HSE Audit and Risk Committee meeting minutes 20 January 2022

Members Present

Brendan Lenihan (Vice Chair), Ann Markey, Fergus Finlay, Pat Kirwan, Colm Campbell, Martin Pitt.

HSE Executive Attendance

Stephen Mulvany (CFO), Dean Sullivan (CSO), Geraldine Smith (ND Internal Audit), Patrick Lynch (ND Governance and Risk), Mairead Dolan (ACFO), Dara Purcell (Corporate Secretary), Hannah Barnes.

Joined the meeting

Brendan White (AND Procurement Head of Sourcing and Contracting) (item 3.4).

Minutes reflect the order in which items were considered and are numbered in accordance with the original agenda.

2.1 Welcome and Introductions

The V/Chair welcomed Committee members to the meeting and held a private session to consider the agenda and papers for the meeting, and the approach to conducting the meeting. Ann Markey agreed to formally act as Committee Chair for the purposes of signing the minutes at this meeting.

2.2 Declarations of Interest

The V/ Chair Brendan Lenihan absented himself for an item relating to a lease in Ballincollig Co. Cork to be considered by the Committee. He has no current conflict of interest in this matter but had been a Director of companies within the lessor group up to 2015 and wished to avoid any perception of a conflict of interest.

3.1 Property Papers and 3.2 Contract

Award The ND Capital and Estates and the Chief Architectural Advisor briefed the Committee on the following property transactions circulated to the Committee prior to the meeting for consideration. Following consideration of the detail for each proposed transaction the Committee agreed to recommend the following transactions to the HSE Board for approval:

• 50-Year Lease by the HSE of Beaumont Convalescent Home (which comprises of Beaumont House, St. Anne’s and Rockfield) and Beaumont Convent
• lease of additional floor and re-negotiation of existing Leases to enter into a new 15 Year Lease at Primary Care Reimbursement Service (PCRS), J5 Plaza, North Park Business Park, Finglas, Dublin 11
• acquisition by way of lease of an office suite at 52 Broomhill road, Tallaght Dublin 24 to provide fit for purpose Business Support/Administrative space
• acquisition by way of lease of office accommodation at Hawthorn House, Millennium Park, Naas, Co. Kildare to provide fit for purpose Business Support/Administrative space in CHO7 serving Dublin South, Kildare and West Wicklow
• proposed lease of additional space at the intended new Primary Care Centre, Tyone, Nenagh, Co. Tipperary
• acquisition by way of lease of a two-floor office suite at The Iveagh Building, Carrickmines, Dublin 18 to provide fit for purpose Business Support / Administrative space in Community Healthcare East (CH East)
• proposed Lease of Primary Care Centre (‘Galway City West’) at Seamus Quirke Road, Galway
• proposed Lease of Primary Care Centre at Swords PCC, Airside Business Park, Swords, Co Dublin
• proposed Lease for additional space at Primary Care Centre Kevin Barry St., Ballina, Co. Mayo
• proposed Lease of additional accommodation space adjacent to the new Primary Care Centre, Kilkenny City East, New Park, Kilkenny City, Co. Kilkenny
• proposed Lease of additional accommodation space at 1 Westfield, Ballincollig, Cork as part of the delivery of Primary Care Services in Cork City
• acquisition of lands for the development of a Primary Care Centre at Finglas, Dublin 11
• contract Award 50 Bed Ward Block Development at Portiuncula University Hospital, Ballinasloe, Co. Galway

3.4 Procurement Contracts - Procurement Pipeline Briefing

Head of Sourcing and Contracting joined the meeting at 09:33.

The Committee discussed with the CFO and Head of Sourcing and Contracting the briefing paper circulated prior to the meeting which provided a draft schedule of the contract approval requests which are expected to be submitted to the Committee for consideration in the coming months. The CFO noted that in each instance work is progressing to finalise the respective procurement processes and contract proposals. The Committee noted the schedule and welcomed the advance notification of upcoming contract approvals.

The CFO informed the Committee that a briefing will be provided to the Committee at its February meeting on the 40/20 procurement exercise and the overall Corporate Procurement Plan.

5.1 Update on Revised Corporate Risks

The Committee reviewed with the CRO, the papers circulated in advance of the Committee meeting for the Corporate Risk Review and Risk Update. The CRO updated the Committee on the EMTs Corporate Risk review 2021, noting that the 2021 process involved two dedicated workshops with the EMT in September and December 2021, individual meetings with EMT members, and a workshop with the Corporate Risk Support Team. As part of this review the EMT considered the observations on current risks contained in the Moody Report 2021 and the criteria for the inclusion and removal of risks on the CRR along with reconciliation with the current risks on it.

The approach adopted to the refresh corporate risks was welcomed by the Committee and the Committee provided the following feedback, which the CRO will report to the EMT for further consideration.

Criteria/ guidance for including risks on the CRR

The ARC wishes to take a look at a later meeting at the proposed set of ‘criteria’ these would be used to define risks to be included on the Corporate Risk Register (CRR). The Committee also provided the CRO with some suggested wording changes to the individual proposed criteria to ensure that these could be made clearer.

Commentary on proposed risks

Risk 10 Workforce Recruitment - The ARC is of the view that ‘recruitment and retention’ remains a principal risk.

Risk 16 Healthcare Regulatory non-compliance - The ARC suggested that the retention of this risk be considered further as it specifically referred to ‘healthcare’ non-compliance [e.g. HIQA/ MHC etc].

Risk 20 Individual Performance – In response to questions from ARC about accountability being seen as a critical organisational risk, the CRO advised that the risk as described was not a wider ‘accountability’ risk but related specifically to the performance achievement process.

Risk 25 Funded Agencies - The ARC view is that with the scale of funding involved and the challenges in many of the relationships with large providers this remains as one of the principal risk areas for the organisation.

The Committee referred again to the risks around data protection needing to be highlighted as part of the ‘top’ risk register.

ARC Risk Workshop

The ARC suggested it would be beneficial for it to dedicate more time to considering the EMT’s approach and agreed to consider it more fully at the Committee’s March meeting.

Update on the Corporate Risk Support Team recruitment process

The CRO informed the Committee that the following posts has been concluded and are at job offer stage:

• Assistant National Director: Enterprise Risk and Business Continuity Management
• General Manager: Enterprise Risk Management
• Grade VIII (7posts): EMT members’ risk teams

The Committee noted that the Letter of Engagement between the HSE and the State Claims Agency for the Risk Information System was signed in December 2021 and that it is intended that the revised CRR will be uploaded to the system.

Actions:

• the CRO will report the feedback provided by the Committee to the EMT for further consideration
• the Committee will further consider the CRR, including the criteria list at its March meeting to ensure a wider understanding of the register.

The Committee met with the ND IA in the absence of management in line with good governance practice. The Committee approved the audit plan 2022 which had been updated following the Committee’s December meeting, and circulated in advance of the meeting for consideration.

The Committee provided guidance and feedback to the NDIA in relation to the overall approach to delivering the audit programme in 2022 and looked forward to seeing the assurance deliverables during the year.

The meeting concluded at 11:00.