GOVERNING BODY MEETING held in public 30 September 2015 Agenda Item 2.1

Transcription

1 GOVERNING BODY MEETING held in public 30 September 2015 Paper Title Finance & Performance Report Month 05, as at 31 August 2015 APPENDIX A Finance & Performance Report, Month 05, as at 31 August 2015

2 Appendix A Finance & Performance Report Month 05 as at 31 August Financial Position 1.1 As at 31 August 15, NHS Eastern Cheshire Clinical Commissioning Group (ECCCG) is reporting a cumulative surplus of 588k. This is in line with its initial Plan and remains on target to deliver its forecast yearend surplus of 1.412m. Table One-A shows the current financial position by key expenditure type. Table One-A: NHS Eastern Cheshire Clinical Commissioning Group's (ECCCG's) 2015/16 Financial Summary to 31 August 2015 Annual Plan Revised Plan (Budget) Budget YTD Actual YTD Variance YTD Forecast For Year Income (241,824) (242,476) (101,032) (101,032) 0 (242,476) Expenditure Programme Costs 236, ,664 98,610 98, ,664 Running Costs 4,400 4,400 1,833 1, ,400 Sub Total 240, , , , , /16 Deficit/(Surplus) (1,402) (1,412) (589) (588) 1 (1,412) 2. Year End Outturn 2.1 As at 31 August 15, ECCCG is forecasting an estimated surplus of 1.4m and remains in line with its 2015/16 Plan. There are a number of pressures that have arisen during the previous two months which are detailed below. 2.2 Continuing Healthcare (CHC) - Cheshire East Council 500k. The work to date has progressed well and a number of cases are now being resolved. To date the positions of 53 out of the 82 clients have been agreed and a Finance/Service Group is currently validating the financial costs for each client s package. The impact of this is expected to be circa 500k over and above the provisions set aside from 1 April 14 to the current date Whilst the number of eligible CHC cases remains as estimated the number of clients who have an additional health need, albeit below the CHC limit, is higher than initially assumed. For these clients only, both NHS South Cheshire CCG and ECCCG have agreed a 70:30 split on funding these Joint Packages (30% being Health). This is Health s estimated contribution based on the fact that Health already pay Cheshire and Wirral Partnership Foundation Trust an additional sum of circa 4m to deliver services to this client group. In addition, the split was based on some case examples which highlighted a Health need but did not contain enough robust information to

3 identify costs and service delivery at a Health or Social Care level. Cheshire East Council was stating a 50:50 split given such difficulties and is now considering Health s proposal There remain seven packages where the outcome is awaited following CHC assessments with the remaining 22 linked to the Responsible Commissioner guidance. Both CCGs and the Local Authority recognise that these clients are the responsibility of organisations outside of our economy and all parties are now engaging with the relevant organisation around each client Whilst CCGs and Local Authorities adhere to the Responsible Commissioner Guidance it is ambiguous in some areas. Therefore this process is expected to be challenging and not entirely risk free Looking forward, work continues to implement a process to ensure future Joint Packages are assessed and paid for based on a client s individual needs, resulting in each partner paying their relevant share. This is expected to be concluded by the end of October Prescribing 850k. The position has deteriorated significantly during the previous two months. In the June 15 report, the forecast position for Prescribing was in line with Plan, despite a marginal overspend cumulatively This has now been revised based on the latest national data from the Prescription Pricing Authority which outlines our expenditure and forecast outturn. The revised position is now forecasting an overspend of 850,000 for the year. Due to the timing of the data being two months in arrears it is acknowledged that this is based on only three month s expenditure and is likely to refine as we proceed through the remaining months The Medicines Management lead and team are now reviewing the latest position to gain an insight into the key movements. This will enable ECCCG to be confident in the forecast outturn as well as developing a number of actions that can improve efficiency and reduce the current forecast overspend. 2.4 Transformation Reserve ( 0.8m). The transformation reserve is intended to support the pump priming requirements of the Transformation Program. As mentioned previously, any emerging pressures in 2015/16 would need to be funded to ensure ECCCG delivers against its agreed 2015/16 surplus Given the emerging pressures around CHC and Prescribing this reserve has been reduced from 2.7m to 1.9m which is a reduction of 810k. This inevitably reduces the level of available funding in year to support any Transformational business cases. 2.5 Better Care Fund (BCF) Performance Fund ( 500k). The Performance Fund included within the BCF is payable based on the delivery of a number of Key

4 Performance Indicators (KPIs). The most significant of which is a reduction in Non Elective Activity (NEL). The BCF included a number of conditions that required the NEL activity and costs to be lower than the agreed baseline The activity for ECCCG overall is above its planned level and not delivering against its KPIs. Therefore 500k has been released to support the emerging pressures as highlighted above. There is a marginal difference between ECCCG s overall activity level versus the reported BCF activity which is currently being investigated. 2.6 Table Two-A shows the forecast outturn by key service area. Table Two-A: NHS Eastern Cheshire Clinical Commissioning Group's (ECCCG's) 2015/16 Financial Summary to 31 August 2015 Original Plan Revised Plan (Budget) Budget YTD Actual YTD Variance YTD Forecast for Year Plan Cost Per Head Forecast Cost Per Head 's 's Income Programme (237,234) (237,886) (100,267) (100,267) 0 (237,886) ( 1,163) ( 1,166) Running Costs (4,400) (4,400) (733) (733) 0 (4,400) ( 22) ( 22) 2013/14 Surplus b'f (190) (190) (32) (32) 0 (190) ( 1) ( 1) Sub Total - Total Income (241,824) (242,476) (101,032) (101,032) 0 (242,476) ( 1,185) ( 1,189) Expenditure Acute Contracts 120, ,169 49,237 50, , Mental Health Contracts 15,636 16,580 6,908 7, , Community Contracts 15,227 17,072 7,113 6,704 (409) 16, Ambulance Contracts 6,789 6,789 2,829 2,681 (148) 6, Commercial Sector Contracts 4,378 4,377 1,824 1,395 (429) 4, Voluntary Sector (20) , ,553 68,147 68, , Other 7,534 8,061 3,359 3,184 (175) 7, Continuing Health Care 15,788 15,788 6,578 6, , NHS Funded Care 5,556 5,556 2,315 1,950 (365) 5, Learning Disabilities 2,182 2, (21) 2, Transformation Fund 2,673 2,673 1, (338) 1, Better Care Fund - Third Parties and Performance Fund 5,416 5,416 2,257 2,004 (253) 4, Prescribing 32,785 32,785 13,660 14, , Sub Total 71,934 72,461 30,192 30,142 (50) 71, Running Costs 4,400 4,400 1,833 1, , Caring Together (CT) Programme Sub Total - Total Expenditure 240, , , , ,064 1,179 1, /16 Final Planned Position - Deficit/(Surplus) (1,402) (1,412) (589) (588) 1 (1,412) ( 7) ( 7)

5 2.7 Tables Two-B to Two-E provide an overview of the forecast and year to date performance against key service areas and their component providers. Table Two-B: NHS Eastern Cheshire Clinical Commissioning Group's (ECCCG's) Acute Contracts Acute Contracts Annual Contract Budget YTD Actual YTD % Revised Annual Budget Variance YTD Forecast Outturn Aintree Hospital NHSFT % Alder Hey Childrens NHSFT % BMI 1, % 1, ,330 Central Manchester NHSFT 6, % 6,259 2,608 2, ,656 Countess of Chester Hospital NHSFT % (21) 113 East Cheshire NHS Trust 75, % 74,063 30,860 31, ,040 Liverpool Community Healthcare Trust % Liverpool Women's NHSFT % (4) 285 Mid Cheshire Hospitals NHSFT 4, % 4,265 1,777 1, ,531 Pennine Acute NHST % (41) 234 Robert Jones & Agnes Hunt NHSFT % (28) 247 Royal Liverpool Broadgreen NHST % Salford Royal NHSFT 1, % 1, (83) 1,481 Spire 2, % 2,556 1,065 1,064 (1) 2,729 Staffs & SOT Partnership NHST % (1) 293 St Helens & Knowsley NHST % Stockport NHSFT 10, % 10,553 4,397 4, ,274 University Hospital of North Midlands NHST 1, % 1, ,794 University Hospital of South Manchester NHSFT 12, % 12,055 5,023 4,923 (100) 12,398 Warrington & Halton NHSFT % (17) 266 Wirral University Hospital NHSFT % Wrightington Wigan Leigh NHSFT % High cost drugs/exclusions and overperformance 1, % (263) (730) Total 120, % 118,169 49,237 50, ,473 Table Two-C: NHS Eastern Cheshire Clinical Commissioning Group's (ECCCG's) Mental Health Contracts Mental Health Contracts Annual % Revised Budget Actual Variance Forecast Contract Annual YTD YTD YTD Outturn Budget Cheshire & Wirral MH Partnership NHSFT 13, % 14,412 6,005 6, ,413 North Staffordshire Combined Healthcare NHST % Other 2, % 2, , ,158 Total 15, % 16,580 6,908 7, ,610

6 Table Two-D: NHS Eastern Cheshire Clinical Commissioning Group's (ECCCG's) Community Contracts Community Contracts Annual % Revised Budget Actual Variance Forecast Contract Annual YTD YTD YTD Outturn Budget Derbyshire Community % (11) 130 East Cheshire NHST 14, % 16,232 6,763 6,763-16,232 Rent Subsidy for Community Buildings 0.0% (60) 446 Other % (289) (338) (176) Total 15, % 17,072 7,113 6,704 (409) 16,632 Table Two-E: NHS Eastern Cheshire Clinical Commissioning Group's (ECCCG's) Ambulance Contracts Ambulance Contracts Annual % Revised Budget Actual Variance Forecast Contract Annual YTD YTD YTD Outturn Budget Northwest Ambulance Service NHST 6, % 6,624 2,760 2,670 (90) 6,620 Other incl ERS Medical Patient Transport % (58) 131 Total 6, % 6,789 2,829 2,681 (148) 6, Contract Performance Key Headlines. The predicted forecast outturn as at Month 05 (latest available data) is 2m above the Plan, being a variance of 1%. This is based on the Month 04 cumulative data and is used as a basis for predicting the next 8 months, taking account of winter trends Some movement between the current position and future reporting months is expected as the data from Providers is quality assured and issues around implementation of the new tariff rules are resolved The following Provider analysis provides an insight into the key variances as at August Stockport NHS Foundation Trust 721k Forecast Overspend. The main increase is High Cost Drug expenditure. ECCCG continues to work with the Trust to validate the information on which it is based. NEL expenditure is currently 39k over year to date associated with General Medicine and work to validate the new Hyper Acute Stroke Unit charges continues. It is expected that the current recharges are overstated and that a retrospective adjustment will be actioned later in the year University Hospital of South Manchester 343k Forecast Overspend. Over performance relates mainly to an increase in Urgent Care activity. The cause is unknown but may well reflect patient s choice of providers, given that the activity in our main provider, East Cheshire Trust has seen a corresponding reduction ECCCG is also working with other commissioners to validate the counting and coding methodology around its Acute Medical Receiving Unit as it has seen an unexplained increase within this service East Cheshire Trust 977k Forecast Overspend. The main reason for the Trust s overperformance relates to planned care. The activity levels are not expected to

7 continue over oncoming months due to the expected increased demand on beds and the subsequent lack of capacity linked with the winter period In addition, the Trust has experienced a significant underperformance on Urgent Care when compared to Plan which has enabled it to increase its planned care ECCCG will be working closely with the Trust to monitor the trends over the upcoming months and to identify where possible any activity which is presenting elsewhere as a consequence of bed pressures. 3. Financial Plan Amendments 3.1 The 2015/16 Financial Plan agreed at the May 15 Governing Body was set against ECCCG s opening allocation of 241,824,000. Throughout the year, ECCCG has had its allocations amended by directives from NHS England. 3.2 Table Three-A outlines the updated allocation for ECCCG as at 31 August 15. Table Three-A: NHS Eastern Cheshire Clinical Commissioning Group's (ECCCG's) Reconciliation of Allocation Governing Body Allocation Updated (Financial Report) Original Plan 241,824 General Practice Information Technology June IAPTS operational processes funding July 15 7 Collaborative fees funding July 15 9 Eating disorders Aug Total 242, Cash Management 4.1 Part of ECCCG s financial duty is to deliver a year end cash balance of less than 250,000 as at 31 March 16 and to manage its cash throughout the year to ensure payments are made to suppliers and staff. 4.2 As at 31 August 15, ECCCG had a cash balance of 3.66m held within its bank account, as shown in Table Four-A. The balance was higher than planned due to invoices not arriving in the month as expected. This will correct itself during September 15 when the late invoice will be paid.

8 Table Four-A: NHS Eastern Cheshire Clinical Commissioning Group's (ECCCG's) Cash Forecast 2015/16 Cash Drawdown Less Payments Forecast Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 15,000 23,000 17,600 18,000 18,750 17,800 17,800 17,800 17,800 17,800 14,700 15,300 14,366 22,880 17,747 17,659 15,436 20,934 17,751 17,782 17,751 17,751 14,752 15,781 Balance , ,000 NHS Eastern Cheshire Clinical Commissioning Group's (ECCCG's) Cash Forecast 2015/16 20, s 15,000 10,000 5, Months Cash Drawdown Less Payments Balance 5. Better Payments Practice Code (BPPC) 5.1 The BPPC is aimed at paying non disputed non NHS trade creditors within 30 days of receipt of goods or a valid invoice, unless other payment terms have been agreed. 5.2 Compliance is measured by achieving 95% or more against the number of invoices paid and is calculated on both the number of invoices and the value of invoices. 5.3 Currently ECCCG has achieved a cumulative average of 98% for invoice numbers and 99% for invoice values as per Table Five-A. During August 15, the achievement against number of invoices dropped due to staff changes within the finance team and

9 the necessary role induction for new starters. The forecast remains on target to achieve compliance at 95% or above by the year end. Table Five-A: NHS Eastern Cheshire Clinical Commissioning Group's (ECCCG's) Better Payments Practice Code (BPPC) Summary Analysis No. of Invoices Value of Invoices Months Received Paid Passed Received Paid Passed Apr % 15,290,498 15,294, % May % 22,741,999 22,718, % Jun % 17,574,478 16,911,661 96% Jul % 17,379,145 17,215,600 99% Aug % 16,044,391 15,942,675 99% Total 2,694 2,633 98% 55,606,975 54,924,592 99% NHS Eastern Cheshire Clinical Commissioning Group's (ECCCG's) Better Payments Practice Code (BPPC) Summary Analysis 105% Percentage 100% 95% No. Passed Value Passed Target 90% Apr-15 May-15 Jun-15 Jul-15 Aug-15 Months

10 6. Productivity Efficiencies for 2015/ ECCCG s Financial Plan for 2015/16 includes circa 2.55m of productivity efficiencies. Table Six-A summarises the productivity schemes along with their forecast outturn. Overall, whilst the individual schemes may vary, the level of anticipated productivity savings that will be delivered in year has decreased to 2.15m, representing a decrease of 0.4m. Table Six-A: NHS Eastern Cheshire Clinical Commissioning Groups (ECCCG) Summary Productivity Scheme Plan Forecast Status Prescribing Red Pro-active Care - Reducing Non Elective Admissions Amber Contract Management Amber Contract Management (AMD Pathway & Pricing) Green Elective Variation Amber Continuing Healthcare Green Caring Together Transformational - - Total 2,548 2, The decrease in productivity savings will not impact on the achievement of the planned 1.4m surplus as the impact has been factored into the forecast. The identified schemes are aimed at reducing expenditure as opposed to stopping services overspending. 6.3 A number of the schemes are phased towards the second half of the financial year and the level of savings have been reduced to reflect latest progress. In some cases, ie, Prescribing, the Medicines Management lead and team are identifying further opportunities for consideration which will be submitted for consideration in the oncoming months. Prescribing is a challenging area for 2015/16 and any options that can be implemented to abate the current forecast overspend will need to be considered by ECCCG. 6.4 Tables Six-B to Table Six-G provide an overview of each productivity scheme providing an insight into the anticipated phasing of the savings and key progress to date, combined with an assessment as to whether the scheme is on track to deliver its productivity targets.

11 Table Six-B: NHS Eastern Cheshire Clinical Commissioning Group's (ECCCG's) Productivity Schemes 2015/16 - Prescribing Productivity Scheme Heading Financial Measures 2015/ /17 Prescribing Savings Schemes Budget vs Actual for GP Prescribing NHS Eastern Cheshire Clinical Commissioning Group's (ECCCG's) Productivity 2015/16: Prescribing 60,000 40,000 20, ,000-40,000-60,000-80, , ,000 Apr 2015 May 2015 Jun 2015 Jul 2015 Aug 2015 Sep 2015 Oct 2015 Nov 2015 Dec 2015 Jan 2016 Feb 2016 Mar 2016 Productivity Plan Productivity Achievement Prescribing is currently reporting a forecast overspend of 0.85m for 2015/16. The Medicines Management Team (MMT) support GP practices in a range of bench-marking schemes to target effort in order to manage prescribing expenditure. These schemes themselves are showing an overspend of 155k as at June 2015 (latest data). Of this, 101k is attributable to the growth in costs of anti-coagulant spending which has outstripped any potential savings. Five out of the seven schemes are being phased in and are expected to deliver some savings throughout the remaining year, although is unlikely to deliver the planned savings target given the position for the first three months. The MMT is working with Primary Care to look at ways to manage the pathways and identify new areas in an attempt to abate the current forecast overspend. Red Table Six-C: NHS Eastern Cheshire Clinical Commissioning Group's (ECCCG's) Productivity Schemes 2015/16 - Pro-active Care Non Elective Activity Productivity Scheme Heading Financial Measures 2015/16 Pro-active Care: Reducing Non- Elective Admissions 250, , , ,000 50, , , ,000 Contract plan vs actual for Non-Elective Admissions in four Main acute Providers NHS Eastern Cheshire Clinical Commissioning Group's (ECCCG's) Productivity 2015/16: Pro-active Care Non-Elective Activity 2016/ Apr 2015 May 2015 Jun 2015 Jul 2015 Aug 2015 Sep 2015 Oct 2015 Nov 2015 Dec 2015 Jan 2016 Feb 2016 Mar 2016 Productivity Plan Productivity Achievement Progress remains on target, however, costs have fluctuated over last two months. Admissions in June indicate more complexpatient need than the other months. Further work will be done linking into capacityand demand modelling work being led by the Systems Resilience Group to understand admission trends. The scheme continues but is likely to deliver less than the planned target savings. Amber

12 Table Six-D: NHS Eastern Cheshire Clinical Commissioning Group's (ECCCG's) Productivity Schemes 2015/16 - Contract Management Productivity Scheme Heading Financial Measures 2015/16 Contract Management Contracts Plan vs Actual does not exceed budget. Savings log maintained for all contracts. NHS Eastern Cheshire Clinical Commissioning Group's (ECCCG's) Productivity 2015/16: Contract Management 2016/ ,000 70,000 60,000 50,000 40,000 30,000 20,000 10,000 0 Apr 2015 May 2015 Jun 2015 Jul 2015 Aug 2015 Sep 2015 Oct 2015 Nov 2015 Dec 2015 Jan 2016 Feb 2016 Mar 2016 Productivity Plan Productivity Achievement Gains in the early months of the financial year reflect rigour ensuring contracts contained correct activity and pricing as they commenced. Year-to-date savings stand at circa 130k. ECCCG's Contracting Team is working with South Manchester CCG to understand impact of coding improvements at University Hospitals South Manchester which have led to significant growth. The scheme is unlikely to deliver the full level of savings expected for the 15/16 year. Amber Table Six-E: NHS Eastern Cheshire Clinical Commissioning Group's (ECCCG's) Productivity Schemes 2015/16 - AMD Pathway and Pricing Productivity Scheme Heading Financial Measures 2015/16 Contract Management: AMD Pathway & Pricing Contract plan vs Actual shows reduction in costs due to price shift. 2016/ ,000 NHS Eastern Cheshire Clinical Commissioning Group's (ECCCG's) Productivity 2015/16: AMD Pathway & Pricing 100,000 80,000 60,000 40,000 20,000 0 Apr 2015 May 2015 Jun 2015 Jul 2015 Aug 2015 Sep 2015 Oct 2015 Nov 2015 Dec 2015 Jan 2016 Feb 2016 Mar 2016 Productivity Plan Productivity Achievement The implementation of the new AMD pathway following the tender exercise in 2014/15 has significantly reduced the costs when compared to the 2015/16 Plan. The scheme remains on target to deliver the savings and is likely to exceed the Plan. Green

13 Table Six-F: NHS Eastern Cheshire Clinical Commissioning Group's (ECCCG's) Productivity Schemes 2015/16 - Elective Variation (Commissioning for Value) Productivity Scheme Heading Financial Measures 2015/16 Elective Variation Referrals reduce vs previous year. Contract plan vs actual shows reduction in First Outpatient attendances. 2016/ ,000 50,000 40,000 30,000 20,000 10,000 0 NHS Eastern Cheshire Clinical Commissioning Group's (ECCCG's) Productivity 2015/16: Elective Variation (Commissioning for Value) Apr 2015 May 2015 Jun 2015 Jul 2015 Aug 2015 Sep 2015 Oct 2015 Nov 2015 Dec 2015 Jan 2016 Feb 2016 Mar 2016 Productivity Plan Productivity Achievement This scheme is being implemented using the national Commissioning for Value packs as a key driver. The scheme detail and approach has been discussed at the Finance Committee and is due to start in Holmes Chapel & Congleton locality and Macclesfield GP practices as a pilot commencing in August 15. Review of the national benchmarking toolindicates that initial pathways should include Cardiovascular Disease, Gastro- Intestinal Pathways, Respiratory Conditions and Diabetes. The Plan remains on target although the impact will be quantified following the pilot evaluation. Amber Table Six-G: NHS Eastern Cheshire Clinical Commissioning Group's (ECCCG's) Productivity Schemes 2015/16 - Continuing Healthcare Productivity Scheme Heading Financial Measures 2015/16 Continuing Healthcare Management of National Risk pool for old CHC cases ("Restitution"); Productivity represents estimated funding to be returned to CCG in 2015/ /17 54,000 NHS Eastern Cheshire Clinical Commissioning Group's (ECCCG's) Productivity 2015/16: Continuing Healthcare 49,000 44,000 39,000 34,000 29,000 Apr 2015 May 2015 Jun 2015 Jul 2015 Aug 2015 Sep 2015 Oct 2015 Nov 2015 Dec 2015 Jan 2016 Feb 2016 Mar 2016 Productivity Plan Productivity Achievement Correspondence received in mid July from NHS England has rebased the contribution levels for 2015/16. The scheme remains on target to deliver the required productivity savings Green

14 7. Activity Performance 7.1 This section of the Finance and Performance Report outlines at an ECCCG level how we are performing against our overall planned levels of activity. This is a helpful indicator as these cover some of the main services for which variation in activity levels has a direct correlation to variations in cost. The associated costs are an extract from the provider contracts and are included within the individual provider contracts and their forecast outturns. 7.2 Tables Seven-A to Seven-I provide an overview of the variances to date along with any supporting information. It is recognised that there are some wider connections to be made around evidencing the links with, for example, the reduction in non-elective activity with the various transformation initiatives already implemented, ie, Proactive Care Coordinators. This is extremely difficult to quantify and work continues in order to understand what conclusions can be drawn. The tables display a combined version of monthly performance plus a monthly assessment on the forecast outturn. Table Seven-A: NHS Eastern Cheshire Clinical Commissioning Group's (ECCCG's) A&E Performance

15 A&E performance overall is broadly in line with Plan in terms of value although activity levels overall are higher. Table Seven-B: NHS Eastern Cheshire Clinical Commissioning Group's (ECCCG's) Day Case Performance

16 Day Case activity and cost are higher than planned due to the increased activity within East Cheshire Trust. During the previous four months the Trust has significantly reduced its 18 week backlog. The Trust recognises that this trend will not continue and is predicting to remain within our overall Plan by the end of the year. Table Seven-C: NHS Eastern Cheshire Clinical Commissioning Group's (ECCCG's) Elective Performance

17 Elective Performance in terms of activity is higher than planned although costs remain on Plan and will reflect the case mix of the patients treated. As with Day Cases, the increased activity in East Cheshire Trust is not expected to continue at such a high level for the remainder of the year as we head into winter and the inevitable demand on beds. Table Seven-D: NHS Eastern Cheshire Clinical Commissioning Group's (ECCCG's) Non-Elective Performance

18 The activity overall for ECCCG is above planned levels whilst the value remains on average in line with our 2015/16 plans. As with Elective, this will reflect a number of issues not least of which is the case mix of patients being treated. Table Seven-E: NHS Eastern Cheshire Clinical Commissioning Group's (ECCCG's) Outpatient First Appointment Performance

19 The increased activity being experienced is a direct correlation to increased referrals. Table Seven-F outlines the increasing trend that was experienced throughout 2014/15 which has stabilised for the first quarter of 2015/16. The data is an extract of specific codes which highlight the change in volume over the previous year. ECCCG is currently undertaking a detailed analysis by specialty and by practice to identify specific trends as well as understanding attrition (drop off) rates to calculate unnecessary referrals. Table Seven-F: NHS Eastern Cheshire Clinical Commissioning Group s (ECCCG s) Outpatient Referrals Outpatient Period 2014/15 Period 2015/16 Category Jun Difference from Previous Quarter +/- Sept Difference from Previous Quarter +/- Dec Difference from Previous Quarter +/- Mar Difference from Previous Quarter +/- Jun Difference from Previous Quarter +/- GP Written Referrals 10, , , , , Other Referrals 6,378 (3.20) 7, , ,395 (12.76) 6,691 (9.52) First Attendances 15, , , , ,762 (0.05) Seen First Attendances , ,126 (7,48) 1,025 (8.97) 1, DNA Subsequent 29,626 (3.72) 29, , , ,518 (0.25) Attendances Seen Subsequent Attendances DNA 2, , , ,403 (5.54) 2,356 (1.96)

20 Table Seven-G: NHS Eastern Cheshire Clinical Commissioning Group's (ECCCG's) Outpatients Follow Up Appointment Performance The increased activity being experienced is a direct correlation to increased referrals. Table Seven-F outlines the increasing trend that was experienced throughout 2014/15 which has stabilised for the first quarter of 2015/16.

21 ECCCG is currently undertaking a detailed analysis by specialty and by practice to identify specific trends as well as understanding attrition (drop off) rates to calculate unnecessary referrals. Table Seven-H: NHS Eastern Cheshire Clinical Commissioning Group's (ECCCG's) GP Referrals All Providers 4,500 GP Referrals All Providers 4,000 Volume 3,500 3,000 2,500 GP Ref. GA 2014/15 GP Ref. GA 2015/16 GP Ref. Seen GA 2014/15 GP Ref. Seen GA 2015/16 2,000 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Referrals for the initial four months of 2015/16 have slowed and are cumulatively 10% higher than that of the previous financial year. Much of this is expected to be due to pressures on Primary Care. The number of referrals seen within these months has also increased by similar levels which may cause an increase in planned expenditure if this trend continues throughout the year.

22 8. Balance Sheet 8.1 The NHS does not operate in a similar manner to Private Companies when it prepares its balance sheet. In summary, the NHS is not funded by share capital and as such does not have any reserves to call against. 8.2 Primarily, the blance sheet reflects the difference between its liabilities, ie, what it owes and its debtors, ie, what is owed to ECCCG plus any cash balances at that point in time. The net liability, which for August 15 was ( 5,382) is funded by the General Fund which in effect is the balancing figure. 8.3 The position remains consistent with that of the 2014/15 yearend accounts and does not show any material movement in the value of debtors or creditors as at August 15. A significant part of the payables and accruals value relates to Prescribing expenditure. The payment for Prescribing runs approximately two months in arrears and as such circa 6m is accrued into the financial position to reflect July and August costs. Table Eight-A: NHS Eastern Cheshire Clinical Commissioning Group's (ECCCG's) Balance Sheet as at 31 August 2015 Fixed assets 118 Debtors and prepayments 978 Bank and cash 3,660 4,638 Payables and accruals (10,138) Net current liabilities (5,500) Net Total Liabilities (5,382) Financed by: Allocation drawn down 105,592 Total expenditure for year to date (100,444) 5,148 General fund brought forward (10,530) Net Total Liabilities (5,382) 9. Procurement of Commissioning Support Services 9.1 As previouly discussed with the Governing Body, ECCCG, along with the Cheshire and Merseyside CCGs, is preparing for the reprocurement of commissioning support services which are curently supplied by the North West Commissioning Support Unit. 9.2 During this process ECCCG has opted to bring in-house specific services due to their strategic fit within the organisation and the expected efficiencies as these services are integrated with existing teams within ECCCG.

23 9.3 As raised at the July 15 Governing Body, the procurement timeframe was expecting a provider to be selected in September 15 with decisions being taken by the Governing Body during the month. 9.4 The procurement timeframe has now slipped due to a number of issues ranging from the supply of TUPE information to the clarification of circa 160 queries, raised by bidders. The revised position assumes completion of the selection process by 14 October 15 with a requirement for ECCCG to consider the recommendation and reach a decision by the end of October Financial Control Environment Assessment 10.1 On 11 August 15, NHS England wrote to every CCG asking for them to complete a self-assessment on the level of financial governance and control within their organisation The initiative is aimed at NHS England delivering one of its key priorities on financial resilience and sustainability. A financial resilience toolkit is to be rolled out during the summer and autumn, with the aim of supporting commissioners to secure robust financial delivery in a year of significant challenge. Building on learnings from a number of recent financial failures in the commissioning system, the toolkit will focus on four areas; prevention, early warning, financial recovery and a menu of supporting tools A key element of the prevention module is an assessment of the financial governance and control environment of each CCG The NHS is facing a very challenging financial year in 2015/16. Although financial balance across the commissioning system was achieved in 2014/15, this was in no small part because of one-off benefits and reactive interventions at a local and national level A significant contributory factor to the financial position last year was a small number of CCGs that deteriorated materially from Plan, thereby threatening the overall financial position of the commissioning system A review of five of the CCGs with the worst financial performance in 2014/15 highlighted a common issue among them; weak financial governance. As a result, all CCGs are being asked to conduct a rapid review of their financial stewardship arrangements to help assess whether they may be vulnerable to unexpected financial deterioration and to identify development needs NHS England has therefore sent a self-assessment checklist and guidance notes for completion. The checklist asks each CCG to evaluate the strength of its financial governance and controls over a range of key areas. The checklist outlines for each area the level of governance and control on a scale from excellent to improvement needed. The descriptions for improvement needed are specifically based on recent

24 observations of organisations in financial distress. The assessment should provide an overall sense of the organisation s standing against each indicator for the organisation s own benefit. The checklist is designed to be aligned with the finance elements of the 2015/16 CCG Assurance Framework and should inform the assurance process The submission was discussed at the August 15 Governance and Audit Committee (GAC) where an approach was agreed in responding to the assessment request. The draft checklist was circulated to the GAC Chair during August 15 for comments with a final draft being submitted to the Governing Body in September 15 for consideration. As part of NHS England s assurance process the checklist is required to be approved either by the Governing Body or delegated to a formal subcommittee, ie, the GAC Table Ten-A outlines ECCCG s submission along with Table Ten-B providing an anonymised list from Merseyside and Cheshire CCGs so that a comparison can be made. Despite the guidance, the assessment is subjective with only subtle changes in wording to distinguish between the various categories. ECCCG s assessment has been reviewed by NHS England to ensure consistency of reporting and assumptions.

25 Table Ten-A: NHS Eastern Cheshire Clinical Commissioning Group's (ECCCG's) Financial Control Environment Assessment Area of consideration Sub-area Excellent Good Moderate Improvement needed 1 Longer term planning Medium term financial strategy, well developed, consistent with and with sufficient funding to deliver commissioning strategy. Meets business rules and sustainable. Adequate contingencies and reserves to respond to unforeseen events. Key risks identified with clear mitigation plans. Finance actively involved in service developments, procurements and wider commissioning agenda. Medium term financial strategy, well developed, largely consistent with sufficient funding to deliver the commissioning strategy. Meets business rules and sustainable. Contingencies and reserves identified to respond to unforeseen events. Key risks identified with some mitigation plans. Finance consulted on service developments, procurements and other changes. Medium term financial strategy largely consistent with commissioning strategy but needs further development and has potential funding gaps. Meets majority of business rules including surplus but some issues re sustainability. Some contingencies and reserves identified but may not be sufficient to respond to unforeseen events. Some key risks identified with mitigation plans but further work required. Limited finance input to service improvements, procurements and improvements except for immediate finance impact. Medium term financial strategy not consistent with commissioning strategy, needs further development and shows significant funding gaps. Does not meet majority of business rules including surplus; issues re sustainability. Some contingencies and reserves identified but not deemed sufficient to respond to unforeseen events. Key risks to be identified and mitigations developed. Service developments, procurements and improvements initiated with limited or no finance input. 2 Detailed financial planning Credibility and degree of stretch Planning assumptions within the guidelines set by NHS England. Plans stretching with challenging, fully identified QIPP. Comprehensive plans with responsibilities and timescales identified. Very high confidence that plan achievable with well worked contingency plans and/or reserves. Plans including QIPP are appropriately phased and reflected in budgets. Planning assumptions within the guidelines set by NHS England. Plans stretching with challenging QIPP. Comprehensive plans with key responsibilities and timescales identified. Moderate to high confidence that plan achievable with contingency plans and/or reserves identified. Key elements of plans including QIPP are phased appropriately and reflected in budgets. Planning assumptions largely within the guidelines set by NHS England with justified exceptions. Achievable QIPP that could be stretched further, or significant amount of unidentified QIPP. Plans with some key responsibilities and timescales identified but further work required. Moderate confidence that plan achievable with some contingency plans and/or reserves identified. Majority of plans including QIPP have phasing that reflects delivery and are reflected in budgets but some work required. Planning assumptions significantly outside the guidelines set by NHS England. QIPP lacks ambition compared to others, and/or has significant elements under developed or unidentified. Plans require responsibilities and timescales to be identified. Low to moderate confidence that plan achievable with limited contingency plans and/or reserves identified. Major issues with phasing of plans including QIPP with phasing out of line with delivery. 3 Alignment with activity and provider contracts Plans well aligned with planned and contracted activity Contracts signed with all main providers. Very high confidence that plans have sufficient financial resource to deliver CCG & national targets Plans largely aligned with planned and contracted activity but some limited gaps being resolved. Contracts signed with providers making up over 80% of expenditure. Moderate to high confidence that plans have sufficient financial resource to deliver CCG & national targets. Plans reasonably aligned with planned and contracted activity but Plans only partially or not aligned with planned and contracted some significant gaps being resolved. activity. Major gaps to be resolved. Contracts signed with providers making up over 70% of expenditure. Contracts with main providers remain unsigned. Moderate confidence that plans have sufficient financial resource to Low/moderate confidence that plans have sufficient financial deliver CCG & national targets. resource to deliver CCG & national targets. Financial performance 4 In year financial performance All business rules forecast to be delivered for full year with contingency plans and reserves available as required. QIPP plan forecast to be achieved. Year to date expenditure to be in line with plan or below with minimal offsetting across categories. Expenditure run rate forecast to be in line with plan with no signs of deterioration. All business rules forecast to be delivered for full year with contingency Business rules largely forecast to be delivered for full year with plans and reserves available as required with only minor exceptions. QIPP plan forecast to be achieved. Year to date expenditure to be in line with plan or below. Expenditure run rate forecast to be in line with plan any signs of deterioration being addressed. some contingency plans and reserves available - more work required to secure plan outturn. QIPP plan forecast to be over 75% achieved. Year to date expenditure to be align with plan overall but with some significant areas of overspend. Expenditure run rate forecast to be broadly in line with plan but with significant signs of deterioration that need to be addressed. Majority of business rules forecast not to be delivered for full year. Limited or no contingency and reserves available. Low confidence that will secure plan outturn. QIPP plan forecast to be less than 75% achieved. Year to date expenditure above plan or some key areas of overspend. Expenditure run rate forecast to be higher than plan. 5 Consistency of reporting with ledgers and NHSE submissions Reports reconcile to ledger with reconciling items fully documented and Reports reconcile to ledger with reconciling items documented and signed off by Chief Financial Officer. major items signed off by Chief Financial Officer. Non-ISFE submissions agree to board reports and are in compliance Non-ISFE submissions agree to board reports and are substantially in with NHS England guidelines including AoB. compliance with NHS England guidelines. Reports don't fully reconcile to ledger with only some items documented. Evidence of sign off by Chief Financial Officer. Non-ISFE submissions normally agree to board reports and are mostly in compliance with NHS England guidelines. Reports don't reconcile to ledger with no evidence of sign off by Chief Financial Officer. Non-ISFE submissions don't routinely agree to board reports and are not in compliance with NHS England guidelines. 6 Financial reporting Comprehensiveness and use as control mechanism Financial reports provide detailed information of actual and budgeted spend on all areas of expenditure. Standard and customised ISFE reports used. Variances from budget and forecast outturn actively reviewed monthly with budget holders identifying actions to achieve agreed outturn. QIPP performance monitored at least monthly at individual initiative level with figures reconciling to I&E performance. Non-financial indicators used extensively to inform QIPP and overall financial performance. Financial reports provide detailed information of actual and budgeted spend on key areas of expenditure. Standard and customised ISFE reports used. Variances from budget and forecast outturn reviewed with budget holders identifying actions to achieve agreed outturn with major areas of concern reviewed monthly. High confidence that agreed actions will resolve variances. QIPP performance monitored monthly at individual initiative level with figures reconciling to I&E performance. Non-financial indicators used to inform QIPP and overall financial performance. Financial reports provide detailed information of actual and budgeted spend on key areas of expenditure but with some issues on timeliness or quality. Standard and customised ISFE reports used but significant use of off-ledger reporting. Variances from budget and forecast outturn reviewed with budget holders identifying actions to achieve agreed outturn with major areas of concern reviewed monthly with moderate confidence that the actions will resolve variances. QIPP performance monitored monthly for key individual initiatives with figures reconciling to I&E performance. All initiatives reviewed at least quarterly. Non- financial indicators used in some cases to inform QIPP and overall financial performance but with further scope. Financial reports don't provide timely and accurate information of actual and budgeted spend on key areas of expenditure. Standard and customised ISFE reports used but extensive use of off-ledger reporting that isn't reconciled to the ledger. Variances from budget and forecast outturn not routinely and systematically reviewed with budget holders. Limited actions identified and agreed to achieve outturn. Low confidence that variances will be resolved or offset. QIPP performance not monitored monthly at individual initiative level. Figures don't reconcile to I&E performance. Non-financial indicators used infrequently to inform QIPP and overall financial performance. 7 Sufficiency of board reporting to manage overall financial position Reporting provides very clear explanation of current and forecast position and underlying run rate, including corrective actions and full risk analysis. I&E, cash and balance sheet all covered with integration with key nonfinancial measures including activity. Format formally & regularly reviewed by appropriate committee. Reporting provides good explanation of current and forecast position including corrective actions and risk analysis for key risks. I&E, cash and balance sheet all covered with integration with key nonfinancial measures including activity. Format reviewed by appropriate committee as need identified. Reporting provides some explanation of current and forecast position including some corrective actions and risk analysis for key risks but reports could be better. Cash and balance sheet partially covered with limited integration with key non-financial measures including activity. Format reviewed from time to time but not approved by appropriate committee. Reporting provides limited explanation of current and forecast position. Corrective actions and risk analysis difficult to understand and not comprehensive. Cash and balance sheet only partially covered. Very limited integration with key non-financial measures. Format not reviewed in last year.

26 8 Standing orders, SFIs and delegated authorities Standing Orders, standing financial instructions and delegated authorities regularly reviewed and approved. Clear guidance documents in place for relevant aspects such as procurement and recruitment. All staff trained on financial governance and training documented. Delegated authorities built into ISFE with complete hierarchies. Standing Orders, standing financial instructions and delegated Standing Orders, standing financial instructions and delegated authorities regularly reviewed and approved. authorities reviewed and approved in the past 12 months but no Guidance documents in place for relevant aspects such as procurement timetable for future reviews. and recruitment. Guidance documents in place for relevant aspects such as Key staff trained on financial governance. procurement and recruitment. Delegated authorities built into ISFE with substantially complete Some evidence of staff training on financial governance but more hierarchies or well documented and approved working arrangements needed. for exceptions. Delegated authorities built into ISFE but with incomplete or out of date hierarchies. Adequate working arrangements in place but not fully documented. Standing Orders, standing financial instructions and delegated authorities not reviewed and approved in the past 12 months. No timetable for future reviews. Limited or no guidance documents for relevant aspects such as procurement and recruitment. Limited or no staff training provided and if delivered it is on an ad hoc basis. Delegated authorities built into ISFE but with incomplete or out of date hierarchies. Working arrangements to operate ISFE inadequate and not documented. 9 Budget setting, monitoring and forecasting and key area cost control Draft budgets prepared by fully trained budget holders with guidance on assumptions including growth, efficiencies and inflation provided by CFO. Budget holders take budget management responsibilities seriously. Budgets include the impact of QIPP and are phased in line with activity or other primary cost driver. Reserves and contingencies transparent and phased appropriately. Budgets formally accepted by budget holders by start of financial year and any budget adjustments clearly documented and agreed. Budget virement process clear with high level sign off of major changes. All areas of expenditure budgeted at sufficiently detailed level to facilitate understanding of actual performance and enable control. Budgets prepared by budget holders with guidance on assumptions including growth, efficiencies and inflation provided by CFO. Majority of budget holders take responsibilities seriously. Budgets including QIPP phased in line with activity or primary cost driver. Reserves and contingencies transparent and phased appropriately. Budgets formally accepted by budget holders by end of April and any budget adjustments clearly documented and agreed. Budget virement process documented with clear system of sign off of major changes. Key areas of expenditure budgeted at sufficiently detailed level to facilitate understanding of actual performance and enable control. Budgets largely prepared by budget holders with some guidance on assumptions including growth, efficiencies and inflation provided by CFO. Some budgets imposed to achieve overall surplus. Some budget holders not taking responsibilities seriously. Most expenditure and QIPP budgets phased in line with activity or primary cost driver but some key lines phased in straight line. Reserves and contingencies not as transparent as they should be to the governing body. Budgets not formally accepted by budget holders and adjustments not always clearly documented and agreed. Budget virement process working but without documented or appropriate sign off of changes. Key areas of expenditure budgeted at reasonably detailed level to facilitate understanding of actual performance and enable control but some evidence of off ledger record keeping. Budgets largely prepared by finance with limited consultation with budget holders. Limited evidence of budget holders taking their responsibilities seriously. Poor or no guidance on assumptions including growth, efficiencies and inflation. Expenditure budgets not phased in line with activity or primary cost driver. Reserves and contingencies not transparent and if exist are hidden in budget lines or phasing. Budgets not formally accepted by budget holders and adjustments not documented and agreed. Budget virement process ad hoc without documented or appropriate sign off. Key areas of expenditure not budgeted at a detailed level so understanding of actual performance difficult. Substantial off-ledger record keeping. Financial controls & processes Systems of financial control Balance sheet including intercompany balances (AoB) & cash Systems & processes (including internal audit response) Balance sheet reviewed and signed off every month with full reconciliations especially for accruals, provisions and prepayments. Agreement of balance returns reconcile to ledger and completed on time - differences with providers and other NHS bodies actively resolved. Supplier statements for all non-nhs providers routinely reconciled with no unresolved issues. Ledger and other systems with financial impact subject to active access and posting control in line with delegated authorities. Cash forecast and drawdown requirements signed off. Cash at bank minimised without overdrafts and no supplementary cash drawdowns. Robust system of controls exists including segregation of duties & control account and other balance sheet reconciliations. Journals fully documented and approved by appropriate level supervisor. Accounts payable and receivable regularly reviewed with minimal overdue debts or delayed payments to creditors. All processes documented with clear responsibilities for delivery and review. No internal audit category 1 findings and recommendations and all lower level recommendations implemented on time and in full. Unqualified external audit report. Balance sheet reviewed every month with full reconciliations for key accounts and minimum quarterly reconciliations for remaining accounts. Agreement of balance returns reconcile to ledger and completed on time - major differences with providers and other NHS bodies actively resolved. Supplier statements for key non-nhs providers routinely reconciled and no major issues. Ledger and other systems with financial impact subject to active access and posting control in line with delegated authorities. Cash forecast and drawdown requirements signed off. Cash at bank minimised with only occasional overdraft or supplementary drawdown requests. Balance sheet reviewed most months with full reconciliations for key accounts and minimum quarterly reconciliations for remaining accounts. Some reconciliations incomplete. Agreement of balance returns reconcile to ledger and completed on time - major differences with providers and other NHS bodies being resolved but some historical and unresolved issues. Supplier statements for non-nhs providers routinely reconciled when issues arise with supplier. Ledger and other systems with financial impact subject to active access and posting control in line with delegated authorities. Some outstanding issues. Cash forecast and drawdown requirements signed off. Overall low cash balances at bank with occasional overdraft or high cash balances. Robust system of controls exists. Segregation of duties, control account Robust system of controls exists with some minor issues. and other balance sheet reconciliations almost 100% in place with only Segregation of duties, control account and other balance sheet minor exceptions. reconciliations substantially in place with only minor exceptions. Journals fully documented and approved by appropriate level Journals well documented and approved by appropriate level supervisor. supervisor with minor exceptions. Accounts payable and receivable regularly reviewed with minimal Accounts payable and receivable regularly reviewed but with some overdue debts or delayed payments to creditors. overdue debts and/or delayed payments to creditors. Key processes documented with clear responsibilities for delivery and Key processes documented with clear responsibilities for delivery review. and review. No more than one internal audit category 1 finding and No more than two internal audit category 1 findings and recommendation in last year. Remaining lower level recommendations recommendations in last year. Remaining lower level implemented on time and in full. recommendations implemented on time and in full. Unqualified external audit report. Unqualified external audit report. Balance sheet reviewed irregularly by CFO. Incomplete reconciliations for key accounts with items on control accounts unresolved for long periods. Agreement of balance returns don't reconcile to ledger and not completed on time. Major differences with providers and other NHS bodies not being resolved. Supplier statements for non-nhs providers not reconciled with frequent issues with suppliers. Ledger and other systems with financial impact not subject to active access and posting control in line with delegated authorities. Cash forecast and drawdown requirements not signed off. Poor cash forecasting and high variability in month end cash balance. System of control poorly documented with some major issues. Issues with segregation of duties, control accounts and other balance sheet reconciliations. Journals poorly documented and not generally approved by appropriate level supervisor. Accounts payable and receivable not regularly reviewed and show significant overdue debts and/or delayed payments to creditors. Key processes not documented, clear responsibilities for delivery and review not clear. More than two internal audit category 1 findings and recommendations in last year and majority of lower level recommendations not implemented on time and in full. Qualified external audit. 12 Risk sharing & income recognition Where applicable, risk sharing arrangements with other CCGs and trusts fully documented and associated financial risks evaluated monthly. Total risk evaluated and CCG share agreed with other parties. All anticipated recharges have agreement. Where CCG receives income for the provision of services commissioned by other organisations financial controls are in place to ensure the CCG is not placed at any risk, and that all transactions and balances are separately identified. No income, expenditure or cash transactions that could be constituted to be brokerage or similar arrangement. Where applicable, risk sharing arrangements with other CCGs and trusts documented and associated financial risks routinely evaluated. Sufficient information for CCG to assess and account for its own risk. Risk included in risk register and in risk adjusted position. All anticipated recharges have outline agreement or a process for getting agreement. Where CCG receives income for the provision of services commissioned by other organisations financial controls are in place to ensure the CCG has minimal risk, and that all transactions and balances can be identified. No income, expenditure or cash transactions that could be constituted to be brokerage or similar arrangement. Where applicable, risk sharing arrangements with other CCGs and trusts documented sufficiently to evaluate associated financial risks. Risk assessed at least quarterly and included in risk register and in risk adjusted position. Majority of anticipated recharges have outline agreement or a process for getting agreement. Where CCG receives income for the provision of services commissioned by other organisations - financial controls need strengthening. CCG has moderate exposure to risk that it can't directly mitigate. Any income, expenditure or cash transactions that could be constituted as brokerage or similar are minimal, transparent arrangements and don't have a major impact on surplus. Where applicable, risk sharing arrangements with other CCGs and trusts not documented sufficiently to evaluate associated financial risks. Majority of anticipated recharges don't have outline agreement or a process for getting agreement. CCG receives income for the provision of services commissioned by other organisations - poor financial controls. CCG has significant exposure to risk that it can't directly mitigate. Significant income has been received non-recurrently or invoices reduced in value on the basis that this will be reversed in future periods. Lack of transparency. 13 Risk management Identification and monitoring process Pro-active horizon scanning process with risks assessed in terms of likelihood and financial impact. Clear responsibility of governing body or appointed committee. Clear documented process for identifying mitigations. Mitigations evaluated financially with early and effective stakeholder engagement. Tracking and reporting system in place with regular reporting to the appropriate committee. All risks on risk register financially assessed monthly. Process for assessing risk well established with risks assessed in terms of likelihood and financial impact. Clear responsibility of governing body or appointed committee. Mitigations evaluated financially with stakeholder engagement. Tracking and reporting system in place with regular reporting to the appropriate committee. All risks on risk register financially assessed with major risks reviewed regularly. Process for assessing risk reasonably well established with risks assessed in terms of likelihood and financial impact - some improvements needed. Responsibility of governing body or appointed committee clear. Risks sometimes overlooked. Mitigations evaluated financially with some stakeholder engagement. Tracking and reporting system in place with regular reporting to the appropriate committee. Key risks on risk register financially assessed but more in depth review required to fully evaluate. Process for assessing risk ill defined - major improvements needed. Unclear responsibilities for assessing and reporting. Only some mitigations evaluated financially with limited stakeholder engagement. Tracking and reporting system poor with irregular reporting to the appropriate committee. Key risks on risk register financially assessed but more in depth review required. 14 Level of net risk Fully quantified risk. All risks matched by fully worked and credible mitigations capable of deployment in-year, leaving a net opportunity. Key risks fully quantified risk. Risks matched by mitigations leaving no net risk. Majority of risks quantified but with some key risks under evaluation. Risks matched by mitigations leaving overall net risk within business rules. Risks only partially quantified & only partially matched by underdeveloped mitigations leaving material net risk outside business rules.