf of the Risk Management Committee (RMC).
Mrs Harris explained that the TPCT had failed by 75% in all areas of its CNST
assessment and was currently developing an action plan which would be monitored
by the RMC. Mrs Harris has asked that the reassessment take place no earlier
than September 04.
The Health and Safety group was now established and an Infection Control
committee had also been established with an Infection Control Nurse now in post.
DEEL was now an established group with monthly meetings taking place. The
group was still developing ways of working but will be a focus for the organisation’s
learning from incidents, complaints, Health & Safety etc. The Clinical Governance
Action Committee had now re-established with a full team of 15-20 members in
place. Mrs Harle was the Non Executive Director Lead. Information Governance
had now been established bringing together key components of information. FHS
process is a complex piece of work and should be presented to the next RMC
meeting.
Mrs Harris reported that the Controls Assurance Report would be submitted on
May 15
th
and asked the Audit Committee whether the scores needed to be
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Audit Committee
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th
March 2004
presented to the Board or just the Audit Committee which would give more
breathing space.
The Chair stated that under the Terms of Reference Controls Assurance falls under
the Audit Committee branch and therefore it was a sensible approach to just be
presented at the Audit Committee.
Mr Macklin highlighted that some progress has been made under Standard 19,
Security Management. A lone worker policy was to be presented to the Board for
approval in March and that a satellite tracking system was in place for those
personnel working in risk situations. He also stated that on signing the lease for
the new Headquarters, 24 hour security was in place along with surveillance
videos.
7.
Performance Indicators (Enclosure 10)
Mr Macklin gave the background to this report highlighting that the new indicators
were issued in December 03. He explained that the new indicators were still a set
of 9 “Key Indicators” plus the remainder of the indicators forming a “balanced
scorecard”. Mr Macklin stated that this would be presented to the Board in March
to note the performance of Sunderland as a “health economy” against the various
performance measures.
Mr Lloyd-Williams stated how well the TPCT had performed with regards to GP
Appraisal having an 80% compliance rate. This is a positive step forward which will
not be far off the deadline. Mrs Straughair stated that GP Appraisal had gone
exceeding well in Sunderland and was very much down to the hard work
undertaken by Dr Stephenson, Mrs Forster and Mrs Taylor who have managed to
involve as many assessors as possible to be trained.
Mr Lloyd-Williams asked what would be the impact if members of the public who
are not currently registered with a dentist wished to be registered. In reply, Mr
Macklin stated that there was availability in the area and the TPCT was
encouraging people to access dentistry.
He explained that an Oral Health
Awareness session had been launched.
Mrs Straughair explained that it was a good point and that it did form part of the
Oral Health Strategy which had been developed and approved by the Board and
that the TPCT would need to monitor access to services.
Mrs Straughair
highlighted that there was a very active Oral Health Group in place which reports to
the PEC.
She also explained that the number of private dentists had been
extended to provide services to NHS patients.
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Audit Committee
12
th
March 2004
9
Any Other Business
The Chair read out a letter from Mrs Rooney with regards to the Research and
Audit Committee (RAC) which asked the Audit Committee to consider three points
of linking the Audit Committee to the RAC. After discussions it was decided that as
Mrs Rooney was a member of both Committee then in the first instance she would
be the link and would bring any relevant information to the Audit Committee under
AOB.
8
Date and Time of Next Meeting
The date and time of the next meeting will be held on Wednesday, 12
th
May 2004,
1.30pm in the Board Room at Armstrong House, Washington.
On a final note the Chair thanked everyone for attending and closed the meeting.
