GOVERNANCE HANDBOOK - Home - Dudley CCG · 1 | P a g e GOVERNANCE HANDBOOK UNIQUE REFERENCE NUMBER:...

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GOVERNANCE

HANDBOOK UNIQUE REFERENCE NUMBER: AC/XX/093/V1.1 DOCUMENT STATUS: Approved by Governing Body – November 2019 DATE ISSUED: November 2019

DATE TO BE REVIEWED: November 2020

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AMENDMENT HISTORY

VERSION DATE AMENDMENT HISTORY

AC/XX/XXX/V1.0 July 2019 First draft for internal review

AC/XX/093/V1.1 October 2019 Following advice from NHS England

AC/XX/093/V1.2 December 2019 TOR added

REVIEWERS This document has been reviewed by:

NAME DATE TITLE/RESPONSIBILITY VERSION

Emma Smith November 2019 Governance Handbook V1.1

Erika Polgar December 2019 NHS England V1.2

APPROVALS

This document has been approved by:

NAME DATE VERSION

Governing Body 14 November 2019 V1.1

NB: The version of this policy posted on the intranet must be a PDF copy of the approved version.

DOCUMENT STATUS This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of the document are not controlled.

RELATED DOCUMENTS These documents will provide additional information:

REFERENCE NUMBER

DOCUMENT TITLE VERSION

n/a CCG Constitution V6.0

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Foreword This handbook has been produced in order to ensure that all committees reporting to, and including the Governing Body are managed effectively and within the guidelines as set out in the Constitution. This Handbook sets out the Board’s Committee structures and governance arrangements, including respective Terms of Reference, decision making powers, sub-committee’s and groups, and membership. This Handbook will be updated annually by the Governance Team, and it will be published on the CCG’s website.

Vision, Values & Aims

The vision of NHS Dudley Clinical Commissioning Group is ‘To promote good health and ensure high

quality health services for the people of Dudley’

The Group will promote good governance and proper stewardship of public resources in pursuance

of its goals and in meeting its statutory duties.

Values Good corporate governance arrangements are critical to achieving the Group’s objectives.

The values that lie at the heart of the Group’s work are to:

a) be a caring organisation

b) be a patient centred organisation

c) work together as teams within the organisation and with partners

d) have quality and safety as the foundation of everything we do

e) be an organisation which leads by example

f) be a learning organisation

g) be an inclusive organisation

h) have a focus on prevention and health promotion

i) be an innovative organisation

j) promote excellent financial management

Aims The Group’s aims are to:

a) be a clinically-led organisation (ensuring close working partnerships between clinicians and

managers)

b) have primary care at the heart of the organisation (ensuring the full engagement of constituent

practices)

c) focus on quality and continuous improvement

d) have the meaningful involvement of patients and public

e) work with partners to improve health outcomes and services and reduce health inequalities

f) live within available resources.

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Contents

1.0 GOVERNANCE ................................................................................................................. 5

2.0 SCHEME OF RESERVATION AND DELEGATION (SORD) ........................................... 7

3.0 SCHEME OF DELEGATED FINANCIAL LIMITS ........................................................... 14

4.0 ROLES AND RESPONSIBILITIES ................................................................................. 18

5.0 STANDARD OF BUSINESS CONDUCT AND MANAGING CONFLICTS OF INTEREST ......................................................................................................................................... 33

6.0 DECLARATIONS OF INTEREST .................................................................................... 37

7.0 COMMITTEE TERMS OF REFERENCE ........................................................................ 38

Appendix 1 – Managing Conflicts of Interest Policy Appendix 2 – Committee Terms of Reference

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1.0 GOVERNANCE 1.1 Committee Structures

All Committees have a responsibility to meet its duties in respect of the underlying assurance processes to:

Indicate the degree of achievement of corporate objectives

Ensure the effectiveness of the management of principal risks

Ensure internal risk management arrangements

Ensure policies for ensuring compliance with regulatory, legal code of conduct arrangements They are also required to operate within their Terms of Reference as defined within the Constitution (Appendix 2) The Governing Body is required to maintain the following statutory/mandated Committees:

Audit and Governance Committee

Remuneration & HR Committee

Primary Care Commissioning Committee The other Committees in place to support the Governing Body are;

Integrated Assurance Committee

Finance and Investment Committee

Policy Commissioning Committee

MCP Procurement Project Board

Joint Commissioning Committee

This Committee is accountable to the

Governing Body and provides the Governing

Body with an independent and

objective view of the CCG’s compliance with

its statutory responsibilities. The

Committee is responsible for

arranging appropriate internal and external

audit

This Committee is accountable to the

Governing Body and makes

recommendations to the Governing Body

about the remuneration, fees and

other allowances (including pension

schemes) for employees and other

individuals who provide services to the CCG

This Committee is required by the terms of the delegation from

NHS England in relation to primary care

commissioning functions. The Primary Care Commissioning Committee reports to the Governing Body and to NHS England

This Committee is accountable to the Group’s Governing Body, ensures full consideration of

financial and associated planning

issues for the Group

This Committee is accountable to the Group’s Governing

Body, is authorised to consider proposed

commissioning plans; the communication and engagement strategy of the Group, and the delivery of this,

and make appropriate recommendations to the Governing Body.

This Committee is accountable to the Group’s Governing

Body, is authorised to review and recommend all issues pertinent to quality and safety for

the Group and to provide assurance to the Governing Body

that the commissioned services are of high

quality. The Committee also monitors

performance against service delivery

indicators and targets

Dudley CCG Governing Body

Audit & Governance Committee

Remuneration & HR Committee

Primary Care Commissioing

Committee

Finance & Investment Committee

Policy & Commissioning

Committee


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1.2 Sub Committees Committees have the powers to establish sub committees or “working groups” in order to focus and support on specific areas. It is also important that the working groups produce regular reports to the committees in order to build into the work plans.

Two other meetings within the Governance Structure are the MCP Procurement Board and the Joint Commissioning Committee.

Multi-Speciality Community Provider (MCP) Procurement Project Board – the MCP Project Board is accountable to the Group’s Governing Body. The Project Board is to take all decisions regarding the Multi-Specialty Community Provider (MCP) procurement except the decision to commence procurement and to award the contract. The Chair for this Committee is the Chief Accountable Officer and the Vice Chair is the Chief Finance Officer.

Black Country and West Birmingham Joint Commissioning Committee – the Joint Committee with NHS Sandwell and West Birmingham, NHS Wolverhampton and NHS Walsall CCGs is accountable to the governing body for establishing a single commissioning view in line with the Sustainable Transformation Plan (STP) arrangements for key services across the Black Country and West Birmingham. No Commissioning functions have yet been delegated to the Joint Commissioning Committee. The Chair & Vice Chair for this Committee is appointed from among the Clinical Chairs of the four CCGs on a rolling basis.

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2.0 SCHEME OF RESERVATION AND DELEGATION (SORD) 2.1 The arrangements made by the Group as set out in this scheme of reservation and delegation of decisions shall have effect as if incorporated in the

Group’s constitution. 2.2 The Clinical Commissioning Group remains accountable for all of its functions, including those that it has delegated. 2.3 The table below indicates which decisions have been reserved to the membership and these decisions can only be taken at a quorate meeting

of the Group itself, as described in the constitution and Standing Orders or under 3.8.1 of Standing Orders in an emergency or in unforeseen circumstances.

2.4 Other decisions have been delegated to the Governing Body and these must be taken at a quorate meeting of that body, as described in the

constitution and Standing Orders, or under 3.8.1 of Standing Orders in an emergency or in unforeseen circumstances. 2.5 Decisions delegated to the Accountable Officer or the Chief Finance Officer must be taken by the relevant individual or someone with express, written

authority to do so on their behalf.

2.6 Decisions delegated to Committees or Sub-Committees must be taken at a quorate meeting of that body, as described in the constitution,

Standing Orders and the relevant terms of reference

Policy Area Decision Reserved to

the Membership

Reserved/ Delegated to Governing

Body

Delegated to Committee

Officer

REGULATION AND CONTROL5.

1. Determine the arrangements by which the members of the Group approve those decisions that are reserved for the membership.

2. Consider and approve applications to NHS England on any matter concerning changes to the Group’s constitution, including terms of reference for the Group’s Governing Body, its committees, membership of committees, the overarching scheme of reservation and delegated powers, arrangements for taking urgent decisions, standing orders and prime financial policies.

3. The approval of any material changes to the CCG’s constitution and other related documents

4. Exercise or delegation of those functions of the clinical commissioning group which have not been retained as reserved by

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the Membership


Body


Officer

the Group, delegated to the Governing Body, delegated to a committee or Sub- Committee of the Group or to one of its members or employees.

5. Prepare the Group’s overarching scheme of reservation and delegation, which sets out those decisions of the Group reserved to the membership and those delegated to the

group’s Governing Body committees and Sub-Committees of the Group, or its members

or employees and which sets out those decisions of the Governing Body reserved to the Governing Body and those delegated to

the Governing Body’s committees and Sub-Committees, members of the Governing Body, an individual who is member of the Group but not the

Governing Body or a specified person for inclusion in the Group’s constitution.

Director with responsibility

for Governance

6. Approve the Group’s overarching scheme of reservation and delegation.

7. Prepare the Group’s operational scheme of delegation, which sets out those key operational decisions delegated to individual employees of the clinical commissioning group, not for inclusion in the Group’s constitution.

Director with responsibility

for Governance

8. Approve the Group’s operational scheme of delegation that underpins the Group’s ‘overarching scheme of reservation and delegation’ as set out in its constitution.

Audit &

Governance

9. Prepare detailed financial policies that underpin the clinical commissioning group’s prime financial policies.

Chief Finance

Officer

10. Approve detailed financial policies. Finance & Investment

11. Approve arrangements for managing exceptional funding requests. Policy &

Commissioning

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the Membership


Body


Officer

12. Determination of process for making grants and loans to voluntary organisations

Chief Finance

Officer

13. Ensure the Group's expenditure does not exceed the aggregate of the CCG's allotments for the financial year

Chief Finance Officer

14. Ensure the Group's use of resources (both its capital resource use and revenue resource use) does not exceed the amount specified by NHS England for the financial year

Chief Finance

Officer

15. Take account of any directions issued by NHS England, in respect of specified types of resource use in a financial year, to ensure the Group does not exceed an amount specified by NHS England

Chief Finance

Officer

16. Publish an explanation of how the Group spent any payment in respect of quality made to it by NHS England


PRACTICE MEMBER

REPRESENTATIVES AND MEMBERS OF GOVERNING

BODY

1. Approve arrangements for identifying practice members to represent practices in matters concerning the work of the Group; and appointing clinical leaders to represent the Group’s membership on the Group’s Governing Body, for example through election (if desired).

2. Approve the appointment of Governing Body members, the process for recruiting and removing members to the Governing Body (subject to any regulatory requirements) and succession planning.

3. Approve arrangements for identifying the Group’s proposed accountable officer.

STRATEGY AND PLANNING

1. Approve the Group’s operating structure. Chief

Accountable Officer

2. Approve the Group’s commissioning plan.

3. Approve the Group’s corporate budgets that meet the financial duties as set out in section 5.3 of the main body of the constitution.

4. Approve variations to the approved budget where variation would have a significant impact on the overall approved levels of income and expenditure or the Group’s ability to achieve its agreed strategic aims.

Finance & Investment

1. Approve the Group’s annual report and annual accounts. Audit &

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the Membership


Body


Officer

ANNUAL REPORTS AND

ACCOUNTS

Governance

2. Approve arrangements for discharging the Group’s statutory financial duties.

Audit & Governance

HUMAN RESOURCES

1. Make recommendations on the terms and conditions, remuneration and travelling or other allowances for Governing Body members, including pensions and gratuities.

Remuneration &

HR

2. Make recommendations on the terms and conditions of employment for all employees of the Group including, pensions, remuneration, fees and travelling or other allowances payable to employees and to other persons providing services to the Group.

Remuneration &

HR

3. Make recommendations on the any other terms and conditions of services for the Group’s employees.

Remuneration & HR

4. Make recommendations on the terms and conditions of employment for all employees of the Group.

Remuneration & HR

5. Make recommendations on the pensions, remuneration, fees and allowances payable to employees and to other persons providing services to the Group.

Remuneration &

HR

6. Recommend pensions, remuneration, fees and allowances payable to employees and to other persons providing services to the Group.

Remuneration & HR

7. Approve disciplinary arrangements for employees, including the Accountable Officer (where he/she is an employee or member of the Clinical Commissioning Group) and for other persons working on behalf of the Group.

Remuneration &

HR

8. Review disciplinary arrangements where the Accountable Officer is an employee or member of another Clinical Commissioning Group.

Remuneration & HR

9. Approve arrangements for discharging the Group’s statutory duties as an employer.

Remuneration & HR

10. Approve human resources policies for employees and for other persons working on behalf of the Group.

Remuneration & HR

QUALITY AND SAFETY

1. Approve arrangements, including supporting policies, to minimise clinical risk, maximise patient safety and to secure continuous

Integrated Assurance

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the Membership


Body


Officer

improvement in quality and patient outcomes.

2. Approve arrangements for supporting NHS England in discharging its responsibilities in relation to securing continuous improvement in the quality of general medical services.


OPERATIONAL AND RISK

MANAGEMENT

1. Prepare and recommend an operational scheme of delegation that sets out who has responsibility for operational decisions within the Group.

Director with the

responsibility for

Governance

2. Approve the Groups arrangements counter fraud and security management

Audit & Governance

3. Approve the Group’s risk management arrangements. Audit &

Governance

4. Approve arrangements for risk sharing and or risk pooling with other organisations (for example arrangements for pooled funds with other clinical commissioning groups or pooled budget arrangements under section 75 of the NHS Act 2006).

5. Approve a comprehensive system of internal control, including budgetary control, which underpins the effective, efficient and economic operation of the Group.

6. Approve proposals for action on litigation against or on behalf of the clinical commissioning group.

7. Approve the Group’s arrangements for business continuity Audit &

Governance

INFORMATION GOVERNANCE

1. Approve the Group’s arrangements for handling complaints. Integrated

Assurance

2. Approve arrangements for ensuring appropriate safekeeping and confidentiality of records and for the storage, management and transfer of information and data.

Audit &

Governance

TENDERING AND CONTRACTING

1. Approve the Group’s contracts for any commissioning support.

2. Approve the Group’s contracts for corporate support (for example finance provision).

Finance & Investment

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the Membership


Body


Officer

PARTNERSHIP WORKING

1. Approve decisions that individual members or employees of the Group participating in joint arrangements on behalf of the Group can make. Such delegated decisions must be disclosed in this scheme of reservation and delegation.

Chief

Accountable Officer

2. Approve decisions delegated to joint committees established under section 75 of the 2006 Act.

Chief Accountable

Officer

COMMISSIONING

AND CONTRACTING FOR CLINICAL

SERVICES

1. Determination of arrangements for discharging the Group’s statutory duties associated with its commissioning functions, including but not limited to securing public involvement, ensuring patient choice, securing continuous improvement in the quality of services, innovation, research, education and training and obtaining appropriate advice.

2. Determination of arrangements put in place to promote a comprehensive health service

3. Determination of arrangements to meet the public sector equality duty

4. Promote the involvement of patients, carers and representatives in decision about their healthcare

5. Determination of the arrangements to secure engagement with the public, patient and their representatives in decisions about their healthcare – Engagement

Policy &

Commissioning

6. Determination of the arrangements to secure engagement with the public, patient and their representatives in decisions about their healthcare - Patient Experience


7. Determination of arrangements for supporting NHS England as regards improving the quality of primary medical services


8. Determination of arrangements for co-ordinating the commissioning of services with other groups and or with the local authority(ies),where appropriate.

Policy &

Commissioning

9. Determination of arrangements for securing health services that are provided in a way that promotes awareness of, and has regard

Policy & Commissioning

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the Membership


Body


Officer

to the NHS Constitution

10. Determination of arrangements for the review, planning and procurement of primary care medical services (under delegated authority from NHS England). To include

GMS, PMS and APMS contracts (including the design of PMS and APMS contracts, monitoring of contracts, taking contractual action, such as issuing branch/remedial notices, and removing a contract);

Newly designed enhanced services (“Local Enhanced Services (LES)” and “Directed Enhanced Services (DES)”);

Design of local incentive schemes as an alternative to the Quality and Outcomes Framework (QOF);

The ability to establish new GP practices in an area; Approving practice mergers; and Making decisions on ‘discretionary’ payments (e.g., returner/retainer

schemes).

Primary Care Commissioning

11. Overseeing the arrangements for co-ordinating the commissioning of services, other than primary medical services as delegated to the Primary Care Committee in 8 above, with other groups and or with the local authority(ies)

Policy &

Commissioning

12. Promoting integration of both health services with other health services and health services with health-related and social care services where the Group considers that this would improve the quality of services or reduce inequalities

Policy &

Commissioning

13. Decisions regarding the Multi-Specialty Community Provider (MCP) procurement except the decision to commence procurement and to award the contract.

MCP Project

Board

14. Decision to commence MCP procurement and to award the contract

COMMUNICATIONS

1. Approve arrangements for handling Freedom of Information requests. Audit &

Governance

2. Determine arrangements for handling Freedom of Information requests. Audit &

Governance

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3.0 Scheme of Delegated Financial Limits

3.1 This Operational Scheme of Delegation should be applied in accordance with the CCG’s Procurement Strategy (As at October 2018)

REF DUTIES / RESPONSIBILITES DELEGATED TO FINANCIAL LIMIT

DEBTOR AND CREDITOR BALANCES

Review schedules of debtor and creditor balances that are over three months old and exceed the specified financial limit.

Audit & Governance Committee Over £10,000

VIREMENT LIMITS

Virements within the departmental approved revenue budgets. Budget Holders Up to £25,000

Nominated Senior Officers* Up to £500,000

Chief Executive Officer or Chief Operating & Finance Officer

No Limit

Virements for Budget restructuring, distribution of reserves, contractual changes and additional allocations

Heads of Financial Management £5,000,000


No Limit

QUOTATION AND TENDER LIMITS

Informal Price Testing Up to £10,000

Competitive Quotations £10,001 to £50,000

Competitive Tendering Over £50,000

NOTE: To comply with European law, the current OJEU limits should be applied: Supplies & Services (Non-Light Touch) wef 1st January 2018 over £118,133 Part B Services wef 1st January 2018 over £181,302 Light Touch Services wef 1st January 2018 over £615,278 .

AUTHORISATION OF TENDERS AND QUOTATIONS

Providing all the conditions and circumstances set out in the Prime Financial Policies have been fully complied with, formal authorisation and awarding of a contract may be decided by the delegated officers in accordance with their specified financial limit

Budget Holders Up to £10,000



Up to £500,000

Chief Executive Officer / Chief Operating & Finance Officer acting jointly

Up to £1,000,000

CCG Governing Body Over £1,000,000

OPENING TENDERS

A member of the CCG Governing Body (who will not have any declared interest in relation to the given tender) will be required to be one of the two approved persons present for the opening of tenders that are expected to be above the specified financial limit

Member of the CCG Governing Body Over £500,000

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NOTE: Only applies if Bravo system via CSU Procurement is not used

WAIVING OF TENDER / QUOTATIONS

Delegated authority to waive tender or obtain quotations (in accordance with Standing Orders and Prime Financial Policies), or to accept a tender or quotation which is not the lowest. NOTE: tenders subject to EU tender regulations cannot be waived

Chief Operating & Finance Officer Up to £250,000

Chief Executive Officer Up to £500,000

CCG Governing Body No limit

DISPOSALS

Competitive tendering or quotation procedures shall not apply to the disposal of items with an estimated sales value in accordance with the specified financial limit

Less than £5,000

AUTHORISE REVENUE AND CAPITAL EXPENDITURE – NON HEALTHCARE

Delegated authority to approve revenue or capital requisitions / expenditure and to certify invoices for non-healthcare purposes. NOTE: These expenditure limits can only be exercised when all other relevant and applicable conditions and circumstances as set out in the Prime Financial Policies have been complied with. For example, quotations or tenders have been sought, the successful quotation or tender has been authorised by the relevant officer(s), and an approved budget is available.



Deputy Chief Finance Officer Head of Financial Management-Corporate

** Head of Financial Management-

Commissioning **

Up to £100,000

Chief Operating & Finance Officer No Limit

Chief Executive Officer No Limit

RAISING REQUISITIONS

Authority to raise requisitions and validate goods received notes Designated Authorised Officers NIL

INVOICE CERTIFICATION – HEALTHCARE

Delegated authority to certify a healthcare invoice for payment NOTE: All healthcare invoices must be certified prior to payment



Deputy Chief Finance Officer Head of Financial Management-Corporate

** Head of Financial Management-

Commissioning **

Up to £250,000

Chief Operating & Finance Officer No Limit

Chief Executive Officer No Limit

HEALTHCARE CONTRACTS

Sign healthcare contracts and service level agreements on behalf of the CCG

Chief Executive Officer and Chief Operating & Finance Officer

No Limit

Authorise regular payments made against formal service level agreements and contracts

Designated Authorised Officers 1/12th of contract value

Deputy Chief Finance Officer 25% of contract value

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Head of Financial Management-Corporate **

Head of Financial Management-Commissioning **

Chief Executive Officer and Chief Operating & Finance Officer

No limit

PETTY CASH EXPENDITURE

Delegated authority to approve purchases from petty cash NOTE: Expenditure charged must be in accordance with the petty cash procedures

Designated Authorised Officers Up to £50

Chief Operating & Finance Officer/Deputy Chief Finance Officer

Head of Financial Management-Corporate **

Head of Financial Management-Commissioning **

Exceptionally up to £200

INDIVIDUAL FUNDING REQUESTS

Delegated authority to approve healthcare related contracts for individual clinical referrals outside of SLA’s and contracts, within available commissioning budget

CCG Authorised Panel Member Up to £25,000


Chief Operating & Finance Officer and Director of Commissioning

Up to £250,000

Chief Executive Officer and CCG Chair acting jointly

No Limit

BUSINESS CASE APPROVAL (Revenue)

Delegated authority to approve business cases relating to new investments

Commissioning Development Committee Up to £100,000

Chief Executive Officer and Chief Operating & Finance Officer acting jointly

with CCG Chair or Vice Chair

Up to £250,000

CCG Governing Body Over £250,000

BUSINESS CASE APPROVAL (Capital)

Delegated authority to approve business cases relating to new investments. The CCG currently has no delegated limit for capital

CCG Governing Body Nil

NHS Commissioning Board All capital cases

BALANCE SHEET AND RESERVES

Delegated Authority to approve balance sheet transactions.

Chief Operating & Finance Officer / Deputy Chief Finance Officer

No limit

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Head of Financial Management-Corporate **/ Head of Financial Management-

Commissioning **

Approval of movements within the balance sheet

Chief Operating & Finance Officer / Deputy Chief Finance Officer

Head of Financial Management-Corporate **/ Head of Financial Management-

Commissioning **

No limit

LOSSES AND SPECIAL PAYMENTS

Delegated authority to approve losses and special payments

Chief Operating & Finance Officer or Chief Executive Officer

Up to £50,000

Audit & Governance Committee Over £50,000

ENGAGEMENT OF CONSULTANCY AND AGENCY STAFF SUPPORT

Delegated authority to engage consultancy support and agency staff; amounts specified are in respect of any one individual, firm or role, and are cumulative in the case of extensions. NOTE: All appointments must be made and managed under the HMT Guidance “Managing Public Money”



Chief Executive Officer & CCG Chair Up to £500,000

CCG Governing Body Over £500,000

* For the purposes of this scheme of delegated financial limits, Nominated Senior Officers are defined as: Chief Nurse & Quality Officer; Head of Commissioning; Head of Communications & Public Insight; Head of Organisational Development & Human Resources and Head of Membership Development & Primary Care, save where they are individually given a delegated limit against a specific item within which the specified limit will apply. ** The Head of Financial Management-Corporate and Head of Financial Management-Commissioning have been added to provide cover in the absence of both the Chief Finance Officer and Deputy Chief Finance Officer. Any potential conflicts of interests will be taken into account when authorisation is required. Approved by Dudley CCG Audit & Governance Committee 18 October 2018.

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4.0 PRIME FINANCIAL POLICIES

1. INTRODUCTION 1.1 General 1.1.1. These prime financial policies and supporting detailed financial policies shall have effect as if

incorporated into the Group’s constitution. 1.1.2. The prime financial policies are part of the Group’s control environment for managing the

organisation’s 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 Accountable Officer and Chief Finance Officer to effectively perform their responsibilities. They should be used in conjunction with the Group's scheme of reservation and delegation.

1.1.3. In support of these prime financial policies, the Group has prepared more detailed policies,

recommended by the Chief Finance Officer and approved by the Finance & Investment Committee known as detailed financial policies. The Group refers to these prime and detailed financial policies together as the Clinical Commissioning Group’s financial policies.

1.1.4. 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.

1.1.5. A list of the Group’s detailed financial policies will be published and maintained on the Group’s

website at www.dudleyccg.nhs.uk 1.1.6. Should any difficulties arise regarding the interpretation or application of any of the prime financial

policies then the advice of the Chief Finance Officer must be sought before acting. The user of these prime financial policies should also be familiar with and comply with the provisions of the Group’s constitution, standing orders and scheme of reservation and delegation.

1.1.7. 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. 1.2 Overriding Prime Financial Policies 1.2.1. 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 the Governing Body’s Audit & Governance 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 Chief Finance Officer as soon as possible.

1.3. Responsibilities and delegation 1.3.1. The roles and responsibilities of group’s members, employees, members of the Governing Body,

members of the Governing Body’s Committees and Sub-Committees, members of the Group’s committee and Sub-Committee (if any) and persons working on behalf of the Group are set out in the CCG Governance Handbook.

1.3.2. The financial decisions delegated by members of the Group are set out in the Group’s scheme of

reservation and delegation or the detailed operational scheme of delegation as appropriate.

http://www.dudleyccg.nhs.uk/

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1.4. Contractors and their employees 1.4.1. 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 Chief Financial Officer to ensure that such persons are made aware of this and that contractual terms ensure that the contractor and their employees comply with the same standards of governance and financial probity as would apply to any employee of the Group.

1.5. Amendment of Prime Financial Policies 1.5.1. To ensure that these prime financial policies remain up-to-date and relevant, the Chief Finance

Officer will review them at least annually. Following consultation with the Accountable Officer and scrutiny by the Governing Body’s Audit & Governance Committee, the Chief Finance Officer will recommend amendments, as fitting, to the Finance & Investment Committee for approval. As these prime financial policies are an integral part of the Group’s constitution, any amendment will not come into force until the Group applies to NHS England and that application is granted.

2. INTERNAL CONTROL

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. The Governing Body is required to establish an Audit & Governance Committee with terms of

reference agreed by the Governing Body. 2.2. The Chief Finance Officer has overall responsibility for the Group’s systems of internal control. 2.3. The Chief Finance Officer will ensure that:

a) financial policies are considered for review and update annually; b) a system is in place for proper checking and reporting of all breaches of financial policies; and c) a proper procedure is in place for regular checking of the adequacy and effectiveness of the

control environment. 3. AUDIT

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. In line with the terms of reference for the Governing Body’s Audit & Governance Committee, the

Head of Internal Audit and the appointed external auditor will have direct and unrestricted access to Audit & Governance Committee members and the Chair of the Governing Body, Accountable Officer and Chief Finance Officer for any significant issues arising from audit work that management cannot resolve, and for all cases of fraud or serious irregularity.

3.2. The Head of Internal Audit and the external auditor will have access to the Audit Committee and

the Accountable Officer to review audit issues as appropriate. All Audit & Governance Committee members, the Chair of the Governing Body and the Accountable Officer will have direct and unrestricted access to the Head of Internal Audit and external auditors.

3.3. The Chief Finance Officer will ensure that:

a) the Group has a professional and technically competent internal audit function; and b) the Governing Body’s Audit & Governance Committee approves any changes to the provision

or delivery of assurance services to the Group.

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4. COUNTERING FRAUD AND CORRUPTION

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. The Governing Body’s Audit & Governance Committee will satisfy itself that the Group has

adequate arrangements in place for countering fraud and shall review the outcomes of counter fraud work. It shall also approve the counter fraud work programme.

4.2. The Governing Body’s Audit & Governance Committee will ensure that the Group has

arrangements in place to work effectively with NHS Counter Fraud Authority. 5. EXPENDITURE CONTROL

5.1. The Group is required by statutory provisions1 to ensure that its expenditure does not exceed the

aggregate of allotments from NHS England and any other sums it has received and is legally allowed to spend.

5.2. The Accountable Officer 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.

5.3. The Chief Finance Officer will:

a) provide reports in the form required by NHS England; b) ensure money drawn from NHS England is required for approved expenditure only is drawn

down only at the time of need and follows best practice; c) 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 NHS England.

6. ALLOTMENTS2

6.1. The Group’s Chief Finance Officer will:

a) periodically review the basis and assumptions used by NHS England for distributing allotments and ensure that these are reasonable and realistic and secure the Group’s entitlement to funds;

b) prior to the start of each financial year submit to the Governing Body for approval a report showing the total allocations received and their proposed distribution including any sums to be held in reserve; and

c) regularly update the Group’s Finance & Investment Committee and Governing Body on significant changes to the initial allocation and the uses of such funds.

7. COMMISSIONING STRATEGY, BUDGETS, BUDGETARY CONTROL AND MONITORING

POLICY the Group will produce and publish an annual commissioning plan3 that explains how it proposes

to discharge its financial duties. The Group will support this with comprehensive medium term financial plans and annual budgets 7.1. The Accountable Officer will annually compile and submit to the Governing Body a commissioning

strategy which takes into account financial targets and forecast limits of available resources.

1 See section 223(H) of the 2012 Act 2 See section 223(G) of the 2012 Act 3 See section 14Z11 of the 2012 Act

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7.2. Prior to the start of the financial year the Chief Finance Officer will, on behalf of the Accountable

Officer, prepare and submit budgets for review by the Finance & Investment Committee and their recommendation to the Group’s Governing Body for approval.

7.3. The Chief Finance Officer shall monitor financial performance against budget and plan, periodically

review them, and report to the Finance & Investment Committee This report should include explanations for variances. These variances must be based on any significant departures from agreed financial plans or budgets.

7.4. The Accountable Officer has overall responsibility for ensuring that information relating to the

Group’s accounts or to its income or expenditure, or its use of resources is provided to NHS England as requested.

7.5. The Policy & Commissioning Committee will approve consultation arrangements for the Group’s

commissioning plan4

. 8. ANNUAL ACCOUNTS AND REPORTS

POLICY the Group will produce and submit to NHS England accounts and reports in accordance with all

statutory obligations5

, relevant accounting standards and accounting best practice in the form and content and at the time required by NHS England 8.1. The Chief Finance Officer will ensure the Group:

a) prepares a timetable for producing the annual report and accounts and agrees it with external auditors and the Audit & Governance Committee

b) prepares the accounts according to the timetable approved by the Audit & Governance Committee;

c) complies with statutory requirements and relevant directions for the publication of annual report;

d) considers the external auditor’s management letter and fully address all issues within agreed timescales; and

e) publishes the external auditor’s management letter on the Group’s website at www.dudleyccg.nhs.uk

9. INFORMATION TECHNOLOGY

POLICY the Group will ensure the accuracy and security of the Group’s computerised financial data 9.1. The Chief Finance Officer is responsible for the accuracy and security of the Group’s computerised

financial data and shall:

a) devise and implement any necessary procedures to ensure adequate (reasonable) protection of the Group's data, programs and computer hardware from accidental or intentional disclosure to unauthorised persons, deletion or modification, theft or damage, having due regard for the Data Protection Act 1998/General Data Protection Regulations;

b) ensure that adequate (reasonable) controls exist over data entry, processing, storage, transmission and output to ensure security, privacy, accuracy, completeness, and timeliness of the data, as well as the efficient and effective operation of the system;

c) ensure that adequate controls exist such that the computer operation is separated from development, maintenance and amendment;

4 See section 14Z13 of the 2012 Act 5 See Schedule 2 section 17 of the 2012 Act


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d) ensure that an adequate management (audit) trail exists through the computerised system and that such computer audit reviews as the chief finance officer may consider necessary are being carried out.

9.2. In addition the Chief Finance Officer 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.

10. ACCOUNTING SYSTEMS

POLICY the Group will run an accounting system that creates management and financial accounts 10.1. The Chief Finance Officer will ensure:

a) the Group has suitable financial and other software to enable it to comply with these policies and any consolidation requirements of NHS England;

b) 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.

10.2. Where another health organisation or any other agency provides a computer service for financial

applications, the Chief Finance Officer shall at least annually seek assurances that adequate controls are in operation.

11. BANK ACCOUNTS

POLICY the Group will keep enough liquidity to meet its current commitments

11.1. The Chief Finance Officer will:

a) 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;

b) manage the Group's banking arrangements and advise the Group on the provision of banking services and operation of accounts;

c) prepare detailed instructions on the operation of bank accounts.

11.2. The Finance & Investment Committee shall approve the overall banking arrangements. 12. INCOME, FEES AND CHARGES AND SECURITY OF CASH, CHEQUES AND OTHER

NEGOTIABLE INSTRUMENTS. POLICY the Group will operate a sound system for prompt recording, invoicing and collection of all monies due 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 functions6

ensure its power to make grants and loans is used to

discharge its functions effectively7

12.1 The Chief Finance Officer is responsible for:

a) designing, maintaining and ensuring compliance with systems for the proper recording, invoicing, and collection and coding of all monies due;

b) establishing and maintaining systems and procedures for the secure handling of cash and other negotiable instruments;

6 See section 14Z5 of the 2012 Act 7 See section 14Z6 of the 2012 Act

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c) approving and regularly reviewing the level of all fees and charges other than those determined by NHS England or by statute. Independent professional advice on matters of valuation shall be taken as necessary;

d) developing effective arrangements for making grants or loans. 13. TENDERING AND CONTRACTING PROCEDURE

POLICY the Group:

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

will seek value for money for all goods and services

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 (other than specialised services sought from or provided by the Department of Health); and for the design, construction and maintenance of building and engineering works (including construction and maintenance of grounds and gardens) for disposals

13.1. The Group shall ensure that the firms / individuals invited to tender (and where appropriate, quote)

are among those on approved lists or where necessary a framework agreement. Where in the opinion of the Chief Finance Officer it is desirable to seek tenders from firms not on the approved lists, the reason shall be recorded in writing to the Accountable Officer or the Group’s Audit & Governance Committee.

13.2. The approval of the award of any contract will be given in accordance with the Group’s detailed

operational scheme of delegation. 13.3. The Governing Body 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: a) the Group’s standing orders; b) the Public Contracts Regulation 2006, any successor legislation and any other applicable law;

and c) take into account as appropriate any applicable NHS Commissioning Board or the

Independent Regulator of NHS Foundation Trusts (Monitor) guidance that does not conflict with (b) above.

13.4. In all contracts entered into, the Group shall endeavour to obtain best value for money. The

Accountable Officer shall nominate an individual who shall oversee and manage each contract on behalf of the Group.

14. COMMISSIONING

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 14.1. The Group will coordinate its work with 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.

14.2. The Accountable Officer will establish arrangements to ensure that regular reports are provided to

the Group’s Finance & Investment Committee detailing actual and forecast expenditure and activity for each contract.

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14.3. The Chief Finance Officer 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.

15. RISK MANAGEMENT AND INSURANCE

POLICY the Group will put arrangements in place for evaluation and management of its risks 15.1 The Chief Finance Officer will ensure that adequate insurance arrangements are in put in place. 15.2 The Accountable Officer will ensure that the Group has effective arrangements in place to manage

risk. This will be achieved through the maintenance of a Risk Management Strategy, Board Assurance Framework and Corporate Risk Register

15.3 The Risk Management Strategy identifies the Group’s risk management process for systematically

identifying risks, analysing the likelihood and impact of their occurrence and then deciding what action to take to mitigate risk.

15.4 A Board Assurance Framework and Corporate Risk Register will be maintained, to provide

evidence that the Group is doing its reasonable best to manage, direct and control itself so as to meet its corporate objectives. The Board Assurance Framework will provide a simple but comprehensive method for the effective and focused management of the principal risks to meeting the strategic objectives of the Group and provide a structure for the evidence to support the Group’s Annual Governance Statement.

16. PAYROLL

POLICY the Group will put arrangements in place for an effective payroll service 16.1. The Chief Finance Officer will ensure that the payroll service selected:

a) is supported by appropriate (i.e. contracted) terms and conditions; b) has adequate internal controls and audit review processes; c) has suitable arrangements for the collection of payroll deductions and payment of these to

appropriate bodies. 16.2. In addition the Chief Finance Officer shall set out comprehensive procedures for the effective

processing of payroll. 16.3 Where another health organisation or any other agency provides a payroll service, the Chief

Finance Officer shall at least annually seek assurances that adequate controls are in operation 17. NON-PAY EXPENDITURE

POLICY the Group will seek to obtain the best value for money goods and services received 17.1. The Group’s Finance & Investment Committee will approve the level of non- pay expenditure on

an annual basis and the Accountable Officer will determine the level of delegation to budget managers through the detailed operational scheme of delegation.

17.2. The Chief Finance Officer shall set out procedures on the seeking of professional advice regarding

the supply of goods and services. 17.3. The Chief Finance Officer will:

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a) advise the Audit & Governance Committee on the setting of thresholds above which quotations (competitive or otherwise) or formal tenders must be obtained; and, once approved, the thresholds should be incorporated in the scheme of reservation and delegation;

b) be responsible for the prompt payment of all properly authorised accounts and claims; c) be responsible for designing and maintaining a system of verification, recording and payment

of all amounts payable. 18. CAPITAL INVESTMENT, FIXED ASSET REGISTERS AND SECURITY OF ASSETS 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 18.1. The Accountable Officer will

a) ensure that there is an adequate appraisal and approval process in place for determining capital expenditure priorities and the effect of each proposal upon plans;

b) be responsible for the management of all stages of capital schemes and for ensuring that schemes are delivered on time and to cost;

c) shall ensure that the capital investment is not undertaken without confirmation of purchaser(s) support and the availability of resources to finance all revenue consequences, including capital charges;

d) be responsible for the maintenance of registers of assets, taking account of the advice of the Chief Finance Officer 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.

18.2. The Chief Finance Officer will prepare detailed procedures for the disposals of assets. 19. INFORMATION GOVERNANCE

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 19.1. The Accountable Officer shall nominate an individual to act as the Group’s Caldicott Guardian who

will: a) be responsible for maintaining all records required to be retained in accordance with NHS

Code of Practice Records Management 2006 and other relevant notified guidance; b) publish and maintain a Freedom of Information Publication Scheme and ensure that

arrangements are in place for effective responses to Freedom of Information requests as required by the relevant legislation;

c) be responsible for ensuring that the Group maintains compliance will all other relevant legislation including the Data Protection Act 1998

19.2. The Chief Finance Officer will act as the Group’s Senior Information Risk Owner. 19.3 Information governance policies to facilitate the above will be approved by the Governing Body

and the Group will use the NHS Data Security & Protection Toolkit to assess its performance in this area.

20. TRUST FUNDS AND TRUSTEES

POLICY the Group will put arrangements in place to provide for the appointment of trustees if the Group holds property on trust 20.1. The Chief Finance Officer 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.

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4.0 ROLES AND RESPONSIBILITIES

4.1 Practice Representatives

4.1.1 Practice representatives represent their practice’s views and act on behalf of the practice in matters

relating to the Group. The role of each practice representative is to ensure effective participation of the practice as a member of the Group by:

participating in group locality and borough meetings including educational events and workshops

acting as the first point of contact for the Group within the practice and facilitating two-way communication between the Group and the practice as required. This includes, but is not limited to, disseminating commissioning updates and information within the practice and seeking comment and feedback from the practice on proposed group policies and commissioning plans.

4.2 GP Representatives of Member Practices 4.2.1 The GP representatives are voting members of the Governing Body. In addition to the general

responsibilities of all Governing Body members, GP representatives will provide clinical leadership for the Group and bring a clinical perspective to the workings of the Group in the discharge of its general duties and functions. They will provide a direct link between the locality from which they represent and the Governing Body.

4.3 Other GP and Primary Care Health Professionals

4.3.1 In addition to the GP representatives identified in section 7.2 above, the Group has identified a

number of clinical lead roles who will be voting members of the Governing Body, to support the work of the Group and represent the Group rather than represent their own individual practices. These currently are:

the Clinical Executive for Policy & Commissioning

the Clinical Executive for Integrated Assurance

the Clinical Executive for Primary Care Commissioning 4.3.2 The span of responsibility attached to these Clinical Executive posts may vary from time to time.

4.3.3 Other clinical lead roles may also be appointed by the Governing Body from time to time.

4.4 All Members of the Group’s Governing Body

4.4.1 Guidance on the roles of members of the Group’s Governing Body is set out in a separate

document8

. In summary, each member of the Governing Body should share responsibility as part of a team to ensure that the Group exercises its functions effectively, efficiently and economically, with good governance and in accordance with the terms of this constitution. Each brings their unique perspective, informed by their expertise and experience.

4.5 The Chair of the Governing Body

4.5.1 The Chair of the Governing Body is responsible for:

8 Clinical commissioning group Governing Body Members – Roles Attributes and Skills, NHS Commissioning

Board Authority, April 2012

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a) leading the Governing Body, ensuring it remains continuously able to discharge its duties and responsibilities as set out in this constitution;

b) building and developing the Group’s Governing Body and its individual members;

c) ensuring that the Group has proper constitutional and governance arrangements in place;

d) ensuring that, through the appropriate support, information and evidence, the Governing Body is

able to discharge its duties;

e) supporting the Chief Accountable Officer in discharging the responsibilities of the organisation;

f) contributing to building a shared vision of the aims, values and culture of the organisation;

g) leading and influencing to achieve clinical and organisational change to enable the Group to deliver its commissioning responsibilities;

h) overseeing governance and particularly ensuring that the Governing Body and the wider group

behaves with the utmost transparency and responsiveness at all times;

i) ensuring that public and patients’ views are heard and their expectations understood and, where appropriate as far as possible, met;

j) ensuring that the organisation is able to account to its local patients, stakeholders and NHS

England;

k) ensuring that the Group builds and maintains effective relationships, particularly with the individuals involved in overview and scrutiny from the relevant local authority(ies).

4.6 The Vice Chair of the Governing Body 4.6.1 The Vice Chair of the Governing Body deputises for the Chair of the Governing Body where he or

she has a conflict of interest or is otherwise unable to act. 4.6.2 Details of how they will be appointed, their tenure of office and resignation or removal from office

are included in the Group’s Standing Orders. 4.7 Role of the Accountable Officer 4.7.1 The Accountable Officer of the Group is a member of the Governing Body, and will be known as

the Chief Accountable Officer.

4.7.2 This role of Accountable Officer has been summarised in a national document9 as:

a) being responsible for ensuring that the Clinical Commissioning Group fulfils its duties to exercise its functions effectively, efficiently and economically thus ensuring improvement in the quality of services and the health of the local population whilst maintaining value for money

b) at all times ensuring that the regularity and propriety of expenditure is discharged, and that

arrangements are put in place to ensure that good practice (as identified through relevant agencies) is embodied and that safeguarding of funds is ensured through effective financial and management systems

9 See the latest version of the NHS Commissioning Board Authority’s Clinical commissioning group Governing

Body members: Role outlines, attributes and skills

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c) working closely with the Chair of the Governing Body, the Accountable Officer will ensure that proper constitutional, governance and development arrangements are put in place to assure the members (through the Governing Body) of the organisation’s on-going capability and capacity to meet its duties and responsibilities. This will include arrangements for the on-going developments of its members and staff.

4.7.3 In addition to the Accountable Officer’s general duties, where the accountable officer is also the

senior clinical voice of the Group they will take the lead in interactions with stakeholders, including NHS England

4.8 Role of the Chief Finance Officer 4.8.1 The Chief Finance Officer is a member of the Governing Body and is responsible for providing

financial advice to the Clinical Commissioning Group and for supervising financial control and accounting systems

4.8.2 This role of Chief Finance Officer has been summarised in a national document10 as:

being the Governing Body’s professional expert on finance and ensuring, through robust systems and processes, the regularity and propriety of expenditure is fully discharged;

making appropriate arrangements to support, monitor on the Group’s finances;

overseeing robust audit and governance arrangements leading to propriety in the use of the Group’s resources;

being able to advise the Governing Body on the effective, efficient and economic use of the Group’s allocation to remain within that allocation and deliver required financial targets and duties;

producing the financial statements for audit and publication in accordance with the statutory requirements to demonstrate effective stewardship of public money and accountability to NHS England;

responsible for the governance function within the Group;

responsible for managing corporate functions provided externally, including the Commissioning Support Service provider(s);

lead on management and negotiation of contracts with providers 4.9 Role of the Registered Nurse 4.9.1 The Registered Nurse is a member of the Governing Body and is responsible for ensuring

commissioned services provide high quality services to patients. 4.9.2 The role is responsible for collective corporate responsibility for strategic and operational

performance as a member of the CCG Board. 4.9.3 The role will be responsible for providing leadership and line management to nurses working within

the CCG, and professional guidance to those working in the wider primary care system where relevant.

10 See the latest version of the NHS Commissioning Board’s Clinical commissioning group Governing Body

members: Role outlines, attributes and skills

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4.10 Role of the Lay Members 4.10.1 The Lay Members are members of the Governing Body and are responsible for bringing specific

expertise and experience to the work of the Governing Body. 4.10.2 Their focus will be strategic and impartial, providing an external view of the work of the CCG that

is removed from the day to day running of the organisation. 4.10.3 The CCG has three lay members on the Governing Body:

Lay member for Governance who is the Chair of the Audit & Governance Committee and Chair of Remuneration & HR Committee

Lay member for Patient & Public Engagement who is Vice Chair of the Remuneration and HR Committee and the Primary Care Commissioning Committee

Lay member for Integrated Assurance who is the Vice Chair of the Integrated Assurance Committee

4.11 Role of the Secondary Care Clinician 4.11.1 The Secondary Care Clinician is a member of the Governing Body and is responsible for bringing

a broader view on health care issues to support the work of the CCG. 4.11.2 The Secondary Care Clinicians is the Chair of the Primary Care Commissioning Committee.

4.11.3 This role of Secondary Care Clinician has been summarised in a national document11 as:

a consultant – either currently employed, or in employment at some time in the period of 10 years ending with the date of the individual‘s appointment to the governing body;

has a high level of understanding of how care is delivered in a secondary care setting;

be competent, confident and willing to give an independent strategic clinical view on all aspects of CCG business;

be highly regarded as a clinical leader, preferably with experience working as a leader across more than one clinical discipline and/or specialty with a track record of collaborative working;

be able to take a balanced view of the clinical and management agenda, and draw on their in depth understanding of secondary care to add value;

be able to contribute a generic view from the perspective of a secondary care doctor whilst putting aside specific issues relating to their own clinical practice or their employing organisation‘s circumstances; and

be able to provide an understanding of how secondary care providers work within the health system to bring appropriate insight to discussions regarding service redesign, clinical pathways and system reform.

4.12 Joint Arrangements with other Organisations 4.12.1 The Group has the following joint arrangements with other organisations:

a) The Chief Accountable Officer is employed by Dudley Clinical Commissioning Group and shall also work for Walsall Clinical Commissioning Group

b) The Chief Finance Officer is employed by Dudley Clinical Commissioning group and shall also

work for Walsall Clinical Commissioning Group.

11 See the latest version of the NHS Commissioning Board’s Clinical commissioning group Governing Body

members: Role outlines, attributes and skills

30 | P a g e

4.13 Responsibilities of member practices to the Group and of the Group, (acting by its Governing Body), to member practices

4.13.1 The Group is a membership organisation and the effective participation of each member practice

will be essential in developing and sustaining high quality commissioning arrangements. 4.13.2 The bilateral accountabilities of the Group (acting by its Governing Body) and its member practices

to one another are described in paragraphs 7.13.3 – 7.13.4 of this constitution. 4.13.3 Member practice responsibilities to the Group. Each member practice shall:

a) appoint a practice representative to undertake the role as described in paragraph 7.1 of this

constitution, in line with the practice’s agreed procedure for nomination and appointment,

b) nominate and release an appropriate representative to attend the Practice Manager Alliance Meetings

c) undertake regular practice meetings to monitor performance against the commissioning indicators

as set out in the Group’s monthly commissioning performance reports.

d) meet with the Group’s GP Engagement Lead and agree plans to support the delivery of the commissioning strategies of the Group.

e) support the Group’s commissioning intentions and commissioning strategies and use, where

appropriate and in accordance with patient choice, local services and pathways as commissioned by the Group

f) access relevant information via agreed group systems as appropriate regarding pathways, referral

guidelines and other relevant commissioning information

g) make reasonable efforts to ensure the member practice remains within its commissioning budget

h) work with the Group to meet its quality and productivity targets set out within the Group’s commissioning strategies.

i) take account of all duties, rights, pledges and values as set out in the NHS Constitution; and

j) respond in a timely manner to reasonable information requests from the Group

4.13.4 Responsibilities of the Group (acting by its Governing Body) to member practices. The

Group shall:

a) ensure that all member practices will receive at least one visit per year from representatives of the

Group to discuss practice level commissioning issues and priorities.

b) ensure that, in addition to the AGM , there will be at least two other group general meetings each

year that do not have the public in attendance.

c) ensure that an annual survey of member practices (designed and administered in conjunction with the LMC) is undertaken to obtain feedback on levels of satisfaction and perceived engagement with the commissioning process and report the survey results will be reported to a public meeting of the Governing Body.

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d) ensure that GP representatives appointed to the Governing Body will be appointed in accordance with the process set out in Standing Orders paragraph 2.2 (Appendix C of this constitution)

e) ensure that member practices are kept informed of Group business through locality meetings,

newsletters and education events, and other appropriate means

f) ensure that, in addition to the GP representatives, each locality has a Group named management point of contact for any concerns or issues.

g) ensure that the Governing Body provides information management tools, training and support to

enable member practices to review information at patient level and support the member practice to meet its financial and quality targets.

4.14 Dispute Resolution Process 4.14.1 This process is to be used in the event of disputes and concerns being raised by either:

practice members who have concerns regarding the Governing Body or general workings of the Group or;

the Governing Body in relation to the behaviour of any practice member. 4.14.2 Issues and concerns raised using this process will be dealt with promptly and in a supportive and

constructive manner. 4.14.3 The process for member practices who wish to raise a grievance or concern is set out below. 4.14.4 Member practices should, in the normal course of events, be able to raise any concerns with their

named group management contact, their GP representative for their locality, or the Group’s GP engagement lead. In circumstances where this routine contact does not resolve the issue satisfactorily, then member practices should follow the procedure set out below:

a) member practices should set out their grievance or issue in writing and submit this to the

Accountable Officer

b) the Accountable Officer will acknowledge receipt of the correspondence within 3 working days.

c) in most instances the Chair and/or the Accountable Officer will make direct contact with the member practice to discuss the matter and agree any appropriate actions to resolve the issue. (Dependent upon the nature of the issue, the Chair will involve other colleagues from the Group with relevant lead responsibilities.) Any agreed actions will be confirmed in writing.

d) if the above actions fail to resolve the issue to the satisfaction of the member practice, then the

matter will be referred to a lay member of the Governing Body, who will be responsible for leading the consideration of the matter at a meeting of the full Governing Body. The member practice will be able to attend to make direct representation to this meeting.

e) member practices may involve the LMC (or other external support) at any stage of this process.

4.14.4 The process for the Governing Body raising concerns with a member practice is set out below: 4.14.5 In the normal course of events any concerns regarding a member practice’s compliance with its

responsibilities as a member of the Group, would be raised informally via routine reporting and contact with the Group management contact or GP engagement lead. Where concerns and issues cannot be resolved via normal day to day contact, then the process set out below should be followed:

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a) the Governing Body will set out the nature of the concerns in writing and send these to the member practice;

b) the member practice will then be asked to meet with the GP locality representative, and/or the

Chair and/or the Accountable Officer to discuss the issue of concern and agree a way forward within an agreed timescale;

c) where appropriate, a recovery/action plan may be identified and agreed between the member

practice and a nominated Clinical Executive, (and the LMC if requested by the member practice). The Clinical Executive will ensure that the member practice is provided with the appropriate information and assistance to support the member practice in the delivery of this plan;

d) the recovery/action plan will be reviewed by the appropriate CCG Committee which will monitor

the member practice’s achievements against the recovery plans objectives;

e) if the member practice does not respond to support and demonstrate improvement in line with the plan, this will be considered by the Governing Body and discussed within the confidential section;

f) Member practices may and the Group will support the member practice to involve the LMC (or

other external support), at any stage of this process.

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5.0 STANDARD OF BUSINESS CONDUCT AND MANAGING CONFLICTS OF INTEREST

5.1 Standards of Business Conduct 5.1.1 Employees, Members, Committee and Sub-Committee members of the Group and members of the

Governing Body (and its Committees) will at all times comply with this constitution and be aware of their responsibilities as outlined in it. They should act in good faith and in the interests of the Group and should follow the Seven Principles of Public Life, set out by the Committee on Standards in Public Life (the Nolan Principles) The Nolan Principles are incorporated into this constitution at Appendix G.

5.1.2 They must comply with the Group’s policy on business conduct, including the requirements set out

in the policy for meeting the Group’s duties with regard to registering and managing conflicts of interest. This policy is available on the Group’s website at http://www.dudleyccg.nhs.uk/publication-scheme-v2/

5.1.3 Individuals contracted to work on behalf of the Group or otherwise providing services or facilities

to the Group will be made aware of their obligation with regard to declaring conflicts or potential conflicts of interest. This requirement will be written into their contract for services.

5.1.4 Due consideration will be given to the available guidelines and protocols from statutory bodies and

recognised national institutions such as the General Medical Council, General Pharmaceutical Council, and Royal College of General Practitioners in managing conflicts of interest.

5.2 Conflicts of Interest 5.2.1 As required by section 14O of the 2006 Act, as inserted by section 25 of the 2012 Act, the Clinical

Commissioning Group will make arrangements to manage conflicts and potential conflicts of interest to ensure that decisions made by the Group will be taken and seen to be taken without any possibility of the influence of external or private interest.

5.2.2 Where an individual, i.e. an employee, group member, member of the Governing Body, or a

member of a Committee or a Sub-Committee of the Group or its Governing Body has an interest, or becomes aware of an interest, which could lead to a conflict of interest in the event of the Group considering an action or decision in relation to that interest, that must be considered as a potential conflict, and is subject to the provisions of this constitution.

An interest will include:

a) a direct pecuniary interest: where an individual may financially benefit from the consequences

of a commissioning decision (for example, as a provider of services); b) an indirect pecuniary interest: for example, where an individual is a partner, member or

shareholder in an organisation that will benefit from the consequences of a commissioning decision;

c) a non-pecuniary interest: where an individual holds a non-remunerative or not-for profit interest

in an organisation, that will benefit from the consequences of a commissioning decision(for example, where an individual is a trustee of a voluntary provider that is bidding for a contract);

d) a non-pecuniary personal benefit: where an individual may enjoy a qualitative benefit from the

consequence of a commissioning decision which cannot be given a monetary value (for example, a reconfiguration of hospital services which might result in the closure of a busy clinic next door to an individual’s house)

http://www.dudleyccg.nhs.uk/publication-scheme-v2/

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e) where an individual is closely related to, or in a relationship, including friendship, with an individual in the above categories.

5.2.3 A potential conflict of interest arises where any of the above interests may be affected by a decision

or proposed decision of the Group, or where as a result of the interest there may be a conflict between the interest and the interest of the Group, or between the individual's interest and their duty to the Group as employee, member or otherwise.

5.2.4 If in doubt, the individual concerned should assume that a potential conflict of interest exists. 5.3 Declaring and Registering Interests 5.3.1 The Group will maintain one or more registers of the interests of:

the members of the Group;

the members of its Governing Body;

the members of its Committees or Sub-Committees and the Committees or Sub-Committees of its Governing Body; and

its employees.

The registers will be published on the Group’s website at http://www.dudleyccg.nhs.uk/publication-scheme-v2/

Individuals will declare any interest that they have in writing to the Governing Body, as soon as they are aware of it and in any event no later than 28 days after becoming aware.

5.3.4 Where an individual is unable to provide a declaration in writing, for example, if a conflict becomes

apparent in the course of a meeting, they will make an oral declaration before witnesses, and provide a written declaration as soon as possible thereafter.

5.3.5 The Audit & Governance Committee will ensure that the register(s) of interest is reviewed regularly,

and updated as necessary. 5.4 Managing Conflicts of Interest: general

5.4.1 Individual members of the Group, the Governing Body, Committees or Sub-Committees, the

Committees or Sub-Committees of its Governing Body and employees will comply with the arrangements determined by the Group for managing conflicts or potential conflicts of interest, as described in the Group’s Conflicts of Interest (including Gifts & Hospitality) Policy and is available on the CCG Website http://www.dudleyccg.nhs.uk/publication-scheme-v2/

5.5 Managing Conflicts of Interest: contractors and people who provide services to the Group 5.5.1 Anyone seeking information in relation to a procurement, or participating in a procurement, or

otherwise engaging with the Clinical Commissioning Group in relation to the potential provision of services or facilities to the Group, will be required to make a declaration of any relevant conflict / potential conflict of interest.

5.5.2 Anyone contracted to provide services or facilities directly to the Clinical Commissioning Group will

be subject to the same provisions of this constitution in relation to managing conflicts of interests. This requirement will be set out in the contract for their services.




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5.5.3 Contractors and people who provide services to the Group are required to comply with the Group’s Conflicts of Interest (including Gifts & Hospitality) Policy referred to at 8.4.1.

5.6 Transparency in Procuring Services 5.6.1 The Group recognises the importance in making decisions about the services it procures in a way

that does not call into question the motives behind the procurement decision that has been made. The Group will procure services in a manner that is open, transparent, non-discriminatory and fair to all potential providers.

5.6.2 The Group will publish a Procurement Strategy approved by its Governing Body which will ensure

that:

all relevant clinicians (not just members of the Group) and potential providers, together with local members of the public, are engaged in the decision-making processes used to procure services;

service redesign and procurement processes are conducted in an open, transparent, non-discriminatory and fair way

5.6.3 Copies of this Procurement Strategy will be available on the Group’s website at

http://www.dudleyccg.nhs.uk/publication-scheme-v2/ under ‘What we spend and how we spend it’. 5.7 THE GROUP AS EMPLOYER 5.7.1 The Group recognises that its most valuable asset is its people. It will seek to enhance their skills

and experience and is committed to their development in all ways relevant to the work of the Group. 5.7.2 The Group will seek to set an example of best practice as an employer and is committed to offering

all staff equality of opportunity. It will ensure that its employment practices are designed to promote diversity and to treat all individuals equally.

5.7.3 The Group will ensure that it employs suitably qualified and experienced staff who will discharge

their responsibilities in accordance with the high standards expected of staff employed by the Group. All staff will be made aware of this constitution, the commissioning strategy and the relevant internal management and control systems which relate to their field of work.

5.7.4 The Group will maintain and publish policies and procedures (as appropriate) on the recruitment

and remuneration of staff to ensure it can recruit, retain and develop staff of an appropriate calibre. The Group will also maintain and publish policies on all aspects of human resources management, including grievance and disciplinary matters

5.7.5 The Group will ensure that its rules for recruitment and management of staff provide for the

appointment and advancement on merit on the basis of equal opportunity for all applicants and staff.

5.7.6 The Group will ensure that employees' behaviour reflects the values, aims and principles set out

above. 5.7.7 The Group will ensure that it complies with all aspects of employment law. 5.7.8 The Group will ensure that its employees have access to such expert advice and training

opportunities as they may require to deliver their responsibilities effectively. 5.7.9 The Group will adopt a Code of Conduct for staff and will maintain and promote effective

'whistleblowing' procedures to ensure that concerned staff have means through which their concerns can be voiced. The Group recognises and confirms that nothing in or referred to in this


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constitution (including in relation to the issue of any press release or other public statement or disclosure) will prevent or inhibit the making of any protected disclosure (as defined in the Employment Rights Act 1996, as amended by the Public Interest Disclosure Act 1998) by any member of the Group, any member of its Governing Body, any member of any of its committees or Sub-Committees or the committees or Sub-Committees of its Governing Body, or any employee of the Group or of any of its members, nor will it affect the rights of any worker (as defined in that Act) under that Act.

5.7.10 Copies of this Code of Conduct, together with the other policies and procedures outlined in this

section, will be available at the 7Group’s website http://www.dudleyccg.nhs.uk/publication-scheme-v2/

5.8 TRANSPARENCY, WAYS OF WORKING AND STANDING ORDERS 5.8.1 General

a) The Group will publish annually a commissioning plan and an annual report, presenting the Group’s annual report to a public meeting.

b) Key communications issued by the Group, including the notices of procurements, public

consultations, Governing Body meeting dates, times, venues, and certain papers will be published on the Group’s website at http://www.dudleyccg.nhs.uk/our-board/

c) The Group may use other means of communication, including circulating information by post, or

making information available in venues or services accessible to the public. 5.8.2 Standing Orders

a) This constitution is also informed by a number of documents which provide further details on how the Group will operate. They are the Group’s:

1. Standing orders (Appendix 4 of the CCGs Constitution) – which sets out the arrangements for

meetings and the appointment processes to elect the Group’s representatives and appoint to the Group’s Committees, including the Governing Body;

2. Scheme of reservation and delegation (Section 2 of this Handbook) – which sets out those

decisions that are reserved for the membership as a whole and those decisions that are the responsibilities of the Group’s Governing Body, the Governing Body’s committees and Sub-Committees, the Group’s Committees and Sub-Committees, individual members and employees;

3. Prime financial policies (Appendix 5 of the CCGs Constitution) – which sets out the

arrangements for managing the Group’s financial affairs.

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6.0 DECLARATIONS OF INTEREST 6.1 The CCG is required to make arrangements to ensure that all persons who are members of the

CCG declare any interest, financial or other, which may led to a conflict with the interests of the CCG and the public, for whom they commission services in relation to a decision to be made by the CCG.

6.2 A Declaration of Interest Form is required to be completed in accordance with the CCG’s Constitution and section 140 of the National Health Service Act 2006. This is held on the Declarations of Interest Database.

6.3 The CCG publishes three registers, Governing Body Members, Primary Care Commissioning Committee Members and a Staff register. The register is updated throughout the year and published as a minimum on an annual basis on the CCG website as per the CCG Conflicts of Interest Policy. Quarterly reminders are sent out to all staff reminding them of their obligation to declare and notify the CCG of any changes with 28 days of the change.

6.4 Under the Health and Social Care Act 2012, there is a legal obligation to manage conflicts of interest appropriately. Committee Chairs have a critical role in ensuring that Declarations of Interest are declared at the start of any meeting and management arrangements are adhered to. It is essential that declarations of interest and actions arising from the declarations are recorded formally and consistently across all CCG governing body, committee and sub-committee meetings.

6.5 Following the NHS England Conflicts of Interest Statutory Guidance, conflicts of interest online training has been included as part of the CCGs Mandatory Training Matrix and is carried out on an annual basis by all staff and new starters.

6.6 Our full conflicts of interest policy has been included in Appendix 1 of this handbook.

6.7 The latest declarations of interest register can be found on the CCGs website. www.dudleyccg.nhs.uk


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7.0 COMMITTEE TERMS OF REFERENCE

7.1 The statutory committees’ terms of reference can be found in Appendix 3 of the CCG’s Constitution.

Audit & Governance Committee

Remuneration and HR Committee

Primary Care Commissioning Committee 7.2 The non-statutory committees’ terms of reference can be found Appendix 2 of this Governance

Handbook:



Policy & Commissioning Committee

MCP Procurement Project Board

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APPENDIX 1

CONFLICT OF INTEREST POLICY

(inc Gifts & Hospitality)

UNIQUE REF NUMBER: GB/XX/063/V4.3.1 DOCUMENT STATUS: Approved by Audit & Governance Committee – 12 December 2018 DATE ISSUED: January 2019 DATE TO BE REVIEWED: January 2020

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AMENDMENT HISTORY


V1 February 2013 Policy created

GB/XX/063/V2.0 March 2015 Unique identifier allocated. Amendments to reflect NHS guidance - Managing Conflicts of Interest: Statutory Guidance For CCGs – December 2014

GB/XX/063/V3.0 October 2016 Amendments to reflect NHS England guidance - Managing Conflicts of Interest: Revised Statutory Guidance For CCGs – June 2016 and to reflect the CCGs Declaration of Relationships Policy

GB/XX/063/V4.0 May 2017 Amendments to reflect model policy issued by NHSE in April 2017

GB/XX/063/4.1 June 2017 Further guidance issued by NHSE in relation to New Models of Care. This has been incorporated as Annex 6 and a sentence in section 12.7

GB/XX/063/4.2 March 2018 Refresh in relation to GDPR and also following Audit added Declaration of Interest Checklist and amended Appendices.

GB/XX/063/4.3 December 2018 Amendments to Declaration of Interest Form – Appendix 1

GB/XX/063/4.3.1 Mary 2019 Amendments to confirm review annually. Does not require approval – will be captured in next review.



Paul Capener February 2013 Governance adviser V1

Sue Johnson March 2015 Deputy Chief Finance Officer V2

Sue Johnson October 2016 Deputy Chief Finance Officer V3

Paul Capener October 2016 Governance adviser V3

Emma Smith October 2016 Governance Support Manager V3

Paul Capener November 2016 Governance adviser V3.1

Paul Capener May 2017 Governance adviser V4

Emma Smith June 2017 Governance Support Manager V4.1

Emma Smith March 2018 Governance Support Manager V4.2

Emma Smith December 2018 Governance Support Manager V4.3

APPROVALS This document has been approved by:

VERSION WHERE DATE

V1 Audit Committee 26 Feb 2013

V2 Audit Committee 27 Mar 2015

V2 CCG Extraordinary Board 30 Mar 2015

V3 Audit & Governance Committee 2 Dec 2016

V3 CCG Board 12 Jan 2017

V4 Audit & Governance Committee 23 May 2017

V4.1 CCG Board 13 July 2017

V4.2 Audit & Governance Committee 24 May 2018

V4.3 Audit & Governance Committee 12 December 2018

NB: The version of this policy posted on the intranet must be a PDF copy of the approved version. DOCUMENT STATUS This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of the document are not controlled. RELATED DOCUMENTS

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These documents will provide additional information

Constitution CCG Policy

Declaration of Relationships CCG Policy

Code of Conduct CCG Policy

Gifts and Hospitality CCG Policy

Counter Fraud, Bribery and Corruption CCG Policy

Standards for Business Conduct CCG Policy

Managing Conflicts of Interest: Statutory Guidance For CCGs – December 2014 NHS England

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Contents

POLICY SUMMARY .............................................................................................................. 43

1.0 INTRODUCTION ............................................................................................................. 44

2.0 WHAT ARE CONFLICTS OF INTEREST? .................................................................... 44

3.0 LEGISLATIVE FRAMEWORK ....................................................................................... 46

4.0 PRINCIPLES AND GENERAL SAFEGUARDS ............................................................. 47

5.0 DECLARATION OF INTERESTS .................................................................................. 49

6.0 REGISTERING INTERESTS .......................................................................................... 50

7.0 PROCUREMENT ISSUES .............................................................................................. 51

8.0 GENERAL CONSIDERATIONS AND USE OF THE PROCUREMENT TEMPLATE .. 52

9.0 DESIGNING SERVICE REQUIREMENTS ..................................................................... 52

10.0 APPOINTMENTS AND ROLES AND RESPONSIBILITIES IN THE CCG IN RELATION TO MANAGING CONFLICTS OF INTEREST ...................................................................... 53

11.0 DECISION-MAKING WHEN A CONFLICT OF INTEREST RISES: GENERAL APPROACHES ............................................................................................................... 55

12.0 DECISION-MAKING WHEN A CONFLICT OF INTEREST ARISES: PRIMARY MEDICAL CARE ............................................................................................................................... 56

13.0 MANAGEMENT OF INTERESTS – COMMON SITUATIONS .................................... 57

14.0 RECORD KEEPING AND MINUTE TAKING ................................................................ 61

15.0 IDENTIFYING AND REPORTING BREACHES ........................................................... 61

16.0 REVIEW ......................................................................................................................... 62

APPENDICES ........................................................................................................................ 63

Appendix 1: Declaration of Interests for Members & Employees ................................... 63

Appendix 2: Declarations of Interest Register Template .................................................. 67

Appendix 3: Template declarations of interest checklist ................................................. 68

Appendix 4: Procurement Template ................................................................................... 70

Appendix 5: Register of Procurement Decision Template ............................................... 73

Appendix 6: Register for the receipt of Gifts and provision and receipt of Hospitality 74

Appendix 7: Summary of key aspects of the guidance on managing conflicts of interest relating to commissioning of new care models .......................................................... 75

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POLICY SUMMARY

Adhering to this policy will help to ensure that we use NHS money wisely, providing best value for

taxpayers and accountability to our patients for the decisions we take.

As a member of staff you should… As an organisation we will…

Familiarise yourself with this policy and

follow it. Refer to the guidance for the

rationale behind this policy

https://www.england.nhs.uk/wp-

content/uploads/2017/02/guidance-

managing-conflicts-of-interest-nhs.pdf

Use your common sense and judgement to

consider whether the interests you have

could affect the way taxpayers’ money is

spent

Regularly consider what interests you have

and declare these as they arise. If in doubt,

declare.

NOT misuse your position to further your

own interests or those close to you

NOT be influenced, or give the impression

that you have been influenced by outside

interests

NOT allow outside interests you have to

inappropriately affect the decisions you

make when using taxpayers’ money

Ensure that this policy and supporting

processes are clear and help staff

understand what they need to do.

Identify a team or individual with

responsibility for:

o Keeping this policy under review to

ensure they are in line with the

guidance.

o Providing advice, training and support

for staff on how interests should be

managed.

o Maintaining register(s) of interests.

o Auditing this policy and its associated

processes and procedures at least once

every three years.

NOT avoid managing conflicts of interest.

NOT interpret this policy in a way which

stifles collaboration and innovation with our

partners

https://www.england.nhs.uk/wp-content/uploads/2017/02/guidance-managing-conflicts-of-interest-nhs.pdf



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1.0 INTRODUCTION

1.1 All Clinical Commissioning Groups (CCGs) manage conflicts of interest as part of their day to day activities. Effective handling of such conflicts is crucial for the maintenance of public trust in the commissioning system. Importantly, it also serves to give confidence to patients, providers, Parliament and tax-payers that CCG commissioning decisions are robust, fair, transparent and offer value for money.

1.2 This policy reflects

the seven principles of public life promulgated by the Nolan Committee

The Good Governance Standards of Public Services

The seven key principles of the NHS Constitution and

The Equality Act 2010.

1.3 The aims of this policy are to:

enable the CCG and clinicians in commissioning roles to demonstrate that they are acting fairly and transparently and in the best interest of their patients and local populations;

ensure that the CCG operates within the legal framework and its constitution, but without being bound by over-prescriptive rules that risk stifling innovation;

safeguard clinically led commissioning, whilst ensuring objective investment decisions;

provide the public, providers, Parliament and regulators with confidence in the probity, integrity and fairness of commissioners’ decisions; and

uphold the confidence and trust between patients and GP, in the recognition that individual commissioners want to behave ethically but may need support and training to understand when conflicts (whether actual or potential) may arise and how to manage them if they do.

1.4 The policy incorporates the safeguards for the management of conflicts of interest set out in NHS

England statutory guidance, including:

the nature of conflicts of interest;

arrangements for declaring interests;

maintaining a register of interests;

keeping a record of the steps taken to manage a conflict;

excluding individuals from decision-making where a conflict arises; and

engagement with a range of potential providers on service design.

1.5 In addition, it sets out:

the additional factors that the CCG must address when commissioning primary medical care services under delegated commissioning arrangements.

the steps that CCG will take to assure the Audit Committee, Health and Wellbeing Board, NHS England and, where necessary, their auditors, that these services are appropriately commissioned from GP practices;

procedures for decision-making in cases where all the GPs (or other practice representatives) sitting on a decision-making group have a potential financial interest in the decision;

arrangements for publishing details of payments to GP practices;

the potential role of commissioning support services; and

the supporting role of NHS England.

2.0 WHAT ARE CONFLICTS OF INTEREST? 2.1 A conflict of interest occurs where an individual’s ability to exercise judgement, or act in a role, is

or could be impaired or otherwise influenced by his or her involvement in another role or relationship. The individual does not need to exploit his or her position or obtain an actual benefit, financial or otherwise, for a conflict of interest to occur.

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“For the purposes of Regulation 6 [National Health Service (Procurement, Patient

Choice and Competition) (No.2) Regulations 20131], a conflict will arise where an

individual’s ability to exercise judgement or act in their role in the commissioning of services is impaired or influenced by their interests in the provision of those services.”

Monitor - Substantive guidance on the Procurement, Patient Choice and Competition Regulations (December 2013)

The CCG uses the following description to define conflicts of interest:

2.2 For the purposes of this policy we describe conflicts of interest as taking one of the following forms:

i. Financial interests: This is where an individual may get direct financial benefits from the consequences of a commissioning decision. This could, for example, include being:

A director, including a non-executive director, or senior employee in a private company or public limited company or other organisation which is doing, or which is likely, or possibly seeking to do, business with health or social care organisations.

A shareholder (or similar ownership interests), a partner or owner of a private or not-for-profit company, business, partnership or consultancy which is doing, or which is likely, or possibly seeking to do, business with health or social care organisations.

A management consultant for a provider. This could also include an individual being:

In secondary employment

In receipt of secondary income from a provider

In receipt of a grant from a provider

In receipt of any payments (for example honoraria, one-off payments, day allowances or travel or subsistence) from a provider;

In receipt of research funding, including grants that may be received by the individual or any organisation in which they have an interest or role; and

Having a pension that is funded by a provider (where the value of this might be affected by the success or failure of the provider).

“A set of circumstances by which a reasonable person would consider that an individual’s ability to apply judgement or act, in the context of delivering, commissioning, or assuring taxpayer funded health and care services is, or could be, impaired or influenced by another interest they hold. Such a conflict may be:

Potential – i.e. there is the possibility of a conflict between the two interests in the future

Actual - i.e. there is a relevant and material conflict between the two interests now

Perceived – i.e. an observer could reasonably suspect there to be a conflict of interest regardless of whether there is one or not. Conflicts can occur with interests held by the individual or their close family members (*), significant other (#), and business partners (dependent on the circumstances and the nature of such relationships)” * ’Family member’ refers to a spouse, civil partner, or partner living in the same residence as the individual, as well as siblings, grandparents, children and adults (who may or may not be living in the same residence) for whom the individual is legally responsible, (for example, an adult whose full power of attorney is held by the individual) #’significant other’ refers to romantic or sexual relationships

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ii. Non-financial professional interests: This is where an individual may obtain a non-financial professional benefit from the consequences of a commissioning decision, such as increasing their professional reputation or status or promoting their professional career. This may, for example, include situations where the individual is:

An advocate for a particular group of patients;

A member of a particular specialist professional body (although routine GP membership of the RCGP, British Medical Association (BMA) or a medical defence organisation would not usually by itself amount to an interest which needed to be declared);

An advisor for the Care Quality Commission (CQC) or the National Institute for Health and Care Excellence (NICE);

A medical researcher. GPs and practice managers, who are members of the governing body or committees of the CCG, should declare details of their roles and responsibilities held within their GP practices. iii. Non-financial personal interests: This is where an individual may benefit personally in ways which are not directly linked to their professional career and do not give rise to a direct financial benefit. This could include, for example, where the individual is:

A voluntary sector champion for a provider;

A volunteer for a provider;

A member of a voluntary sector board or has any other position of authority in or connection with a voluntary sector organisation;

Suffering from a particular condition requiring individually funded treatment;

A member of a lobby or pressure group with an interest in health. iv. Indirect interests: This is where an individual has a close association with an individual who has a financial interest, a non-financial professional interest or a non-financial personal interest in a commissioning decision (as those categories are described above) for example, a:

Spouse / partner

Close relative e.g., parent, grandparent, child, grandchild or sibling;

Close friend;

Significant other;

Business partner. A declaration of interest for a “business partner” in a GP partnership should include all relevant collective interests of the partnership, and all interests of their fellow GP partners (which can be done by cross referring to the separate declarations made by those GP partners, rather than by repeating the same information verbatim).

2.3 It is the aim of Dudley CCG to create an environment where people feel able to voluntarily

disclose relationships through its declaration process, including those which may be of a sensitive nature such as romantic or sexual relationships. Therefore, staff are encouraged to disclose relationships at the earliest opportunity, when a close personal relationship develops (either within the CCG or external organisations/agencies who have involvement with Dudley CCG) and where a conflict of interest could arise. To this end, the CCG has implemented a Declaration of Relationships Policy, which should be read in conjunction with this Conflict of Interest Policy.

3.0 LEGISLATIVE FRAMEWORK 3.1 The starting point is section 14O of the Act. This sets out the minimum requirements in terms of

what both NHS England and CCGs must do in terms of managing conflicts of interest. For all CCGs, this means that they must:

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Maintain appropriate registers of interests; Publish or make arrangements for the public to access those registers;

Make arrangements requiring the prompt declaration of interests by the persons specified (members and employees) and ensure that these interests are entered into the relevant register;

Make arrangements for managing conflicts and potential conflicts of interest (e.g. developing appropriate policies and procedures); and

Have regard to guidance published by NHS England and Monitor in relation to conflicts of interest.

3.2 Section 14O is supplemented by the procurement specific requirements set out in the National Health Service (Procurement, Patient Choice and Competition) (No.2) Regulations 2013. In particular, regulation 6 requires the following:

The CCG must not award a contract for the provision of NHS health care services where conflicts, or potential conflicts, between the interests involved in commissioning such services and the interests involved in providing them affect, or appear to affect, the integrity of the award of that contract; and

The CCG must keep a record of how it managed any such conflict in relation to NHS commissioning contracts it enters into. (As set out below, details of this should also be published by the CCG.)

3.3 An interest is defined for the purposes of regulation 6 as including an interest of the following:

a member of the CCG;

a member of the CCG’s Board;

a member of its committees or sub-committees;

an employee or

a contractor of services (sub-contractor)

3.4 As with section 14O, regulation 6 sets out the basic framework within which the CCG must operate.

The detailed requirements are set out in the guidance issued by Monitor (Substantive guidance on

the Procurement, Patient Choice and Competition Regulations) and, in particular, section 7 of that

statutory guidance. 3.5 Monitor’s view is that care must be taken to ensure that conflicts do not affect, or appear to affect,

the integrity of the award of commissioning contracts. It is important to ensure that the management

of conflicts of interest includes the management of perceived conflicts and that there is an

appropriate record of how such issues are managed, particularly in the context of specific

procurement decisions. Please see below for further guidance on how such information should be

recorded and published. Clear and robust decision making processes must be put in place to deliver

co-commissioning and give the public and providers’ confidence in the integrity of the decisions

made.

3.6 This Policy is also designed to ensure that the CCG meets its requirements in relation to the NHS

England publication “Managing Conflicts of Interest: Revised Statutory Guidance for CCGs (28

June 2016)” and "Managing Conflicts of Interest in the NHS - Guidance for staff and organisations

(February 2017)"

4.0 PRINCIPLES AND GENERAL SAFEGUARDS 4.1 The general safeguards that will be needed to manage conflicts of interest will vary to some extent,

depending on at what stage in the commissioning cycle decisions are being made. The following

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principles will be integral to the CCG’s commissioning of all services, including decisions on whether to continue to commission a service, such as by contact extension.

4.2 Conflicts of interest can be managed by:

Doing business appropriately. If commissioners get their needs assessments, consultation mechanisms, commissioning strategies and procurement procedures right from the outset, then conflicts of interest become much easier to identify, avoid and/or manage, because the rationale for all decision-making will be clear and transparent and should withstand scrutiny;

Being proactive, not reactive. Commissioners should seek to identify and minimise the risk of conflicts of interest at the earliest possible opportunity, for instance by:

considering potential conflicts of interest when electing or selecting individuals to join the governing body or other decision-making bodies;

ensuring individuals receive proper induction and training so that they understand their obligations to declare conflicts of interest.

They should establish and maintain registers of interests, and agree in advance how a range of possible situations and scenarios will be handled, rather than waiting until they arise.

Assuming that individuals will seek to act ethically and professionally, but may not always be sensitive to all conflicts of interest. Rules should assume people will volunteer information about conflicts and, where necessary, exclude themselves from decision- making, but there should also be prompts and checks to reinforce this;

Being balanced and proportionate. Rules should be clear and robust but not overly prescriptive or restrictive. They should ensure that decision- making is transparent and fair, but not constrain people by making it overly complex or cumbersome;

Openness. Ensuring early engagement with patients, the public, clinicians and other stakeholders, including local Healthwatch and Health and Wellbeing Board, in relation to proposed commissioning plans;

Responsiveness and best practice. Ensuring that commissioning intentions are based on local health needs and reflect evidence of best practice – securing ‘buy in’ from local stakeholders to the clinical case for change;

Transparency. Documenting clearly the approach taken at every stage in the commissioning cycle so that a clear audit trail is evident;

Securing expert advice. Ensuring that plans take into account advice from appropriate health and social care professionals, e.g. through clinical senates and networks, and draw on commissioning support, for instance around formal consultations and for procurement processes;

Engaging with providers. Early engagement with both incumbent and potential new providers over potential changes to the services commissioned for a local population;

Creating clear and transparent commissioning specifications that reflect the depth of engagement and set out the basis on which any contract will be awarded;

Following proper procurement processes and legal arrangements, including even-handed approaches to providers;

Ensuring sound record-keeping, including up to date registers of interests and procurement decisions; and

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A clear, recognised and easily enacted system for dispute resolution.

4.3 These general processes and safeguards should apply at all stages of the commissioning process, but will be particularly important at key decision points, e.g., whether and how to go out to procurement of new or additional services.

5.0 DECLARATION OF INTERESTS

5.1 All persons referred to in paragraph 6.1 (Register of Interests) must declare any interests. Declarations of interest should be made as soon as reasonably practicable and by law within 28 days after the interest arises.

5.2 The CCG will ensure that, as a matter of course, declarations of interest are made and regularly

confirmed or updated. This includes the following circumstances:

On appointment:

Applicants for any appointment to the CCG or its governing body or any committees will be asked to declare any relevant interests. When an appointment is made, a formal declaration of interests will again be made and recorded.

At meetings:

All attendees are required to declare any interest they have in any agenda item before it is discussed or as soon as it becomes apparent. Even if an interest is declared in the register of interests, it should still be declared in meetings where matters relating to that interest are discussed. Declarations of interest will be recorded in minutes of meetings.

Quarterly:

The CCG has a system in place to satisfy themselves on a quarterly basis that their register of interests is accurate and up to date.

On changing role or responsibility:

Where an individual changes role or responsibility within the CCG or its governing body, any change to the individual’s interests should be declared.

On any other change of circumstances:

Wherever an individual’s circumstances change in a way that affects the individual’s interests (e.g. where an individual takes on a new role outside the CCG or sets up a new business or relationship), a further declaration should be made to reflect the change in circumstances. This could involve a conflict of interest ceasing to exist or a new one materialising.

5.4 In keeping with the regulations, individuals who have a conflict should declare this as soon as

they become aware of it, and in any event not later than 28 days after becoming aware.

5.5 Whenever interests are declared, they should be reported to the Governance Support Manager,

who will then update the register accordingly.

Statutory requirements The CCG must make arrangements to ensure individuals declare any conflict or potential conflict in relation to a decision to be made by the group as soon as they become aware of it, and in any event within 28 days. CCGs must record the interest in the registers as soon as they become aware of it.

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See Annex 1 for Declaration of Interest Template.

6.0 REGISTERING INTERESTS

6.1 The CCG will maintain registers of interest (in the form shown at Annex 2) for:

All CCG employees, including:

o All full and part time staff; o Any staff on sessional or short term contracts; o Any students and trainees (including apprentices); o Agency staff; and o Seconded staff

In addition, any self-employed consultants or other individuals working for the CCG under a contract for services should make a declaration of interest in accordance with this guidance, as if they were CCG employees.

Members of the governing body: All members of the CCG’s committees, sub-committees / sub-groups, including:

o Co-opted members; o Appointed deputies; and o Any members of committees/groups from other organisations.

Where the CCG is participating in a joint committee alongside other CCGs, any interests which are declared by the committee members should be recorded on the register(s) of interest of each participating CCG.

All members of the CCG (i.e., each practice) This includes each provider of primary medical services which is a member of the CCG under Section 14O (1) of the 2006 Act. Declarations should be made by the following groups:

o GP partners (or where the practice is a company, each director); o Any individual directly involved with the business or decision-making of the CCG.

6.2 All interests declared must be promptly transferred to the relevant CCG register. An interest will

remain on the public register for a minimum of 6 months after the interest has expired. In addition, the CCG must retain a private record of historic interests for a minimum of 6 years after the date on which it expired. The CCG’s published register of interests will state that

Note: Monitoring compliance with this policy will be considered as part of any legal or professional body investigation. Failure to declare an interest where this policy deems it to be appropriate may result in the board member being removed from office in line with the CCG’s Constitution. Failure to comply with this policy will be addressed under the disciplinary processes of the CCG, or otherwise as set out in the CCG’s Standing Orders for Members of the Governing Body.

Statutory requirements The CCG must maintain one or more registers of interest of: the members of the group, members of its governing body, members of its committees or sub-committees of its governing body, and its employees. The CCG must publish, and make arrangements to ensure that members of the public have access to these registers on request.

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historic interests are retained by the CCG for 6 years and this information can be requested from the Governance Support Manager

6.3 The CCG will also maintain a register of procurement decisions taken (in the form provided at

Annex 4), including:

the details of the decision;

who was involved in making the decision (i.e. governing body or committee members and others with decision-making responsibility); and

a summary of any conflicts of interest in relation to the decision and how this was

managed by the CCG. 6.4 The register will be updated whenever a procurement decision is taken.

6.5 In the interests of transparency, the register of interests and the register of decisions will be publicly available and easily accessible to patients and the public including by ensuring that both registers are available in a prominent place on the CCG’s website; and making both registers available upon request for inspection at the CCG headquarters. Individuals without internet access will be invited to view the register(s) at the CCG’s headquarters.

6.6 In exceptional circumstances, where the public disclosure of information could give rise to a real

risk of harm or is prohibited by law, an individual’s name and/or other information may be redacted from the publicly available register(s). Where an individual believes that substantial damage or distress may be caused, to him/herself or somebody else by the publication of information about them, they are entitled to request that the information is not published. Such requests must be made in writing. Decisions not to publish information must be made by the Conflicts of Interest Guardian for the CCG, who should seek appropriate legal advice where required, and the CCG should retain a confidential un-redacted version of the register(s).

6.7 All persons who are required to make a declaration of interest(s) or a declaration of gifts or

hospitality will be made aware that the register(s) will be published in advance of publication. This will be done by the provision of a fair processing notice that details the identity of the data controller, the purposes for which the registers are held and published, and contact details for the data protection officer. This information will additionally be provided to individuals identified in the registers because they are in a relationship with the person making the declaration.

6.8 The registers must be published as part of the CCG’s annual report and annual governance

statement. This will be done using a web link to the registers

7.0 PROCUREMENT ISSUES

7.1 The NHS Act, the Health and Social Care Act (“the HSCA”) and associated regulations set out the statutory rules with which commissioners are required to comply when procuring and contracting for the provision of clinical services. They need to be considered alongside the Public

Contract Regulations2

and, where appropriate, EU procurement rules. Monitor's Substantive guidance on the Procurement, Patient Choice and Competition Regulations advises that the requirements within these create a framework for decision making that will assist commissioners to comply with a range of other relevant legislative requirements.

7.2 The Procurement, Patient Choice and Competition Regulations place requirements on

commissioners to ensure that they adhere to good practice in relation to procurement, do not engage in anti-competitive behaviour that is against the interest of patients, and protect the right of patients to make choices about their healthcare.

7.3 The regulations set out that commissioners must:

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manage conflicts and potential conflicts of interests when awarding a contract by prohibiting

the award of a contract where the integrity of the award has been, or appears to have been, affected by a conflict; and

keep appropriate records of how they have managed any conflicts in individual cases. 7.4 Commissioning support services (CSSs) can play an important role in helping the CCG to decide

the most appropriate procurement route, undertake procurements and manage contracts in ways that manage conflicts of interest and preserve integrity of decision-making. The CCG receives appropriate assurance that a CSS’ business processes are robust and enable the CCG to meet its duties in relation to procurement (including those relating to the management of conflicts of interest).

7.5 Where a CCG is undertaking procurement, one way to demonstrate that the CCG is acting fairly and transparently is for the CSSs to prepare and present information on bids, including an assessment of whether providers meet prequalifying criteria and an assessment of which provider provides best value for money.

7.6 A CCG cannot, however, lawfully delegate commissioning decisions to an external provider of commissioning support. Although CSSs are likely to play a key role in helping to develop specifications, preparing tender documentation, inviting expressions of interest and inviting tenders, the CCG itself:

determines and signs off the specification and evaluation criteria;

decides and signs off decisions on which providers to invite to tender; and

makes final decisions on the selection of the provider.

8.0 GENERAL CONSIDERATIONS AND USE OF THE PROCUREMENT TEMPLATE

8.1 The most obvious area in which conflicts could arise is where a CCG commissions (or continues to commission by contract extension) healthcare services, including GP services, in which a member of the CCG has a financial or other interest. This may most often arise in the context of co- commissioning of primary care, particularly with regard to delegated or joint arrangements, but may also arise in respect of any commissioning issue where GPs are current or possible providers. The CCG will use the procurement template at Annex 3 when drawing up commissioning plans for services where this potentially is the case.

8.2 The CCG will make evidence of its deliberations on conflicts publicly available. The template

evidences this and supports CCGs in fulfilling their duty in relation to public involvement. It

provides appropriate assurance:

that the CCG is seeking and encouraging scrutiny of its decision-making process;

to Health and Wellbeing Board, local Healthwatch and to local communities that the proposed service meets local needs and priorities; it will enable them to raise questions if they have concerns about the approach being taken;

to the Audit & Governance Committee and, where necessary, external auditors, that a robust process has been followed in deciding to commission the service, in selecting the appropriate procurement route, and in addressing potential conflicts; and

to NHS England in their role as assurers of the co-commissioning arrangements.

9.0 DESIGNING SERVICE REQUIREMENTS

9.1 It is good practice to engage relevant providers, especially clinicians, in confirming that the design of service specifications will meet patient need. Such engagement, done transparently and fairly,

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is entirely legal. However, conflicts of interest can occur if a commissioner engages selectively with only certain providers (be they incumbent or potential new providers) in developing a service specification for a contract for which they may later bid.

9.2 The CCG will seek, as far as possible, to specify the outcomes that it wishes to see delivered

through a new service, rather than the process by which these outcomes are to be achieved. As well as supporting innovation, this helps prevent bias towards particular providers in the specification of services.

9.3 Such engagement should follow the three main principles of procurement law, namely equal

treatment, non-discrimination and transparency. This includes ensuring that the same information is given to all.

9.4 Other steps include:

advertise the fact that a service design/re-design exercise is taking place widely and invite comments from any potential providers and other interested parties (ensuring a record is kept of all interactions);

as the service design develops, engage with a wide range of providers on an ongoing basis to seek comments on the proposed design, e.g. via the commissioner’s website or via workshops with interested parties;

use engagement to help shape the requirement to meet patient need but take care not to gear the requirement in favour of any particular provider(s);

if appropriate, engage the advice of an independent clinical adviser on the design of the service;

be transparent about procedures;

ensure at all stages that potential providers are aware of how the service will be

commissioned;

maintain commercial confidentiality of information received from providers. 9.5 When engaging providers on service design, the CCG has ultimate responsibility for service

design and for selecting the provider of services. Monitor has issued guidance on the use of provider boards in service design.

9.6 The CCG will also ensure that it has systems in place for managing conflicts of interest on an

ongoing basis, by monitoring a contract that has been awarded to a provider in which an individual commissioner has a vested interest.

10.0 APPOINTMENTS AND ROLES AND RESPONSIBILITIES IN THE CCG IN RELATION TO

MANAGING CONFLICTS OF INTEREST

10.1 The CCG has arrangements for managing conflicts of interest, and potential conflicts of interest,

in such a way as to ensure that they do not, and do not appear to, affect the integrity of its

decision-making. 10.1 The CCG has reviewed its governance structures for managing conflicts of interest to ensure that

they reflect current guidance and are appropriate, particularly in relation to co-commissioning. This has entailed consideration of the following:

the make-up of its governing body and committee structures (including, where relevant, the approach set out below for decision-making in delegated commissioning of primary care);

whether there are sufficient management and internal controls to detect breaches of the CCG’s conflicts of interest policy, including appropriate external oversight and adequate provision for whistleblowing;

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how non-compliance with policies and procedures relating to conflicts of interest will be managed (including how this will be addressed when it relates to contracts already entered into). As well as actions to address non-compliance, the CCG has procedures in place to review any lessons to be learned from such cases, by the CCG’s Audit Committee conducting an incident review;

reviewing and revising approaches to the CCG’s registers of interest, together with the

introduction of a record of decisions, as set out above;

Whether any training or other programmes are required to assist with compliance, including

participation in training offered by NHS England.

SECONDARY EMPLOYMENT 10.3 The CCG will take all reasonable steps to ensure that employees, committee members,

contractors and others engaged under contract with them are aware of the requirement to inform the CCG if they are employed or engaged in, or wish to be employed or engage in, any employment or consultancy work in addition to their work with the CCG. The purpose of this is to ensure that the CCG is aware of any potential conflict of interest. Examples of work which might conflict with the business of the CCG, including part-time, temporary and fixed term contract work, include:

Employment with another NHS body;

Employment with another organisation which might be in a position to supply goods/services to the CCG;

Directorship of a GP federation; and

Self-employment, including private practice, in a capacity which might conflict with the work of the CCG or which might be in a position to supply goods/services to the CCG.

10.4 The CCG requires that individuals obtain prior permission to engage in secondary

employment, and reserve the right to refuse permission where it believes a conflict will arise which cannot be effectively managed. In particular, it is unacceptable for pharmacy advisers or other advisers, employees or consultants to the CCG on matters of procurement to themselves be in receipt of payments from the pharmaceutical or devices sector.

APPOINTING GOVERNING BODY OR COMMITTEE MEMBERS AND SENIOR MANAGERS

10.5 The CCG considers on a case by case basis whether conflicts of interest should exclude individuals from being appointed to the governing body or to a committee or sub-committee of the CCG or governing body, as set out in the CCG’s Constitution.

10.6 This includes an assessment of the materiality of the interest, in particular whether the individual

(or a family member or business partner) could benefit from any decision the governing body might make. This will be particularly relevant for any profit sharing member of any organisation but will also be considered for all employees and especially those operating at senior or governing body level.

10.7 The extent of the interest also forms part of this consideration process. If it is related to an area of business significant enough that the individual would be unable to make a full and proper contribution to the governing body, that individual cannot become a member of the governing body.

10.8 Any individual who has a material interest in an organisation which provides, or is likely to provide,

substantial services to the CCG (either as a provider of healthcare or commissioning support

services) cannot be a member of the governing body if the nature of their interest is such that

they are likely to need to exclude themselves from decision-making on so regular a basis that it

significantly limits their ability to effectively operate as a governing body member. Specific

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considerations in relation to delegated commissioning of primary care are set out below in section

12.

ROLE OF THE CCG CONFLICTS OF INTEREST GUARDIAN

10.9 The CCG is required to appoint the Chair of the Audit Committee as its Conflict of Interest

Guardian. This person will, in collaboration with the CCG Governance Support Manager:

Act as a conduit for GP practice staff, members of the public and healthcare professionals who have any concerns with regards to conflicts of interest;

Be a safe point of contact for employees or workers of the CCG to raise any concerns in relation to this policy;

Support the rigorous application of conflict of interest principles and policies;

Provide independent advice and judgment where there is any doubt about how to apply conflicts of interest policies and principles in an individual situation;

Provide advice on minimising the risks of conflicts of interest.

ROLE OF THE PRIMARY CARE COMMISSIONING CHAIR

10.10 The Chair of the Primary Care Commissioning Committee has a significant role in ensuring the potential and actual conflicts of interest are appropriately managed within meetings, and any business conducted by its sub-committees and/or sub-groups. This is reflected in section 12 of this policy in relation to the way this committee must conduct its business to safeguard against any interests.

11.0 DECISION-MAKING WHEN A CONFLICT OF INTEREST RISES: GENERAL APPROACHES

11.1 Where certain members of a decision-making body (be it the governing body, its committees or sub-committees, or a committee or sub-committee of the CCG) have a material interest, they should either be excluded from relevant parts of meetings, or join in the discussion but not participate in the decision making itself (i.e., not have a vote).

11.2 The chair of the meeting has responsibility for deciding whether there is a conflict of interest and

the appropriate course of corresponding action. In making such decisions, the chair will consult

the member of the governing body who has responsibility for issues relating to conflicts of interest.

All decisions, and details of how any conflict of interest issue has been managed, should be

recorded in the minutes of the meeting and published in the registers. 11.3 The CCG will to decide in advance who will take the chair’s role for discussions and decision-

making in the event that the chair of a meeting is conflicted, or how that will be decided at a meeting where that situation arises.

11.4 Depending on the nature of the conflict, GPs or other practice representatives could be permitted

to join in discussions by the governing body, or such other decision-making body as the CCG has created, about the proposed decision, but should not take part in any vote on the decision.

11.5 In many cases, e.g., where a limited number of GPs have an interest, it is straightforward for

relevant individuals to be excluded from decision making. In the context of delegated commissioning, the committee structure set out below in relation to decision making for primary medical care has been designed to ensure that lay member and executive involvement ensures that robust decisions can be taken even where there are actual or potential conflicts of interest identified.

11.6 In some cases, all of the GPs or other practice representatives on a decision making body could

have a material interest in a decision, e.g., where the CCG is proposing to commission services on a direct award basis from all GP practices in the area, or where it is likely that all or most practices would wish to be qualified providers for a service under AQP. Where such a situation

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relates to primary medical services, the arrangements set out below provide a mechanism for decision-making.

11.7 For decision making where such a conflict arises and which are not covered by the primary

medical care arrangements, the CCG adopts the following approach:

where the initial responsibility for the decision does not rest with the governing body, refer the decision to the governing body and exclude all GPs or other practice representatives with an interest from the decision making process, i.e., so that the decision is made only by the non-GP members of the governing body including the lay and executive members and the registered nurse and secondary care doctor;

where the decision rests with the governing body, consider

a) requiring another of the Group’s committees or sub-committees, which can be quorate

to progress the item of business, or if this is not possible,

b) Inviting on a temporary basis one or more of the following to make up the quorum (where these are permitted members of the Governing Body or committee/sub-committee in question) so that the Group can progress the item of business:

i) A member of the Group who is an individual

ii) An individual appointed by a member to act on its behalf in the dealings between

it and the Group:

iii) A member of a relevant Health and Wellbeing Board

iv) A member of a Governing Body of another clinical commissioning group.

ensure that rules on quoracy enable decisions to be made. These arrangements must be recorded in the minutes.

11.8 Specific issues and potential approaches in relation to delegated or joint commissioning of

primary care are set out below.

12.0 DECISION-MAKING WHEN A CONFLICT OF INTEREST ARISES: PRIMARY MEDICAL

CARE

12.1 Procurement decisions relating to the commissioning of primary medical services will be made by a committee of the CCG’s governing body.

12.2 The membership of the committee has been constituted so as to ensure that the majority is held

by lay and executive members, including non-GP clinical representatives (ie the CCG’s secondary care specialist and Governing Body Nurse Lead).

12.3 Any conflicts of interest issues will be considered on an individual basis. The specific composition is included in the terms of reference, and these ensure that the chair and vice-chair must always be lay members of the committee.

12.4 A standing invitation will be made to the CCG’s local Healthwatch and Health and Wellbeing

Board to appoint representatives to attend commissioning committee meetings, including, where

appropriate, for items where the public is excluded from a particular item or meeting for reasons

of confidentiality. These representatives do not form part of the membership of the committee.

12.5 As a general rule, meetings of these committees, including the decision making and the deliberations leading up to the decision, will be held in public (unless the CCG has concluded it is appropriate to exclude the public).

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12.6 The arrangements for primary medical care decision making do not preclude GP participation in strategic discussions on primary care issues, subject to appropriate management of conflicts of interest. They apply to decision making on procurement issues and the deliberations leading up to the decision.

12.7 The CCG is committed to ensuring that potential and/or actual conflicts of interest are properly

managed as it considers new models of care. As such, the CCG will adopt the principles described within Annex K of NHS England's revised statutory guidance for managing conflicts of interest as published in June 2017, and reproduced as Annex 6 of this Policy.

13.0 MANAGEMENT OF INTERESTS – COMMON SITUATIONS

13.1 This section sets out the principles and rules to be adopted by staff in common situations, and

what information should be declared.

13.2 Gifts • Staff should not accept gifts that may affect, or be seen to affect, their professional

judgement.

Gifts from suppliers or contractors: • Gifts from suppliers or contractors doing business (or likely to do business) with the CCG

should be declined, whatever their value. • Low cost branded promotional aids such as pens or post-it notes may, however, be

accepted where they are under the value of £612 in total, and need not be declared. Gifts from other sources (e.g. patients, families, service users):

• Gifts of cash and vouchers to individuals should always be declined. • Staff should not ask for any gifts. • Gifts valued at over £50 should be treated with caution and where possible declined. In

exceptional circumstances these can only be accepted on behalf of Dudley CCG not in a personal capacity. These should be declared by staff.

• Modest gifts accepted under a value of £50 do not need to be declared. • A common sense approach should be applied to the valuing of gifts (using an actual amount,

if known, or an estimate that a reasonable person would make as to its value). • Multiple gifts from the same source over a 12 month period should be treated in the same

way as single gifts over £50 where the cumulative value exceeds £50. What should be declared

• Staff name and their role with the CCG. • A description of the nature and value of the gift, including its source. • Date of receipt. • Any other relevant information (e.g. circumstances surrounding the gift, action taken to

mitigate against a conflict, details of any approvals given to depart from the terms of this policy).

• Gifts that are offered but declined and the reason for declining 13.3 Hospitality

• Staff should not ask for or accept hospitality that may affect, or be seen to affect, their professional judgement.

• Hospitality must only be accepted when there is a legitimate business reason and it is proportionate to the nature and purpose of the event.

12 The £6 value has been selected with reference to existing industry guidance issued by the ABPI:

http://www.pmcpa.org.uk/thecode/Pages/default.aspx


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• Particular caution should be exercised when hospitality is offered by actual or potential suppliers or contractors. This can be accepted, and must be declared, if modest and reasonable. Senior approval must be obtained.

Meals and refreshments:

• Under a value of £25 - may be accepted and need not be declared. • Of a value between £25 and £7513 - may be accepted and must be declared. • Over a value of £75 - should be refused unless (in exceptional circumstances) senior

approval is given. A clear reason should be recorded on the CCG’s register(s) of interest as to why it was permissible to accept.

• A common sense approach should be applied to the valuing of meals and refreshments (using an actual amount, if known, or a reasonable estimate).

Travel and accommodation:

• Modest offers to pay some or all of the travel and accommodation costs related to attendance at events may be accepted and must be declared.

• Offers which go beyond modest, or are of a type that the CCG itself might not usually offer, need approval by senior staff, should only be accepted in exceptional circumstances, and must be declared. A clear reason should be recorded on the CCG’s register(s) of interest as to why it was permissible to accept travel and accommodation of this type. A non-exhaustive list of examples includes:

• offers of business class or first class travel and accommodation (including domestic travel) • offers of foreign travel and accommodation.

What should be declared

• Staff name and their role with the CCG. • The nature and value of the hospitality including the circumstances. • Date of receipt. • Any other relevant information (e.g. action taken to mitigate against a conflict, details of any

approvals given to depart from the terms of this policy). • Hospitality that is offered but declined and the reason for declining

A gifts and hospitality register will be maintained in the format shown in Annex 5. 13.4 Outside Employment

• Staff should declare any existing outside employment on appointment and any new outside employment when it arises.

• Where a risk of conflict of interest arises, the general management actions outlined in this policy should be considered and applied to mitigate risks.

• Where contracts of employment or terms and conditions of engagement permit, staff may be required to seek prior approval from the organisation to engage in outside employment.


• Staff name and their role with the CCG. • The nature of the outside employment (e.g. who it is with, a description of duties, time

commitment). • Relevant dates. • Other relevant information (e.g. action taken to mitigate against a conflict, details of any

approvals given to depart from the terms of this policy). 13.5 Shareholdings and other ownership issues

• Staff should declare, as a minimum, any shareholdings and other ownership interests in any publicly listed, private or not-for-profit company, business, partnership or consultancy which is doing, or might be reasonably expected to do, business with the CCG.

13 The £75 value has been selected with reference to existing industry guidance issued by the ABPI



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• Where shareholdings or other ownership interests are declared and give rise to risk of conflicts of interest then the general management actions outlined in this policy should be considered and applied to mitigate risks.

• There is no need to declare shares or securities held in collective investment or pension funds or units of authorised unit trusts.


• Staff name and their role with the CCG. • Nature of the shareholdings/other ownership interest. • Relevant dates. • Other relevant information (e.g. action taken to mitigate against a conflict, details of any

approvals given to depart from the terms of this policy). 13.6 Patents

• Staff should declare patents and other intellectual property rights they hold (either individually, or by virtue of their association with a commercial or other organisation), including where applications to protect have started or are ongoing, which are, or might be reasonably expected to be, related to items to be procured or used by the CCG.

• Staff should seek prior permission from the CCG before entering into any agreement with bodies regarding product development, research, work on pathways etc, where this impacts on the organisation’s own time, or uses its equipment, resources or intellectual property.

• Where holding of patents and other intellectual property rights give rise to a conflict of interest then the general management actions outlined in this policy should be considered and applied to mitigate risks.


• Staff name and their role with the CCG. • A description of the patent. • Relevant dates. • Other relevant information (e.g. action taken to mitigate against a conflict, details of any

approvals given to depart from the terms of this policy) 13.7 Loyalty interests

• Loyalty interests should be declared by staff involved in decision making where they: • Hold a position of authority in another NHS organisation or commercial, charity, voluntary,

professional, statutory or other body which could be seen to influence decisions they take in their NHS role.

• Sit on advisory groups or other paid or unpaid decision making forums that can influence how the CCG spends taxpayers’ money.

• Are, or could be, involved in the recruitment or management of close family members and relatives, close friends and associates, and business partners.

• Are aware that the CCG does business with an organisation in which close family members and relatives, close friends and associates, and business partners have decision making responsibilities.


• Staff name and their role with the CCG. • Nature of the loyalty interest. • Relevant dates. • Other relevant information (e.g. action taken to mitigate against a conflict, details of any

approvals given to depart from the terms of this policy). 13.8 Sponsored events

• Sponsorship of events by appropriate external bodies will only be approved if a reasonable person would conclude that the event will result in clear benefit the CCG and the NHS.

• During dealings with sponsors there must be no breach of patient or individual confidentiality or data protection rules and legislation.

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• No information should be supplied to the sponsor from whom they could gain a commercial advantage, and information which is not in the public domain should not normally be supplied.

• At the CCG’s discretion, sponsors or their representatives may attend or take part in the event but they should not have a dominant influence over the content or the main purpose of the event.

• The involvement of a sponsor in an event should always be clearly identified. • Staff within the CCG involved in securing sponsorship of events should make it clear that

sponsorship does not equate to endorsement of a company or its products and this should be made visibly clear on any promotional or other materials relating to the event.

• Staff arranging sponsored events must declare this to the CCG. What should be declared

• The CCG will maintain records regarding sponsored events in line with the above principles and rules.

• 13.9 Sponsored research • Funding sources for research purposes must be transparent. • Any proposed research must go through the relevant health research authority or other

approvals process. • There must be a written protocol and written contract between staff, the CCG, and/or institutes

at which the study will take place and the sponsoring organisation, which specifies the nature of the services to be provided and the payment for those services.

• The study must not constitute an inducement to prescribe, supply, administer, recommend, buy or sell any medicine, medical device, equipment or service.

• Staff should declare involvement with sponsored research to the CCG. What should be declared

• The CCG will retain written records of sponsorship of research, in line with the above principles and rules.

• Staff should declare: • their name and their role with the CCG. • Nature of their involvement in the sponsored research. • relevant dates. • Other relevant information (e.g. what, if any, benefit the sponsor derives from the

sponsorship, action taken to mitigate against a conflict, details of any approvals given to depart from the terms of this policy).

13.10 Sponsored posts

• External sponsorship of a post requires prior approval from the CCG. • Rolling sponsorship of posts should be avoided unless appropriate checkpoints are put in

place to review and withdraw if appropriate. • Sponsorship of a post should only happen where there is written confirmation that the

arrangements will have no effect on purchasing decisions or prescribing and dispensing habits. This should be audited for the duration of the sponsorship. A written agreement will be put in place that details the circumstances under which the CCG will have the ability to exit sponsorship arrangements if conflicts of interest which cannot be managed arise.

• Sponsored post holders must not promote or favour the sponsor’s products, and information about alternative products and suppliers should be provided.

• Sponsors should not have any undue influence over the duties of the post or have any preferential access to services, materials or intellectual property relating to or developed in connection with the sponsored posts.


• The CCG will retain written records of sponsorship of posts, in line with the above principles and rules.

• Staff should declare any other interests arising as a result of their association with the sponsor, in line with the content in the rest of this policy.

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14.0 RECORD KEEPING AND MINUTE TAKING

14.1 As set out above a clear record of any conflicts of interest is kept by the CCG in its register of interests. It also records procurement decisions made, and details of how any conflicts that arose in the context of the decision have been managed. These registers are available for public inspection as detailed above.

14.2 The CCG ensures that details of all contracts, including the contract value, are published on its

website as soon as contracts are agreed. Where the CCG decides to commission services through Any Qualified Provider (AQP), the information published on its website includes the type of services being commissioned and the agreed price for each service. Further, the CCG incorporates all such details in its annual report. Where services are commissioned through an AQP approach information is publicly available about those providers who qualify to provide the service.

14.3 It is imperative that the CCG ensures complete transparency in its decision making processes

through robust record-keeping. If any conflicts of interest are declared or otherwise arise in a meeting, the chair must therefore ensure the following information is recorded in the minutes:

who has the interest;

the nature of the interest and why it gives rise to a conflict, including the magnitude of any interest;

the items on the agenda to which the interest relates;

how the conflict was agreed to be managed; and

evidence that the conflict was managed as intended (for example recording the points during the meeting when particular individuals left or returned to the meeting).

15.0 IDENTIFYING AND REPORTING BREACHES 15.1 There will be situations when interests will not be identified, declared or managed appropriately

and effectively. This may happen innocently, accidentally, or because of the deliberate actions of staff or other organisations. For the purposes of this policy these situations are referred to as ‘breaches’.

15.2 It is the duty of every CCG employee, governing body member, committee or sub-committee

member and GP practice member to speak up about genuine concerns in relation to the administration of the CCG’s policy on conflicts of interest management, and to report these concerns. These individuals should not ignore their suspicions or investigate themselves, but rather speak to the CCG Conflict of Interest Guardian or Governance Support Manager.

15.3 Any non-compliance with this conflicts of interest policy must be reported in accordance with the

terms of this policy, and the CCG’s whistle blowing policy (where the breach is being reported by an employee or worker of the CCG) or with the whistle blowing policy of the relevant employer organisation (where the breach is being reported by an employee or worker of another organisation).

15.4 Failure to comply with the CCG’s policies on conflicts of interest management, pursuant to

statutory guidance, can have serious implications for the CCG and any individuals concerned, which could result in cival, criminal, disciplinary or professional regulatory action.

15.5 The CCG will investigate each reported breach according to its own specific facts and merits, and give relevant parties the opportunity to explain and clarify any relevant circumstances. Following investigation the organisation will:

• Decide if there has been or is potential for a breach and if so the what severity of the breach is.

• Assess whether further action is required in response – this is likely to involve any staff member involved and their line manager, as a minimum.

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• Consider who else inside and outside the organisation should be made aware • The outcome of the investigation will be reported to the Audit & Governance Committee for

their consideration and to agree recommended actions. 15.6 Action taken in response to breaches of this policy will be in accordance with the disciplinary

procedures of the CCG and could involve organisational leads for staff support (e.g. Human Resources), fraud (e.g. Local Counter Fraud Specialists), members of the management or executive teams and organisational auditors. Breaches could require action in one or more of the following ways: • Clarification or strengthening of existing policy, process and procedures. • Consideration as to whether HR/employment law/contractual action should be taken against

staff or others. • Consideration being given to escalation to external parties. This might include referral of

matters to external auditors, NHS Protect, the Police, statutory health bodies (such as NHS England, NHS Improvement or the CQC), and/or health professional regulatory bodies.

15.7 Inappropriate or ineffective management of interests can have serious implications for the

organisation and staff. There will be occasions where it is necessary to consider the imposition of sanctions for breaches. Sanctions should not be considered until the circumstances surrounding breaches have been properly investigated. However, if such investigations establish wrong-doing or fault then the CCG can and will consider the range of possible sanctions that are available, in a manner which is proportionate to the breach. This includes:

Employment law action against staff, which might include o Informal action (such as reprimand, or signposting to training and/or guidance). o Formal disciplinary action (such as formal warning, the requirement for additional

training, re-arrangement of duties, re-deployment, demotion, or dismissal).

Reporting incidents to the external parties described above for them to consider what further investigations or sanctions might be.

Contractual action, such as exercise of remedies or sanctions against the body or staff which caused the breach.

Legal action, such as investigation and prosecution under fraud, bribery and corruption legislation.

15.8 The CCG will report identified breaches to NHS England in accordance with the stipulated CCG

Improvement & Assessment Framework requirements for reporting upon conflicts of interest and breaches.

15.9 Anonymised details of breaches to this policy will be published on the CCG’s website for the

purpose of learning and development.

16.0 REVIEW 16.1 This policy will be reviewed in annually unless an earlier review is required. This will be led by

the Governance Support Manager

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APPENDICES

Appendix 1: Declaration of Interests for Members & Employees

Appendix 2: CCG Register of Interests

Appendix 3: Declaration of Interest Checklist

Appendix 4: Procurement Template

Appendix 5: Register of procurement decisions and contracts awarded

Appendix 6: Register for the receipt of Gifts and provision and receipt of Hospitality

Appendix 7: Summary of key aspects of the guidance on managing conflicts of interest relating

to commissioning of new care models

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Appendix 1: Declaration of Interest Form

Declaration of Interest Form This form is required to be completed in accordance with the CCG’s Constitution and section 14O of The National Health Service Act 2006, the NHS (Procurement, Patient Choice and Competition) Regulations 2013, the Substantive Guidance on the Procurement, Patient Choice and Competition Regulations and the NHS England Managing Conflicts of Interest – Revised Statutory Guidance for CCGs 2017.

Full Name (including Title):

Job Title or Relationship with the CCG: (or NHS England in the event of joint committees):

Team: (ie, Comms, Finance…)

Employment Type: (ie Employed by CCG, Contractor, Agency, External Committee Member, Graduate, CSU)

Please tick in the box provided, which Board/Committee(s) you attend. Please also detail any Sub Committee(s).

Board Audit & Governance Finance, Perf & BI Quality & Safety

Primary Care Commissioning Development

Remuneration & HR

Other Sub-Committees:

Detail of interests held (complete all that are applicable):

Description of Interest (including for indirect Interests, details of the relationship with the person who has

the interest)

Type of Interest - Please tick as appropriate

(See attached guidance) Date Interest relates to: Actions to

be taken to mitigate

risk (see Section B)

Financial Interest

Non-Financial

Professional Interest

Non- Financial Personal Interest

Indirect Interest From To

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The information submitted will be held by the CCG for personnel or other reasons specified on this form and to comply with the organisation’s policies. This information may be held in both manual and electronic form in accordance with the Data Protection Act 1998. Information may be disclosed to third parties in accordance with the Freedom of Information Act 2000 and, in the case of ‘decision making staff’ (as defined in the statutory guidance on managing conflicts of interest for CCGs) may be published in registers that the CCG holds.

Decision making staff should be aware that the information provided in this form will be added to the CCG’s registers which are held in hardcopy for inspection by the public and published on the CCG’s website. Decision making staff must make any third party whose personal data they are providing in this form aware that the personal data will held in hardcopy for inspection by the public and published on the CCG’s website and must inform the third party that the CCG’s privacy policy is available on the CCG’s website. If you are not sure whether you are a ‘decision making’ member of staff, please speak to your line manager before completing this form. I confirm that the information provided above is complete and correct. I acknowledge that any changes in these declarations must be notified to the CCG via email to [email protected] as soon as practicable and no later than 28 days after the interest arises. I am aware that if I do not make full, accurate and timely declarations then civil, criminal, or internal disciplinary action may result.

I do give my consent for this information to published on registers that the CCG holds.

I do not give my consent for this information to published on registers that the CCG holds. Please give reasons:

Print Name: Signature:

Position: Date:

(Member of staff)

Print Name: Signature:

Position: Date:

(Line Manager)

Please return to the Governance Support Manager or via email [email protected]

mailto:[email protected]


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SECTION A - TYPES OF INTEREST

Type of Interest Description

Financial Interests

This is where an individual may get direct financial benefits from the consequences of a commissioning decision. This could, for example, include being:

A director, including a non-executive director, or senior employee in a private company or public limited company or other organisation which is doing, or which is likely, or possibly seeking to do, business with health or social care organisations;

A shareholder (or similar owner interests), a partner or owner of a private or not-for-profit company, business, partnership or consultancy which is doing, or which is likely, or possibly seeking to do, business with health or social care organisations.

A management consultant for a provider;

In secondary employment (see paragraph 56 to 57);

In receipt of secondary income from a provider;

In receipt of a grant from a provider;

In receipt of any payments (for example honoraria, one off payments, day allowances or travel or subsistence) from a provider

In receipt of research funding, including grants that may be received by the individual or any organisation in which they have an interest or role; and

Having a pension that is funded by a provider (where the value of this might be affected by the success or failure of the provider).

Non-Financial Professional Interests

This is where an individual may obtain a non-financial professional benefit from the consequences of a commissioning decision, such as increasing their professional reputation or status or promoting their professional career. This may, for example, include situations where the individual is:

An advocate for a particular group of patients;

A GP with special interests e.g., in dermatology, acupuncture etc.

A member of a particular specialist professional body (although routine GP membership of the RCGP, BMA or a medical defence organisation would not usually by itself amount to an interest which needed to be declared);

An advisor for Care Quality Commission (CQC) or National Institute for Health and Care Excellence (NICE);

A medical researcher.

Non-Financial Personal Interests

This is where an individual may benefit personally in ways which are not directly linked to their professional career and do not give rise to a direct financial benefit. This could include, for example, where the individual is:

A voluntary sector champion for a provider;

A volunteer for a provider;

A member of a voluntary sector board or has any other position of authority in or connection with a voluntary sector organisation;

Suffering from a particular condition requiring individually funded treatment;

A member of a lobby or pressure groups with an interest in health.

Indirect Interests

This is where an individual has a close association with an individual who has a financial interest, a non-financial professional interest or a non-financial personal interest in a commissioning decision (as those categories are described above). For example, this should include:

Spouse / partner;

Close relative e.g., parent, grandparent, child, grandchild or sibling;

Close friend;

Business partner.

SECTION B – MITIGATING ACTIONS

Please ensure that the mitigating actions are discussed and agreed with your line manger and write A, B, C, D or E

A no action required

B restricting an individual’s involvement in discussions and from decision making

C removing an individual from the whole decision making process

D removing and individual from their role altogether if the conflict is so significant that they are unable to operate effectively in the role

E keeping an audit trail of the actions taken

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Appendix 2: Declarations of Interest Register Template

Title First Name Surname Job Title

Declared Interest-

(Name of the

organisation and

nature of business) Fin

an

cia

l

Inte

res

ts

No

n-F

ina

nc

ial

Pro

fes

sio

na

l

Inte

res

tsN

on

-Fin

an

cia

l

Pe

rso

na

l

Inte

res

ts Is the

interest

direct or

indirect?

Nature of Interest From To Action taken to mitigate risk

Type of Interest Date of Interest

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Appendix 3: Template declarations of interest checklist

Under the Health and Social Care Act 2012, there is a legal obligation to manage conflicts of interest appropriately. It is essential that declarations of interest and actions arising from the declarations are recorded formally and consistently across all CCG governing body, committee and sub-committee meetings. This checklist has been developed with the intention of providing support in conflicts of interest management to the Chair of the meeting- prior to, during and following the meeting. It does not cover the requirements for declaring interests outside of the committee process.

Timing

Checklist for Chairs Responsibility

In advance of the meeting

1. The agenda to include a standing item on declaration of interests to enable individuals to raise any issues and/or make a declaration at the meeting.

Meeting Chair and secretariat

2. A definition of conflicts of interest should also be accompanied with each agenda to provide clarity for all recipients.


3. Agenda to be circulated to enable attendees (including visitors) to identify any interests relating specifically to the agenda items being considered.


4. Members should contact the Chair as soon as an actual or potential conflict is identified.

Meeting members

5. Chair to review a summary report from preceding meetings i.e., sub- committee, working group, etc., detailing any conflicts of interest declared and how this was managed.

Meeting Chair

A template for a summary report to present discussions at preceding meetings is detailed below.

6. A copy of the members’ declared interests is checked to establish any actual or potential conflicts of interest that may occur during the meeting.

Meeting Chair

During the meeting

7. Check and declare the meeting is quorate and ensure that this is noted in the minutes of the meeting.

Meeting Chair

8. Chair requests members to declare any interests in agenda items- which have not already been declared, including the nature of the conflict.

Meeting Chair

9. Chair makes a decision as to how to manage each interest which has been declared, including whether / to what extent the individual member should continue to participate in the meeting, on a case-by-case basis, and this decision is recorded.


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10. As minimum requirement, the following should be recorded in the minutes of the meeting:

Individual declaring the interest;

At what point the interest was declared;

The nature of the interest;

The Chair’s decision and resulting action taken;

The point during the meeting at which any individuals retired from and returned to the meeting - even if an interest has not been declared.

Visitors in attendance who participate in the meeting must also follow the meeting protocol and declare any interests in a timely manner.

A template for recording any interests during meetings is detailed below.

Secretariat

Following the

meeting

11. All new interests declared at the meeting should be promptly updated onto the declaration of interest form;

Individual(s) declaring interest(s)

12. All new completed declarations of interest should be transferred onto the register of interests.

Designated person responsible for registers of interest

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Appendix 4: Procurement Template

To be used when commissioning services from GP practices, including provider consortia organisations in which GPs have a financial interest. NHS Dudley Clinical Commissioning Group

Service

Questions Comments/Evidence

Questions for all three procurement routes

How does the proposal deliver good or improved

outcomes and value for money – what are the

estimated costs and the estimated benefits? How

does it reflect the CCG’s proposed commissioning

priorities? How does it comply with the CCG’s

commissioning obligations?

How have you involved the public in the decision to

commission this service?

What range of health professionals have been

involved in designing the proposed service?

What range of potential providers have been involved

in considering the proposals?

How have you involved your Health and Wellbeing

Board? How does the proposal support the priorities

in the relevant joint health and wellbeing strategy?

What are the proposals for monitoring the quality of

the service?

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What systems will there be to monitor and publish data

on referral patterns?

Have all conflicts and potential conflicts of interests

been appropriately declared and entered in registers

which are publicly available? Have

you recorded how you have managed any conflict or

potential conflict?

Why have you chosen this procurement route?

What additional external involvement will there be in

scrutinising the proposed decisions?

How will the CCG make its final commissioning

decision in ways that preserve the integrity of the

decision-making process and award of any contract?

Additional question when qualifying a provider on a list or framework or pre selection for tender

(including but not limited to any qualified provider (AQP)) or direct award (for services where

national tariffs do not apply)

How have you determined a fair price for the service?

Additional question when qualifying a provider on a list or framework or pre selection for tender

(including but not limited to AQP) or direct award where GP practices are likely to be qualified

providers

How will you ensure that patients are aware of the full range of qualified providers from whom they can choose?

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Additional questions for proposed direct awards to GP providers

Questions Comments/Evidence

What steps have been taken to demonstrate that the

services to which the contract relates are capable of

being provided by only one provider?

In what ways does the proposed service go above and

beyond what GP practices should be expected to

provide under the GP contract?

What assurances will there be that a GP practice is

providing high-quality services under the GP contract

before it has the opportunity to provide any new

services?

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Appendix 5: Register of Procurement Decision Template

Dudley CCG - Register of Procurement Decisions

2016/2017

Ref Contract / Service Title Procurement Description

Existing Contract or New

procurement (if existing include

details)

Procurement type -

CCG Procurement

Collaborative

procurment with

partners CCG Clinical Lead (name)

CCG Contract

manager (name)

Decision Making process

and name of decision

making committee

Summary of

Conflicts of Interest

and how these were

managed Contract Awarded (Supplier name & registered address)

Contract value

(£) (Total)

Contract value

(£) to CCG

The CCG Procurement Register is a register of procurement decisions taken, who was involved in making the decision and a summary of any conflicts of interest in relation to the decision and how this was managed by the CCG.

This allows us to demonstrate that we are acting fairly and transparently and in the best interest of our patients and local population. All CCGs must maintain a register of procurement decisions taken. This is in line with the requirements of the document "Managing Conflicts of Interest: Statutory Guidance for CCGs" published in December 2014 by NHS England

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Appendix 6: Register for the receipt of Gifts and provision and receipt of Hospitality

Register for the Receipt of Gifts and Provision & Receipt of Hospitality

Refe

ren

ce

Date

of

off

er

Dudley CCG Other body

(A)c

cep

ted

or

(D)e

clin

ed

Details

Asso

cia

ted

Valu

e (

£)

Ap

pro

x. if

no

t kn

ow

n

APPROVAL FOR HOSPITALITY GIVEN AND

RECEIVED

Offered

To CCG

(mark as

A)

By CCG

(mark as

B)

Name & Position Name & Position and

organisation

Description of the gift or

hospitality given /

offered / received

Venue (where

applicable)

Approved

by

Reasons for offer,

Acceptance or

Decline

Date

1

2

3

4

5

6

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Appendix 7: Summary of key aspects of the guidance on managing conflicts of interest relating to commissioning of

new care models

Introduction Conflicts of interest can arise throughout the whole commissioning cycle from needs assessment, to procurement exercises, to contract monitoring. They arise in many situations, environments and forms of commissioning.

Where CCGs are commissioning new care models 28

, particularly those that include primary medical services, it is likely that there will be some individuals with roles in the CCG (whether clinical or non-clinical), that also have roles within a potential provider, or may be affected by decisions relating to new care models. Any conflicts of interest must be identified and appropriately managed, in accordance with this statutory guidance. This annex is intended to provide further advice and support to help CCGs to manage conflicts of interest in the commissioning of new care models. It summarises key aspects of the statutory guidance which are of particular relevance to commissioning new care models rather than setting out new requirements. Whilst this annex highlights some of the key aspects of the statutory guidance, CCGs should always refer to, and comply with, the full statutory guidance. Identifying and managing conflicts of interest The statutory guidance for CCGs is clear that any individual who has a material interest in an organisation which provides, or is likely to provide, substantial services to a CCG (whether as a provider of healthcare or provider of commissioning support services, or otherwise) should recognise the inherent conflict of interest risk that may arise and should not be a member of the governing body or of a committee or sub-committee of the CCG. In the case of new care models, it is perhaps likely that there will be individuals with roles in both the CCG and new care model provider/potential provider. These conflicts of interest should be identified as soon as possible, and appropriately managed locally. The position should also be reviewed whenever an individual’s role, responsibility or circumstances change in a way that affects the individual’s interests. For example where an individual takes on a new role outside the CCG, or enters into a new business or relationship, these new interests should be promptly declared and appropriately managed in accordance with the statutory guidance. There will be occasions where the conflict of interest is profound and acute. In such scenarios (such as where an individual has a direct financial interest which gives rise to a conflict, e.g., secondary employment or involvement with an organisation which benefits financially from contracts for the supply of goods and services to a CCG or aspires to be a new care model provider), it is likely that CCGs will want to consider whether, practically, such an interest is manageable at all. CCGs should note that this can arise in relation to both clinical and non- clinical members/roles. If an interest is not manageable, the appropriate course of action may be to refuse to allow the circumstances which gave rise to the conflict to persist. This may require an individual to step down from a particular role and/or move to another role within the CCG and may require the CCG to take action to terminate an appointment if the individual refuses to step down. CCGs should ensure that their contracts of employment and where a member of CCG staff participating in a meeting has dual roles, for example a role with the CCG and a role with a new care model provider organisation, but it is not considered necessary to exclude them from the whole or any part of a CCG meeting, he or she should ensure that the capacity in which they continue to participate in the discussions is made 28

Where we refer to ‘new care models’ in this note, we are referring to any Multi-speciality Community Provider (MCP), Primary and Acute Care Systems (PACS) or other arrangements of a similar scale or scope that (directly or indirectly) includes primary medical services. letters of appointment, HR policies, governing body and committee terms of reference and standing orders are reviewed to ensure that they enable the CCG to take appropriate action to manage conflicts of interest robustly and effectively in such circumstances.

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clear and correctly recorded in the meeting minutes, but where it is appropriate for them to participate in decisions they must only do so if they are acting in their CCG role. CCGs should take all reasonable steps to ensure that employees, committee members, contractors and others engaged under contract with them are aware of the requirement to inform the CCG if they are employed or engaged in, or wish to be employed or engaged in, any employment or consultancy work in addition to their work with the CCG (for example, in relation to new care model arrangements). CCGs should identify as soon as possible where staff might be affected by the outcome of a procurement exercise, e.g., they may transfer to a provider (or their role may materially change) following the award of a contract. This should be treated as a relevant interest, and CCGs should ensure they manage the potential conflict. This conflict of interest arises as soon as individuals are able to identify that their role may be personally affected. Similarly, CCGs should identify and manage potential conflicts of interest where staff are involved in both the contract management of existing contracts, and involved in procurement of related new contracts. Governance arrangements Appropriate governance arrangements must be put in place that ensure that conflicts of interest are identified and managed appropriately, in accordance with this statutory guidance, without compromising the CCG’s ability to make robust commissioning decisions. We know that some CCGs are adapting existing governance arrangements and others developing new ones to manage the risks that can arise when commissioning new care models. We are therefore, not recommending a “one size fits” all governance approach, but have included some examples of governance models which CCGs may want to consider. The principles set out in the general statutory guidance on managing conflicts of interest (paragraph 19-23), including the Nolan Principles and the Good Governance Standards for Public Services (2004), should underpin all governance arrangements. CCGs should consider whether it is appropriate for the Governing Body to take decisions on new care models or (if there are too many conflicted members to make this possible) whether it would be appropriate to refer decisions to a CCG committee. Primary Care Commissioning Committee Where a CCG has full delegation for primary medical services, CCGs could consider delegating the commissioning and contract management of the entire new care model to its Primary Care Commissioning Committee. This Committee is constituted with a lay and executive majority, and includes a requirement to invite a Local Authority and Healthwatch representative to attend (see paragraph 97 onwards of the CCG guidance). Should this approach be adopted, the CCG may also want to increase the representation of other relevant clinicians on the Primary Care Commissioning Committee when new care models are being considered, as mentioned in Paragraph 98 of this guidance. The use of the Primary Care Commissioning Committee may assist with the management of conflicts/quorum issues at governing body level without the creation of a new forum/committee within the CCG. If the CCG does not have a Primary Care Commissioning Committee, the CCG might want to consider whether it would be appropriate/advantageous to establish either: A new care model commissioning committee (with membership including relevant non-conflicted clinicians, and formal decision making powers similar to a Primary Care Commissioning Committee (“NCM Commissioning Committee”); or

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A separate clinical advisory committee, to act as an advisory body to provide clinical input to the Governing Body in connection with a new care model project, with representation from all providers involved or potentially involved in the new care model but with formal decision making powers remaining reserved to the governing body (“NCM Clinical Advisory Committee”). NCM Commissioning Committee The establishment of a NCM Commissioning Committee could help to provide an alternative forum for decisions where it is not possible/appropriate for decisions to be made by the Governing Body due to the existence of multiple conflicts of interest amongst members of the Governing Body. The NCM Commissioning Committee should be established as a sub-committee of the Governing Body. The CCG could make the NCM Commissioning Committee responsible for oversight of the procurement process and provide assurance that appropriate governance is in place, managing conflicts of interest and making decisions in relation to new care models on behalf of the CCG. CCGs may need to amend their constitution if it does not currently contain a power to set up such a committee either with formal delegated decision making powers or containing the proposed categories of individuals (see below). The NCM Commissioning Committee should be chaired by a lay member and include non-conflicted GPs and CCG members, and relevant non-conflicted secondary care clinicians. NCM Clinical Advisory Committee This advisory committee would need to include appropriate clinical representation from all potential providers, but have no decision making powers. With conflicts of interest declared and managed appropriately, the NCM Clinical Advisory Committee could formally advise the CCG Governing Body on clinical matters relating to the new care model, in accordance with a scope and remit specified by the Governing Body. This would provide assurance that there is appropriate clinical input into Governing Body decisions, whilst creating a clear distinction between the clinical/provider side input and the commissioner decision-making powers (retained by the Governing Body, with any conflicts on the Governing Body managed in accordance with this statutory guidance and constitution of the CCG). From a procurement perspective the Public Contracts Regulations 2015 encourage early market engagement and input into procurement processes. However, this must be managed very carefully and done in an open, transparent and fair way. Advice should therefore be taken as to how best to constitute the NCM Clinical Advisory Committee to ensure all potential participants have the same opportunity. Furthermore it would also be important to ensure that the advice provided to the CCG by this committee is considered proportionately alongside all other relevant information. Ultimately it will be the responsibility of the CCG to run an award process in accordance with the relevant procurement rules and this should be a process which does not unfairly favour any one particular provider or group of providers. When considering what approach to adopt (whether adopting an NCM Commissioning Committee, NCM Clinical Advisory committee or otherwise) each CCG will need to consider the best approach for their particular circumstances whilst ensuring robust governance arrangements are put in place. Depending on the circumstances, either of the approaches in paragraph 17 above may help to give the CCG assurance that there was appropriate clinical input into decisions, whilst supporting the management of conflicts. When considering its options the CCG will, in particular, need to bear in mind any joint / delegated commissioning arrangements that it already has in place either with NHS England, other CCGs or local authorities and how those arrangements impact on its options.

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Provider engagement It is good practice to engage relevant providers, especially clinicians, in confirming that the design of service specifications will meet patient needs. This may include providers from the acute, primary, community, and mental health sectors, and may include NHS, third sector and private sector providers. Such engagement done transparently and fairly, is entirely legal. However, conflicts of interest, as well as challenges to the fairness of the procurement process, can arise if a commissioner engages selectively with only certain providers (be they incumbent or potential new providers) in developing a service specification for a contract for which they may later bid. CCGs should be particularly mindful of these issues when engaging with existing / potential providers in relation to the development of new care models and CCGs must ensure they comply with their statutory obligations including, but not limited to, their obligations under the National Health Service (Procurement, Patient Choice and Competition) (No 2) Regulations 2013 and the Public Contracts Regulations 2015. Further support If you have any queries about this advice, please contact: england.co- [email protected].



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APPENDIX 2 Committee Terms of Reference

Finance & Investment Committee



MCP Project Board

Joint Commissioning Committee

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Governing Body’s


AMENDMENT HISTORY

VERSION DATE AMENDMENT HISTORY REVIEWER

V4.0 7 August 2019 Full refresh in line with Committee Structure Emma Smith

V4.1 September 2019 Further Comments incorporated Carolyn Flavell

APPROVALS


VERSION BOARD/COMMITTEE DATE

V4.1 Finance & Investment Committee Confirmed via Email Sep 19


Please note that any changes to these Terms of Reference must be done in line with the Terms of

Reference Development Guidance. The Governance Team must be included in any revision to ensure

that the statutory duties are unaffected and in line with the CCGs Constitution.

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Finance and Investment Committee – Terms of Reference 1. Introduction & Purpose 1.1 The Finance and Investment Committee (the ‘Committee’) is established in accordance with

paragraph 6.7.1(c) of NHS Dudley Clinical Commissioning Group’s constitution. These terms of reference set out the membership, remit, responsibilities and reporting arrangements of the Committee and will have effect as if incorporated into the constitution.

1.2 The Committee will review its terms of reference annually. Any resulting changes to the terms of

reference will be approved by the governing body or the group if they relate to the membership of the Committee (Standing Order 4.1) before becoming part of an application for change to be approved by the group and submitted to the NHS Commissioning Board (constitution 1.4).

2. Authority 2.1 The committee has delegated authority to make decisions on behalf of the Governing Body as

defined by the Scheme of Reservation and Delegation. The Committee will apply best practice to the decision making process.

2.2 The Committee is authorised to seek any information it requires from any employee and all employees are directed to co-operate with any request made by the Committee. The Committee is authorised by the Governing Body to obtain outside legal or independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers this necessary.

3. Membership

Voting Members 3.1 All voting members of the Committee will be required to attend at least 75% of meetings in a 12

month period. Comments/questions from members unable to attend can be received by the Chair, shared as appropriate at the meeting and minuted accordingly.

Locality Lead (Chair)

Lay Member for Governance (Vice Chair)

Secondary Care Clinician

Chief Operating and Finance Officer (or their nominated deputy)

Chief Nurse (Primary Care)

Director for Commissioning Participating attendees

3.2

Deputy Director of Commissioning

Head of Financial Management – Commissioning

Head of Financial Management – Corporate

Head of Performance

Head of Contracts

Practice Manager Representative

Clinical Lead for IT and Estates

CCG Estates Lead

CCG IT Lead

3.3 The Committee may invite other individuals or non-members to attend a meeting to contribute to its discussions where relevant and appropriate.

4. Nominated Deputy

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4.1 Members may nominate a deputy to attend if there are occasions when the member is unavailable. This should be the exception rather than the rule. The deputy must be appropriately briefed and have decision making authority to adequately deputise for the member.

5. Designated Officer 5.1 The lead director will be responsible for supporting the Chair in the management of the

Committee’s business and for drawing members’ attention to best practice, national guidance and other relevant documents as appropriate.

5.2 The lead director for this Committee is the Chief Operating and Finance Officer. 6. Quorum 6.1 A meeting of the Committee will be quorate provided the following are present as a minimum:

One must be the Chair or Vice Chair

One must be a Secondary Care Clinician or Director of Commissioning

One must be the Chief Operating and Finance Officer (or Nominated Deputy) 6.2 Should quoracy not be achieved the Committee may:

Continue the meeting, but refer any decisions to a subsequent meeting

On occasion take a decision by email provided that:

All members of the committee are included in the email

The decision taken is by quorum of the Committee as laid down in its Terms of Reference

If the decision is one which requires a vote, it shall be at the discretion of the Chair to decide whether use of email is appropriate

The decision is reported to the next meeting and is minuted

The e-mails reflecting the decision are copied to all members of the Committee, are printed, appended to the minutes and are retained on file.

7. Frequency and notice of meetings 7.1 The Committee will normally meet on a bi-monthly basis. The committee may hold additional

meetings in exceptional circumstances with at least one week’s notice of the date 8. Agenda items

8.1 All agenda items are to be submitted to the designated officer at least 10 working days prior to

the meeting and papers will be circulated at least 5 working days prior to the meeting. 9. Remit, duties and responsibilities 9.1 The Committee will oversee all aspects of the financial arrangements of the group. It will give

detailed consideration to the group’s financial issues to provide the Governing Body with assurance that the financial issues of the group are being appropriately addressed.

9.2 The Committee will oversee the contracts with other organisations that the group holds,

concentrating principally on its main healthcare providers and the Commissioning Support Unit. 9.3 The Committee will ensure the development of suitable information systems to support the

business interests of the group, including the financial reporting and forecasting, and will perform the following duties:

Finance

Develop the group’s financial strategy, including the key financial assumptions underpinning the group’s financial plans.

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Ensure that key financial policies are developed and implemented appropriately.

Review and agree the annual financial plans/budget and key financial targets and measures.

Oversee the development, management and delivery of the group’s annual capital programme.

Undertake scrutiny of significant business cases to ensure affordability.

Set the financial objectives for the group’s QIPP plan and monitor achievement against these

Review the group’s in-year financial management performance and agree any plans for corrective action.

Determine the financial arrangements related to Quality Premia.

Risks

Provide assurance to the governing body that significant finance and investments risks are being adequately managed, and agree remedial action where necessary.

In performing its duties, the Committee shall examine and take into account:

Key finance indicators and forecasts

QIPP plans and progress reports

Monthly/yearly consolidated financial performance summaries and related budgets

Monthly/yearly balance sheet

Working capital performance and cash flow

Investment including capital programme and business cases

Relevant elements of the Board Assurance Framework and Corporate Risk Register

Risks and related action plans associated with financial plans

The financial relationship with other NHS bodies (in particular service providers), to include reports from contract review meetings relating to finance and investment

Reports on performance of the Commissioning Support Unit against specified service contract

To assess relevant elements of formal risks in relation to the CCGs role in the JCC and STP

IT

The IT Strategy Group is a Sub-Committee of the Finance and Investment Committee and will be responsible for the approval of the IT Strategy

The Committee will receive updates on progress in the delivery of the IT Strategy

Ensures the CCG adequately meets requirements of the NHS Long Term Plan and NHSE Strategy

To receive the STP IT Strategy and assure the Governing Body that the CCG will input to Black Country Local Digital Roadmap

Estates

The Estates Strategy Group is a Sub-Committee of the Finance and Investment Committee and will be responsible for the approval of the Estates Strategy

The Committee will receive updates on progress in the delivery of the Estates Strategy and also the Health Economy Estates Strategy Group

To receive the STP Estates Strategy and assure the Governing Body that the CCG will input to Black Country Local Digital Roadmap

Review appropriate business cases for investments Contract Management and Performance The Committee will provide scrutiny and control in respect of the award, monitoring and performance managing of contracts held by Dudley CCG, as well as the underpinning policies and guidance. Specifically, the Committee will:

i Ensure that procurements are appropriately project managed with risks identified and

mitigating actions planned. ii Recommend approval of contract awards within the committee’s delegated authority.

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iii Monitor contractual performance and receive regular performance information in respect of material individual providers.

iv Agree and monitor performance rectification action plans if required. v Scrutinise contracting and procurement policies and processes and provide

recommendations to the Governing Body or approve if within the committee’s delegated authority.

10. Internal Audit 10.1 The Committee will be required to receive internal audit reports, monitor the implementation of

the management recommendations and consider any recommendations with a risk rating greater than 2 for their risk register.

11. Risk Management 11.1 The Committee has a responsibility to manage any risks identified that impact on its

responsibilities. Each committee will consider risks aligned to the relevant corporate objectives. The committee will keep a committee risk register to document the management of risk at each meeting which will clarify the risk, the action, the timeframe and the executive ownership. This will be reported in the monthly executive summary report to the Governing Body. All risks will be actively managed by the Committee until the residual risk is deemed tolerable when it will either be closed or tolerated.

11.2 The Chair is responsible for ensuring that the:

1. Agenda items are linked to the risk register 2. The register is reviewed to add, amend, close or transfer risks at each committee meeting 3. identified risks relevant to other committees are transferred to its chair 4. assurance report includes any unmitigated red risks depending on risk appetite

12. Report to 12.1 The lead director will report on the committee and function activities at each Governing Body

meeting including its management of identified risks. 12.2 The Designated Officer will be required to provide a Committee Annual Report that will be taken

to the Governing Body for assurance. This annual report should also describe how the Committee has fulfilled its terms of reference and give details of any significant issues that the Committee considered in relation to the financial statements and how they were addressed.

12.3 To support this role the Committee is authorised to establish any sub-committee or working group

as necessary. 12.4 Please see Appendix 1 for the reporting structure.

13. Managing Conflicts of Interest 13.1 Conflicts of interest are a common and sometimes unavoidable part of the delivery of healthcare.

The CCG is required to manage any conflicts of interest through a transparent and robust system. Meeting attendees are encouraged to be open and honest in identifying any potential conflicts during the meeting. The Chair will be required to recognise any potential conflicts that may arise from themselves or a member of the meeting.

13.2 It is imperative that CCGs ensures complete transparency in any decision-making processes

through robust record-keeping. If any conflicts of interest are declared or otherwise arise in a meeting, the Chair must ensure the following information is recorded in the minutes; who has the interest, the nature of the interest and why it give rise to a conflict; the items on the agenda to

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which the interest relates; how the conflict was agreed to be managed and evidence that the conflict was managed as intended.

13.3 If any member has an interest, pecuniary or otherwise, in any matter and is present at the meeting

at which the matter is under discussion, he/she will declare that interest as early as possible and shall not participate in the discussions. The Chair will have the authority to request that member to withdraw until the item under discussion has been concluded. All declarations of interest will be recorded in the minutes.

13.4 Should the meeting not be quorate due to a conflict of interest, quoracy should be managed in

line with the CCGs Conflict of Interest Policy. 14. Review of Committee effectiveness 14.1 The Committee will annually self-assess and report to the Governing Body on its performance in

delivery of these terms of reference. 14.2 These terms of reference will be reviewed at least annually to ensure they remain fit for purpose

and approved by the Governing Body. 15. Confidentiality 15.1 Papers that are marked ‘in confidence, not for publication or dissemination’ shall remain

confidential to the members of the committee unless the Chair indicates otherwise. Members, representative or any persons in attendance shall not reveal or disclose the contents of these papers without express permission of the Chair. This prohibition shall apply equally to the content of any discussion during the meeting which may take place on such papers.

16. General Data Protection Regulations (GDPR) and Data Protection Act (DPA) 2018 16.1 Committee members will give due regard to the responsibilities of the CCG to comply with GDPR

and DPA legislation. 17. Freedom of Information Act 2000 17.1 All papers are subject to the Freedom of Information Act. All papers that are exempt from public

release under the FOI Act must be clearly marked ‘in confidence, not for publication’. These papers may not be copied or distributed outside of the committee membership without the expressed permission of the Chair. FOI exemption 41 (duty of confidence) applies.

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APPENDIX 1

REPORTING STRUCTURE (SUB COMMITTEES)

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Governing Body’s


AMENDMENT HISTORY



V1.1 9 September 2019

Amend made following IA Committee meeting. Dir Public Health a Member and reference to escalating to Board

Emma Smith

APPROVALS



V1.0 Integrated Assurance Committee 23 July 2019




that the statutory duties are unaffected and in line with the CCG’s Constitution.

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Integrate Assurance Committee – Terms of Reference 1. Introduction & Purpose 1.1 The Integrated Assurance Committee (the committee) is established in accordance with Dudley

Clinical Commissioning Group’s constitution, standing orders and scheme of delegation. 1.2 Ensuring that robust governance and management arrangements are in place to secure and

improve patient safety, clinical effectiveness and the quality of care across all services commissioned by the CCG.

1.3 Ensuring that risks and performance issues are identified and managed across the CCG and its

commissioned services as a whole, so that emerging issues, tensions and trade-offs are identified and managed effectively and where appropriate, escalated to the Board.

1.4 Ensuring that the CCG's overall clinical governance and assurance structures and procedures remain fit for purpose and effective.

1.5 The Committee is authorised to direct urgent action on behalf of the Board where necessary to

address emerging risks or concerns. 1.6 The Committee will foster and facilitate a culture of learning and ongoing quality improvement

across the CCG and wider STP/ICS footprint 1.7 It will do this by keeping under review both quality improvement and clinical assurance on issues

affecting the quality of all services commissioned by the CCG encompassing: ▪ Patient Safety, ▪ Clinical effectiveness and ▪ Patient experience.

2. Authority 2.1 Integrated Governance Committee (the Committee) has been established as a subcommittee of

the Clinical Commissioning Group (CCG) Board. The Committee has no executive powers, other than those specifically delegated in these Terms of Reference.

2.2 These Terms of Reference set out the membership, remit, responsibilities and reporting

arrangements of the committee and shall have effect as if incorporated into the CCG’s Constitution and Standing Orders.

2.3 The Committee is required to give assurance to the Board that robust governance and

management processes are in place to manage performance and risk (including patient safety, clinical effectiveness and quality of care) across the full range of services commissioned by the CCG; to report regularly; and to bring to the attention of the Board any significant emerging issues.

2.4 The Committee is authorised by the Governing Body to obtain outside legal or independent

professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers this necessary.

3. Membership

Voting Members

3.1 All voting members of the Committee will be required to attend at least 75% of meetings in a 12 month period. Comments/questions from members unable to attend can be received by the Chair, shared as appropriate at the meeting and minuted accordingly.

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Voting Members

Chair – Clinical Executive for Integrated Assurance

Vice Chair ‐ Lay Member for Integrated Assurance

Lay Member for Governance

Lay Member for Patient and Public Involvement

Secondary Care Clinician

Chief Nurse


Director of Commissioning

Director of Communications and Engagement

Director of Public Health

Participating attendees

Head of Membership Development & Primary Care

Head of Quality and Patient Safety

Head of Quality Assurance

Designated Nurse for Safeguarding Adults

Designated Nurse for Safeguarding Children

Designated Nurse for Looked After Children

Contracting representative

Head of Medicines Management

Healthwatch representative

3.2 The Committee may invite other individuals or non-members to attend a meeting to contribute to its discussions where relevant and appropriate.

4. Nominated Deputy 4.1 Members may nominate a deputy to attend if there are occasions when the member is

unavailable. This should be the exception rather than the rule. The deputy must be appropriately briefed and have decision making authority to adequately deputise for the member.

5. Designated Officer 5.1 The Designated Officer will be responsible for supporting the Chair in the management of the


5.2 The Designated Officer for this Committee is the Chief Nursing Officer. 6. Quorum 6.1 A meeting of the Committee will be quorate provided that the following are present

(telephone/video conferencing arrangements accepted) as a minimum:

Chair or Vice Chair

Lay Member or Secondary Care Clinician

Chief Nursing Officer (or nominated deputy)

Other Executive Director 6.2 If a quorate member of the Committee should be required to leave prior to the conclusion of the

meeting, the chair should confirm that the meeting is still quorate or not. If the meeting is no longer quorate, it may continue but decisions will have to be ratified at the next meeting.

6.3 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.

6.4 Should quoracy not be achieved the Committee may:

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7. Frequency and notice of meetings 7.1 The Committee will meet on a monthly basis. The Committee may hold additional meetings in

exceptional circumstances by giving at least one week’s notice of the date. Members are expected to maintain regular attendance at meetings. If circumstances make this impossible, this will be addressed by the Chair with the individual member concerned and alternative arrangements will be determined

8. Agenda items


the meeting and papers will be circulated at least 5 working days prior to the meeting. 9. Remit, duties and responsibilities The functions below will be delivered by the Committee:

Provider Quality Compliance

Patient Experience and Complaints

Quality Assurance

Quality Improvements

CQUINS

Regulator Instruction

Serious Incidents & Never Events

Safeguarding

Infection Control and Prevention

National Inquires

Local Reviews

Clinical Governance

Provider Complaints

NICE Guidance

Performance Management Framework

Compliance with National Policies

Effectiveness of Medicines Management

Harm and Audit

In year Performance Position

Monthly Performance Reports

External Performance Assessment (IAF)

Contractual Mechanisms

Quality Premium Payment

Monitor Remedial Actions Plans

Primary Care Quality Assurance Framework

Individual complex case management

System mortality

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Providing assurance that commissioned services are being delivered in a high quality and safe manner, ensuring that quality and continual improvement sits at the heart of everything the CCG does. This includes jointly commissioned services, care homes and STP wide collaborative commissioned services. Seeking assurance that the commissioning strategy for the CCG fully reflects all elements of quality (patient experience, effectiveness and patient safety), keeping in mind that the strategy and response may need to adapt and change. Ensuring that a clearly defined escalation process is in place for safety and quality measures, performance issues, taking action as required to ensure that improvements in quality are implemented where necessary and to ensure appropriate engagement of external bodies on areas of concern Having a collaborative approach to the analysis of incidents, complaints, serious incidents, never events, serious case reviews and national reports, and that lessons and good practice from this analysis is shared across the organisation and with the services we commission. Gaining assurance that the clinical governance within the CCG is continually developing to ensure that commissioned services are responding to national requirements. Oversee and be assured that effective arrangements are in place for all quality assurance processes either delivered ‘in-house’ by the CCG or purchased from the Commissioning Support Unit (CSU) or elsewhere including Infection Prevention, including those services delivered across the STP footprint Be assured that effective arrangements are in place for implementation of NICE guidance and quality standards by all providers including public health.

Oversee and be assured that effective management of risk is in place to manage and address clinical governance issues. Have oversight of the process and compliance issues concerning serious incidents requiring investigation (SIs); being informed of all Never Events and informing the Governing Body of any escalation or sensitive issues in good time. Receive patient experience reports (both qualitative and quantitative), including complaints, comments and concerns reports that identify themes and trends, and recommend areas for improvement in practice through the commissioning process. Seek assurance on the performance of NHS organisations in terms of the Care Quality Commission, NHSI, NHSE and any other relevant regulatory bodies Oversight of organisational learning with respect to quality and safety issues arising from commissioned services. Receive and scrutinise independent investigation reports relating to patient safety issues and agree publication plans To communicate any identified trends or common risks to all relevant internal and external stakeholders and, where necessary, develop actions plans to reduce risk and improve quality Approval of policy as it relates to quality & safety; risk management; safeguarding vulnerable adults and children. Approval of Terms of Reference for sub-committees of the Committee. The Committee has established an Integrated Operational Assurance Group (IOAG) to review and monitor contractual performance, quality and safety of health care commissioned by Dudley CCG. The IOAG will have authority to make decisions and take action within the scope of the groups TOR. An exception report will be submitted to the Committee from the IOAG highlighting key concerns and items that require escalation and action to be taken by The Committee

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10. Internal Audit 10.1 The Committee will be required to receive internal audit reports, monitor the implementation of



responsibilities. Each Committee will consider risks aligned to the relevant corporate objectives. The Committee will keep a risk register to document the management of risk at each meeting which will clarify the risk, the action, the timeframe and the executive ownership. This will be reported in the monthly executive summary report to the Governing Body. All risks will be actively managed by the Committee until the residual risk is deemed tolerable when it will either be closed or tolerated.


5. agenda items are linked to the risk register; 6. a risk action plan is completed for the top rated risks (normally not more than 3); 7. register is reviewed to add, amend, close or transfer risks at each meeting; 8. identified risks relevant to other committees are transferred to its chair; 9. assurance report includes any unmitigated risks usually with a rating >6 depending on risk

appetite 10. when the key risk triggers are hit the internal escalation process is followed

12. Report to 12.1 The Designated Officer will report on the Committee’s activities to each Governing Body meeting

including its management of identified risks. 12.2 The Designated Officer will be required to provide a Committee Annual Report that will be taken

to the Governing Body for assurance. This annual report should also describe how the Committee has fulfilled its terms of reference and give details of any significant issues that the Committee considered and how they were addressed.

12.3 To support this role the Committee is authorised to establish any sub-committee or working group

as necessary. 12.4 Please see Appendix 1 for reporting structure. 13. Managing Conflicts of Interest

Conflicts of interest are a common and sometimes unavoidable part of the delivery of healthcare. The CCG is required to manage any conflicts of interest through a transparent and robust system. Meeting attendees are encouraged to be open and honest in identifying any potential conflicts during the meeting. The Chair will be required to recognise any potential conflicts that may arise from themselves or a member of the meeting.


through robust record-keeping. If any conflicts of interest are declared or otherwise arise in a meeting, the Chair must ensure the following information is recorded in the minutes; who has the interest, the nature of the interest and why it gives rise to a conflict; the items on the agenda to which the interest relates; how the conflict was agreed to be managed and evidence that the conflict was managed as intended.

13.2 If any member has an interest, pecuniary or otherwise, in any matter and is present at the meeting

at which the matter is under discussion, he/she will declare that interest as early as possible and

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shall not participate in the discussions. The Chair will have the authority to request that member

to withdraw until the item under discussion has been concluded. All declarations of interest will

be recorded in the minutes.


line with the CCG’s Conflict of Interest Policy. 14. Review of Committee effectiveness 14.1 The Committee will annually self-assess and report to the Governing Body on its performance in

delivery of these terms of reference. 14.2 These terms of reference will be reviewed at least annually to ensure they remain fit for purpose

and approved by the Governing Body. 15. Confidentiality 15.1 Papers that are marked ‘in confidence, not for publication or dissemination’ shall remain

confidential to the members of the Committee unless the Chair indicates otherwise. Members, representative or any persons in attendance shall not reveal or disclose the contents of these papers without express permission of the Chair. This prohibition shall apply equally to the content of any discussion during the meeting which may take place on such papers.

16. General Data Protection Regulations (GDPR) and Data Protection Act (DPA) 2018 16.1 Committee members will give due regard to the responsibilities of the CCG to comply with GDPR

and DPA legislation. 17. Freedom of Information Act 2000 17.1 All papers are subject to the Freedom of Information Act. All papers that are exempt from public

release under the FOI Act must be clearly marked ‘in confidence, not for publication’. These papers may not be copied or distributed outside of the Committee membership without the expressed permission of the Chair. FOI exemption 41 (duty of confidence) applies.

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APPENDIX 1


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Governing Body’s


AMENDMENT HISTORY



V5.0 13 August 2019 Amends incorporated following review from Dir of Commissioning

Neill Bucktin

APPROVALS



V5.0 Policy & Commissioning Committee 12 September 2019




that the statutory duties are unaffected and in line with the CCGs Constitution.

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Policy & Commissioning Committee – Terms of Reference

1. Introduction & Purpose

1.1 The Policy & Commissioning Committee (the ‘Committee’) is established in accordance with paragraph 6.7.1(e) of NHS Dudley Commissioning Group’s constitution. These terms of reference set out the membership, remit, responsibilities and reporting arrangements of the Committee and will have effect as if incorporated into the constitution.

1.2 The Committee will review its terms of reference annually. Any resulting changes to the terms of reference will be approved by the governing body or the group if they relate to the membership of the Committee (Standing Order 4.1) before becoming part of an application for change to be approved by the group and submitted to the NHS Commissioning Board (constitution 1.4).

2. Authority 2.1 The Committee has delegated authority to make decisions on behalf of the Governing Body as

defined by the Scheme of Reservation and Delegation. The Committee will apply best practice to the decision making process.

2.2 The Committee is authorised to seek any information it requires from any employee and all

employees are directed to co-operate with any request made by the Committee. The Committee is authorised by the Governing Body to obtain outside legal or independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers this necessary

3. Membership

Members: 3.1 All voting members of the Committee will be required to attend at least 75% of meetings in a 12

month period. Comments/questions from members unable to attend can be received by the Chair, shared as appropriate at the meeting and minuted accordingly.

Locality Lead (Chair)

Secondary Care Clinician (Vice-Chair)

Clinical Executive for Policy & Commissioning

Lay Member – Patient & Public Involvement

Chief Nurse


3.2 Participating Attendees:

Head of Membership Development and Primary Care

Deputy Director of Commissioning

Director of Communications and Public Insight

GP Prescribing Lead

Clinical Lead IT & Estates

Specialist in Pharmaceutical Public Health

Head of Financial Management – Commissioning

3.3 The Committee may invite other individuals or non-members to attend a meeting to contribute

to its discussions where relevant and appropriate.

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4. Nominated Deputy

4.1 Members may nominate a deputy to attend if there are occasions when the member is unavailable. This should be the exception rather than the rule. The deputy must be appropriately briefed and have decision making authority to adequately deputise for the member.

5. Designated Officer 5.1 The Designated Officer will be responsible for supporting the Chair in the management of the


5.2 The Designated Officer for this Committee is the Director of Commissioning. 6. Quorum 6.1 A meeting of the Committee will be quorate provided that the following are present

(telephone/video conferencing arrangements accepted) as a minimum:

Chair or Vice Chair

Director of Commissioning or other Director

Lay Member or Clinical Executive for Policy & Commissioning 6.2 Should quoracy not be achieved the Committee may:


Continue the meeting and make recommendations to the Governing Body







7. Frequency and notice of meetings

7.1 The Committee will meet bi-monthly. The Committee may hold additional meetings in

exceptional circumstances by giving at least one week’s notice of the date.

8. Agenda items


the meeting and papers will be circulated at least 5 working days prior to the meeting.

9. Remit, duties and responsibilities

9.1 The Committee will oversee all aspects of commissioning policy (with the exception of primary

care commissioning) within the group. The Committee will ensure that effective commissioning and QIPP plans are in place. It will give detailed consideration to the group’s commissioning issues including its procurement of, and investment (or disinvestment) in, commissioned services, and any equality and diversity implications arising from these plans.

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9.2 In considering plans and proposals the Committee will ensure that statutory duties are met in relation to: -

effectiveness, efficiency and economy

improvement in quality of services

reducing inequalities

obtaining appropriate advice

promoting innovation and research

promoting integration 9.3 The Committee will perform the following duties:

Commissioning

Review and approve commissioning policies.

Consider the Director of Public Health’s annual report and the Joint Strategic Needs Assessment and formulate the group’s contribution to the Joint Health and Wellbeing Strategy.

Review proposed commissioning intentions and plans and make appropriate recommendations to the Governing Body regarding these.

Monitor and review commissioning strategies / work programmes and their implementation.

Determine arrangements to enable patients to make informed choices (for example, through the provision of relevant and timely information and where appropriate the development of personal budgets and care plans).

Determine the arrangements put in place to secure proper partnership agreements to govern joint commissioning and collaborative/partnership working.

Consider and act upon the commissioning implications of any issues referred by the Integrated Assurance Committee and/or the Finance & Investment Committee.

QIPP

Develop the group’s QIPP plans and make appropriate recommendations to the Governing Body regarding these.

Monitor the effective delivery of the QIPP plan and report any significant risks to delivery of the QIPP (financial or otherwise) to the Governing Body, recommending and monitoring remedial action as necessary.

Clinical developments and innovation

Approve business cases (that have been prepared in accordance with the group’s agreed business case process) for new service/clinical developments up to a value of £100,000 per annum and make appropriate recommendations to the Governing Body for those of a value in excess of £100,000 per annum if affordable within Committee’s delegated budgets.

Promote innovative approaches to service design and commissioning. Medicines Management and Optimisation

Receive reports from the Prescribing Sub-Committee and the Area Clinical Effectiveness Sub Committee on at least a quarterly basis.

Equality and diversity

Ensure that the equality and diversity implications of commissioned services are properly considered, in the context of the agreed Equality and Diversity Strategy.

Risk management

Provide assurance to the governing body that significant commissioning risks are being adequately managed. This will be achieved by monitoring the Board Assurance Framework and Corporate Risk Register with respect to such risks.

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10. Internal Audit

10.1 The Committee will be required to receive internal audit reports, monitor the implementation of



responsibilities. Each Committee will consider risks aligned to the relevant corporate objectives. The Committee will keep a risk register to document the management of risk at each meeting which will clarify the risk, the action, the timeframe and the executive ownership. This will be reported in the monthly executive summary report to the Governing Body. All risks will be actively managed by the Committee until the residual risk is deemed tolerable when it will either be closed or tolerated.


12. agenda items are linked to the risk register; 13. a risk action plan is completed for the top rated risks (normally not more than 3); 14. register is reviewed to add, amend, close or transfer risks at each meeting; 15. identified risks relevant to other committees are transferred to its chair; 16. assurance report includes any unmitigated risks usually with a rating >6 depending on risk

appetite 17. when the key risk triggers are hit the internal escalation process is followed

12. Report to the Governing Body 12.1 The lead director will report on the Committee’s activities to each Governing Body meeting

including its management of identified risks.

12.2 The Designated Officer will be required to provide a Committee Annual Report that will be taken

to the Governing Body for assurance. This annual report should also describe how the

Committee has fulfilled its terms of reference, give details of any significant issues that the

Committee considered and how they were addressed and deal with the matters identified in 14

below.

12.3 To support this role the Committee is authorised to establish any sub-committee or working group as necessary.

12.4 Please see Appendix 1 for reporting structure. 13. Managing Conflicts of Interest 13.1 Conflicts of interest are a common and sometimes unavoidable part of the delivery of healthcare.

The CCG is required to manage any conflicts of interest through a transparent and robust system. Meeting attendees are encouraged to be open and honest in identifying any potential conflicts during the meeting. The Chair will be required to recognise any potential conflicts that may arise from themselves or a member of the meeting.


through robust record-keeping. If any conflicts of interest are declared or otherwise arise in a

meeting, the Chair must ensure the following information is recorded in the minutes; who has

the interest, the nature of the interest and why it gives rise to a conflict; the items on the agenda

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to which the interest relates; how the conflict was agreed to be managed and evidence that the

conflict was managed as intended.

13.3 If any member has an interest, pecuniary or otherwise, in any matter and is present at the meeting at which the matter is under discussion, he/she will declare that interest as early as possible and shall not participate in the discussions. The Chair will have the authority to request that member to withdraw until the item under discussion has been concluded. All declarations of interest will be recorded in the minutes.


line with the CCG’s Conflict of Interest Policy.

14 Review of Committee effectiveness

14.1 The Committee will annually self-assess and report to the Governing Body on its performance

in delivery of these terms of reference.

14.2 These terms of reference will be reviewed at least annually to ensure they remain fit for purpose

and approved by the Governing Body.

15 Confidentiality

15.1 Papers that are marked ‘in confidence, not for publication or dissemination’ shall remain

confidential to the members of the committee unless the Chair indicates otherwise. Members,

representative or any persons in attendance shall not reveal or disclose the contents of these

papers without express permission of the Chair. This prohibition shall apply equally to the

content of any discussion during the meeting which may take place on such papers.

16 General Data Protection Regulations (GDPR) and Data Protection Act (DPA) 2018

16.1 Committee members will give due regard to the responsibilities of Dudley CCG to comply with

Data Protection legislation including GDPR and DPA 2018.

17 Freedom of Information Act 2000

17.1 All papers are subject to the Freedom of Information Act. All papers that are exempt from public

release under the FOI Act must be clearly marked ‘in confidence, not for publication’. These

papers may not be copied or distributed outside of the Committee membership without the

expressed permission of the Chair. FOI exemption 41 (duty of confidence) applies.

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APPENDIX 1


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Dudley Multi-Specialty Community Provider Procurement

Project Board Terms of Reference – Version 2.5

AMENDMENT HISTORY


V2.0 January 2017 First draft of TOR

V2.1 January 2017 Formatted in to CCG Standard formatting

V2.2 March 2018 Revision to Membership – CCG Non Executive Director

V2.3 May 2018 Slight amends following NHSE revision of Constitution

V2.5 November 2019 Revision to Membership – to add Chief Nurse who has overall

responsibility for Primary Care to ensure primary care issues are

properly reflected



Taps Mtemechani ?? January 2017 Commissioning Manager V2.0

Emma Smith 13 January 2017 Governance Support Manager V2.1

Neill Bucktin 21 March 2018 Director of Commissioning V2.2

Emma Smith 08 May 2018 Governance Support Manager V2.3

Neill Bucktin September 2018 Director of Commissioning V2.4

Neill Bucktin November 2019 Director of Commissioning V2.5

APPROVALS



V2.1 Governing Body March 2017

V2.2 Governing Body May 2017

V2.3 MCP Project Board June 2018

V2.4 MCP Project Board October 2018

V2.5 MCP Project Board November 2019



Reference Development Guidance. Changes must be agreed at Committee and ratified through the

Governing Body. The Governance Team must be included in any revision to ensure that the statutory

duties are unaffected and in line with the CCG’s Constitution.

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MCP Procurement Project Board – Terms of Reference 3. Introduction & Purpose

3.1 The MCP Procurement Project Board (the ‘Project Board) is established in accordance with paragraph 6.7.1(e) of NHS Dudley Commissioning Group’s constitution and is a formal Committee of the Governing Body.

3.2 The CCG’s Governing Body has delegated authority to the Project Board to take all decisions regarding the Multi-specialty Community Provider (MCP) procurement except the decision to commence procurement and to award the contract.

2. Membership

Members:

2.1 The Board will be chaired by the Chief Executive Officer and the membership comprise:


Chief Finance and Operating Officer (Vice Chair)

Director of Communications and Engagement

CCG Non-Executive Director

Patient representative(s)

Dudley MBC representatives (adult social care and public health) Participating Attendees:

2.2 The following will be in attendance:-

Mills and Reeves (legal advisers)

Good Governance Institute (governance advisers)

Deloitte (financial advisers)

Members of the Project Team, Programme Lead and Work stream Leads 2.3 Work streams will be established for the following areas as necessary by the appropriate

leads:-

Commissioning – Director of Commissioning

Finance – Finance Manager (Commissioning)

Outcomes Framework – Head of Intelligence

Information Governance – Governance Support Manager

Information Technology – Head of Information Technology

Patient and Public Engagement – Director of Communications and Engagement 2.4 Work stream leads will report to the Project Team and a programme plan will be developed and

maintained by the programme lead to reflect the above work streams.

Programme Lead – Commissioning Manager for Community Services and New Care Model 3. Secretary 3.1 A named individual will be responsible for supporting the Chair in the management of the Project

Board’s business and for drawing members’ attention to best practice, national guidance and other relevant documents as appropriate.

4. Quorum 4.1 Meetings of the Project Board will be deemed quorate when at least four members are present,

one of which must be either the designated chair or deputy. Decisions will be made on the basis of a simple majority.

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5. Frequency and notice of meetings 5.1 The Project Board will normally meet on a monthly basis. No unscheduled or rescheduled

meetings will take place without members having at least one week’s notice of the date. The agenda and supporting papers will be circulated to all members at least five working days before the date the meeting will take place.

5.2 A schedule of meetings will be produced and agreed in advance for the planned duration of the

project but with ad-hoc flexibility to ensure that any key decisions are taken without prejudicing the agreed timeline of the project.

5.3 The Project Board reserves the right to call a meeting at any time if an urgent matter arises. 6. Authority 6.1 The Project Board is authorised by the Governing Body to investigate any activity within its terms

of reference. 6.2 The Project Board, via the chair, will report to the CCG Governing Body. The Project Board will

have responsibility for the Project Team. 7. Remit, duties and responsibilities 7.1 The Project Board will have the following responsibilities:

a. To ensure the procurement of a MCP in line with CCG’s strategic intentions b. To develop a procurement plan that reflects the CCG’s intentions and the requirements of

regulators in particular NHSE, NHSI and the CQC c. To ensure that the implementation of the plan enables the procurement process to comply

with relevant legislation d. To ensure that the implementation of the plan enables the procurement process to comply

with requirements of the regulators including the Integrated Support and Assurance Process e. To ensure that good project governance arrangements are in place including appropriate

work streams, leadership, risk management and reporting f. To ensure that all relevant stakeholders are involved appropriately in the project g. To ensure that a communications plan is developed and implemented h. To ensure that the project is appropriately resourced and led i. To ensure that the project procures, receives and acts upon expert external advice and

support j. To take appropriate opportunities to influence the design nationally of relevant policies and

processes relating to the development of new care models k. To report to the CCG Governing Body in a timely way and that risks to delivery of the project

are identified and mitigations proposed 8. Managing Conflicts of Interest

8.1 Conflicts of interest are a common and sometimes unavoidable part of the delivery of

healthcare. The CCG is required to manage any conflicts of interest through a transparent and robust system. Meeting attendees are encouraged to be open and honest in identifying any potential conflicts during the meeting. The Chair will be required to recognise any potential conflicts that may arise from themselves or a member of the meeting.


through robust record-keeping. If any conflicts of interest are declared or otherwise arise in a

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meeting, the Chair must ensure the following information is recorded in the minutes; who has the interest, the nature of the interest and why it gives rise to a conflict; the items on the agenda to which the interest relates; how the conflict was agreed to be managed and evidence that the conflict was managed as intended.

8.3 If any member has an interest, pecuniary or otherwise, in any matter and is present at the

meeting at which the matter is under discussion, he/she will declare that interest as early as possible and shall not participate in the discussions. The Chair will have the authority to request that member to withdraw until the item under discussion has been concluded. All declarations of interest will be recorded in the minutes.


line with the CCG’s Conflict of Interest Policy. 9. Review of Committee effectiveness 9.1 The Project Board will annually self-assess and report to the Governing Body on its

performance in delivery of these terms of reference. 9.2 These terms of reference will be reviewed at least annually to ensure they remain fit for purpose. 10. Confidentiality 10.1 Papers that are marked ‘in confidence, not for publication or dissemination’ shall remain

confidential to the members of the committee unless the Chair indicates otherwise. Members, representative or any persons in attendance shall not reveal or disclose the contents of these papers without express permission of the Chair. This prohibition shall apply equally to the content of any discussion during the meeting which may take place on such papers.

11. General Data Protection Regulations (GDPR) and Data Protection Act (DPA) 2018 11.1 Committee members will give due regard to the responsibilities of Dudley CCG to comply with

Data Protection legislation including GDPR and DPA 2018.

12. Freedom of Information Act 2000 12.1 All papers are subject to the Freedom of Information Act. All papers that are exempt from public

release under the FOI Act must be clearly marked ‘in confidence, not for publication’. These papers may not be copied or distributed outside of the Committee membership without the expressed permission of the Chair. FOI exemption 41 (duty of confidence) applies.

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INSERT LOGO FOR EACH CCG

Black Country Joint Commissioning Committee

(Joint Commissioning Committee)

Terms of Reference – Version D8.0

AMENDMENT HISTORY


D1.0 31 March 2017 Emma Smith proposed TOR template

D1.0 3 April 2017 Peter McKenzie & Sara Saville submitted amends

D2.0 4 April 2017 Presented back to T&FG for comment

D2.0 4 April 2017 Michelle Carolan provided comments

D3.0 5 April 2017 Amended following Task and Finish Group meeting

D4.0 20 April 2017 Amended following BCWBJC

D5.0 12 July 2017 Amended following feedback from CCG GB

D6.0 1 Aug 2017 Amended following feedback from JCC and project manager comments

D7.0 19 Sept 2017 Amended for consistent use of Joint Commissioning Committee

D8.0 26 Oct 2017 Amended following discussions at JCC regarding delegation to West Birmingham and CLG TOR



Emma Smith 31 March 2017 Governance Support Manager D1.0

Sara Saville 31 March 2017 Head of Corporate Governance D1.0

Peter McKenzie 3 April 2017 Corporate Operations Manager D1.0

Michelle Carolan 4 April 2017 D2.0

BCWBJC 20 April 2017 AOs of the Black Country and West Birmingham CCGs

D4.0

Four CCG GB 12 July 2017 GB members D5.0

APPROVALS



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Black Country Joint Commissioning Committee – Terms of Reference 1. Introduction & Purpose 1.1 The Black County Joint Commissioning Committee (the ‘Joint Commissioning Committee’) is

established in accordance with paragraph 6.4.4 of NHS Dudley Clinical Commissioning Group’s (CCG) constitution, paragraph 6.5.4 of NHS Wolverhampton CCG constitution, paragraph 6.6.4 of NHS Sandwell & West Birmingham CCG constitution and paragraph 5.10.4 of NHS Walsall CCG constitution.

1.2 The purpose of the Joint Commissioning Committee is to establish a single commissioning view

in line with the Sustainable Transformation Plan (STP) arrangements for key services across the Black Country through the creation of a Joint Commiss ion ing Committee of the four CCGs.

1.3 Individual CCGs will remain accountable for meeting their statutory duties. Each CCG has

nominated its representative members and the Joint Commissioning Committee will have delegated authority from each CCG to make binding decisions on behalf of each CCG.

1.4 Currently the STP has no formal authority or governance and the Joint Commissioning

Committee will provide a basis for coordinated collective action to commission the arrangements in the plan.

1.5 It is a committee comprising representatives of the following organisations:

Wolverhampton CCG,

Sandwell & West Birmingham CCG,

Dudley CCG and

Walsall CCG 1.6 These terms of reference set out the membership, remit, responsibilities and reporting

arrangements of the Joint Commissioning Committee and will have effect as if incorporated into the constitution.

2. Membership

2.1 Each member of the Committee as defined in Paragraph 2.2 shall have one vote. There will be

one vote, per role, per organisation. The Committee shall reach decisions by a simple majority of members present, but with the Chair having a second and deciding vote, if necessary.

2.2 Each of the four CCGs shall nominate four members of the Joint Commissioning Committee from

their Governing Body, which will be their Chair, and Accountable Officer, one Chief Finance Officer and one lay member. Each of the four CCGs will nominate one lay member from their Governing Body as their fourth member.

2.3 NHS England lead for commissioning specialised services will be a co-opted member to support

the committee’s work on developing proposals for the commissioning specialised services – using the ‘seat at the table’ model.

2.4 The Joint Commissioning Committee will be clinically led, with the Chair being taken by one of

the CCG Chair members and will rotate amongst them every six months in line with a schedule determined by the committee.

2.5 The Vice Chair of the Joint Commissioning Committee will be elected from amongst the Chairs

who will deputise for the Chair of the Joint Commissioning Committee as required. 2.6 Other representation that will normally be in attendance (members but non-voting) will include:

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Programme Director Communications Lead Administration support

2.6 Governing Body elected GPs, Clinical Executives, Executive Nurses, Other NHS England

representation, other GP members or employees of the CCG (not already listed in the membership) may be asked to attend the committee for the purposes of specific agenda items. This will be in an advisory and non-voting capacity. NHS England’s National Statutory Guidance on “Managing Conflicts of Interest” will be observed and complied with at all times.

3. Administrative Support 3.1 The Chair of the Joint Commissioning Committee will be responsible for arranging administrative

support for meetings of the Committee. This will include circulating the agenda and papers for the meeting five clear working days in advance of the meeting, taking minutes and actions of the meeting.

3.2 The Programme Director shall be responsible for supporting the Chair in the management of the


4. Quorum

4.1 A meeting of the Joint Commissioning Committee will be quorate provided that at least five

members comprising of the following are present:

Chair or Vice Chair

One member from each CCG

One Accountable Officer

One Chief Finance Officer

One lay member

5. Frequency of meetings

5.1 The Joint Commissioning Committee will formally meet on a monthly basis. There may be a

need for the Committee to meet informally from time to time. Any informal meetings will support the work of the Committee and will have no delegated decision-making authority.

5.2 Meetings of the Joint Commissioning Committee shall ordinarily be held in public and the agenda

and supporting papers will be made available for public inspection. The Joint Commissioning Committee may resolve to exclude the public from a meeting that is open to the public (whether during the whole or part of the proceedings) whenever publicity would be prejudicial to the public interest be reason of the confidential nature of the business to be transacted or for other special reasons stated in the resolution and arising from the nature of that business or of the proceedings or for any other reason permitted by the Public Bodies (Admission to Meetings) Act 1960 as amended or succeeded from time to time.

5.3 The Joint Commissioning Committee will also meet in ‘shadow form’ whilst its terms of reference

are considered by the constituent CCGs and until it has delegated decision making authority for specified commissioning services. Meetings during this period will be held in private session.

6. Remit Duties and Responsibilities

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6.1 The Joint Commissioning Committee’s specific responsibilities will be delegated to it by each of the four constituent CCGs and will, where appropriate, be reflected in each CCG’s Scheme of Reservation and Delegation. The committee will provide the mechanism for any regulatory requirements for shared CCG reporting, assurance or decision making.

6.2 The responsibilities of the Joint Commissioning Committee will be reviewed regularly as the

single commissioning view for the Black Country develops. The Joint Commissioning Committee’s initial responsibilities will be:-

To make binding decisions on those matters delegated to the Joint Commissioning

Committee on behalf of the CCG

To make recommendations to the four CCGs on the scope of services that should be

commissioned at a Black Country system level;

To organise, on behalf of the four CCGs, the joint commissioning of Specialised Services

across the Black Country with NHSE;

To have oversight of the commissioning of acute and mental health services that have

been established as being within the scope of services commissioned at system level,

which will include:-

o Mapping financial risks across the system;

o Identifying Clinical priorities for transformation;

To establish and manage a transformation programme to support the development of a

single commissioning view for the Black Country;

To develop an Organisational Development plan across the four CCGs to identify the

immediate benefits from shared working and to support the implementation of the

transformation plan; and

To make recommendations for the deployment of resources to support the

implementation of the Transformation Programme.

6.3 The Joint Commissioning Committee will be supported in its work by a Clinical Leadership

Group to advise on clinical strategy. The Clinical Leadership Group will develop its ToR in agreement with the STP and will provide advice and support to the JCC as requested. The Clinical Leadership Group will comprise of lead clinicians from across the STP area. The Clinical Leadership Group has no delegated authority, but will, by virtue of the clinical knowledge and expertise of the membership have a voice of authority to make recommendations and support the clinical leadership of the Joint Commissioning Committee.

6.4 The Joint Commissioning Committee will have the power to establish any task and finish group

and determine the ToR for this so long as it is in line with the responsibilities given to the Joint Commissioning Committee.

7. Managing Conflicts of Interest 7.1 Conflicts of interest are a common and sometimes unavoidable part of the delivery of healthcare.

The Joint Commissioning Committee is required to manage any conflicts of interest through a transparent and robust system. A lay member will act as a conduit and safe point of contact for anyone with concerns relating to conflicts of interest and provide advice and judgement in the management of conflicts. In the event that the Chair and Vice Chair are conflicted the lay member will Chair the meeting or part of. Members of the Joint Commissioning Committee are encouraged to be open and honest in identifying any potential conflicts during the meeting. The Chair of the Committee will be provided with the latest Declaration of Interest register at each meeting and will be required to recognise any potential conflicts that may arise from themselves or a member of the meeting.

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7.2 It is imperative that members of relevant CCGs ensure complete transparency in any decision-making processes through robust record-keeping. Wherever a conflict of interest may be perceived, the matter must always be resolved in favour of the public interest rather than the individual member. If any conflicts of interest are declared or otherwise arise in a meeting, the chair must ensure the following information is recorded in the minutes; who has the interest, the nature of the interest and why it give rise to a conflict; the items on the agenda to which the interest relates; how the conflict was agreed to be managed and evidence that the conflict was managed as intended.

8. Relationship with CCG Governing Body 8.1 The Joint Commissioning Committee is accountable to the each retrospective governing body

to ensure that it has effectively discharging its functions. 8.2 All CCG governing body meetings will receive a copy of the Joint Commissioning Committee

meetings minutes. The Joint Commissioning Committee will also make any recommendations or decisions reserved for the governing body directly.

8.3 Establish Task and Finish Groups as required which will report directly to the Joint

Commissioning Committee. 9. Review of Joint Committee Effectiveness 9.1 The Joint Commissioning Committee will annually self-assess and report to the respective

governing bodies and on its performance in the delivery of its objectives. 9.2 The Joint Commissioning Committee’s terms of reference and duties will be reviewed regularly,

including at the point of Chair rotation and in line with any defined milestones in the Joint Commissioning Committee’s transformation plan. This will ensure that the Joint Commissioning Committee reflects any changes as the STP develops.

9.3 Any changes to the terms of reference will be approved by the resective governing bodies.

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