CCG Assurance and the Balanced Scorecard Balanced Scorecard An overview of the tool, and its role in CCG assurance Khadir Meer Richard Wells July 2013
Contents 1. Background: development of the Balanced Scorecard 2. Introduction to the Balanced Scorecard 3. Using the Balanced Scorecard: Process guidance Timelines 2
Background Development of the Balanced Scorecard
Context The Interim CCG Assurance Framework was published in May 2013. This sets out a nationally consistent approach to the formal interactions between CCGs and ATs on a quarterly and annual basis. The publication of the Interim Assurance Framework kicks off an engagement process with CCG staff, patient groups and other key stakeholders. A final Framework to be published in the autumn. 4
Interim CCG Assurance Approach A core component of the Interim CCG Assurance Framework is the Balanced Scorecard, which will be used to assure CCG s operational delivery. Whilst an outline of the Scorecard featured in the draft Framework, there was a need to develop a tool to support the application of the process, specifically to supplement the wider discussions taking place between Area Teams and CCGs. This slide pack addresses this need by describing: The relationship between CCG Assurance and the Balanced Scorecard The functionality of the Balanced Scorecard The process and actions required of CCGs and NHS England to produce each Balanced Scorecard The alignment of the Scorecard production cycle with the Assurance cycle : 5
The CCG Assurance Cycle, and the Balanced Scorecard The Interim CCG Assurance Framework outlined an annual assurance process informed by Quarterly Checkpoints. Q1 Checkpoint Q2 Checkpoint Q3 Checkpoint Q4 Checkpoint Annual Assessment On a Quarterly basis, the relevant NHS England Area Team must meet its local CCGs and review their effectiveness in discharging their statutory responsibilities. This includes reviewing the CCG s delivery against plans, the performance of commissioned healthcare providers, progress in addressing remaining authorisation conditions, and discussion of local strategic issues. The aggregate result of the quarterly conversations will form the key elements of annual assurance demonstrating clearly that a CCG has delivered against its plan. 6
The Balanced Scorecard Overview of the tool
Principles used during development of the Balanced Scorecard The Balanced Scorecard has been built around guidance contained in the Interim Assurance Framework. This approach set out in the Assurance Framework will be tested in Quarters 1 & 2 and learning will be fed into Q3 and beyond. The process aims to be constructive, supporting the continued development of CCGs, and providing a constructive challenge where needed. CCGs, Area teams, Regional teams and National teams will all play a role in assurance process. An interim data solution has been developed while the Integrated Intelligence Tool is built. As the process develops we will continue to focus on minimising bureaucracy for both CCGs and Area Teams to ensure the process is effective and efficient to run. The balanced scorecard will be generated centrally, by drawing on existing published data. This will ensure a consistent standard of reporting and will minimise the burden on CCGs. CCGs will be asked to populate indicators around: Quality of care provided by the CCGs local providers Progress against CCG s local priorities Finance (internal and external audit) Each Domain of the BSC will be populated at different time points during the first 8 weeks following the end of the quarter; this is due to the fact that various data sources are feeding the population of the tool. 8
Overview of the Balanced Scorecard The Balanced Scorecard (BSC) is the primary tool underpinning the draft CCG Assurance Framework. Its scope includes the key aspects of a CCG s operational delivery for which NHS England must be assured. This includes the: 1. the quality of care being provided to patients 2. the NHS Constitution 3. the Outcomes Framework 4. financial performance 5. progress in addressing remaining CCG authorisation criteria 6. progress in delivering any agreed action plans to address performance issues identified as part of assurance The Scorecard is intended to supplement the wider discussions taking place between Area teams and CCGs, and to summarise key issues not to replace these detailed conversations. It is also important to recognise that Area Teams may need to meet particular CCGs within a given quarter, for example on a monthly basis; this is for local determination by Area Teams based on a risk assessment of the CCG s current state of development and inherited challenges as a new organisation. The BSC is designed to provide points for discussion as part of a broader discussion. It should not dominate or limit the assurance agenda which may develop into a much broader discussion. 9
Core features of the Balanced Scorecard The Balanced Scorecard is an Excel-based tool with multiple component sections, and enables the user to reach a rational view on the quality of a CCG s operational delivery at a given point in time The component sections are drawn into an aggregated summary page which includes a RAG rating for each domain; the table below provides an overview of the key sections of the tool: Section BSC Summary Summary Overall assurance assessment of CCG, drawn from whole BSC once Reporting Technical description of BSC data points Self-Certification CCG self assesses own delivery against range of criteria Domain 1 Data against same indicators as CCG self-certification, populated by NHS England Domain 2 Domain 3 Domain 4 Data against NHS Constitution metrics, populated by NHS England Data against package of patient health outcomes measures, populated by either NHS England or CCG depending on metric Data analysis of CCG s financial performance, populated by NHS England Domain 5 Commentary on CCG s progress in addressing authorisation conditions, populated by NHS England Support / Intervention Area for CCGs immediate development needs to be captured These sections will be expanded in turn over the following slides. 10
In Depth: BSC Summary The front page of the Balanced Scorecard is the BSC Summary tab. This draws the relevant RAG or summary box from each section into a front page; it is important to note the BSC does not create an overall RAG for a CCG. Overall RAGs for Domains 1 to 4 are shown, covering the NHS constitution, patient health outcomes, and financial performance. There is no RAG rating for Domain 5, authorisation conditions. These numbers show how many indicators have been breached in each Domain. These cells indicate whether the CCG has completed all necessary self-certification. 11
In Depth: Reporting The Reporting section follows the BSC Summary, and describes the data points in the Scorecard, including details of the numerators and denominators applied to different measures, and the frequency the data is updated. Data points are grouped by Domain. The Category column refers to the name of a given measure as it appears in the relevant BSC section. The Indicator Detail column explains the calculation method for each data point in the BSC. The frequency of data update for each measure is also included; the BSC includes data collected at a wide range of intervals, from weekly through to quarterly. Whilst data might be updated on a weekly basis, for example, the CCG Assurance Reporting Period could differ A&E data is collected weekly but the reported period is monthly. The data source is also listed in this section. 12
In Depth: Self-certification / Unify submission The Self Certification section requires each CCG to provide a status update on the performance of their major Providers and the CCG itself. The CCG is also asked for information on: 1. A CCG s local priorities (this will feed into Domain 3) 2. Internal and external financial audit opinions (this will feed into Domain 4) For QI only, in the absence of formal data, CCGs are asked to report on: 1. IAPT: is CCG progressing as expected against trajectory? 2. FFT: are providers meeting the 15% response rates on FFT? *The above two indicators will feed into Domain 3 and will not feed into the RAG calculation for the Domain while they are collected through self certification. The following indicator: does provider currently have any unclosed Serious Untoward Incidents will not inform the overall RAG calculation for Domain 1. For Quarter 1 only, CCGs will need to list between 5-10 of their main providers (where CCG commissioning constitutes more than 5% of the provider s income). As a general guide, it is expected that a CCGs main providers only will be listed and only therefore only in exceptional circumstances will more than 5 providers be listed. The Self-Certification section automatically populates Domain 1 of the Scorecard; the only distinction between the two sections is that Domain1 cannot be directly edited. Domain 1 has a RAG rating box: this will be rated red if the CCG has noted that enforcement action is in hand, and amber red if an issue has been identified but mitigating action is not in place (this is explained within the tool) 13
Uploading to Unify: basic guidance UNIFY2 is a flexible system for collecting, validating, storing and reporting data. It provides a trusted data store across all data sets including historical data. 1. If you have an account, you can log To log into UNIFY2: http://nww.unify2.dh.nhs.uk/unify/interface/homepage.aspx. in here. 1. If you do not have an account and need to register for one, this can be done by selecting Request a Unify account. 2. Once CCG s complete the Excel spread sheet called CCG_SCV1.2xls, they should log onto the system as above, navigate to Data Collection and Management. 3. Then select NON DCT Homepage For more information on UNIFY2, please refer to Annex 1 UNIFY 2 - General Overview. 14
Uploading to Unify: basic guidance In the Reference row called CCG_AF or CCG Assurance Framework click upload. Click browse to upload document from your home drive, and then click auto sign off For more information on UNIFY2, please refer to Annex 1 UNIFY 2 - General Overview. 15 NHS Presentation to [XXXX Company] [Type Date]
In Depth: Domain 2 The NHS Constitution is addressed in Domain 2 of the Balanced Scorecard. Data points in scope include Referral to Treatment, cancer treatment waits, ambulatory arrival times, and mixed sex accommodation breaches. The tool lists an operational standard and a lower threshold for each metric. If a result falls between the operational standard and the lower threshold, it receives an amber rating, whilst green requires a result of at or above the operational standard. The date at which the data for each measure was populated is listed alongside the relevant RAG. There is an additional space in this section of the BSC for CCG s to indicate whether there are future concerns on any of the indicators in this Domain. This should be filled in during the assurance meeting whilst reflecting on the information in this Domain. An Overall RAG rating is calculated for this Domain: If one data point is rated red, the overall RAG will be amber; if more than one data point is rated red, the overall RAG will also be red. 16
In Depth: Domain 3 Domain 3 of the Scorecard focusses on patient health outcomes in six areas, and reconsiders Local Priorities (first referenced in Domain 1). These patient health outcomes relate to prevention of premature deaths, quality of life for patients with long term conditions (LTCs), recovery from illness and injury, positive experience of care, safe care environments, and access to psychological therapies. Please note: because of data availabiltiy issues, indicators 1-4 cannot be collected in Q1 There are several measures within each of the six areas of focus for Domain 3. For each measure, the baseline and latest position are included (data source is CCG or NHS England dependent on data point). Unit of measurement is defined for each data point. Where the data point has an associated Quality Premium, this is confirmed and the target explained. An Overall RAG is calculated for this Domain. The RAG calculation mirrors that of Domain 2. 17
In Depth: Domain 4 The Scorecard covers CCG financial performance in Domain 4. Data points are divided into primary and supporting measures, and each data point is RAG rated (the methodology for each RAG rating is adjacent to the relevant result). Area and Regional teams populate the data for this Domain. Data points include underlying surplus or deficit, management of non-recurrent funds, QIPP delivery, activity against plan, and compliance with running cost requirements. Indicators 1,7,8,12 will not be measured in Q1. Data relating to indicator 11 will come from Unify. An overall RAG is calculated for this Domain. Two red ratings result in an overall red; all measures must be green rated to achieve an overall green. 18
In Depth: Domain 5 Any remaining CCG authorisation criteria are described in Domain 5; NHS England, regional authorisation teams populate this section of the Scorecard. This section acts as a prompt to address progress against Rectification Plans. No RAG rating for this Domain. The number of remaining conditions in each authorisation domain is calculated, and the total is noted at the base of the page. 19
In Depth: Support The Support section of the Scorecard requires Area Team and a given CCG to determine an appropriate response to any Domain with an overall Red or Amber-Red rating. The RAG rating for each Domain that is Red is carried through to the Support section. Each proposed mitigation for a Red or Amber- Red issue should be discussed at the assurance meeting. In agreeing this response, Area teams must reach agreement on: 1. The underlying cause 2. A plan for action / recovery 3..Timeline for recovery 4. Whether support or intervention is appropriate 20
CCG Plan Area teams should fill out a CCG plan for any CCGs with one or more Red or Amber Red rated Domain. This should be agreed with the CCG and should reflect discussions held at the Checkpoint meeting about any issue areas and steps being taken to address these 21 NHS Presentation to [XXXX Company] [Type Date]
Using the Balanced Scorecard Process guidance & timelines
Summary of the process 0-7 weeks 1. Self certification information uploaded to UNIFY, by CCG 2. Balanced Score Card finalised, with Area and Regional Team input 0-8 weeks 3. CCG Assurance Meetings held between CCG and Area team 9-10 weeks 4. Assurance of support proposals and moderation of any proposed intervention 11-12 weeks CCGs to fill in self certification information relating to all of Domain 1, elements of 3 and 4 CCG Board to sign off self certification information CCG to upload self certification information to UNIFY Regional authorisation teams to fill in outstanding conditions template, send to London authorisation team Area finance teams upload information relating to Domain 4 (finance) to UNIFY Area teams to QA CCGs self certification upload to UNIFY Regional finance teams to ratify UNIFY upload relating to Domain 4 London Business Intelligence (BI) team to populate domains 2,3, of the BSC from data warehouse in South region London BI team to QA Domains 2,3 and finalise BSC Area teams to conduct CCG assurance meetings CCGs with all Green / Amber Green domains and no support requirement to publish BSC locally CCGs with one or more Amber / Red domains discuss appropriate support / intervention Area teams to refresh BSC with agreed support / intervention Area teams to draft CCG plan for those CCGs with one or more Red or Amber Red Domain. Support/ intervention proposals for CCGs with one or more Amber / Red domains is discussed at regional level to ensure consistency and fairness in approach In exceptional circumstances only, Intervention proposals for CCGs to be reviewed and approved by National Assurance and Authorisation committee CCGs with one or more Amber / Red domains to publish BSC locally Area teams to send support / intervention information to Regional BI teams, BI teams to save to WM SharePoint London BI team to upload BSC to WM SharePoint London BI team to update warehouse with information on confirmed intervention and support proposals 23
Step 1: Self certification information uploaded to UNIFY, by CCG Process step Action Lead 1: CCG to complete UNIFY 2 self certification template CCG will be required to complete the UNIFY self-certification template which captures information on: Quality of care provided by the CCG and its local providers Progress against CCG s local priorities Finance (internal and external audit) CCGs progress against IAPT trajectory Whether CCGs providers are meeting 15% response rate on FFT For Quarter 1 only, CCGs will need to list between 5-10 of their main providers (where CCG commissioning constitutes more than 5% of the provider s income). As a general guide, it is expected that a CCGs main providers only will be listed and only therefore only in exceptional circumstances will more than 5 providers be listed. Once completed, the self certification element must be approved by the CCG s Governing Body. CCG Please note: All questions within the UNIFY 2 template must be answered for the file to be successfully uploaded. If a CCG requires further UNIFY users to be set up please click here: http://nww.unify2.dh.nhs.uk/unify/interface/homepage.aspx 24
Step 2: Balanced Score Card finalised, with Area and Regional Team input Process steps Action Lead 2A: ATs and Regional Teams to quality assure and populate UNIFY submissions ATs should access UNIFY to view and verify self-certification return for each of their CCGs. This will involve checking all entries are appropriate e.g. % are given where specified. ATs should also populate finance data for each of their CCGs to UNIFY. Regional teams will then be asked to verify this information. This will conclude the population and verification of data for Domain 4. The London Business intelligence team will co-ordinate the population of domains 2, 3 and 5; Domains 2 and 3 will be transferred from a data warehouse in the South of England. Each data set will be available at different points in time Area Teams Regional Teams Business Intelligence Domain 5 will involve a co-ordination exercise with each of the CCG authorisation leads in each of regions. This will take place following the meeting of the authorisation and assurance sub committee, once outstanding authorisation conditions have been confirmed. The London Business intelligence team will bring all this information together to form a final BSC. The BSC will be uploaded to the West Midlands SharePoint. If an Area Team requires UNIFY users to be set up please click here: http://nww.unify2.dh.nhs.uk/unify/interface/homepage.aspx 25
Step 2: Populating Domains 2 and 3 Domain 2 NHS Constitution Referral to Treatment waiting times for non urgent consultant led treatment Diagnostic test waiting times A & E waits Cancer patients 2 week wait Cancer waits 31 days Cancer waits 62 days Category A Ambulance calls Mixed sex accommodation breaches Q1 data ready to populate BSC 19 th August 7 th August 6 th July 7 th August 7 th August 7 th August 5 th August 18 th July Domain 3 Health Outcomes 1. Preventing people from dying prematurely 2. Enhancing quality of life for people with long term conditions 3. Helping people to recover from ill health or following injury Friends and Family Test Incidence of healthcare associated infection (HCAI) i) MRSA Incidence of healthcare associated infection (HCAI) i) C difficile IAPT Coverage - performance against plan Q1 data ready to populate BSC Indicators used for Annual Assurance only Combined Measure 30 th July 9 th August 9 th August Not available for Q1 26
Step 2: Balanced Score Card finalised, with Area and Regional Team input Process steps Action Lead 2B: ATs to disseminate BSC Regional Business Intelligence teams to download each of their CCG s BSC files from West Midlands SharePoint, and share with Area Teams. Area Teams will disseminate BSC to their respective CCGs. The Balanced Scorecard will be published in Excel and will contain 10 sheets: Regional Business Intelligence Teams Area Teams 1. Overall RAG rating to each Domain, for summary 2. Reporting guidance, for information 3. Guide/FAQ, for information 4. Domain 1, results including RAG 5. Domain 2, results including RAG 6. Domain 3, results including RAG 7. Domain 4, results including RAG 8. Domain 5, results including RAG 9. Escalation Framework, for information 10. Support/Intervention log to record what has been recommended and agreed in relation to each of these All Domains, except domain 5 are RAG rated. The domains within the framework are not aggregated to produce an overall RAG rating for the CCG. 27
Step 3: CCG Assurance Meetings held between CCG and Area team Process steps 3A: CCG Quarterly Assurance Meeting to be held Action Area teams will conduct a checkpoint meeting with their respective CCGs. The purpose of the meeting is to discuss areas of concern, or emerging risk as highlighted by the Balanced Scorecard. The checkpoint meeting should be supportive and developmental. The nature of the discussion will vary depending on the outcome of the Domains, but will be focussed on providing the CCG with the right level of support to address potential issues in a pro active manner. To come to a joint understanding of the appropriate response to a Domain that is Amber Red or Red rated, Area teams and CCGS will discuss and agree: cause of the problem a plan for action / improvement a timeline for improvement whether support or intervention would be appropriate Lead Area Teams CCG The Area team will develop a short CCG plan, to reflect discussions held at the Checkpoint meeting. 28
Step 3: RAG based conversations For CCGs with Green or Amber-Green RAG Domains A CCG with a Green or Amber-Green RAG rated domain may identify further developmental support is required to continue to build their capacity and performance. Requesting support does not mean the CCG s rating changes to an Amber-Red or Red. For CCGs with one or more Amber-Red or Red RAG Domains A CCG with one or more Amber-Red or Red Domains will trigger a discussion about appropriate support or intervention. Discussion will focus on indicators and Domains that been breached, to understand whether support or intervention may help to address the issue. 29
When support is appropriate Step 3: Guidance: When support is appropriate Where CCG Assurance identifies performance concerns which require support above and beyond broader discussions about CCG Development, NHS England has a duty to provide assistance or support to a CCG. In the majority of cases we expect this to take the form of conversations where CCGs are supported to address problems and set out plans to improve performance. Types of support Where it is agreed that support may be the appropriate way forward, different types of support options could include: - Providing model document/guidance, with informal advice available if needed - Making advice/expertise available to the CCG - Facilitating peer review and partnership with other CCGs - Creatively collaborating with partner organisations such as NICE and NHS Improving Quality to gain broader professional input into problem solving - Facilitating conversations with key partner organisations and facilitating best practice modelling - In limited circumstances, providing specific funding for agreed improvement initiatives Things to note - Support is expected to be the agreed way forward in the vast majority of cases - Where performance concerns persist under agreed support, NHS England would expect the level of support to be reassessed. - Where a CCG has been subject to support on any Balanced Scorecard domain for more than two consecutive quarters, an escalation to intervention should be considered. 30
When intervention is appropriate Step 3: Guidance: When intervention is appropriate Where CCG Assurance identifies significant performance concerns or where existing development and support have been insufficient to deliver improvements, NHS England has the power to directly intervene in a CCG where there are concerns that a CCG is failing or is at significant risk of failing to discharge its functions. Types of intervention Where intervention may be the appropriate way forward, the options could include the Board; - Directing the CCG as to how it discharges its functions - Directing the CCG or the Accountable Officer (AO) to stop carrying out any functions for a defined period - Terminating the AO s appointment and appoint a new AO - Varying a CCGs constitution - Carrying out certain functions on behalf of a CCG or arrange for another CCG to do so - Dissolving the CCG Things to note Intervention should only be considered as a last resort following attempts to resolve issues locally and where it is deemed there is a significant risk of a CCG failing to carry out its functions. To reflect the seriousness of this situation and to ensure consistency in national judgements, any intervention action will need to be ratified by the Authorisation and Assurance committee of NHS England 31
Step 3: CCG Assurance Meetings held between CCG and Area team Process steps Action Lead 3B: Balanced Scorecards for CCGs with Green or Amber-Green RAG domains to be formally published locally For CCGs with only Green or Amber-Green Domains, the Balanced Scorecard should be published locally, on the CCG s website as soon as possible after the checkpoint meeting (and wherever possible, no more than 12 weeks after the quarter end) CCG 32
Step 4: Regional review, to ensure consistency Process steps Action Lead 4: Regional review to ensure consistency For CCGs with one or more Amber-Red or Red rated Domains, support or intervention agreed at the checkpoint meeting will be discussed at the Regional Assurance Meeting. Regional Assurance Meeting Regional Teams The purpose of regional assurance meetings is to: Moderate proposals of agreed support, to ensure a fair and consistent approach is being taken across the region Consider effectiveness of existing support, whether to continue, or whether to remove it based on progress towards agreed trajectories for improvement Review requests for intervention as detailed in CCG action plan. Make recommendations for intervention to the NHS England Authorisation and Assurance Committee 33
Step 5: National review of intervention proposals Process steps Action Lead 5A: National approval of escalation at National Authorisation and Assurance committee All proposals for intervention will be shared with the NHS England Authorisation and Assurance Committee. National Assurance The purpose of national assurance through the Authorisation and Assurance Committee is to: National team Review and formally agree decisions as outlined in CCG action plans. Moderate proposals for intervention, to ensure a fair and consistent approach is being taken nationally. Review effectiveness of interventions currently in place, whether to continue, or whether to remove it based on progress towards agreed trajectories for improvement. Following confirmation of outcome Area teams to send support / intervention information to Regional BI teams, BI teams to save to WM SharePoint London BI team to update warehouse with information on confirmed intervention and support proposals 34
Step 5: National Moderation to review intervention proposals Process steps Action Lead 5B: Formal publication of all outstanding Balanced Scorecard Following the completion of the above steps, Balanced Scorecards should be formally published on individual CCG websites including details of proposed support and intervention as appropriate. CCG 35
Timelines by quarter Task London team to - co ordinate collection of information on outstanding authorisation conditions Est. weeks following end of quarter Q1 3 weeks 18 July Area teams to upload finance data for each CCG via 6 weeks 5-9 August UNIFY CCGs to upload self certificate information via UNIFY 6 weeks 5 9 August Regional teams to verify UNIFY finance information for their CCGs 7 weeks 12 16 August Area team to verify self certification data uploaded to 7 weeks 12 16 UNIFY August London BI team to import data relating to Domains 2,3 8 weeks 19 August Upload BSC to share point Balanced Scorecard available for download 8 weeks 23 August Q2 tbc Following Q1 Q3 tbc Following Q1 Q4 tbc Following Q1 Area teams to download and disseminate BSC for each of the individual CCGs Area teams to conduct quarterly checkpoint meetings 9-11 weeks Area team to refresh BSC with agreed support / Intervention where appropriate 9 weeks 26 August 26 August - 13 September 12 weeks 16 Sept 36
Timelines by quarter - continued Task No. of weeks following end of quarter Q1 Q2 Q3 Q4 CCGs with Green / Amber Green Domains publish Balanced Score card on website Area Teams to write plan for each CCG with Red / Amber Red Domain 12 weeks 16 September onwards 12 weeks 16-20 September Regional moderation panel 13 weeks 23-27 September National team to write report, outlining all regional and area team recommendations for intervention 14 weeks 1 October Assurance and authorisation committee 15 weeks 8 October Area team to refresh BSC in light of regional and 15 weeks 9 October national moderation, share with Regional BI to who will upload to WM SharePoint CCG notified of outcome 15 weeks 9 October BSC published on individual CCG websites 15 weeks 10 October onwards 37
Who to contact for more information For more information or if you have any questions, email your regional office: London england.londonsubmissions@nhs.net South england.operations-south@nhs.net North england.ccg-north@nhs.net Midlands gareth.harry@nhs.net 38