nhs newham ccg board part i meeting · declarations of interest. no interests were declared. 1.2...

NHS Newham CCG Board Part I meeting

3:30pm - 4:00pm, Thursday 24 October 2019 Committee

Rooms, NHS Newham CCG

4th Floor, Unex Tower, 5 Station Street, London E15 1DA

Newham CCG - Acronyms List

ACRONYM MEANING

A&E Accident & Emergency

ACS Accountable Care System

APMS Alternative Provider Medical Services (a type of Primary care contract)

AQP Any qualified provider

BAF Board Assurance Framework

Bart's / BHT Barts Health NHS Trust

BAU Business as usual

BCP Business continuity plan

BHRUT Barking, Havering and Redbridge University Hospitals NHS Trust

BMA British Medical Association

CAS Clinical Assessment Service

CCG Clinical Commissioning Group

CCG IAF Clinical Commissioning Group Improvement and Assessment Framework

CCU Critical Care Unit

CEG Clinical Effectiveness group

CEPN Community Education Provider Network

CHN Community Health Newham Directorate

CHP Community Health Partners

CHS Community Health Systems

CIL Construction Industry Levy

CPD Continuing Professional Development

CQC Care Quality Commission

CQRM Clinical Quality Review Meeting

CQUINs Commissioning for Quality and Innovation (Payment Framework)

CSU Commissioning Support Unit

CYP Children and Young People

DASL Drug and Alcohol Service in London

DES Direct Enhanced Service

DoH/ DH Department of Health

DoPM Newham Department of Psychological MedicineDRSS Diabetes Retinopathy Screening Service

DToC Delayed Transfers of Care

ED Emergency Department

ELFT East London Foundation Trust

ELHCP East London Health and Care Partnership

EMIS web Egton Medical Information Systems (System that records patient consults)

EPCS Extended Primary Care Service

EPCT Extended Primary Care Team

EPR Electronic Patient Record

ETTF Estates and Technology Transformation Fund

FOI Freedom of Information

GB Governing Body

GIA Gross internal area

GLA Greater London Authority

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GMC General Medical Council

GMS General Medical Services (a type of Primary care contract)

GP General Practitioner

HBPoS Health Based Places of Safety

HEE Health Education England

HLP Healthy London Partnership

HMT Her Majesty's Treasury

HoT Heads of Terms (Contract Summary)

HUH The Homerton University Hospital NHS Foundation Trust

IAPT Increasing Access to Psychological Therapy

ICC Integrated Care Committee

ICP Integrated care partnership

ICS Integrated Care System

IG Information Governance

IMCA Independent Mental Capacity Advocate

IMT Information Management and Technology

IPS Individual placement and support schemes

ITT Invitation to Tender

ITU Intensive Therapy Unit

IUC Integrated urgent care

JCC Joint Commissioning Committee

JSNA Joint Strategic Needs Assessment

KGH King George Hospital

KPI Key Performance Indicator

LAP Local Area Partnership

LAS London Ambulance Service

LAs Local Authorities

LBN London Borough of Newham

LBWF London Borough of Waltham Forest

LCFS Local Counter Fraud Specialist

LD Learning Disability

LD SAF Learning Disability Self-Assessment Framework

LEB London Estates Board

LEDU London Estates Development Unit

LES Local enhanced service

LMC Local Medical Committee

MHCC Mental Health Commissioning Committee

MM Medicines management

MoLCV Medicines of limited clinical value

MOU Memorandum of understanding

MPIG Minimum Practice Income Guarantee

MSK Musculoskeletal

NAFO Newham Alternative Funding Option

NCCG Newham Clinical Commissioning Group

NDPP National diabetes prevention programme

NEL North East London

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NELCA North East London Commissioning Alliance

NELCSU North East London Commissioning Support Unit

NELFT North East London Foundation Trust

NHC Newham Health Collaborative

NHS PS NHS Property Services

NHSE NHS England

NHSI NHS Improvement

NICE National Institute of Health and Care Excellence

NUH Newham University Hospital

NWP Newham Wellbeing Partnership

OOH Out of hours

OPD Outpatient department

OPE One Public Estate

PALS Patient Advice and Liaison Service

PCCC Primary Care Commissioning Committee

PCH Primary Care Home

PCT Primary Care Trusts

PHE Public Health England

PMS Personal Medical Services (a type of Primary care contract)

PPE Patient and Public Engagement

PPG Patient and Public Group

PREM Patient Reported Experience Measure

PROM Patient Reported Outcome Measures

QIPP Quality, Innovation, Productivity and Prevention

QOF Quality Outcome Framework (Assessor Validation Reports)

R&D Research & Development

RAG Red, Amber, Green

RICS Royal Institute of Chartered Surveyors

RLH Royal London Hospital

ROI Return on Investment

RTT Referral to treatment

SEP Strategic Estates Plan

SMI Severe mental illness

SPA Single Point of Access

SPR Service Program Review

STP Sustainability and Transformation Plan or Partnership

THCCG Tower Hamlets Clinical Commissioning Group

TOR Terms of reference

TSCL Transforming Services Changing Lives

TST Transforming Services Together

UCC Urgent Care Centre

UCLP UCLPartners/ University College London Partners

UCWG Urgent Care Working Group

UEC Urgent and Emergency Care

UTC Urgent Treatment Centre

WELC Waltham Forest, East London and City (Integrated Care Programme)

WFCCG Waltham Forest Clinical Commissioning Group

Whipps X / WX Whipps Cross Hospital

WTE Whole Time Equivalent

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2019-20 Newham CCG Board meetings attendance log

Apr-19 Jul-19 Oct-19 Dec-19 Feb-20 Members Dr Clare Davison Dr Nadeem Faruq Dr Catherine Gaynor Dr Muhammad Naqvi Dr Arpana Patel Dr Bapu Sathyajith Dr Rima Vaid Ellie Robinson Grainne Siggins Ajith Lekshmanan Jane Milligan Henry Black Fiona Smith Phil Horwell Livia Royle Selina Rodrigues Selina Douglas Satbinder Sanghera Chetan Vyas Steve Collins John Wicks

Colin Ansell Vineeta Manchanda Mariette Davis Jason Strelitz

Key:

Member was present at this meeting Member was not present at this meeting Member was not a Board member at the time of this meeting

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NCCG Board Part I 3:30-4:00 pm Thursday 24 October 2019 Committee Rooms, Unex Tower, 5 Station Street, Stratford, E15 1DA

Agenda

No Item Page Action Required Owner

1. Welcome

1.1 Welcome, introductions, apologies Declarations of interest

Verbal Chair

1.2 Minutes of the meeting held 4 July 2019 and matters arising:

Action log

7

11

Approve

Discussion

Chair

Chair

2. Patient and public engagement

2.1 Questions from the public Verbal Discussion Chair

3. Strategic and discussion items

3.1 WEL Governance arrangements 12 Approve Satbinder Sanghera

4. Any other business

5. Date of next meeting:

TBC, Committee Rooms, Unex Tower, Stratford, London, E15 1DA

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Newham CCG Board 04 July 2019

Committee Rooms, Unex Tower, Stratford, London, E15 1DA

Minutes

Present:

Elected Members

Dr Nadeem Faruq Elected GP Representative, Newham CCG

Dr Catherine Gaynor Elected GP Representative, Newham CCG

Dr Muhammad Naqvi (Chair) Chair and Elected GP Representative, Newham CCG

Dr Arpana Patel Elected GP Representative, Newham CCG

Dr Bapu Sathyajith Elected GP Representative, Newham CCG

Dr Rima Vaid Deputy Chair and Elected GP Representative, Newham CCG

Appointed Members – voting

Ajith Lekshmanan Lay Member for Audit and Governance, Newham CCG

Jane Milligan Accountable Officer, NELCA

Ellie Robinson Lay Member for Patient and Public Participation, Newham CCG

Fiona Smith Registered Nurse, Newham CCG

Jason Strelitz Director of Public Health, London Borough of Newham

Appointed Members – non-voting

Selina Rodrigues Healthwatch Newham

In attendance

Jason Clarke (minutes) Risk and Information Governance Manager, Newham CCG

Steve Collins Director of Finance, Estates and IT, WEL CCGs

Selina Douglas Managing Director, WEL CCGs

Satbinder Sanghera Director of Corporate Services, WEL CCGs

Chetan Vyas Director of Quality and Safety, WEL CCGs

Business Items

1. Welcome, introduction, apologies for absence and declarations of interest

1.1 W / I / A / Dec of Interests

Welcome

The Chair welcomed the members to the meeting and with a quorum being present the meeting was declared open.

Apologies were received from the following members:

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Dr Clare Davison, Elected GP Representative, NHS Newham CCG Phil Horwell, Lay Member – Remuneration, NHS Newham CCG Henry Black, Chief Finance Officer, NELCA Colin Ansell, Director of Commissioning (Adults), London Borough of Newham

Declarations of interest.

No interests were declared.

1.2 Minutes – meeting(s)

The minutes of the meeting held on 25 April 2019 were agreed as an accurate record of the matters discussed.

1.3 Action Log

The action log was reviewed and the following information received:

CCG 167 – This action is currently on hold whilst we review WEL wide qualityimprovement programmes. Chetan Vyas is leading on this piece of work, which seeks to build on the work of the University College London Academy and the East London Health and Care Partnership.

CCG 178 – Selina and Colin met to discuss. There has been limited progress onintegrated commissioning due to recruitment. An update is likely in September/October. There has been a commitment arrange an organisational development session focused on Childrens services.

CCG 183 – This has been completed and can be removed from the action log. CCG 184 – This action as written has been completed and can be removed. The

CCG continue to meet regularly with NHC, and noted the positive work that hastaken place to date with the new Clinical Directors. The Board heard that NHC hada new finance lead and a plan in place for the recruitment of a permanent ChiefExecutive Officer. The Board felt that it might be helpful to have sight of the actionplan for Newham Health Collaborative. Action: JC will request that Jenny Mazerlocirculates the action plan.

CCG 185 – SS noted that there was a workshop scheduled on 11th July 2019. CCG 186 – This action has been completed and can be closed.

2. Patient and Public Engagement

2.1 Questions from the public

There were no questions from the public.

3. Strategic items

3.1 WEL Governance arrangements

Satbinder Sanghera presented the WEL Governance arrangements to the Board. Key points included:

i. highlighting the work to date to develop the WEL governance arrangements. TheBoard heard that this included two development sessions and a number of WELBoard to Board meetings

ii. informing the Board of the direction of travel nationally towards 1 CCG acrosseach STP footprint by April 2021.

iii. informing the Board where the report has been presented to date, andhighlighting the key discussion points at these meetings. SS noted that the reporthad been presented to the Boards at Tower Hamlets and Waltham Forest CCGson 2 July 2019 and 3 July 2019 respectively.

iv. requesting that at this time the Scheme of Reservation and Delegation of theWEL Board be withdrawn.

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v. a recommendation that establish a WEL Board, and hold the first meeting of thisnew Board on 24 July 2019.

In discussion the Board:

i. sought clarity on why the recommendation to establish the WEL Board was not beingpresented to Member Council and NHSE for approval. The Board were informed thatconstitutionally the WEL Board would be a body created by the governing bodies ofthe respective WEL CCGs. This means that from a governance perspective, the WELBoard reports to the individual CCG Boards and therefore does not require membercouncil approval.

ii. queried the planned role of Healthwatch on the WEL Board. It was noted thatindividually across WEL, there is a different approach to the role that Healthwatchundertake. The Board were informed that the current proposal was to take aconsensus view across the three CCGs, respecting the current variation in how eachrespective Board engages with Healthwatch. The Board heard that Healthwatch havebeen offered the opportunity to have an item on the agenda at each WEL Boardmeeting, but would not be considered a formal member of the Board. The offer wasseen as a commitment to maintain the strong relationships built with Healthwatchacross WEL.

iii. sought clarity on the potential makeup of the WEL Board. The Board were informedthat there would be representation from the three local authorities and three generalpractice representatives from each CCG, inclusive of the respective CCG Chairs.

The Board approved

i. the establishment of the WEL Boardii. the TOR and Membership of the WEL Board, subject to the amendment of 1

additional safeguarding Board Nurseiii. the standing orders for WELiv. the Conflict of Interest Policy, subject to an amendment to 5.3 which will enable

the secondary care consultant from within North East London to be on the WELBoard

v. the recommendation to hold the first meeting of the WEL Board on 24th July 2019.

3.2 Board membership

Ajith Lekshmanan was conflicted for this item and left the room for the following discussion.

Satbinder Sanghera presented the Board membership report. Key points included:

i. highlighting that Lay members are recruited for an initial 2 year term. After theinitial term the Board has the option to extend for up to a further 2 year period.

ii. The recommendation to the Board is to extend the term for an initial 3 monthperiod. This would allow for the conclusion of the review of Lay Member rolesand responsibilities being undertaken by Deloitte.

Discussion points included:

i. noting that the lay member for governance is also the CCG’s Audit Chair. TheBoard were assured.

ii. For the purposes of quorum, 2 out of the 3 lay members were required to attendiii. a recommendation to extend the term for 3 months with the option of exercising

an additional month in the event of any unforeseen delays.

The Board agreed the extension of the term.

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4. Any other business

4.1 CEPN Report

Dr Catherine Gaynor noted that a CEPN report had been prepared for the Board meeting prior to the agenda being revised.

Action: Jason Clarke agreed to ensure that a Word version of the report be circulated to Board members.

4.2 Public Health Strategy for Newham

Jason Strelitz informed the Board that a workshop had been scheduled on Weds 10th July 2019 at 1pm to support the development of the Public Health Strategy for Newham.

5. Date of next meeting

5.1 TBC, Committee Rooms, 4th Floor, Unex Tower, Stratford, London, E15 1DA

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Action

reference

Meeting

date

Minute

referenceAction Owner

Target completion

dateUpdate

CCG 167 28/06/2018 3.1

CEPN: Carry out a feasibility study and develop a business

case for establishing the Improvement Academy as a social

enterprise.

C Gaynor Oct-19 JC shared the repprt with the P1 Papers

CCG 178 27/09/2018 3.3

Discuss the performance and provision of children’s

services, as well as joint working with the local authority on

this, at a future meeting.

Selina

Douglas/Sara

h Garner

Feb-20An update on this will be provided closer to

the completion date

CCG 180 27/09/2018 3.5 Develop a talent management process across NEL J Milligan Feb-20An update on this will be provided closer to

the completion date

CCG 184 19/12/2018 3.2

Develop a timeline and detailed action plan for the work of

the GP federation oversight group to be approved by the

Board before ratification at Practice Council.

S Sanghera/ J

MazareloNov-19

A request was made at the last Board

meeting to share the NHC action plan with

the Board. An NHC update report was

presented to the PII of the September PCC

Committee and we are currently reviewing

this paper ahead of further circulation.

CCG 185 19/12/2018 3.3

Board Assurance Framework:

Dedicate a Board development session to review the BAF

risk descriptions, ratings and committee responsible for their

assurance - following the session in January to discuss the

strategic priorities as a borough.

S Sanghera/

C VyasNov-19

Discussions under way with WEL Audit

Chairs and the Governance Leads to

develop a WEL BAF. Approval of strategic

objectives will support this and a draft will

be taken to the WEL Board in November

Newham CCG Board part I action log - 24/10/2019

Highlighted items represent a recommendation to remove from register

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Newham CCG Board 24th October 2019 Unex Tower, Stratford, E15 1DA

Title WEL (WALTHAM FOREST, NEWHAM, TOWER HAMLETS) CCG GOVERNANCE ARRANGEMENTS

Agenda item 2.1

Author Satbinder Sanghera, Director of Corporate Services

Presented by Satbinder Sanghera, Director of Corporate Services

Contact for further information

Satbinder Sanghera, Director of Corporate Services, [email protected], 020 36882388

This paper is for ☒ Decision ☐ Monitor ☐ Discussion ☐ For Information

Action required 1. To approve the TOR and Membership of the WEL Joint Committees2. To approve the Scheme of Reservation & Delegation of the WEL Board3. To approve the Standing Financial Instructions of the WEL Board

Executive summary

To propose WEL Joint Committee Terms of Reference, Scheme of Reservation & Delegation and Standing Financial Instructions.

Supporting papers Appendix A – Strategy & Transformation Terms of Reference Appendix B - Finance & Performance Terms of Reference Appendix C - Quality & Safety Terms of Reference Appendix D - Scheme of Reservation and Delegation Appendix E – Standing Financial Instructions

Next Steps/ Onward Reporting

None

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Where has the paper been already presented?

“No previous presentation to any previous meetings/forums”

How does this fit with NHS Newham CCG strategic Priorities?

• Making sure our governance is fit for purpose

Risk Failure to approve the recommendations will mean that the WEL system does not have streamlined and aligned governance arrangements and will not be consistent with the direction of one CCG by 2021 alongside a WEL sub system and borough based arrangements, and collaborative working with our partners.

This will increase the risk of not being able to implement our system plan/intentions and have a system that is able to make progress on key health indicators.

As the Long Term Plan stipulates, ‘Every ICS will need streamlined commissioning arrangements to enable a single set of commissioning decisions at system level….

This is potentially at risk if the governance changes are not approved and this will put at risk the ability of the WEL CCG to deliver the improvements in outcomes, quality and performance that the Board aspires to for the population of our population.

Equality impact In establishing new governance structures there is a duty to ensure that Boards and committees within the WEL structure are diverse in relation to all equalities characteristics. It is also important that there is a Board Development programme in place to allow Board members to develop as a team and to develop the skills required. There is also a need to ensure that the WEL Board will have due regard to the Public Sector Equality Duty when exercising its decision-making functions, and that in doing so it will consider the equalities impact and potential inequalities in each of its constituent CCG areas.

Stakeholder engagement

“No previous presentation to any previous meetings/forums”

Financial Implications

The development of the WEL system and structures are designed to support the requirement to deliver 20% savings against the Running Cost Allowance, ensure a cost effective and fit for purpose structure with a cohesive approach to delivery of each CCG’s statutory financial duties. It is supported by transitional financial arrangements previously agreed to ensure stability and equitability of individual CCG’s financial positions.

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1. Introduction and background

1.1

1.2

The Board meeting in July approved the requested changes to establish a WEL Board. At that board meeting it was noted that there would be a further proposal regarding the committee structure. This report proposes the final changes required to fully implement the interim WEL committee model prior to the move to the one CCG by April 2021 alongside a WEL sub system and borough based arrangements.

These new arrangements are vital to deliver:

• Strategic alignment with the NHS Long Term Plan and in particular the commitment tostreamline the commissioning function and in the future have a strategic commissioning function across North East London

• Sustainability for the whole system including providers, commissioners and partners

• Improvements in outcomes, quality and performance and reducing variation across WEL.

2. Background

2.1

2.2

2.3

2.4

The NHS Long Term Plan published in January 2019 sets out the vision for NHS services as they transition from the current system to the development and implementation of Integrated Care Systems.

Every STP system in England is undergoing a process to streamline their commissioning arrangements to enable a single aligned strategic commissioning direction to providers locally.

The three boards came together for the third time in January 2019 where a mandate was agreed to take the work forward and options for new arrangements. Following that the three boards came together two more times to review the effectiveness of the WEL Transition Programme and provide strategic direction. Since July the WEL Board has formally met on three occasions.

Running concurrently across NEL are the establishment of primary care networks and the development of Sustainability & Transformation Partnerships (STPs) into Integrated Care Systems (ICSs). Work has also started on developing proposals for the creation of the one CCG alongside a WEL sub system and borough based arrangements.

3. Committee Structure

3.1

3.2

It is proposed that we establish three joint committees that do align and correspond to our directorate structure and key responsibilities. The three committees would be:

Finance & Performance Committee Strategy & Transformation Committee Quality & Safety Committee

The option to combine Finance, Performance and Commissioning functions under one committee has been considered thoroughly but the view of the Lay Members on the Governance Working Group and the Transition Programme Board is that this would make the committee to unwieldy.

All committees ensure good representation from GPs, Lay Members and Executive members as well as other relevant Board Members.

The terms of reference of each committee are attached.

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4. Developing Proposals

4.1 The Governance Working Group consisting of Lay Members for Audit and Governance have overseen all the work undertaken over the last few months. The Transition Programme Board has also received monthly updates and undertaken deep dives.

5. Constitutional Implications

5.1 The creation of a Joint Board and Joint Committees is permitted by the current CCG constitutions, under the heading of ‘Joint Arrangements’, specifically it makes reference to establishing joint committees (boards) and entering into joint arrangements with other CCGs. CCGs governance arrangements also currently permit committees in common meetings. Audit and Remuneration Committees have been meeting in common over the last two years. Previously it was indicated that the creation of Joint Committees would require constitutional changes but this is no longer the case because of the way that the Joint Committees have been established and the powers and functions that they have been delegated by each CCG board.

Scheme of Reservation and Delegation (Appendix D) sets out the services and functions that the CCG Governing Bodies wish to delegate to the newly established Joint Board. Appendix E sets out the Standing Financial Instructions that are linked to the Scheme of Reservation and Delegation.

6. Next Steps

6.1 The next steps will be to develop and consider proposals to move to one CCG as set out in the NHS Long Term Plan and that will include proposals for sub system working and embedding borough based arrangements.

WEL CCGs will also be considering how to develop joint committee proposals with our key providers.

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WEL CCGs

Strategy and Transformation Committee

Terms of Reference

Version: 1.0

Date: 30 September 2019

Meeting WEL CCGs’ Strategy and Transformation Committee

Constitution The WEL CCGs’ Joint Board of Newham CCG, Tower Hamlets CCG, and Waltham Forest CCG have established a joint committee to be known as the WEL CCGs’ Strategy and Transformation Committee (‘the committee’).

Role of the committee

The Committee has a general remit to oversee and review any aspect of WEL CCG operations to ensure the core Board functions and priorities are properly reflected and delivered, and to make any recommendation it considers appropriate to the Board in pursuit of this requirement. The purpose of the Strategy and Transformation Committee is:

To ensure the implementation of its objectives through the developmentof commissioning strategies, governance arrangements and ways ofworking.

To develop and monitor effectiveness and adherence to a WELcommissioning framework and oversee future planning toward a NELCAtransition.

To oversee and monitor operational delivery against key performancestandards and targets.

To seek assurance that there are effective arrangements in place todeliver the strategic and operational plans of the CCGs.

To undertake a deep dive into key priorities at risk of not achieving theiraims or objectives.

To oversee development of the CCG financial strategy to ensure it meetsBoard Priorities, statutory requirements, national guidance and is alignedto the commissioning strategy as determined by the Board.

Membership Members:

Three CCG Chairs Managing Director Director of Commissioning and Performance / Deputy MD Executive Director of Finance Director of Corporate Services Director of Quality and Safety Director of Primary Care

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Three Lay members one from each CCG

Attendees:

Only members of the committee have the right to attend committee meetings, although other individuals may be invited to attend all or part of a meeting as appropriate. They may include provider trust representatives or WEL CCG GPs not on the committee. These other individuals do not have voting rights.

The committee also has the right to meet with another WEL CCGs committee if there are matters of common concern.

The committee will ensure that any conflicts of interest arising at a meeting are dealt with in accordance with the NHS Code of Conduct, Code of Accountability, and the CCGs’ standards of business conduct policies.

Chair The Committee shall be chaired by the Managing Director

The vice chair is the Director of Commissioning and Performance / Deputy Managing Director.

Quorum The quorum of the Committee is four members, which must include at least one of the Chairs and one lay member and a member of the Executive. A duly convened meeting of the Committee at which a quorum is present shall be competent to exercise all or any of the authorities, powers and discretions vested in or exercisable by the committee.

Decision-making

The chair of the Committee will work to establish unanimity as the basis for decisions of the Committee. If the Committee cannot reach a unanimous decision, the chair will put the matter to a vote, with decisions confirmed by a simple majority of voting members, subject to the meeting being quorate. In the circumstance of a tie, the chair will have a second and casting vote.

The committee will ensure that any conflicts of interest are dealt with in accordance with the CCG’s conflict of interest policy.

Duties of the Committee

The Governing Body has delegated the following functions to the Strategy and Transformation Committee:

Leading the transition planning efforts to NELCA (1 CCG) including thedevelopment of any corporate governance models or frameworks

Overseeing the development and review of WEL CCGs annualcommissioning intentions;

Overseeing the delivery of these strategic and operational commissioningplans by undertaking scrutiny of performance and contract monitoring;

Coordinating and directing the operations of the CCG in accordance with thestrategic direction set by the Governing Body, ensuring operational deliveryon behalf of the Governing Body;

Overseeing the delivery of work programmes that support the WEL ClinicalCommissioning Group’s strategy and operational commissioning plan,including areas of joint commissioning with partner organisations;

Overseeing the review and monitoring of any improvement plan; Overseeing the commissioning activities of the WEL Commissioning Groups

to ensure that they promote the health and wellbeing of communities as well

17

as addressing health inequalities, prioritising investment / disinvestment and commissioning activities to ensure cost effective care is delivered;

Taking account of the views of patients, the public and local clinicians whenprioritising investment / disinvestment recommendations to the WEL CCGsJoint Board in the context of prioritisation of the clinical commissioninggroup’s resources, making recommendations to the WEL CCGs Joint Boardas necessary;

Take account of collaborative commissioning activities, including those ofclinical networks, to ascertain if they will have wider contracting / financialimplications for the WEL CCG;

Overseeing the coordination and integration of services to support thedelivery of effective, high quality accessible services;

Deploying the resource of the organisation effectively and efficiently todeliver the strategies of the organisation;

Horizon scanning to enable review and discussion of the implications andimplementation of key policy documentation issued by NHS England, theDepartment of Health and other statutory authorities for recommendation tothe Governing Body regarding the potential impact on plans and on servicescommissioned by the CCG;

Overseeing the operational commissioning and contracting of healthcareservices for the WEL population;

Overseeing integration of commissioning functions across the WEL healthand social care community;

Recommending direction to the Governing Body on proposals, businesscases, service change, funding requests and procurements where they are inline with the CCG’s strategic plan, financial scheme of delegation andapproved budgets;

Ensuring that the organisation has systems in place to obtain appropriateadvice from persons who, taken together, have a broad range of professionalexpertise in healthcare and public health;

Undertaking regular scrutiny of financial, quality and safety risks of theorganisation;

Taking decisions and action on any other appropriate matter within thedelegated authority of its individual members;

Ensuring the development and performance management of delivery plansto reduce health inequalities;

Ensuring the principle of patients’ rights to choice under the NHSConstitution is maintained by commissioners and providers;

Provide oversight and delivery of risk management arrangements including areview of the CCGs risk register, ensuring any agreed actions are completed.Provide oversight of data / information quality and compliance arrangements,ensuring standards of good practice in relation to information quality;

Developing policies and procedures relating to CCG operations within thefunctions of the Committee as set out in its Terms of Reference;

Establishing appropriate Sub-Groups to assist in discharging delegatedresponsibilities of the Committee as set out in its Terms of Reference;

Seeking assurance of appropriate compliance by the WEL CCGs with thelegal requirements for: business continuity emergency preparedness, resilience and response information governance health and safety

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Frequency of meetings

Meetings shall be held monthly and not less than 6 times a year.

Notice of meetings

Meeting dates are set by the Board secretary for each financial year in advance. Information on changes to meeting dates or the calling of additional meetings should be provided to members and attendees within five days of the meeting.

Meeting papers will be dispatched a minimum of three working days (not including the day of the meeting or the day of despatch) before each meeting.

Notice of all meetings shall comprise venue, time and date of the meeting, together with an agenda of items to be discussed and supporting papers.

Administration and minutes of meetings

The Board secretary, or whoever covers these duties, shall be secretary to the Committee and shall attend to take minutes of the meeting and provide appropriate support to the chair and committee members.

Reporting responsibilities

The committee shall:

submit to the WEL CCGs’ Joint Board complete copies of minutes of allmeetings; and

submit an annual report of its work to the WEL CCGs’ Joint Board .

Authority The Committee is authorised by the WEL CCGs’ Joint Board to investigate any activity within its terms of reference. It is authorised to seek any information it requires in this regard from any employee and all employees are directed to cooperate with any request made by the committee. The Committee is authorised by the WEL CCGs’ Joint Board to obtain outside legal or other independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers this necessary.

The Committee will be responsible for determining any additional or reconfigured sub-structural arrangements to support fulfilment of the committee’s remit.

Other The Committee shall, at least annually, review its performance and terms of reference to ensure it is operating at maximum effectiveness and recommend any changes it considers necessary to the WEL CCGs’ Joint Board for approval.

Sign off dates Approved at [INDIVIUDAL COMMITTEES]: xxx 2019

Approved at [INDIVIDUAL GBS]: xxx 2019

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WEL CCGs

Joint Finance and Performance Committee

Terms of Reference

Version: 0.7

Date: 10 September 2019

Meeting WEL CCGs’ Joint Finance and Performance Committee

Constitution The governing bodies of Newham CCG, Tower Hamlets CCG, and Waltham Forest CCG have established a joint committee to be known as the WEL CCGs’ Joint Finance and Performance Committee (‘the committee’).


The Joint Finance and Performance Committee has delegated responsibility from the three CCGs’ Governing Body’s for oversight of Strategic Finance and CCG performance.

The Finance and Performance Committee assists the Governing Body’s in its duty to act efficiently, effectively and economically. The committee oversees the current and projected financial position of the CCG and ensures cohesive and coordinated planning and effective delivery of the CCG’s annual QIPP plan. It also assures the Governing Body that the CCG has enough capacity and capability to deliver its strategic objectives. Moreover, the Committee will oversee delivery and performance of commissioned services in respect of services not reserved to the Primary Care Commissioning Committee. From a performance perspective, the purpose of the committee is as follows:

To oversee performance of commissioned services; and, To oversee the performance of the CCGs and their delivery of agreed

outcomes.

Membership Members: Three GP Board Members, one from each CCG Three Lay members one from each CCG Managing Director;• Executive Director of Finance Director of Quality and Safety Director of Corporate Services Director of Commissioning and Performance / Deputy MD

Attendees:

Directors of Integrated Commissioning x 3 Deputy Director of Finance Deputy Directors of Primary Care

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Local Authority’s Strategic Directors, in an advisory capacity; one fromeach local authority

Local Authority’s Director of Public Health, in an advisory capacity on arotational basis

Senior representatives of Barts Health Trust, ELFT and NELFT A representative from local Healthwatch will be invited to attend in a

patient advocacy and advisory capacity

The Director of Corporate Services will have oversight of the committee’s function. The committee may also extend invitations to other personnel with relevant skills, experience or expertise as necessary to deal with the business on the agenda. Such personnel will be in attendance and will have no voting rights.


The three GP Board Members will have GP deputies who will be able to attend as voting members in their absence


The committee will ensure that any conflicts of interest arising at a meeting are dealt with in accordance with the NHS Code of Conduct, Code of Accountability, and the CCGs’ standards of business conduct policies.

Chair The Committee shall be chaired by a Lay Member with a further Lay Member undertaking the role of vice chair.

Quorum The quorum of the Committee is four members, one of which must be a GP Board Member with representation from each CCG.

A duly convened meeting of the Committee at which a quorum is present shall be competent to exercise all or any of the authorities, powers and discretions vested in or exercisable by the committee. A Lay Member will chair meetings of the Committee convened as Part 2, where GPs are excluded on grounds of conflict of interest. The Quorum of Part 2 meetings is three members.

Decision-making




The key duties of the Finance & Performance Committee are as follows

Strategic Finance

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To monitor, advise on and recommend to each Governing Bodymatters relating to the CCG’s financial strategy and policies.

To advise each Governing Body on the effective and efficient use ofresources.

To review the CCG’s monthly financial performance and identify thekey issues and risk requiring discussion of decision by eachGoverning Body, recognising that the primary ownership andaccountability for the CCG’s financial performance rests with eachCCG Governing Body.

To develop and propose medium-term financial plans (3 to 5 years),and from the annual operating plans for each year to ensure eachorganisation is making financial decisions that support the strategicdirection of care and to ensure financials plans are affordable,sustainable, and enable statutory duties and business planning rulesto be met.

To consider and recommend to Board requests for all new in-yearinvestments and confirm funding sources.

To consider and recommend to Board approve new contractual /commissioning arrangements such as exceptions to the NHSstandard contract, contractual changes relating to ICS, changes thatrequire NHSE approval, changes that shift the balance ofcommissioning powers to other organisations, and material risk sharearrangements.

To financially evaluate material business cases and pilots includingthe value for money of existing cases.

To monitor, advise on and recommend to each Governing Bodymatters relating to the CCG’s financial strategy and policies.

To advise each Governing Body on the effective and efficient use ofresources.

To review the CCG’s monthly financial performance and identify thekey issues and risk requiring discussion of decision by eachGoverning Body, recognising that the primary ownership andaccountability for the CCG’s financial performance rests with eachCCG Governing Body.

To review and monitor delivery of the CCG’s QIPP plans and anyplans for corrective action.

To provide a forum for financial issues to be debated andrecommendations made for potential resolution.

To evaluate, scrutinise and quality assure the financial validity ofCCG investments, disinvestments and business cases.

To review any risks for which the Committee is responsible to ensurethat effective plans are in place to reduce the risk score and thatassociated actions are completed on time. Consider whether any newrisks need to be added to the Register or whether any risks requireimmediate escalation to the Governing Body.

Performance:

The committee will review monthly reports detailing performance ofcommissioned services against contract standards, national and local

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targets and the WEL CCGs Strategic Plans. Review may be on an exception basis.

In monitoring operational performance will assess potential shortfalls and risk and recommend actions to address them;

Set and monitor key performance indicators (KPIs) relating to WEL CCGs performance, for example as outlined in the CCG Assurance Framework;

Identifying, monitoring and escalating appropriate risks in relation to performance, pertaining to the work plan of this committee;

review the WEL CCG’s benchmarked performance against statutory frameworks including the NHS Outcomes Framework and Improvement and Assessment Framework;

ensure robust action plans are developed and implemented to address any areas of unsatisfactory performance and drive improvement

overseeing the continuous development of the scope, format, presentation and mechanisms of the system of performance reporting

review those risks on the WEL CCGs risk register and Governing Body Assurance Framework which have been assigned to the committee and ensure that appropriate and effective mitigating actions are in place

seek assurance that the WEL CCG is fulfilling its statutory duties for inclusion, equality and diversity


The Committee will consider the frequency and timing of meetings needed to allow it to discharge all its responsibilities. The Committee will meet at least monthly at appropriate intervals in the financial reporting and audit cycle and otherwise as required, not less than ten times a year. The Chair can call a meeting of the Committee as and when required with at least three weeks’ notice.

Notice of meetings

Meeting dates are set by the Board secretary for each financial year in advance. Information on changes to meeting dates or the calling of additional meetings should be provided to members and attendees within five days of the meeting. Meeting papers will be dispatched a minimum of three working days (not including the day of the meeting or the day of despatch) before each meeting. Notice of all meetings shall comprise venue, time and date of the meeting, together with an agenda of items to be discussed and supporting papers.


The Board Secretary, or whoever covers these duties, shall be secretary to the Committee and shall attend to take minutes of the meeting and provide appropriate support to the Chair and committee members.



submit a headline report to next Governing Body meeting; and,

submit an annual report of its work to the governing bodies.

In addition, Lay Members hold a responsiblity for updating the Governing bodies on issues arising, where appropriate.

Authority

The Committee is authorised by the WEL CCGs’ governing bodies to investigate any activity within its terms of reference. It is authorised to seek

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any information it requires in this regard from any employee and all employees are directed to cooperate with any request made by the committee. The Committee is authorised by the governing bodies to obtain outside legal or other independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers this necessary.


Other The Committee shall, at least annually, review its performance and terms of reference to ensure it is operating at maximum effectiveness and recommend any changes it considers necessary to the WEL CCGs’ Joint Board for approval.

Sign off dates Approved at []: xxx 2019


N.B – reference to governing bodies shall mean reference to the WEL CCGS’ Joint Board where the context so demands.

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WEL CCGs

Joint Quality and Safety Committee

Terms of Reference

Version: 2.0

Date: 9 October 2019

Meeting WEL CCGs’ Joint Quality and Safety Committee

Constitution The WEL CCGs Joint Board of Newham CCG, Tower Hamlets CCG, and Waltham Forest CCG have established a joint committee to be known as the WEL CCGs’ Joint Quality and Safety Committee (‘the committee’).


The Joint Quality and Safety Committee has delegated responsibility from the three CCGs’ WEL CCGs Joint Board for oversight of quality and safety.

The committee will seek assurance that there are effective arrangements in place for monitoring and improving the quality, safety, experience and operational performance of all services commissioned by the CCGs, as well as any directly-provided services.

This includes assurance that processes are in place for quality: the monitoring of key quality, safety, experience and clinical measures, the delivery of safeguarding responsibilities and accountabilities, and the review of serious untoward incident themes and trends, never events, complaints and patient experience reports; and

Membership Members

Board Nurse (Quality) (chair) – from the WEL CCGs’ Joint Board

Board Nurse (Safeguarding) (Vice chair) – from the WEL CCGs’ Joint Board

WEL CCGs’ Director of Quality and Safety

Three GPs (one from each CCG)

A lay member (PPE/I)

Secondary care clinician

Attendees:

WEL CCGs’ Senior Leads for Quality and Safety

WEL CCGs Senior Leads for Children’s and Adult’s Safeguarding CCG

Directors of Integrated Commissioning

Director of Commissioning & Performance

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Chair The Committee shall be chaired by the Board Nurse (Quality).

The vice chair is the Board Nurse (Safeguarding).

Quorum The quorum of the Committee is three members.

A duly convened meeting of the Committee at which a quorum is present shall be competent to exercise all or any of the authorities, powers and discretions vested in or exercisable by the committee.

Decision-making




The Committee shall provide oversight and give assurance to the WEL CCGs Joint Board that it is assured on the quality of services commissioned by the CCGs, in that they meet recognised standards, are safe and equitable, manage risk effectively, deliver patient satisfaction, and meet key statutory obligations.. It will lead on the strategic direction of, and formulation of priorities for, quality and safety.

The committee’s duties include:

providing objective scrutiny and assurance to the WEL CCGs Joint Board onthe CCGs’ overall delivery of the quality, safety and safeguarding elementsof their operational plans;

overseeing areas of concern to establish risk and clarify potential harm,understand mitigating actions, and follow through to ensure that they areeffective;

oversight of strategic, developmental, and policy matters and risk relating tothe quality, safety and safeguarding agenda, in terms of financial efficiency,clinical effectiveness, patient safety and patient experience;

ensuring that all CCG commissioned services (including acute, community,mental health and primary care) that the complete pathway is taken intoaccount in assessing the quality of services to residents

ensuring that the CCGs have in place a strategy for safeguarding and thatsystems are in place to embed safeguarding into all contracting andprocurement processes;

placing quality, safety and safeguarding risks on the BAF andrecommending courses of action to the joint management team, other Boardsub-committees and WEL CCGs Joint Board;

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assuring Serious Incident and Never Event reporting across the system andensuring that the outcomes of Serious Incident and Never Eventinvestigations are acted upon and learning taken forward, plus ratificationand closure of Serious Incidents;

endorsing statutory reports (e.g. safeguarding, infection control, emergencyplanning) prior to presentation to the CCGs’ Joint Board for ratification;

receiving and acting on reports relating to inequalities in access tohealthcare services, quality, and outcomes;

receiving and acting on reports that identify indicators in the CommissioningOutcomes Framework (or equivalent) where there is scope for local qualityimprovement;

receiving and acting on reports that benchmark local quality and safetyoutcomes, using the Commissioning Outcomes Framework (or equivalent)and other intelligence;

ensuring delivery of the requirements on information governance in theCCGs;

ensuring that the patient voice is captured in the commissioning cycle andinforms commissioning decisions;

ensuring that provider quality assurance frameworks are in place and able toidentify all quality and patient safety issues at the earliest opportunity;

receiving and acting on reports on quality, safety and safeguarding issuesarising from redesign of services and/or pathways;

overseeing any payment arrangements for providers linked to quality andoutcomes (e.g. through the CQUIN scheme);

reviewing external scrutiny of local providers by the Care QualityCommission, Health and Social Care Scrutiny Committees, andHealthwatch;

receiving and providing assurance on summary reports on any regulatoryaction taken against the CCGs and their commissioned services;

receiving, reviewing, triangulating with other sources of intelligence, andensure appropriate actions have been taken in relation to all complaints andpatient experience and engagement information for the WEL CCGs;

receiving assurance from its safeguarding sub-committee, covering in detailrisks and concerns relating to safeguarding adults and children;

approving relevant policies, such as the policy for procedures of limitedclinical effectiveness;

holding providers to account against the NHS Operating Framework;

seeking assurance of the effectiveness of remediation in areas where localproviders are flagged as outliers against regional or national qualitystandards;

scrutinise and review provider quality accounts and agree commissionerresponses;

champion a culture of quality improvement across the WEL CCGs ensuringthere is a collaborative approach with providers

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monitor the work to drive quality improvements in primary medical care through regular reports from the CCGs’ primary care commissioning committees.


Meetings shall be held monthly and not less than six times a year.

Notice of meetings

Meeting dates are set by the Board secretary for each financial year in advance. Information on changes to meeting dates or the calling of additional meetings should be provided to members and attendees within five days of the meeting.

Meeting papers will be dispatched a minimum of three working days (not including the day of the meeting or the day of despatch) before each meeting.

Notice of all meetings shall comprise venue, time and date of the meeting, together with an agenda of items to be discussed and supporting papers.


The Board secretary, or whoever covers these duties, shall be secretary to the Committee and shall attend to take minutes of the meeting and provide appropriate support to the chair and committee members.



submit to the WEL CCGs Joint Board complete copies of minutes of all meetings; and

submit an annual report of its work to the WEL CCGs Joint Board.

submit a Committee annual work programme to the WEL CCGs Joint Board

In addition, the safeguarding boards will report through to this Committee though minutes, assurance reports, an annual review, and verbal updates from members.

Authority

The Committee is authorised by the WEL CCGs Joint Board to investigate any activity within its terms of reference. It is authorised to seek any information it requires in this regard from any employee and all employees are directed to cooperate with any request made by the committee. The Committee is authorised by the WEL CCGs Joint Board to obtain outside legal or other independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers this necessary.


Other

The Committee shall, at least annually, review its performance and terms of reference to ensure it is operating at maximum effectiveness and recommend any changes it considers necessary to the WEL CCGs’ Joint Board for approval.

Sign off dates Approved at [INDIVIUDAL QUALITY COMMITTEES]: xxx 2019


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Prime Financial Policies (SFIs) – WEL CCGs

Version – 1

29

6

Authorship : WEL Executive Director of Finance

Committee Approved : WEL Audit Committees in Common

Approved Date :

Target Audience : All CCG staff, Lay and Committee Members

Version No. : 1

Revision History

Revisions to the policy guidance and template document may be issued from time to time. A new revision history will be issued with each change.

New Version Number

Issued by Nature of Revision Approved by and Date

Date on Intranet

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Appendix E – Prime Financial Policies

Contents

1 PRIME FINANCIAL POLICIES ..................................................................................................................4

1.1 General .................................................................................................................................................4

1.1.7. Overriding Prime Financial Policies …....................................................................................................4

1.2 Responsibilities and delegation ............................................................................................................4

1.3 Contractors and their employees .........................................................................................................5

1.4 Amendment of Prime Financial Policies ...............................................................................................5

2 INTERNAL CONTROL .............................................................................................................................5

3 AUDIT....................................................................................................................................................5

4 FRAUD AND CORRUPTION ...................................................................................................................6

5 ALLOTMENTS ................................................................................. .....................................................6

6 COMMISSIONING STRATEGY, BUDGETS, BUDGETARY CONTROL AND MONITORING..........................7

7 ANNUAL ACCOUNTS AND REPORTS .....................................................................................................9

8 INFORMATION TECHNOLOGY ..............................................................................................................9

9 ACCOUNTING SYSTEMS ........................................................................................................................9

10 BANK ACCOUNTS .................................................................................................................................10

11 INCOME, FEES AND CHARGES AND SECURITY OF CASH, CHEQUES AND OTHER NEGOTIABLE

INSTRUMENTS. ....................................................................................................................................10

12 TENDERING AND CONTRACTING PROCEDURE ...................................................................................11

13 COMMISSIONING ...............................................................................................................................21

14 ROLE OF CSU ………………………………………………......................................................................................21

15 RISK MANAGEMENT AND INSURANCE ... ........................................................................................... 22

16 PAYROLL ............................................................................................................................................. 23

17 NON‐PAY EXPENDITURE ..................................................................................................................... 24

18 CAPITAL INVESTMENT, FIXED ASSET REGISTERS AND SECURITY OF ASSETS .......................................26

19 RETENTION OF RECORDS .....................................................................................................................28

20 TRUST FUNDS AND TRUSTEES ..............................................................................................................28

21 STORES AND RECEIPT OF GOODS …………………………………………………………………………………………………….29

22 DISPOSALS AND CONDEMNATIONS, LOSSES AND SPECIAL PAYMENTS ……………………………………………29

23 ACCEPTANCE OF GIFTS BY STAFF AND LINK TO STANDARDS OF BUSINESS CONDUCT ……………………. 30

24 PAYMENTS TO INDEPENDENT CONTRACTORS ……………………………………………………………………….………..30

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1. Introduction

1.1. General

1.1.1. These prime financial policies shall have effect as if incorporated into the constitution of each CCG within WEL.

1.1.2. The prime financial policies are part of the WEL CCGs’ (referred to as Group in this document) control environment for managing the organisations’ financial affairs. They contribute to good corporate governance, internal control and managing risks. They enable sound administration, lessen the risk of irregularities and support commissioning and delivery of effective, efficient and economical services. They also help the WEL Managing Director and WEL Executive Director of Finance to effectively perform their responsibilities. They should be used in conjunction with the scheme of reservation and delegation adopted by the group.

1.1.3. These prime financial policies identify the financial responsibilities which apply to everyone working for the group and its constituent organisations. They do not provide detailed procedural advice and should be read in conjunction with the detailed financial policies. The WEL Executive Director of Finance is responsible for approving all detailed financial policies.

1.1.4. A list of the group’s detailed financial policies will be published and maintained on the group’s website at www…………..

1.1.5. Should any difficulties arise regarding the interpretation or application of any of the prime financial policies then the advice of the WEL Executive Director of Finance must be sought before acting. The user of these prime financial policies should also be familiar with and comply with the provisions of the WEL CCGs’ constitutions, Standing Orders and the group’s scheme of reservation and delegation.

1.1.6. Failure to comply with prime financial policies and Standing Orders can in certain circumstances be regarded as a disciplinary matter that could result in dismissal.

1.1.7. Overriding Prime Financial Policies – If for any reason these prime financial policies are not complied with, full details of the non-compliance and any justification for non-compliance and the circumstances around the non-compliance shall be reported to the next formal meeting of group’s audit committee for referring action or ratification. All of the group’s members and employees have a duty to disclose any non-compliance with these prime financial policies to the WEL Executive Director of Finance as soon as possible.

1.2. Responsibilities and delegation

1.2.1. The roles and responsibilities of group’s members, employees, members of the WEL CCGs’ Joint Board, members of the WEL CCGs’ Joint Board’s committees and sub-committees, members of the group’s committees and sub-committees (if any) and persons working on behalf of the group are set out in the constitution.

1.2.2. The financial decisions delegated by members of the group are set out in the group’s scheme of reservation and delegation.

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1.3. Contractors and their employees

1.3.1. Any contractor or employee of a contractor who is empowered by the group to commit the group to expenditure or who is authorised to obtain income shall be covered by these instructions. It is the responsibility of the WEL Executive Director of Finance to ensure that such persons are made aware of this.

1.4. Amendment of Prime Financial Policies

1.4.1. To ensure that these prime financial policies remain up-to-date and relevant, the WEL Executive Director of Finance will review them at least annually. Following consultation with the WEL Managing Director and scrutiny by the WEL CCGs’ Audit Committees meeting in Common, the WEL Executive Director of Finance will recommend amendments, as fitting, to the WEL CCGs’ Joint Board for approval. As these prime financial policies are an integral part of the group’s constitutions, any amendment will not come into force until the group applies to the NHS England and that application is granted.

2. Internal Control

2.1. POLICY – the group will put in place a suitable control environment and effective internal controls that provide reasonable assurance of effective and efficient operations, financial stewardship, probity and compliance with laws and policies

2.1.1. The role of the Audit Committee

In accordance with Standing Orders the three CCGs shall formally establish Audit Committees, with clearly defined terms of reference as agreed by each CCG Board and following guidance from the NHS Audit Committee Handbook (2018).

An independent audit committee is a central means by which a WEL CCGs’ Joint Board ensures effective internal control arrangements are in place. In addition, the audit committees provides a form of independent check upon the executive arm of the WEL CCGs’ Joint Board.

2.1.2. The role of the WEL Managing Director

The WEL Managing Director has overall responsibility for the group’s systems of internal control.

3. Audit

3.1. POLICY – the group will keep an effective and independent internal audit function and fully comply with the requirements of external audit and other statutory reviews.

3.1.1. In accordance with the WEL CCGs’ Audit Committees terms of reference the person appointed by the group to be responsible for internal audit and the Audit Committees appointed external auditor will have direct and unrestricted access to audit committee members and the chair of the WEL CCGs’ Joint Board, managing Director and Director of Finance for any significant issues arising from audit work that management cannot resolve, and for all cases of fraud or serious irregularity.

3.1.2. The person appointed by the group to be responsible for internal audit and the external auditor will have access to the audit committee and the WEL Managing Director to review audit issues as appropriate. All audit committee members, the chair of the WEL CCGs’ Joint Board

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and the WEL Managing Director will have direct and unrestricted access to the head of internal audit and external auditors.

3.1.3. The WEL Executive Director of Finance will ensure that:

3.1.3.1. The group has a professional and technically competent internal audit function; and

3.1.3.2. The audit committee approves any changes to the provision or delivery of assurance services to the group.

4. Fraud, Corruption and Bribery

4.1. POLICY – the group requires all staff to always act honestly and with integrity to safeguard the public resources they are responsible for. The group will not tolerate any fraud perpetrated against it and will actively chase any loss suffered

4.1.1. The Audit Committees meeting in Common will satisfy themselves that the group has adequate arrangements in place for countering fraud and shall review the outcomes of counter fraud and anti-bribery work. It shall also approve the counter fraud, corruption and bribery work programme.

4.1.2. The WEL Audit Committees meeting in Common will ensure that the group has arrangements in place to work effectively with NHS Protect.

4.1.3. In line with their responsibilities, the WEL Managing Director and WEL Executive Director of Finance shall monitor and ensure compliance with Directions issued by the Secretary of State for Health on fraud and corruption.

4.1.4. The Local Counter Fraud Service shall report to the WEL Executive Director of Finance.

4.2. The Bribery Act 2010, which repealed existing corruption legislation, has introduced the offences of offering and receiving a bribe. It also places specific responsibility on organisations to have sufficient and adequate procedures in place to prevent bribery and corruption taking place. Under the Bribery Act 2010, Bribery is defined as “Inducement for an action which is illegal, unethical or a breach of trust. Inducements can take the form of gifts, loans, rewards or other privileges”. Corruption is broadly defined as “the offering or acceptance of inducements, gifts, favours, payment or benefit-in-kind which may influence the action of any person. Corruption does not always result in a loss. The corrupt person may not benefit directly from their deeds; however, they may be unreasonably using their position to give some advantage to another”. To demonstrate that the organisation has sufficient and adequate procedures in place and to demonstrate openness and transparency, all staff are required to comply with the requirements of the Prime Financial Policies. For more detailed information, please see the Anti-Bribery policy.

4.3. The Local Counter Fraud Service will provide a written report to the WEL Audit Committees meeting in Common, at least annually, on counter fraud work within the WEL CCG’s.

5. Allotments

5.1. The group’s Director of Finance will:

5.1.1. Periodically review the basis and assumptions used by the NHS England for distributing allotments and ensure that these are reasonable and realistic and secure the group’s entitlement to funds;

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5.1.2. Prior to the start of each financial year submit to the WEL CCGs’ Joint Board for approval a report showing the total allocations received and their proposed distribution including any sums to be held in reserve;

5.1.3. Regularly update the WEL CCGs’ Joint Board on significant changes to the initial allocation and the uses of such funds.

6. Commissioning & Financial Strategy, Budgets, Budgetary Control and Monitoring

6.1. POLICY – the group will produce and publish an annual commissioning plan that explains how it proposes to discharge its financial duties. The group will support this with comprehensive medium term financial plans and annual budgets.

6.1.1. The group is required by statutory provisions to ensure that its expenditure does not exceed the aggregate of allotments from the NHS England and any other sums it has received and is legally allowed to spend.

6.1.2. The Managing Director will compile and submit to the WEL CCGs’ Joint Board a commissioning strategy which takes into account financial targets and forecast limits of available resources.

6.1.3. The WEL CCGs’ Joint Board will approve consultation arrangements for the group’s commissioning plan.

6.1.4. The Managing Director has overall executive responsibility for ensuring that the group complies with certain of its statutory obligations, including its financial and accounting obligations, and that it exercises its functions effectively, efficiently and economically and in a way which provides good value for money.

6.1.5. Prior to the start of the financial year the WEL Executive Director of Finance will, on behalf of the Managing Director, prepare and submit budgets for approval by the WEL CCGs’ Joint Board.

6.1.6. The WEL Managing Director will:

6.1.6.1. Ensure money drawn from the NHS England is required for approved expenditure only is drawn down only at the time of need and follows best practice;

6.1.6.2. Be responsible for ensuring that an adequate system of monitoring financial performance is in place to enable the group to fulfil its statutory responsibility not to exceed its expenditure limits, as set by direction of the NHS England.

6.1.6.3. Provide reports in the form required by NHS England

6.1.6.4. Ensure that adequate training is delivered on an on-going basis to budget holders to help them manage successfully.

6.1.6.5. Ensure that members of the WEL CCGs’ Joint Board are aware of DH guidance on financial issues.

6.1.7. The Managing Director may delegate the management of a budget to permit the performance of a defined range of activities.

6.1.8. The Accountable Officer and delegated budget holders must not exceed the budgetary total or virement limits set by the WEL CCGs’ Joint Board.

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6.1.9. Any budgeted funds not required for their designated purpose(s) revert to the immediate control of the Managing Director, subject to any authorised use of virement.

6.1.10. Non-recurring budgets should not be used to finance recurring expenditure without the authority in writing of the Managing Director, as advised by the Director of Finance.

6.2. Budgetary Control and Reporting

6.2.1. The WEL Executive Director of Finance shall monitor financial performance against budget and plan, periodically review them, and report to the WEL CCGs’ Joint Board. Systems of budgetary control will be devised and maintained. These will include:

6.2.1.1. Monthly financial report to the WEL CCGs’ Joint Board in a form approved by the WEL CCGs’ Joint Board containing:

6.2.1.2. Income and expenditure to date showing trends and forecast year-end position;

6.2.1.3. Movements in working capital;

6.2.1.4. Movements in cash and capital;

6.2.1.5. Capital project spend and projected outturn against plan;

6.2.1.6. Explanations of any material variances from plan. These variances must be based on any significant departures from agreed financial plans or budgets;

6.2.1.7. Details of any corrective action where necessary and the Managing Director's and / or Director Finance's view of whether such actions are sufficient to correct the situation;

6.2.2. Each individual, group and budget holder is responsible for ensuring that:

6.2.2.1. Such information as is required by the WEL Director of Finance is provided to enable budgets to be compiled.

6.2.2.2. Any likely overspending or reduction of income which cannot be met by virement is not incurred without the prior consent of the WEL CCGs’ Joint Board;

6.2.2.3. The amount provided in the approved budget is not used in whole or in part for any purpose other than that specifically authorized, subject to the rules of virement;

6.2.2.4. No permanent employees are appointed without the approval of the Managing Director other than those provided for within the available resources and manpower establishment as approved by the WEL CCGs’ Joint Board.

6.2.3. The WEL Managing Director is responsible for identifying and implementing cost improvements and income generation initiatives in accordance with the requirements of the Local Delivery Plan and a balanced budget.

6.3. Capital Expenditure

6.3.1. The general rules applying to delegation and reporting shall also apply to capital expenditure.

6.4. Monitoring Returns

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6.4.1. The WEL Managing Director is responsible for ensuring that information relating to the group’s accounts or to its income or expenditure, or its use of resources is provided to the NHS England as requested.

7. Annual Accounts and Reports

7.1. POLICY – the group will produce and submit to the NHS England accounts and reports in accordance with all statutory obligations relevant accounting standards and accounting best practice in the form and content and at the time required by the NHS England.

7.1.1. The WEL Director of Finance will ensure the group:

7.1.1.1. Prepares a timetable for producing the annual report and accounts and agrees it with external auditors and the three CCG Boards;

7.1.1.2. Prepares the accounts according to the timetable approved by the three CCG Boards;

7.1.1.3. Complies with statutory requirements and relevant directions for the publication of annual report;

7.1.1.4. Considers the external auditor’s management letter and fully addresses all issues within agreed timescales; and

7.1.1.5. Publishes the external auditor’s management letter on the group’s website at www.xxxxxxxxx

7.1.2. The three CCG Boards annual accounts must be audited by an auditor appointed by the Audit Committees meeting in Common. The CCGs’ audited annual accounts must be presented to a public meeting and made available to the public.

7.1.3. Each WEL CCG will publish an annual report, in accordance with guidelines on local accountability, and present it at a public meeting. The document will comply with the Department of Health's Manual for Accounts.

8. Information Technology

8.1. POLICY – the group will ensure the accuracy and security of the group’s computerised financial data

8.1.1. The WEL Director of Finance is responsible for the accuracy and security of the group’s computerised financial data.

8.1.2. In addition the WEL Director of Finance shall ensure that new financial systems and amendments to current financial systems are developed in a controlled manner and thoroughly tested prior to implementation. Where this is undertaken by another organisation, assurances of adequacy must be obtained from them prior to implementation.

9. Accounting Systems

9.1. POLICY – the group will run an accounting system that creates management and financial accounts

9.1.1. The WEL Director of Finance will ensure:

9.1.1.1. The group has suitable financial and other software to enable it to comply with these policies and any consolidation requirements of the NHS England;

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9.1.1.2. That contracts for computer services for financial applications with another health organisation or any other agency shall clearly define the responsibility of all parties for the security, privacy, accuracy, completeness, and timeliness of data during processing, transmission and storage. The contract should also ensure rights of access for audit purposes.

9.1.2. Where another health organisation or any other agency provides a computer service for financial applications, the WEL Director of Finance shall periodically seek assurances that adequate controls are in operation.

10. Bank Accounts

10.1. POLICY – the group will keep enough liquidity to meet its current commitments

10.1.1. The WEL Director of Finance will review the banking arrangements of the group at regular intervals to ensure they are in accordance with Secretary of State directions, best practice and represent best value for money.

10.1.2. The audit committee shall approve the banking arrangements.

10.2. The WEL Director of Finance will prepare detailed instructions on the operation of bank and OPG accounts which must include:

• the conditions under which each bank and OPG account is to be operated;

• those authorised to sign cheques or other orders drawn on the CCG's accounts.

10.2.1. The WEL Director of Finance must advise the CCG's bankers in writing of the conditions under which each account will be operated.

10.3. Tendering and Review

10.3.1. The WEL Director of Finance will review the banking arrangements of the WEL CCGs at regular intervals to ensure they reflect best practice and represent best value for money by periodically seeking competitive tenders for the WEL CCGs’ banking business.

10.3.2. Competitive tenders should be sought at least every 5 years. This review is not necessary for OPG accounts. The results of the tendering exercise should be reported to the WEL CCGs’ Joint Board.

11. Income, fees and charges and security of cash, cheques and other negotiableinstruments

11.1. POLICY – the group will:

11.1.1. Operate a sound system for prompt recording, invoicing and collection of all monies due

11.1.2. Seek to maximise its potential to raise additional income only to the extent that it does not interfere with the performance of the group or its functions3

11.1.3. Ensure its power to make grants and loans is used to discharge its functions effectively

11.2. The WEL Director of Finance is responsible for:

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• Designing, maintaining and ensuring compliance with systems for the proper recording,invoicing, and collection and coding of all monies due;

• Establishing and maintaining systems and procedures for the secure handling of cashand other negotiable instruments;

• Approving and regularly reviewing the level of all fees and charges other than thosedetermined by the NHS England or by statute. Independent professional advice onmatters of valuation shall be taken as necessary;

• For developing effective arrangements for making grants or loans.

11.3. Fees and Charges

11.3.1. The CCG shall follow the Department of Health's advice in the "Costing" Manual in setting prices for NHS service agreements.

11.3.2. All employees must inform the WEL Director of Finance promptly of money due arising from transactions which they initiate / deal with, including all contracts, leases, tenancy agreements, private patient undertakings and other transactions.

11.4. Debt Recovery

11.4.1. The WEL Director of Finance is responsible for the appropriate recovery action on all outstanding debts.

11.4.2. Income not received should be dealt with in accordance with losses procedures.

11.4.3. Overpayments should be detected (or preferably prevented) and recovery initiated.

11.5. Security of Cash, Cheques and other Negotiable Instruments

12. Tendering and Contracting Procedure

12.1. POLICY – the group:

12.1.1. will ensure proper competition that is legally compliant within all purchasing to ensure we incur only budgeted, approved and necessary spending

12.1.2. will seek value for money for all goods and services

12.1.3. shall ensure that competitive tenders are invited for the supply of goods, services, materials and manufactured articles

12.2. Duty to comply with Standing Orders and Prime Financial Policies

12.2.1. The procedure for making all contracts by or on behalf of the group shall comply with these Standing Orders and Prime Financial Policies (except where Suspension of Standing Orders is applied).

12.2.2. Generally all decisions on a contract award must be able to stand up to scrutiny and it is advised that the overarching principles of procurement are observed as follows:

12.2.2.1. Transparency – the group will be required to publicly account for their expenditure.

12.2.2.2. Proportionality – matching value, complexity and risk of the services contracted i.e. higher benefits require more resources and consideration/expertise on route to market.

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12.2.2.3. Non-Discrimination – no exclusion of suppliers, non- discriminatory tender documentation.

12.2.2.4. Equality of Treatment – All potential providers to be treated equally.

12.2.3. The use of framework agreements or existing Dynamic Purchasing Systems (DPS) may offer a value for money sourcing option as they are often quick and easy to use. The group shall ensure that where frameworks/DPS are used for a procurement, only firms/individuals listed on the framework/DPS in question are invited to quote. Where it is decided that tenders/quotes are to be sought outside of an established framework/DPS, the justification for doing so must be recorded.

12.2.4. The WEL Director of Finance may only negotiate contracts on behalf of the group, and the group may only enter into contracts, within the statutory framework set up by the 2006 Act, as amended by the 2012 Act. Such contracts shall comply with:

12.2.4.1. the group’s standing orders;

12.2.4.2. the Public Contracts Regulation 2015 (SI 2015/102), any successor legislation and any other applicable law; and

12.2.4.3. take into account as appropriate any applicable NHS England or the Independent Regulator of NHS Foundation Trusts (Monitor) guidance that does not conflict with (12.2.4.2) above.

12.2.5. In all contracts entered into, the group shall endeavour to obtain best value for money. The WEL Managing Director shall nominate an individual who shall oversee and manage each contract on behalf of the group.

12.2.6. The WEL Managing Director shall put in place effective systems to ensure the CCG is compliant with the Bribery Act 2010.

12.2.7. The WEL CCGs’ Joint Board shall agree limits whereby tendering may be waived or circumstances under which tendering may not be applied. All waivers should be reported to the Audit Committees meeting in Common.

12.2.8. The WEL Managing Director shall establish formal procedures for tendering which shall be made available to all staff involved in tendering activities.

12.3. EU Directives Governing Public Procurement

12.3.1. Directives by the Council of the European Union promulgated by the Department of Health (DH) prescribing procedures for awarding all forms of contracts shall have effect as if incorporated in these standing orders and prime financial policies.

12.3.2. CCG’s should consider obtaining support from the DH and other government agencies.

12.4. Capital Investment Manual and other Department of Health Guidance

The WEL CCGs shall comply as far as is practicable with the requirements of the Department of Health "Capital Investment Manual" and “Estate code” in respect of capital investment and estate and property transactions.

In consideration of capital purchasing the Procurement process is to evaluate different models with the Finance Team. i.e. Lease, Rent, Purchase, Build etc.

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This particular area of procurement is diverse and there are a number of routes to market that are determined by the type of capital purchase. Consideration as to whether the purchasing decision is Design and Build where OJEU value of Works come into force or whether the purchase is for Supply of Goods or Supply of Services invoke the pertinent OJEU or Contract Finder route to market. The total value of the contract will be greater than £172,514 for supplies and services and £4,322,012 for works (figures are for 2015 - this figure is reviewed and must be updated every two years). Services classified as Social and Other Specific Services will have a higher threshold of £625,050 from April 2016 and a Light Touch Regime will apply for these services.

When procuring capital, consideration should also be given to alternative routes such as Any Qualified Provider.

In the case of management consultancy contracts, the group shall comply as far as it is practicable with Department of Health guidance “The Procurement of Management Consultants within the NHS”.

12.5. Formal Competitive Tendering

12.5.1. General Applicability

The group shall ensure that competitive tenders are invited for:

• the supply of goods, materials and manufactured articles;

• the rendering of services including all forms of management consultancy services (otherthan specialised services sought from or provided by the DH);

• or the design, construction and maintenance of building and engineering works (includingconstruction and maintenance of grounds and gardens); for disposals.

12.5.2. Health Care Services

Where the CCG elects to invite tenders for the supply of healthcare services these Standing Orders and Prime Financial Policies shall apply as far as they are applicable to the tendering procedure and need to be read in conjunction with Prime Financial Policy ref No.12.7

12.5.3. Exceptions and instances where formal tendering need not be applied.

12.5.4. Formal tendering procedures need not be applied where:

the estimated expenditure or income does not, or is not reasonably expected to, exceed thecurrent EU thresholds or

where the supply is proposed under special arrangements negotiated by the DH in whichevent the said special arrangements must be complied with; 12.6.4.3. regarding disposalsas set out in Prime Financial Policy No. 12.14 ;

procuring health services, subject to applying the rules.

12.5.5. Formal tendering procedures may be waived in the following circumstances:

in very exceptional circumstances where the Accountable Officer decides that formaltendering procedures would not be practicable or the estimated expenditure or income wouldnot warrant formal tendering procedures, and the circumstances are detailed in anappropriate CCG record;

where the requirement is covered by an existing contract;

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where specialist expertise is required and is available from only one source; when the task is essential to complete the project, and arises as a consequence of a recently

completed assignment and engaging different consultants for the new task would beinappropriate;

there is a clear benefit to be gained from maintaining continuity with an earlier project.However in such cases the benefits of such continuity must outweigh any potential financialadvantage to be gained by competitive tendering;

for the provision of legal advice and services providing that any legal firm or partnershipcommissioned by the CCG is regulated by the Law Society for England and Wales for theconduct of their business (or by the Bar Council for England and Wales in relation to theobtaining of Counsel’s opinion) and are generally recognised as having sufficient expertise inthe area of work for which they are commissioned

where DH purchasing agreements are in place and have been approved by the WEL CCGs’Joint Board;

where a consortium arrangement is in place and a lead organisation has been appointed tocarry out tendering activity on behalf of the consortium members;

where the timescale genuinely precludes competitive tendering but failure to plan the worko properly would not be regarded as a justification for a single tender. It is important to

note that failure to plan the work properly would not be regarded as a justification fora single tender.

when the task is essential to complete the project, and arises as a consequence of a recentlycompleted assignment and engaging different consultants for the new task would beinappropriate;

The WEL Director of Finance will ensure that any fees paid are reasonable and withincommonly accepted rates for the costing of such work.

where allowed and provided for in the Capital Investment Manual. The waiving of competitive tendering procedures should not be used to avoid competition or

for administrative convenience or to award further work to a consultant originally appointedthrough a competitive procedure.

Where it is decided that competitive tendering is not applicable and should be waived, thefact of the waiver and the reasons should be documented and recorded in an appropriateCCG record and reported to the audit committee at each meeting.

12.5.6. Fair and Adequate Competition

The CCG shall ensure that invitations to tender are sent to a sufficient number of firms.

Individuals to provide fair and adequate competition as appropriate, and in no case less than two firms / individuals, having regard to their capacity to supply the goods or materials or to undertake the services or works required. Where total expenditure over the term of the proposed contract is estimated to exceed £20,000, a minimum of three firms/individuals should be invited to tender.

12.5.7. Framework agreement

The use of framework agreements or existing Dynamic Purchasing Systems (DPS) may offer a value for money sourcing option as they are often quick and easy to use. The group shall ensure that where frameworks/DPS are used for a procurement, only firms/individuals listed on the framework/DPS in question are invited to quote. Where it is decided that tenders/quotes are to be sought outside of an established framework/DPS, the justification for doing so must be recorded.

12.5.8. Applicability to Health Services

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Health and social care services fall within Social and Other Specific Services under EU Procurement Regulations. This means there is no legal requirements to follow one of the strict procedures set out by the procurement rules, or comply with minimum tendering timescales. However, requirements such as acting transparently and treating providers equally do still apply and compliance is required. CCG’s will be responsible to the NHS England and Monitor who will have the power to audit the procedure for probity and compliance.

The National Health Service (Procurement, Patient Choice and Competition) (No. 2) Regulations 2013 and ‘Procurement guide for commissioners of NHS-funded services July 2010’ provides mandatory guidance as to when it may be appropriate to run a tender process for NHS funded health services and should be read in conjunction with this guide.

Where the group elects to invite tenders for the supply of health services these Standing Orders and Prime Financial Policies shall apply as far as they are applicable to the tendering procedure and need to be read in conjunction with Prime Financial Policies No. 12.7

Subject to the Procurement guide, it may be appropriate to procure health services within “Any Qualified Provider” (AQP) rules. This means that for a prescribed range of health services, any provider that meets advertised criteria for entering a market, can compete for business within that market, without constraint by the commissioning organisation.

12.5.9. When running an AQP procurement, the group will need to:

Develop and confirm service specification with provider engagement Advertise procurement in Contract Finder or OJEU as appropriate. Evaluate responses using agreed criteria Ensure there is agreement on the tariff the commissioner is willing to pay. Each AQP must be financially and legally sound and the group will be responsible for

ensuring this is the case. For an organisation to be awarded on AQP they must be registered with the Care Quality

Commission (or other relevant body) for that service. Accredit successful providers Publish contract award decisions in Contract Finder or OJEU as appropriate Maintain an auditable documentation trail

12.5.10. The group must be able to demonstrate at each stage of the procurement process that they have acted in a transparent and proportionate manner and have not acted in an unduly discriminatory manner.

12.5.11. AQP contracts should be reviewed 9 months prior to the end of the contract to ensure the review of the service etc. has taken place.

12.5.12. The use of the e-tendering portal, whilst not mandatory, will support compliance with tendering process by keeping an electronic audit of documentation.

12.5.13. An award under Any Qualified Provider results in an NHS Standard Contract being awarded. This means a contract is awarded with zero activity i.e. it doesn’t necessarily result in performance of a contract.

12.5.14. It is also good practice to issue a Prior Information Notice (PIN) and use the Pro- Contract e-tendering portal to support compliance with the tendering process and keeping an electronic audit of documentation.

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12.5.15. Competitive Tendering cannot be waived for building and engineering construction works and maintenance without Departmental of Health approval.

12.5.16. Items estimated to be below the limits set in this Prime Financial Policy for which formal tendering procedures are not used which subsequently prove to have a value above such limits shall be reported to the WEL Managing Director, and be recorded in an appropriate CCG record. A regular report of such incidents should be presented to the Audit Committee as part of its forward planner.

12.6. Contracting / Tendering Procedure – see detailed procedures available in Procurement Dept

12.7. Exceptions to using approved contractors:

If in the opinion of the Director of Finance and the managing Director or the director with lead responsibility for clinical governance it is impractical to use a potential contractor from the framework agreement (for example where specialist services or skills are required and there are insufficient suitable potential contractors on the list), or where a list for whatever reason has not been prepared, the WEL Managing Director should ensure that appropriate checks are carried out as to the technical and financial capability of those firms that are invited to tender or quote.

12.8. Quotations: Competitive and non-competitive

12.8.1. Quotations are required where formal tendering procedures are not adopted and where the intended expenditure or income exceeds, or is reasonably expected to exceed £5,000 but not exceed £172,514

12.8.2. Competitive Quotations: Thresholds and processes for competitive quotations

Up to £4,999 - One written quotation with supporting justification on how value for money has been considered; or - Formal competitive tender advertised via Contracts Finder; or- Use of established framework or Dynamic Purchasing System (DPS)

£5,000 and £19,999 - Two written quotations; or - Formal competitive tender advertised via Contracts Finder; or- Use of established framework or Dynamic Purchasing System (DPS)

£20,000 - £99,999 - Three Written quotations; or - Formal competitive tender advertised via Contracts Finder; or- Use of established framework or Dynamic Purchasing System (DPS)

£100,000 - < Current EU Threshold

- Three Competitive Quotations (sealed). No Contract Notice or advertisement required*; or - Formal competitive tender advertised via Contracts Finder; or- Use of established framework or Dynamic Purchasing System (DPS)

=> Current EU Threshold - Formal Competitive Tendering by advertisement in Contract Finder and the Official Journal of the EU (OJEU) as appropriate; or - Use of established framework or Dynamic Purchasing System (DPS)

For healthcare services please obtain procurement advice as sub-threshold contracts may require advertising in some circumstances

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12.8.2.1. Quotations should be obtained based on specifications or terms of reference prepared by, or on behalf of, the group.

12.8.2.2. Quotations should be in writing unless the WEL Managing Director or his nominated officer determines that it is impractical to do so in which case quotations may be obtained by telephone. Confirmation of telephone quotations should be obtained as soon as possible and the reasons why the telephone quotation was obtained should be set out in a permanent record.

12.8.2.3. All quotations should be treated as confidential and should be retained for inspection.

12.8.2.4. The Managing Director or Director of Finance or their nominated officers should evaluate the quotation and select the quote which gives the best value for money. If this is not the lowest quotation if payment is to be made by the CCG, or the highest if payment is to be received by the CCG, then the choice made and the reasons why should be recorded in a permanent record.

12.8.3. Non-competitive quotations in writing may be obtained in the following circumstances:

12.8.3.1. the supply of proprietary or other goods of a special character and the rendering of services of a special character, for which it is not, in the opinion of the Responsible Officer, possible or desirable to obtain competitive quotations;

12.8.3.2. the supply of goods or manufactured articles of any kind which are required quickly and are not obtainable under existing contracts;

12.8.3.3. miscellaneous services, supplies and disposals;

12.8.3.4. where the goods or services are for building and engineering maintenance the responsible works manager must certify that the first two conditions of this Prime Financial Policy (i.e.: (i) and (ii) of this Prime Financial Policy) apply.

12.8.4. No quotation shall be accepted which will commit expenditure in excess of that which has been allocated by the Group and which is not in accordance with Prime Financial Policies except with the authorisation of either the WEL Managing Director or Director of Finance.

12.8.5. Authorisation of Tenders and Competitive Quotations

Providing all the conditions and circumstances set out in these Prime Financial Policies have been fully complied with, formal authorisation and awarding of a contract may be decided by the following staff / committees to the value of the contract as follows:

DELEGATED TO

DELEGATION OF AUTHORITY APPROVED BY

LEVEL OF AUTHORITY

Non-Budget Managers who are requisitioners

Budget Manager against budgets they are responsible for, notified to the DoF

Up to £15,000

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Delegated Budget Managers

Budget Holder, notified to the DoF Up to £15,000

JMT direct reports, Heads of Finance

Budget Holder, notified to the DoF Up to £50,000

Deputy Directors

Managing Director,, notified to the DoF

Up to £150,000

Directors Managing Director,, notified to the DoF

Up to £250,000

Budget Holders, DoF and MD

WEL CCGs’ Joint Board must approve award of tender and will delegate authority to authorise payment arising to the AO, MD and DoF & Executive Directors

Over £1,000,000

Deputy DoF Notified to Finance & Performance Joint Committee

Up to £500,000

AO, ACFO, MD, DoF

Notified to WEL Collaboration of CCGs Joint Board

Up to £10,000,000

Finance & Performance Joint Committee

Notified to WEL Collaboration of CCGs Joint Board

Up to £10,000,000

NB Level of Authority is dependent on the availability of funding resources

These levels of authorisation may be varied or changed and need to be read in conjunction with the CCG WEL CCGs’ Joint Board’s Scheme of Delegation.

Formal authorisation must be put in writing. In the case of authorisation by the CCG WEL CCGs’ Joint Board this shall be recorded in their minutes.

12.9. Instances where formal competitive tendering or competitive quotation is not required

Where competitive tendering or a competitive quotation is not required, the CCG should adopt one of the following alternatives:

• the group shall use DH purchasing arrangements for procurement of all goods andservices unless the WEL Managing Director or nominated officers deem it inappropriate.The decision to use alternative sources must be documented.

• if the group does not use the DH purchasing arrangements - where tenders or quotationsare not required, because expenditure is below £1,000, the CCG shall procure goods andservices in accordance with procurement procedures approved by the WEL Director ofFinance.

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12.9.1. Private Finance for capital procurement

The group should normally market-test for PFI (Private Finance Initiative funding) when considering a capital procurement. When the WEL CCGs’ Joint Board proposes, or is required, to use finance provided by the private sector the following should apply:

The WEL Managing Director shall demonstrate that the use of private finance representsvalue for money and genuinely transfers risk to the private sector.

Where the sum exceeds delegated limits, a business case must be referred to theappropriate Department of Health for approval or treated as per current guidelines.

The proposal must be specifically agreed by the WEL CCGs’ Joint Board. The selection of a contractor/finance company must be on the basis of competitive tendering

or quotations.

12.10. Compliance requirements for all contracts

The WEL CCGs’ Joint Board may only enter into contracts on behalf of the CCG within the statutory powers delegated to it by the Secretary of State and shall comply with:

12.10.1. The CCG's Standing Orders and Prime Financial Policies;

12.10.2. EU Directives and other statutory provisions;

12.10.3. Such of the NHS Standard Contract Conditions as are applicable;

12.10.4. ‘Standards for Better Health’;

It is currently unclear as to whether clinical commissioning groups will be able to use private finance for capital procurement. This paragraph should be updated accordingly in line with future guidance from the Department of Health or NHS Commissioning WEL CCGs’ Joint Board.

12.10.5. Any relevant directions including the Capital Investment Manual, Estate code and guidance on the Procurement and Management of consultants;

12.10.6. Healthwatch – in terms of their expectation of good practice

12.10.7. Contracts with Foundation Trusts must be in a form compliant with appropriate NHS guidance;

12.10.8. Where appropriate contracts shall be in or embody the same terms and conditions of contract as was the basis on which tenders or quotations were invited;

12.10.9. In all contracts made by the CCG, the WEL CCGs’ Joint Board shall endeavour to obtain best value for money by use of all systems in place. The WEL Managing Director shall nominate an officer who shall oversee and manage each contract on behalf of the CCG.

12.11. Personnel and Agency or Temporary Staff Contracts

The Managing Director shall nominate officers with delegated authority to enter into contracts of employment, regarding staff, agency staff or temporary staff service contracts.

12.12. Healthcare Services Agreements

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Service agreements with NHS providers for the supply of healthcare services shall be drawn up in accordance with the NHS Operating Framework and administered by the CCG. Service agreements other than service agreements with a Foundation Trust are not contracts in law and are not enforceable by the courts.

The Managing Director shall nominate officers to commission service agreements with providers of healthcare in line with a commissioning plan approved by the WEL CCGs’ Joint Board.

12.13. Disposals

Competitive tendering or quotation procedures shall not apply to the disposal of:

12.13.1. any matter in respect of which a fair price can be obtained only by negotiation or sale by auction as determined (or pre-determined in a reserve) by the WEL Managing Director or his nominated officer;

12.13.2. obsolete or condemned articles and stores, which may be disposed of in accordance with the supplies policy of the CCG;

12.13.3. items to be disposed of with an estimated sale value of less than £10,000, this figure to be reviewed on a periodic basis;

12.13.4. items arising from works of construction, demolition or site clearance, which should be dealt with in accordance with the relevant contract;

12.13.5. land or buildings concerning which DH guidance has been issued but subject to compliance with such guidance.

12.14. The Managing Director shall be responsible for ensuring that best value for money can be demonstrated for all services provided on an in-house basis. The CCG may also determine from time to time that in-house services should be market tested by competitive tendering.

12.15. Applicability of Prime Financial Policies on Tendering and Contracting to funds held in trust

These Instructions shall not only apply to expenditure from Exchequer funds but also to works, services and goods purchased from the group’s trust funds and private resources.

12.16. Cancellation of Contracts

Except where specific provision is made in standard NHS contracts or standard schedules of conditions approved for use within the NHS, there shall be inserted into every written contract a clause empowering the group to cancel the contract and to recover from the contractor the amount of any loss resulting from such cancellation, if the contractor shall have offered, or given or agreed to give, any person any gift or consideration of any kind as an inducement or reward for doing or forbearing to do or for having done or forborne to do any action in relation to the obtaining or execution of the contract or any other contract with the group, or for showing or forbearing to show favour or disfavour to any person in relation to the contracts or any other contract with the group, or if the like acts shall have been done by any person employed by him/her or acting on his/her behalf (whether with or without the knowledge of the contractor), or if in relation to any contract with the group the contractor or any person employed by him/her or acting on his/her behalf shall have committed any offence under the Prevention of Corruption Acts 1889 and 1916 and the appropriate legislation.

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12.17. Determination of Contracts for Failure to Deliver Goods or Material

There shall be inserted in every written contract for the supply of goods or materials a clause to secure that, should the contractor fail to deliver the goods or materials or any portion thereof within the time or times specified in the contract, the group may without prejudice determine the contract either wholly or to the extent of such default and purchase other goods, or material of similar description to make good (a) such default, or (b) in the event of the contract being wholly determined the goods or materials remaining to be delivered. The clause shall further secure that the amount by which the cost of so purchasing other goods or materials exceeds the amount which would have been payable to the contractor in respect of the goods or materials shall be recoverable from the contractor.

13. Commissioning

13.1. POLICY – working in partnership with relevant national and local stakeholders, the group will commission certain health services to meet the reasonable requirements of the persons for whom it has responsibility

13.1.1. The group will coordinate its work with the NHS England, other clinical commissioning groups, local providers of services, local authority(ies), including through Health & Wellbeing Boards, patients and their carers and the voluntary sector and others as appropriate to develop robust commissioning plans.

13.1.2. The Managing Director will establish arrangements to ensure that regular reports are provided to the WEL CCGs’ Joint Board detailing actual and forecast expenditure and activity for each contract.

13.2. The Director of Finance will maintain a system of financial monitoring to ensure the effective accounting of expenditure under contracts. This should provide a suitable audit trail for all payments made under the contracts whilst maintaining patient confidentiality.

13.2.1. The Director of Finance will account for out of area treatments / Non Contract Activity financial adjustments in accordance with national guidelines.

14. Role of Commissioning Support Unit (CSU)

14.1. Introduction

The WEL group CCGs have commissioned North East London Commissioning Support Unit (NELCSU) to provide support services. Areas covered include:

• Health needs opportunity assessment

• Business intelligence, informatics and information technology

• Communications and Freedom of Information

• Support for commissioning/QIPP planning and service redesign

• Procurement and market management

• Provider management

• Corporate

• Support outside of the £25 per head running cost allowance

14.2. Authorisation of contract invoices

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CSU can approve commissioning invoices on behalf of the group CCGs, committing the CCG to pay them, that are in line with contracted values without reference to the CCG. This can only be done once the contract values have been formally agreed by the CCG Board.

The above authorisation will be limited to a schedule of contracts to be provided to the CSU in April of each financial year. The schedule will set out how much is to be paid on each contract each month and must be approved in writing by the WEL Director of Finance.

The group can withdraw this authorisation at any point and on any individual contract within the contract period by providing the WEL Managing Director of the CSU with written instruction to that effect. Only the WEL Managing Director or Director of Finance can provide such a withdrawal of authorisation.

15. Risk Management and Insurance

15.1. POLICY – the group will put arrangements in place for evaluation and management of its risks

15.2. Programme of Risk Management

The Managing Director shall ensure that the group has a programme of risk management, in accordance with current Department of Health assurance framework requirements, which must be approved and monitored by the WEL CCGs’ Joint Board.

The programme of risk management shall include:

• a process for identifying and quantifying risks and potential liabilities;

• engendering among all levels of staff a positive attitude towards the control of risk;

• management processes to ensure all significant risks and potential liabilities areaddressed including effective systems of internal control, cost effective insurance cover,and decisions on the acceptable level of retained risk;

• contingency plans to offset the impact of adverse events;

• audit arrangements including; internal audit, clinical audit, health and safety review;

• a clear indication of which risks shall be insured;

• arrangements to review the risk management programme.

The existence, integration and evaluation of the above elements will assist in providing a basis to make a statement on the effectiveness of internal control within the Annual Report and Accounts as required by current Department of Health guidance.

15.3. Insurance: Risk Pooling Schemes administered by NHSLA

The WEL CCGs’ Joint Board shall decide if the CCGs will insure through the risk pooling schemes administered by the NHS Litigation Authority or self-insure for some or all of the risks covered by the risk pooling schemes. If the WEL CCGs’ Joint Board decides not to use the risk pooling schemes for any of the risk areas (clinical, property and employers / third party liability) covered by the scheme this decision shall be reviewed annually.

15.4. Insurance arrangements with commercial insurers

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15.4.1. There is a general prohibition on entering into insurance arrangements with commercial insurers. There are, however, three exceptions when CCGs may enter into insurance arrangements with commercial insurers. The exceptions are:

• for insuring motor vehicles owned by the CCG including insuring third party liability arisingfrom their use;

• where the CCG is involved with a consortium in a Private Finance Initiative contract andthe other consortium members require that commercial insurance arrangements areentered into;

• where income generation activities take place. Income generation activities shouldnormally be insured against all risks using commercial insurance. If the incomegeneration activity is also an activity normally carried out by the CCGs for a NHS purposethe activity may be covered in the risk pool. Confirmation of coverage in the risk poolmust be obtained from the NHS Litigation Authority. In any case of doubt concerning aCCG’s powers to enter into commercial insurance arrangements the WEL Director ofFinance should consult the Department of Health.

15.5. Arrangements to be followed by the WEL CCGs’ Joint Board in agreeing Insurance cover

• Where the WEL CCGs’ Joint Board decides to use the risk pooling schemes administeredby the NHS Litigation Authority the WEL Director of Finance shall ensure that thearrangements entered into are appropriate and complementary to the risk managementprogramme. The WEL Director of Finance shall ensure that documented procedurescover these arrangements.

• Where the WEL CCGs’ Joint Board decides not to use the risk pooling schemesadministered by the NHS Litigation Authority for one or other of the risks covered by theschemes, the WEL Director of Finance shall ensure that the WEL CCGs’ Joint Board isinformed of the nature and extent of the risks that are self-insured as a result of thisdecision. The WEL Director of Finance will draw up formal documented procedures forthe management of any claims arising from third parties and payments in respect oflosses which will not be reimbursed.

• All the risk pooling schemes require scheme members to make some contribution to thesettlement of claims (the ‘deductible’). The WEL Director of Finance should ensuredocumented procedures also cover the management of claims and payments below thedeductible in each case.

16. Payroll and Human Resources

16.1. POLICY – the group will put arrangements in place for an effective payroll service

16.1.1. The Managing Director will ensure that the payroll service selected:

• is supported by appropriate (i.e. contracted) terms and conditions;

• has adequate internal controls and audit review processes;

• has suitable arrangements for the collection of payroll deductions and payment of theseto appropriate bodies.

16.1.2. In addition the Director of Finance shall set out comprehensive procedures for the effective processing of payroll.

16.2. Funded Establishment

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16.2.1. The manpower plans incorporated within the annual budget will form the funded establishment.

16.2.2. The funded establishment of any department may not be varied without the approval of Managing Director.

16.3. Staff Appointments

16.3.1. No officer or Member of the WEL CCGs’ Joint Board or employee may engage, re- engage, or re-grade employees, either on a permanent or temporary nature, or hire agency staff, or agree to changes in any aspect of remuneration:

• unless authorised to do so by the Managing Director; and

• within the limit of their approved budget and funded establishment.

16.3.2. The WEL CCGs’ Joint Board will approve procedures presented by the Managing Director for the determination of commencing pay rates, condition of service, etc, for employees.

16.4. Contracts of Employment

16.4.1. The WEL CCGs’ Joint Board shall delegate responsibility to an officer for:

• Ensuring that all employees are issued with a Contract of Employment in a form

approved by the WEL CCGs’ Joint Board and which complies with employment

legislation; and dealing with variations to, or termination of, contracts of employment.

17. Non-Pay Expenditure

17.1. POLICY – the group will seek to obtain the best value for money goods and services received

17.2. The WEL CCGs’ Joint Board will approve the level of non-pay expenditure on an annual basis and the Managing Director will determine the level of delegation to budget managers.

17.3. The Managing Director shall set out procedures on the seeking of professional advice regarding the supply of goods and services.

17.4. The Managing Director will set out:

• the list of managers who are authorised to place requisitions for the supply of goods andservices;

• the maximum level of each requisition and the system for authorisation above that level.

17.5. The Director of Finance will:

• advise the WEL CCGs’ Joint Board on the setting of thresholds above which quotations(competitive or otherwise) or formal tenders must be obtained; and, once approved, thethresholds should be incorporated in the scheme of reservation and delegation;

• prepare procedural instructions on the obtaining of goods, works and servicesincorporating the thresholds;

• be responsible for the prompt payment of all properly authorised accounts and claims.Payment of contract invoices shall be in accordance with contract terms, or otherwise, inaccordance with national guidance;

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• be responsible for designing and maintaining a system of verification, recording andpayment of all amounts payable.

• be responsible for ensuring that payment for goods and services is only made once thegoods and services are received.

17.6. Joint Finance Arrangements with Local Authorities and Voluntary Bodies

17.7. The WEL CCGs’ Joint Board may confirm contracts to purchase from a voluntary organisation or a local authority using its powers under Section 256 of the NHS Act 2006. The WEL CCGs’ Joint Board may confirm contracts to transfer money from the NHS to the voluntary sector or the health related functions of local authorities where such a transfer is to fund services to improve the health of the local population more effectively than equivalent expenditure on NHS services, using its powers under Section 256 of the NHS Act 2006, as amended by section 29 of the Health Act 1999.

17.8. Managers and officers must ensure that they comply fully with the guidance and limits specified by the Managing Director and that:

• all contracts (except as otherwise provided for in the Scheme of Delegation), leases,tenancy agreements and other commitments which may result in a liability are notified tothe Director of Financer in advance of any commitment being made;

• contracts above specified thresholds are advertised and awarded in accordance with EUrules on public procurement;

• where consultancy advice is being obtained, the procurement of such advice must be inaccordance with guidance issued by the Department of Health;

• no order shall be issued for any item or items to any firm which has made an offer of gifts,reward or benefit to directors or employees, other than:

• isolated gifts of a trivial character or inexpensive seasonal gifts, such as calendars;

• conventional hospitality, such as lunches in the course of working visits;

17.8.1. (This provision needs to be read in conjunction with Standing Order No. 6 and the principles outlined in the national guidance contained in HSG 93(5) “Standards of Business Conduct for NHS Staff”; the Code of Conduct for NHS Managers 2002); and the ABPI Code of Professional Conduct relating to hospitality / gifts from pharmaceutical / external industry.

• no requisition / order is placed for any item or items for which there is no budget provisionunless authorised by the WEL Director of Finance on behalf of the Managing Director;

• all goods, services, or works are ordered on an official order except works and servicesexecuted in accordance with a contract, care homes, NHS SLAs, NHS Non ContractActivity, telephone bills and utilities; and purchases from petty cash;

• verbal orders must only be issued very exceptionally - by an employee designated by theManaging Director and only in cases of emergency or urgent necessity. These must beconfirmed by an official order and clearly marked "Confirmation Order";

• orders are not split or otherwise placed in a manner devised so as to avoid the financialthresholds;

• goods are not taken on trial or loan in circumstances that could commit the WEL CCGs toa future uncompetitive purchase;

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• changes to the list of members / employees and officers authorised to certify invoices arenotified to the Director of Finance;

• purchases from petty cash are restricted in value and by type of purchase in accordancewith instructions issued by the Director of Finance;

• petty cash records are maintained in a form as determined by the Director of Finance.

17.9. The Managing Director and Director of Finance shall ensure that the arrangements for financial control and financial audit of building and engineering contracts and property transactions comply with the guidance contained within Con code and Estate code. The technical audit of these contracts shall be the responsibility of the relevant director.

17.10. Joint Finance Arrangements with Local Authorities and Voluntary Bodies - Payments to local authorities and voluntary organisations made under the powers of section 28A of the NHS Act 1977 shall comply with procedures laid down by the Director of Finance which shall be in accordance with the Acts.

18. Capital Investment, Fixed Asset Registers and Security of Assets

18.1. POLICY – the group will put arrangements in place to manage capital investment, maintain an asset register recording fixed assets and put in place polices to secure the safe storage of the group’s fixed assets

18.2. The Managing Director will

• ensure that there is an adequate appraisal and approval process in place for determiningcapital expenditure priorities and the effect of each proposal upon plans;

• be responsible for the management of all stages of capital schemes and for ensuring thatschemes are delivered on time and to cost;

• shall ensure that the capital investment is not undertaken without confirmation ofpurchaser(s) support and the availability of resources to finance all revenueconsequences, including capital charges;

• be responsible for the maintenance of registers of assets, taking account of theadvice of the Director of Finance concerning the form of any register and the method of updating, and arranging for a physical check of assets against the asset register to be conducted once a year.

• The Director of Finance will prepare detailed procedures for the disposals of assets.

18.3. Asset Registers

18.3.1. The Managing Director is responsible for the maintenance of registers of assets, taking account of the advice of the Director of Finance concerning the form of any register and the method of updating, and arranging for a physical check of assets against the asset register to be conducted once a year.

18.3.2. Each CCG shall maintain an asset register recording fixed assets. The minimum data set to be held within these registers shall be as specified in the Capital Accounting Manual as issued by the Department of Health.

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18.3.3. Additions to the fixed asset register must be clearly identified to an appropriate budget holder and be validated by reference to:

o properly authorised and approved agreements, architect's certificates, supplier'sinvoices and other documentary evidence in respect of purchases from thirdparties;

o stores, requisitions and wages records for own materials and labour includingappropriate overheads;

o lease agreements in respect of assets held under a finance lease andcapitalised.

18.3.4. Where capital assets are sold, scrapped, lost or otherwise disposed of, their value must be removed from the accounting records and each disposal must be validated by reference to authorisation documents and invoices (where appropriate).

18.3.5. The Director of Finance shall approve procedures for reconciling balances on fixed assets accounts in ledgers against balances on fixed asset registers.

18.3.6. The value of each asset shall be indexed to current values in accordance with methods specified in the Capital Accounting Manual issued by the Department of Health.

18.3.7. The value of each asset shall be depreciated using methods and rates as specified in the Capital Accounting Manual issued by the Department of Health.

18.3.8. The Director of Finance of the CCG shall calculate and pay capital charges as specified in the Capital Accounting Manual issued by the Department of Health.

18.4. Security of Assets

18.4.1. The overall control of fixed assets is the responsibility of the Managing Director.

18.4.2. Asset control procedures (including fixed assets, cash, cheques and negotiable instruments, and also including donated assets) must be approved by the Director of Finance. This procedure shall make provision for:

o recording managerial responsibility for each asset;

o identification of additions and disposals;

o identification of all repairs and maintenance expenses;

o physical security of assets;

o periodic verification of the existence of, condition of, and title to, assets recorded;

o identification and reporting of all costs associated with the retention of an asset;

o reporting, recording and safekeeping of cash, cheques, and negotiableinstruments.

18.4.3. All discrepancies revealed by verification of physical assets to fixed asset register shall be notified to the Director of Finance.

18.4.4. Whilst each employee and officer has a responsibility for the security of property of the CCG, it is the responsibility of WEL CCGs’ Joint Board and senior employees in

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all disciplines to apply such appropriate routine security practices in relation to NHS property as may be determined by the WEL CCGs’ Joint Board. Any breach of agreed security practices must be reported in accordance with agreed procedures.

18.4.5. Any damage to the CCGs’ premises, vehicles and equipment, or any loss of equipment, stores or supplies must be reported by the WEL CCGs’ Joint Board and employees in accordance with the procedure for reporting losses.

18.4.6. Where practical, assets should be marked as CCG property.

19. Retention of Records

19.1. POLICY – the group will put arrangements in place to retain all records in accordance with NHS Code of Practice Records Management 2006 and other relevant notified guidance

19.2. The Managing Director shall:

• be responsible for maintaining all records required to be retained in accordance with NHSCode of Practice Records Management 2006 and other relevant notified guidance;

• ensure that arrangements are in place for effective responses to Freedom of Informationrequests;

• publish and maintain a Freedom of Information Publication Scheme.

20. Trust Funds and Trustees

20.1. POLICY – the group will put arrangements in place to provide for the appointment of trustees if the group holds property on trust

20.1.1. The Director of Finance shall ensure that each trust fund which the group is responsible for managing is managed appropriately with regard to its purpose and to its requirements.

20.2. Corporate Trustee

The discharge of the group’s corporate trustee responsibilities are distinct from itsresponsibilities for exchequer funds and may not necessarily be discharged in the samemanner, but there must still be adherence to the overriding general principles of financialregularity, prudence and propriety. Trustee responsibilities cover both charitable and non- charitable purposes.

The Managing Director shall ensure that each trust fund which the WEL CCGs areresponsible for managing is managed appropriately with regard to its purpose and to itsrequirements.

20.3. Accountability to Charity Commission and Secretary of State for Health

• The trustee responsibilities must be discharged separately and full recognition given tothe group’s dual accountabilities to the Charity Commission for charitable funds held ontrust and to the Secretary of State for all funds held on trust.

• The Schedule of Matters Reserved to the WEL CCGs’ Joint Board and the Scheme ofDelegation make clear where decisions regarding the exercise of discretion regarding thedisposal and use of the funds are to be taken and by whom. All CCG WEL CCGs’ JointBoard members and group officers must take account of that guidance before takingaction.

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20.4. Applicability of Prime Financial Policies to funds held on Trust

• In so far as it is possible to do so, most of the sections of these Prime Financial Policieswill apply to the management of funds held on trust.

• The over-riding principle is that the integrity of each Trust must be maintained andstatutory and Trust obligations met. Materiality must be assessed separately fromExchequer activities and funds.

21. Stores and Receipt of Goods

21.1. For goods supplied via the NHS Supply Chain central warehouses, the WEL Managing Director shall identify those authorised to requisition and accept goods from the store. The authorised person shall check receipt against the delivery note before forwarding this to the Director Finance who shall satisfy himself that the goods have been received before accepting the recharge.

22. Disposals and Condemnations, Losses and Special Payments

22.1. Disposals and Condemnations - The Director of Finance must prepare detailed procedures for the disposal of assets including condemnations, and ensure that these are notified to managers.

22.1.1. When it is decided to dispose of a CCG asset, the Head of Department or authorised deputy will determine and advise the Director of Finance of the estimated market value of the item, taking account of professional advice where appropriate. The disposal of any asset with a book value or estimated market greater than £50,000 shall require prior approval of the WEL CCGs’ Joint Board.

22.1.2. All unserviceable articles shall be:

• Condemned or otherwise disposed of by an employee authorised for that purpose by theDirector of Finance;

• Recorded by the Condemning Officer in a form approved by the Director of Financewhich will indicate whether the articles are to be converted, destroyed or otherwisedisposed of. All entries shall be confirmed by the countersignature of a second employeeauthorised for the purpose by the Director of Finance.

22.1.3. The Condemning Officer shall satisfy himself as to whether or not there is evidence of negligence in use and shall report any such evidence to the Director of Finance who will take the appropriate action.

22.2. Losses and Special Payments

The Director of Finance must prepare procedural instructions on the recording of andaccounting for condemnations, losses, and special payments.

Any employee or officer discovering or suspecting a loss of any kind must eitherimmediately inform their Head of Department, who must immediately inform theManaging Director and the Director of Finance or inform an officer charged withresponsibility for responding to concerns involving loss. This officer will then appropriatelyinform the Director of Finance and / or Managing Director. Where a criminal offence issuspected, the Director of Finance must immediately inform the police if theft or arson isinvolved. In cases of fraud and corruption or of anomalies which may indicate fraud or

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corruption, the Director of Finance must inform the relevant LCFS and Operational Fraud Team (OFT) in accordance with Secretary of State for Health’s Directions.

22.2.1. Suspected fraud - The Director of Finance will notify the NHS Protect and the external auditor of all frauds.

22.2.2 For losses apparently caused by theft, arson, neglect of duty or gross carelessness, except if trivial, the Director of Finance must immediately notify the WEL CCGs’ Joint Board and the external auditor.

22.2.3. Within limits delegated to it by the Department of Health, the WEL CCGs’ Joint Board shall approve the writing-off of losses.

22.2.4. The Director of Finance shall be authorised to take any necessary steps to safeguard the CCG's interests in bankruptcies and company liquidations.

22.2.5. For any loss, the Director of Finance should consider whether any insurance claim can be made.

22.2.6. The Director of Finance shall maintain a Losses and Special Payments Register in which write-off action is recorded.

22.2.7. No special payments exceeding delegated limits shall be made without the prior approval of the Department of Health.

22.2.8. All losses and special payments must be reported to the audit committee at every meeting.

22.2.9. No payment(s) exceeding delegated limits determined by the WEL CCGs’ Joint Board shall be made without the prior approval of the Director of Finance. This requirement will also be specified to the Shared Service provider in the Service Level Agreement.

23. Acceptance of gifts by staff and link to standards of business conduct

The Director of Finance shall ensure that all staff are made aware of the group policy on acceptance of gifts and other benefits in kind by staff. This policy follows the guidance contained in the Department of Health circular HSG (93) 5 ‘Standards of Business Conduct for NHS Staff’; the Code of Conduct for NHS Managers 2002; and the ABPI Code of Professional Conduct relating to hospitality / gifts from pharmaceutical / external industry and is also deemed to be an integral part of these Standing Orders and Prime Financial Policies.

24. Payments to Independent Contractors

24.1. The group will approve additions to, and deletions from, approved lists of contractors, taking into account the health needs of the local population, and the access to existing services. All applications and resignations received shall be dealt with equitably, within any time limits laid down in the contractors NHS terms and conditions of service.

24.2. The Managing Director shall:

• ensure that lists of all contractors, for which the group is responsible, are maintained inan up to date condition;

• ensure that systems are in place to deal with applications, resignations, inspection ofpremises, etc, within the appropriate contractor's terms and conditions of service.

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24.3. The Director of Finance shall:

• ensure that contractors who are included on the group's approved lists receive payments;

• maintain a system of payments such that all valid contractors' claims are paid promptlyand correctly, and are supported by the appropriate documentation and signatures;

• ensure that regular independent verification of claims is undertaken, to confirm that:

• rules have been correctly and consistently applied;

• overpayments are detected (or preferably prevented) and recovery initiated;

• suspicions of possible fraud are identified and subsequently dealt with in line with theSecretary of State for Health’s Directions on the management of fraud and corruption.

• ensure that arrangements are in place to identify contractors receiving exceptionally high,low or no payments, and highlight these for further investigation; and

• ensure that a prompt response is made to any query raised by either the PrescriptionPricing Division or the Dental Practice WEL CCGs’ Joint Board Division of the NHSBusiness Services Authority, regarding claims from contractors submitted directly tothem.

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The WEL Collaboration of CCGs

Joint Board: draft scheme of reservation and delegation

Version: 7.0

Date: 07 October 2019

1. Context The WEL CCGs have established a joint board that brings together the leadership of the three WEL CCGs to:

reduce unwarranted variation in the range and quality of servicesavailable to people living in the three WEL boroughs by improvingoutcomes in areas that are below average and driving up outcomesoverall;

provide a joined-up approach to the commissioning of health services,enabling the CCGs to work collectively and effectively with providers toimprove the experience and outcomes of care;

to provide a collective mechanism for agreeing and monitoring theCCGs’ delivery of relevant components of the North East LondonSustainability and Transformation Programme; and

enable the CCGs to manage financial and other risks collectively.This scheme of reservation and delegation (SORD) sets out the functions that have been delegated by the CCGs to the joint board. It sits within the CCGs’ broader SORDs. Decisions within the remit of the joint board have previously been delegated to one or more individual CCG’s governing bodies within WEL. The principle of subsidiarity has been applied to this SORD. This means that the joint board will deal with issues relevant to the three CCGs. Issues where borough-based decision-making is preferable remain reserved to the individual CCGs’ governing bodies.(These functions remaining with the CCG Governing bodies are listed in Appendix1) Where decisions are taken at the WEL level by the joint board, decision-making will be informed by local engagement additional to the presence of board members from each CCG. The CCGs remain individually accountable for all their functions, including those that they have delegated.

2. The role of thejoint board

As set out in the terms of reference of the Joint Board, decisions relating to primary and community care provision in a single CCG’s geographic area are reserved to that CCG’s governing body or Primary Care Commissioning Committee Subject to this, the joint board will have the following role: Strategy and planning

agree the vision, values and strategic direction of the WEL CCGs;

approval of the WEL CCGs’ shared commissioning plan;

approval of the WEL CCGs’ annual operating plan;

monitoring the CCGs’ budgets and financial performance;

monitoring of other plans in respect of the application of financialresources to support the WEL CCGs’ shared commissioning plan;

approval of the WEL CCGs’ joint operating structure;

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monitoring of the WEL CCGs’ combined corporate budgets;

approval of variations to approved budgets where variation would havea significant impact on the overall approved levels of income andexpenditure or the WEL CCGs’ ability to achieve their strategic aims;

approval of NHS contracts in line with the CCGs’ financial policies;

approval of proposals on non-NHS contracts amounting to, or likely toamount to, over £150,000 over a three-year period or the period of thecontract if longer

approval of audit committees’ proposals in individual cases for thewrite-off of losses or making of special payments above the limits ofdelegation to the WEL Managing Director and WEL Executive Directorof Finance (for losses and special payments) of up to £100k previouslyapproved by the joint board[ add where this is documented]; and

approval of individual compensation payments;Quality and safety

approval of arrangements, including supporting policies, to minimiseclinical risk, maximise patient safety, and secure continuousimprovement in quality and patient outcomes; and

approval of arrangements for supporting NHS England in dischargingits responsibilities in relation to securing continuous improvement in thequality of general medical services;

Partnership working

formulation and approval of a common WEL CCGs position on areaswithin the competence of, and to be considered by, the NEL JointCommissioning Committee;

approval of decisions that individual members or employees of the WELCCGs participating in joint arrangements on behalf of the CCGs canmake (such delegated decisions must be disclosed in this scheme ofreservation and delegation); and

approval of decisions delegated to joint committees established undersection 75 of National Health Service Act 2006;

Commissioning and contracting for clinical and other services

approval of the arrangements for discharging the WEL CCGs’ statutoryduties associated with their commissioning functions, including but notlimited to promoting the involvement of each patient, patient choice,reducing inequalities, improvement in the quality of services, obtainingappropriate advice and public engagement and consultation;

approval of arrangements for co-ordinating the commissioning ofservices with the WEL local authorities and other CCGs whereappropriate; and

approval of WEL CCGs’ contracts for any commissioning and corporatesupport all in accordance with CCG agreed prime financial policies;

Operational and risk management

approval of the WEL CCGs’ common risk management arrangements;

approval of arrangements for risk sharing and/or risk pooling withorganisations outside of the WEL CCGs;

approval of a comprehensive system of internal control, includingbudgetary control, that underpin the effective, efficient and economicoperation of the WEL CCGs;

approval of proposals for action on litigation against or on behalf of oneor more of the WEL CCGs; and

approval of the WEL CCGs’ common arrangements for businesscontinuity and emergency planning;

Human resources

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approval of arrangements for discharging the WEL CCGs’ statutoryduties as employing organisations;

approval of human resources policies for employees and other peopleworking on behalf of the WEL CCGs, including arrangements forappointment, removal, and all forms of remuneration;

approval of changes in management structure and function across theWEL CCGs;

approval of disciplinary arrangements for employees and for otherpeople working on behalf of the WEL CCGs;

disciplining of members of the WEL CCGs’ governing bodies andemployees who are in breach of statutory requirements or standingorders;

monitoring of the development and implementation of an organisationaldevelopment plan for the WEL CCGs; and

approval of recommendations of the Remuneration Committeesregarding directors and senior employees and recommendations of theaccountable officer for staff not covered by the RemunerationCommittees;

Policy and regulation

approval of the WEL CCGs’ overarching scheme of reservation anddelegation; and

approval of the WEL CCGs’ operational scheme of delegation thatunderpins the CCGs’ overarching scheme of reservation and delegationand sets out who has responsibility for operational decisions across theCCGs;

approval of the terms of reference and reporting arrangements for thegovernance infrastructure operating across the WEL CCGs;

receipt of reports from the CCGs’ joint management team and otherofficers, including those that the CCGs are required by the Secretary ofState or other regulation to establish and to action appropriately;

approval of any urgent decisions relevant to the WEL CCGs taken bythe Accountable Officer /WEL Managing Director or chair of one of thethree CCGs;

approval of detailed financial policies;

approval of arrangements for managing exceptional / individual fundingrequests;

approval of a single policy for who can execute a document bysignature or use of the seal;

confirmation of decisions of WEL-wide committees where they do nothave executive powers;

approval of common arrangements for handling freedom of informationrequests and complaints;

ensuring that the WEL CCGs meet the public sector equality duty;

approval of arrangements for ensuring appropriate safekeeping andconfidentiality of records and for the storage, management and transferof information and data; and

approval of the arrangements for discharging the WEL CCGs’ statutoryfinancial duties;

3. Evaluation This SORD will be kept under review by the joint board to ensure that its provisions meet the needs of the WEL CCGs. This will be done at least as part of the joint board’s twice-yearly formal review of its operation and performance, as described in the terms of reference. Any changes to it must be agreed by the governing bodies of the WEL CCGs.

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nhs newham ccg board part i meeting · declarations of interest. no interests were declared. 1.2...

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