Herefordshire CCG Governance Framework

Herefordshire CCG Governance Framework

Herefordshire CCG Page 2 of 39

Contents:

Page

CCG Governance Framework 3

Groups reporting to Clinical Executive 4

Executive v Scrutiny responsibilities (1) 5

Executive v Scrutiny responsibilities (2) 6

Quality and Patient Safety Committee – Terms of Reference 7

Clinical Executive – Terms of Reference 12

Finance, Performance and Resources Committee – Terms of Reference 17

Audit and Assurance Committee – Terms of Reference 22

Communications and Involvement - Terms of Reference 28

Governing Body - Terms of Reference 33

Remunerations Committee – Terms of Reference






OVERVIEW

Chair: Lay Member – Public and Patient Involvement and Primary

Care

Vice Chair Chief Nursing Officer

Administrator and Secretary CCG Business Support Team

CCG Executive Lead Chief Nursing Officer

Frequency of Meetings The Committee will meet bi-monthly.

Agendas and papers will be distributed at least three working

days in advance of the meeting, unless there are exceptional

circumstances for individual papers

Minutes to be distributed five working days after the meeting

Quorum Chair/Vice Chair plus at least 4 members of the committee

including 1 Governing Body GP

Membership Responsibility to cascade information to:

Governing Body Members (voting)

Lay Member – Patient & Public

Involvement or Primary Care

Lay Members

Quality and Patient Safety Committee Terms of Reference Last reviewed at Committee: 05.09.17

Approved at Governing Body:

Next Review: September 2018

Master copy saved: Q:\CCG\HCCG\1. Committees\2. a TORs\Approved TORs 2016.17


Lay Member – Audit & Assurance or

Primary y Care

Lay Members

Clinical Chair or Clinical Vice Chair Clinical Leads

Governing Body - GP Lead Clinical Leads

Secondary Care Lead

Chief Finance Officer SMT and Key Managers

Chief Nursing Officer SMT and Key Managers

Director of Operations SMT and Key Managers

Director of Primary Care SMT and Key Managers

HealthWatch Representative (Co-opted)

Additional members may be co-opted to contribute to specialised areas of discussion

Should a member be unavailable for a meeting, they may nominate a fully briefed deputy to attend in their

place at the agreement of the Chair.

Members of the Committee may nominate deputies as long as these are arrangements are recorded

formally in the Committees minutes

Nominated deputies include for Clinical Chair – Clinical Vice Chair; GP Leads - GP Lead; for Lay members

–Lay Member for Primary Care; Chief Finance Officer – Deputy Finance Officer, Chief Nurse – Deputy Chief

Nurse

Open invitation for attendance

Accountable Officer

Reading Membership Responsibility to cascade information where appropriate

to:

FPR Committee Members


1. Introduction

The Quality and Safety Committee (QPS Committee) is established in accordance with Herefordshire

Clinical Commissioning Group’s (CCG) constitution, standing orders and scheme of delegation. These

terms of reference set out the membership, remit responsibility and reporting arrangements of the QPS

Committee and shall have effect as if incorporated into the clinical commissioning group’s constitution and

standing orders.

2. Purpose of the Committee

As a sub-committee of the Governing Body, the primary role of the QPS Committee is to monitor and

review the quality of services commissioned by the CCG, and promote a culture of continuous improvement

and innovation in

The safety of treatment and care received by patients

The effectiveness of treatment and care received by patients

The experience patients and their carers have of treatment and care received

It shall provide strategic leadership and direction to support the CCG in commissioning high quality

services. It shall support the objectives of the CCG and its Governing Body, and the provision of assurance

to the Governing Body and Audit Committee.

3. Conduct of the Committee

The QPS Committee will conduct its business in accordance with any national guidance relevant

codes of conduct and good governance practice including Nolan’s seven principles of public life

The QPS Committee will, at least annually, review its own performance, membership and terms of

reference. Any resulting changes to the terms of reference will be submitted to the CCG Governing

Body for approval

4. Conflict of Interest Declaration

The Committee Chair will ask at the beginning of each meeting whether any member has a conflict

of interest to declare about any cases being discussed at the meeting

If a member has a direct or indirect connection with an issue on the agenda which may impact on

their ability to be objective they must declare an interest to the Chair. A decision will then be taken

as to whether it is appropriate or not for this member to remain involved.

If a member has been approached and offered advice on the management of a case then this must

be declared to the Chair.

5. Authority

The Committee is authorised by the HCCG Governing Body to investigate any activity within its

Terms of Reference.

Is authorised to seek any information it requires from any employee and all employees are directed

to co-operate with any requests made by the Committee.

The Committee will undertake will subsume the authority, roles and responsibilities of the Quality,

Finance and Resources Committee, in relation to quality and patient safety as defined in the CCGs

scheme of delegation and constitution.


6. Responsibilities and Duties

The duties of the QPS Committee are to be driven by the priorities for the Clinical Commissioning

Group and any associated risks or areas of quality improvement. In order to fulfil its role effectively,

the Committee will:

Provide assurance that commissioned services are being delivered in a high quality and safe

manner, ensuring that quality sits at the heart of everything the CCG does.

Ensure that the provision of high quality is the focus enshrined in all commissioned services and

Herefordshire CCG expectations of its providers to assess and monitor performance against the

quality standards and identify exceptions

Ensure, by the use of benchmarking and clinical evidence, that variations in clinical practice are

identified and addressed and that clinical intervention is based upon best available evidence

Oversee arrangements for managing provider performance against the Quality schedule and

Commissioning for Quality and Innovation (CQUIN) scheme

Receive assurance and provide scrutiny and challenge to all commissioned services ensuring they

meet and exceed relevant statutory and regulatory obligations for the delivery of quality

Receive assurance on behalf of Herefordshire CCG in response to reports from external agencies

relevant to the quality and performance of its commissioned services, including Care Quality

Commission, Monitor and any other relevant regulatory bodies

Receive assurance that the relevant standards in relation to safeguarding children and

safeguarding adults, infection prevention and control, information governance and research are

being complied with and that the risks associated with those items are identified and controlled

Have oversight of the process and compliance issues concerning serious incidents requiring

investigation (SIRI’s) being informed of all Never Events and informing the Governing Body of any

escalation or sensitive issues in a timely manner

Review the outcomes associated with all Serious Incidents including Never Events to ensure that

learning is shared across the CCG and its commissioned services as appropriate

Receive and scrutinise independent investigations reports relating to patient safety and agree

publication plans

Promote research and development within commissioned services and seek assurance of robust

research governance that it is accordance with the Research Governance Framework

To receive regular reports to demonstrate that patient experience obtained through quality

monitoring, patient surveys, patient and public feedback, complaints, PALs, HealthWatch, etc is

being used to drive quality improvement

Review the Risk Register and Quality Assurance Framework on behalf of Herefordshire CCG

Governing Body ensuring they are an accurate reflection of existing risks, key controls and

assurances and incorporate action plans to deliver against gaps in assurance

Review and provide commissioner response to provider annual Quality Accounts

Drive improvements, excellence and innovation in healthcare assurance across commissioned

services and ensure that best practice has been applied in the decision making processes

Support improvement in the quality of primary medical care services, working collaboratively with

NHS England where required

Agree the strategic priorities and annual work plans for quality, governance and assurance work,

linked to Herefordshire CCG strategic priorities and monitor, by exception, any deviations from plan

Lead the development and implementation of Herefordshire CCG Quality Strategy and Quality

Assurance Framework

Ensure quality is a key theme of the commissioning work undertaken via the Service

Transformation and Innovation Group (STIG)


Ensure that appropriate clinical governance arrangements are in place for the CCG commissioning

functions

Ensure information Governance processes and standards are compliant with national requirements

Review and agree key clinical policies or changes to medicines management prescribing guidance

and polices as appropriate

Have due regard to the public sector equality duty and the CCG’s equality objectives

7. Reporting Arrangements

This committee will:

Ensure that a Quality and Patient Safety highlight report is submitted to all Herefordshire CCG

Governing Body meetings

Provide minutes of meetings to Herefordshire CCG Governing Body and Audit Committee

Escalate any significant clinical or financial risk or quality issues to Herefordshire CCG Governing

Body

Share for information committee minutes with the Finance, Performance & Resources Committee

on a monthly basis

8. Accountability and Delegation

The QPS Committee is a committee of the Governing Body and is accountable to it. As a sub-committee of

the Governing Body it has the delegated authority to make recommendations on any matters of quality and

risk and to act where there is a pressing need. It also has the authority to approve business cases,

guidelines and polices on behalf on the Herefordshire CCG Governing Body, in line with the CCGs scheme

of delegation.

9. Review of Terms of Reference

These terms of reference will be reviewed by the committee no later than 1 year from approval of current

Terms of Reference.


OVERVIEW

Chair: GP Clinical Lead

Vice Chair Accountable Officer


CCG Executive Lead Accountable Officer

Frequency of Meetings Once a month


days in advance of the meeting.

Minutes to be distributed five working days after the meeting.

Quorum Chair or Deputy Chair plus 4 CCG members of the committee


Chair Governing Body GP Leads

Clinical Vice Chair GP Leads

Governing Body GP Lead

Governing Body GP Lead

Secondary Care Clinician

Practice Manager

Accountable Officer Key Managers

Clinical Executive Terms of Reference Last reviewed at Committee: Clinical Executive July 2017

Approved at Governing Body: 26th

September 2017

Next Review: March 2018

Master copy saved: Q:\CCG\HCCG\1. Committees\ToRs\2017-18


Chief Nursing Officer Key Managers

Chief Finance Officer Key Managers

Director of Operations Key Managers

Director of Corporate Development Key Managers

Director of Primary Care Key Managers

Director of Transformation Key Managers





formally in the Committees minutes


Lay Members

Reading Membership Responsibility to cascade information where appropriate to:

Executive Leads SMT and Key Managers


1. Introduction

The CCG Clinical Executive is established in accordance with the CCG’s constitution, standing orders and

scheme of delegation. These terms of reference set out the membership, remit, responsibility and reporting

arrangements of the group, and shall have effect as if incorporated into the CCGs constitution and standing

orders.


The purpose of the CCG Clinical Executive is to bridge the gap between the role of the CCG Governing

Body in setting Strategy and delivering health improvements for the people of Herefordshire, and the

operational business of commissioning services and placing contracts on a daily basis.

The volume of commissioning decisions is too great for the CCG Governing Board, hence the need for a

Clinical Executive. The Clinical Executive has a critical role in ensuring that commissioning decisions are in

line with Governing Board Strategies, key responsibilities include:

Ensuring that commissioning decisions and intentions are consistent with the overall strategies set

by the CCG Governing Body within the strategic context of the Herefordshire &Worcestershire STP .

Receiving and approving outline business cases; and making recommendations to the Governing

Body, to ensure that proposals reflect agreed policies and strategies, are consistent with care

pathways agreed (or to be agreed) with providers and that procurement proposals are consistent

with the CCG Governing Body strategy.

Providing assurance to the CCG Governing Body that current service improvement initiatives are

discussed and debated, approved appropriately, prioritised against the CCG strategy and objectives

and have the appropriate governance structure surrounding them.

Acting as key project and programme gateway review point to ensure that QIPP and service

redesign projects and programmes have been sufficiently planned, scoped, costed and resourced,

and potential benefits, outcomes and risks have been identified.

Coordinating all elements of the CCG Portfolio related to QIPP, service transformation and

redesign, in order to realise continuous improvement of commissioned services and ensure value

for money is delivered for Herefordshire citizens and patients.

Ensuring the CCG understands and, where appropriate, aligns its work programme with its key

partners and interdependencies. Offer advice to the CCG Governing Body on the content and

direction of strategies.

3. Conduct of the Clinical Executive

The CCG Clinical Executive will conduct its business in accordance with any national guidance and

relevant codes of conduct and good governance practice including Nolan’s seven principles of

public life.

The Clinical Executive will work in accordance with the CCGs constitution, scheme of delegation

and conflict of interest policy and procedures.


The Clinical Executive will, at least once annually, review its own performance, membership and

terms of reference. Any resulting changes to the terms of reference will be submitted to the CCG

Governing Body for approval.


The Group Chair will ask at the beginning of each meeting for declarations of conflicts of interest

relating to agenda items.

If a member has a direct or indirect connection with an item on the agenda which may impact on

their ability to discuss and reach decisions objectively they must declare a conflict of interest to the

Chair. A decision will be reached as to whether it is appropriate for the member to be involved in

discussions and/or Decision making

If a member has been approached and offered advice on an agenda item then this must be

declared to the Chair

5. Authority

In order to facilitate the achievement of good portfolio management the Clinical Executive is

authorised by the Governing Body to investigate any activity within its terms of reference.

Minutes of the Clinical Executive will be provided for information to the CCG Governing Body.

Matters for consideration by the Clinical Executive may be nominated by any member of the Team

or the CCG Governing Body.

The Clinical Executive is authorised by the CCG Governing Body to obtain outside legal or other

independent professional advice and to secure the attendance of advisers with relevant experience

and expertise if it considers this necessary

The Clinical Executive is authorised by the CCG Governing Body to commission any reports or

surveys it deems necessary to help it fulfil its obligations.

The Clinical Executive will undertake will subsume the authority, roles and responsibilities of the

Service Improvement and Transformation Group as defined in the CCGs scheme of delegation

6. Further Responsibilities and Duties

To fulfil its role effectively, the Clinical Executive will have specific responsibilities. It will:

Identify and prioritise areas for QIPP, service improvement and transformation initiatives in line with

CCG Strategy and Objectives, CCG Clinical Outcomes, patient feedback, the Joint Strategic Needs

Assessment, and in response to issues raised by CCG Governing Body and other stakeholders

Oversee and support the development of ideas and concepts into formal service improvement and

transformation proposals, Evaluating business cases, against a set of criteria, and agree business

cases on behalf of the CCG Board in line with the scheme of delegation

Provide a forum to engage partners and stakeholders, in both CCG and partners/stakeholders work

programmes

Oversee and monitor the implementation of all service improvement and transformation projects and

provide assurance to the CCG Governing Body

Act as an escalation point for current service improvement and transformation programme

implementation, authorise corrective action if QIPP, service improvement and transformation

programmes are behind schedule or not delivering improvement


Assess the impact of programmes in terms of patient outcomes and experience, quality of care,

financial impact and contribution to health outcomes and other targets, ensuring all service

improvement and transformation projects are designed to improve clinical outcomes, promote equality

and diversity, and reduce inequalities

Oversee and monitor the implementation and effectiveness of the CCGs Operating Model and

supporting policies

Oversee the development of the CCGs QIPP plans, assessing the potential impact on patient

outcomes, value for money and contribution to transformation plans

Ensuring risks to delivery are identified, and mitigating actions are in place and implemented

Ensuring appropriate advice and review, including clinical advice and input, has been undertaken and

taking advise from and by Clinical Reference groups and Programme boards in the development of

the CCGs commissioning strategy, commissioning intentions and in the developments business cases

Establish appropriately skilled and resourced task and finish projects as required from time to time.


This committee will:

Receive Action notes and reports from the following committees:

Information, Management and Technology; Medicines Optimisation Group; Service Redesign and

transformation Programme Boards and QIPP workstreams.

Work with the Programme Management Office Function to create, review and update a monthly

Programme Dashboard of all current implementations

Provide minutes of meetings and key activities to the CCG Governing Body

Escalate any significant clinical or financial risk or quality issues to either the CCG Governing Body,

the CCG Quality and Patient Safety Committee or the CCG Finance and Performance Committee

as appropriate.


This is a committee of the CCG Governing Body. As such the committee has delegated authority from the

CCG Governing Body to make recommendations on any matters relating to service improvement and

transformation. It also has the authority to approve business cases, service improvement and

transformation projects, guidelines and polices on behalf of the HCCG Governing Body, in line with the

CCGs scheme of delegation.



Terms of Reference.


OVERVIEW

Chair: Clinical Vice Chair

Vice Chair Lay Member for Audit and Assurance


CCG Executive Lead Chief Finance Officer

Frequency of Meetings The Committee will meet every month





Quorum Chair/Vice Chair plus at least 4 members of the committee;

with at least 1 Governing Body GP in attendance

If quoracy is not met: where it is known before a meeting or

due to exceptional circumstances at the start of a meeting that

quoracy requirements cannot be met the Chair of the meeting

in liaison with the Accountable Officer, will decide to

either formally postpone the meeting or hold the meeting as

an informal briefing

If the latter takes place no formal decisions can be taken or

minutes of previous meeting be approved. However the

Finance, Performance and Resources

Committee Terms of Reference Last reviewed at Committee: 15/08/17

Approved at Governing Body:




meeting may continue to meet to allow those present to be

briefed and discuss key items but no decisions can be taken.

If there is a time-limited decision that was due to be made at

the committee, and due to exceptional circumstances quoracy

requirements are not made, then an e-vote can be undertaken,

as permitted under the CCGs constitution, with Committee and

Governing Body members.


Governing Body Members (voting)

Clinical Vice Chair (Chair)

Lay Member – Audit and Assurance Lay Members

Lay Member – Patient & Public

Involvement or Primary Care

Lay Members

GP Lead Clinical Lead

Practice Manager Lead Practice Manager

Chief Finance Officer SMT and Key Managers

Chief Nursing Officer SMT and Key Managers

Director of Operations SMT and Key Managers

Director of Corporate Development SMT and Key Managers





formally in the Committees minutes.

Nominated deputies include for GP GB Leads - fellow GP Leads; for Lay members –Lay Member for

Primary Care/PPI; Chief Finance Officer – Deputy Finance Officer; Chief Nursing Officer – Deputy Chief

Nursing Officer



Accountable Officer

Clinical Chair or Clinical Vice Chair



QPS Committee Members

1. Introduction

The Committee is established in accordance with Herefordshire Clinical Commissioning Group’s (CCG)

constitution, standing orders and scheme of delegation. These terms of reference set out the membership,

remit responsibility and reporting arrangements of the Committee and shall have effect as if incorporated

into the clinical commissioning group’s constitution and standing orders.


This Committee ensures full consideration of:

Financial performance and associated planning issues

Performance of key providers against key contact standards and associated targets and

performance measures

Performance against HCCG Key Performance Indicators and Targets

Key financial and corporate policies and processes

3. Conduct of the Committee

The Finance, Performance & Resources will conduct its business in accordance with any national

guidance relevant codes of conduct and good governance practice including Nolan’s seven

principles of public life. It will work in accordance with the CCG’s Constitution, Scheme of

Delegation and Conflict of Interest Policy and Procedures.

The Committee will, at least once annually, review its own performance, membership and Terms of

Reference. Any resulting changes to the terms of reference will be submitted to the HCCG












5. Authority

The Committee is authorised by the HCCG Governing Body to investigate any activity within its

Terms of Reference.

Is authorised to seek any information it requires from any employee and all employees are directed

to co-operate with any requests made by the Committee.

The Committee is authorised by the Governing Body to obtain outside legal or other independent

professional advice and to secure the attendance of external representation with relevant

experience and expertise if it considers this necessary.

The Committee will undertake will subsume the authority, roles and responsibilities of the Quality,

Finance and Resources Committee, in relation to finance and performance issues as defined in the

CCGs scheme of delegation and constitution.


The Finance, Performance and Resources Committee shall act on behalf of the CCG in accordance with

powers delegated by the Governing Body as follows:

To receive and consider detailed monthly monitoring reports and year-end forecasts of performance

against financial and contractual performance targets.

Review plans for overview the QIPP delivery plans and delivery of QIPP initiatives.

To make recommendations, as necessary, to the HCCG Governing Body on the actions to be taken

with regard to finance and contractual performance issues

To consider draft annual revenue and capital budgets and to make recommendations to the HCCG

Governing Board.

To consider and agree, where appropriate in-year changes to budgets in line with Standing

Financial Instructions and budget approval policies.

To consider and agree the delegated budgetary limits to responsible officers.

To consider the HCCGs annual performance targets and to recommend action plans to the

Governing Body for their achievement.

To monitor the use of any HCCGs Charitable Funds.

The Committee shall also consider and where appropriate make recommendations on issues

specifically referred to it by the HCCG.

To approve, review and agree HCCGs financial and corporate policies and procedures

To monitor the HCCG’s cash limit and resource limit.

To monitor and review performance of key providers against contract standards and targets and

agree remedial actions or performance notices where relevant


To receive and monitor performance of Commissioning Support Unit against contract standards and

targets and agree remedial actions or performance notices where relevant

To monitor the work programme of the Information Management Technology Group and review how

IM&T resource commitments are proposed to be utilised

To monitor and act as Information Governance Committee to ensure Information Governance

policies and procedures are in place and enacted

To have oversight of , and to review, key corporate policies and procedures including emergency

planning and information governance

To monitor receipt of any pharmaceutical rebates


This committee will;

Ensure that a Finance, Performance and Resources report is submitted to each HCCG Governing

Body.

Provide minutes of meetings to HCCG Governing Body, Quality and Patient Safety and Audit &

Assurance Committee.

Escalate any significant clinical or financial risk or quality issues to HCCG Governing Body and

Quality and Patient Safety Committee.


This is a Committee of the HCCG Governing Body As such the Committee has delegated authority from

the HCCG Governing Body to make recommendations on any matters of quality and risk and to act where

there is a pressing need. It also has the authority to approve business cases, guidelines and polices on

behalf on the HCCG Governing Body, in line with the HCCG’s Scheme of Delegation.



Terms of Reference.


OVERVIEW

Chair: Lay Member for Audit & Assurance

Vice Chair Lay Member for Patient & Public Involvement


CCG Executive Lead Chief Finance Officer

Frequency of Meetings The Committee will meet at a minimum of quarterly intervals or

to facilitate end of year discussions or at the request of

auditors.

Papers to be received at least seven working days prior to

meeting date.

Agendas and papers will be distributed at least five working


circumstances for individual papers.

Minutes to be distributed five working days after the meeting.

Quorum 2 members of the Committee


Lay Member for Audit & Assurance

Lay Member for Patient & Public

Involvement

Lay Member for Primary Care

Audit & Assurance Committee Terms of Reference Last reviewed at Committee: 24

October 2017

Approved at Governing Body: (28 November 2017 tbc)




Independent Chair for Remunerations &

Appointments


CCG Accountable Officer

CCG Chief Finance Officer

CCG Director of Operations

CCG Director of Corporate Development

CCG Executive Lead Nurse

CSU Financial Controller

CCG Practice Manager Lead

External Audit – Grant Thornton

Internal Audit – RSM

Head of Counter Fraud

Additional members may be co-opted to contribute to specialised areas of discussion.

Should an invitee be unavailable for a meeting, they may nominate a fully briefed deputy to attend in their


The Chair of the Governing Body will also be invited to attend one meeting each year in order to form a view

on, and understanding of, the Committee’s operations.

Regardless of attendance, external audit, internal audit, local counter fraud and security management (NHS

Protect) providers will have full and unrestricted rights of access to the Audit & Assurance Committee.


to:

Finance Director – NHS England Regional Team


1. Introduction

The Audit & Assurance Committee is established in accordance with Herefordshire Clinical

Commissioning Group’s (CCG) constitution, standing orders and scheme of delegation. These terms of

reference set out the membership, remit responsibility and reporting arrangements of the Audit &

Assurance Committee and shall have effect as if incorporated into the Clinical Commissioning Group’s

constitution and standing orders.


As a committee of the Governing Body, the primary role of the Audit & Assurance Committee is to

critically review the CCG’s financial reporting and internal control principles, and ensure an appropriate

relationship with both internal and external auditors is maintained. The duties of the Committee are

driven by the priorities identified by the CCG and the associated risks.

3. Remit and Responsibilities of the Committee

The duties of the Audit & Assurance Committee are to be driven by the priorities for the Clinical

Commissioning Group and any associated risks or areas of quality improvement. In order to fulfil its role

effectively, the Committee will:

Integrated Governance, Risk Management and Internal Control

The Committee shall review the establishment and maintenance of an effective system of integrated

governance, risk management and internal control, across the whole of the Clinical Commissioning

Group’s activities that support the achievement of the Clinical Commissioning Group’s objectives. Its

work will dovetail with that of any committee, which the Clinical Commissioning Group could establish to

seek assurance that robust internal controls including clinical quality is in place. In particular, the

Committee will review the adequacy and effectiveness of:

All risk and control related disclosure statements (in particular the governance statement), together

with any appropriate independent assurances, prior to endorsement by the Clinical Commissioning

Group.

The underlying assurance processes that indicate the degree of achievement of Clinical

Commissioning Group objectives, the effectiveness of the management of principal risks and the

appropriateness of the above disclosure statements.

The policies for ensuring compliance with relevant regulatory, legal and code of conduct

requirements, and related reporting and self-certification.

The policies and procedures for all work related to fraud and corruption as set out in Secretary of

State Directions and as required by the NHS Counter Fraud and Security Management Service.

In carrying out this work the Committee will primarily utilise the work of internal audit, external audit and

other assurance functions, but will not be limited to these sources. It will also seek reports and

assurances from officers as appropriate, concentrating on the over-arching systems of integrated

governance, risk management and internal control, together with indicators of their effectiveness. This

will be evidenced through the Committee’s use of an effective assurance framework to guide its work

and that of the audit and assurance functions that report to it.


Internal audit

The Committee shall ensure that there is an effective internal audit function that meets mandatory NHS

Internal Audit Standards and provides appropriate independent assurance to the Audit & Assurance

Committee, Accountable Officer and Clinical Commissioning Group. This will be achieved by:

Consideration of the provision of the internal audit service, the cost of the audit and any questions of

resignation and dismissal.

The Committee will tender and retender internal audit services at its discretion.

Review and approval of the internal audit strategy, operational plan and more detailed programme

of work, ensuring that this is consistent with the audit needs of the organisation, as identified in the

assurance framework.

Considering the major findings of internal audit work (and management’s response) and ensuring

co-ordination between the internal and external auditors to optimise audit resources.

Ensuring that the internal audit function is adequately resourced and has appropriate standing within

the Clinical Commissioning Group.

An annual review of the effectiveness of internal audit.

External audit

The Committee shall review the work and findings of the external auditors and consider the implications

and management’s responses to their work. This will be achieved by:

Consideration of the performance of the external auditors, as far as the rules governing the

appointment permit.

Discussion and agreement with the external auditors, before the audit commences, on the nature

and scope of the audit as set out in the annual plan, and ensuring co-ordination, as appropriate,

with other external auditors in the local health economy.

Discussion with the external auditors of their local evaluation of audit risks and assessment of the

Clinical Commissioning Group and associated impact on the audit fee.

Review of all external audit reports, including the report to those charged with governance,

agreement of the Annual Audit Letter before submission to the Clinical Commissioning Groups

Governing Body and any work undertaken outside the annual audit plan, together with the

appropriateness of management responses.

Other Assurance Functions

The Audit & Assurance Committee shall review the findings of other significant assurance functions,

both internal and external and consider the implications for the governance of the Clinical

Commissioning Group. These will include, but will not be limited to, any reviews by Department of

Health arm’s length bodies or regulators/inspectors (for example, the Care Quality Commission and

NHS Litigation Authority) and professional bodies with responsibility for the performance of staff or

functions (for example, Royal Colleges and accreditation bodies).

Counter fraud

The Committee shall satisfy itself that the Clinical Commissioning 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.


Management

The Committee shall request and review reports and positive assurances from officers on the overall

arrangements for governance, risk management and internal control. The Committee may also request

specific reports from individual functions within the Clinical Commissioning Group as they may be

appropriate to the overall arrangements.

Financial Statements

The Audit & Assurance Committee shall monitor the integrity of the financial statements of the Clinical

Commissioning Group and any formal announcements relating to the Clinical Commissioning Group’s

financial statements (Statutory annual accounts).

The Committee shall ensure that the systems of financial control reporting to the Clinical Commissioning

Group, are subject to review as to ensure completeness.

The Audit & Assurance Committee shall review the annual report and financial statements before

submission to the governing body and GP Parliament, focusing particularly on:

The wording in the governance statement and other disclosures relevant to the terms of reference

of the Committee;

Changes in, and compliance with, accounting policies, practices and estimation techniques;

Unadjusted mis-statements in the financial statements;

Significant judgements in preparing of the financial statements;

Significant adjustments resulting from the audit;

Letter of representation; and

Qualitative aspects of financial reporting.

4. Conduct of the Audit & Assurance Committee

The Audit & Assurance Committee will conduct its business in accordance with any national

guidance relevant codes of conduct and good governance practice including Nolan’s seven

principles of public life.

The Audit & Assurance Committee will, at least annually, review its own performance, membership

and terms of reference. Any resulting changes to the terms of reference will be submitted to the

CCG Governing Body for approval.

Conflict of Interest Declaration

The committee Chair will ask at the beginning of each meeting whether any member has a conflict

of interest to declare about any cases being discussed at the meeting.



as to whether it is appropriate or not for this member to remain involved.

If a member has been approached and offered advice on the management of a case then this must be

declared to the Chair.


5. Relationship to the Governing Body

The Committee is authorised by Herefordshire CCG Governing Body to investigate any activity

within its terms of reference.

It is authorised to seek any information it requires from any employee and all employees are

directed to co-operate with any requests made by the Committee.

The Committee is authorised by the Governing Body to obtain outside legal or other independent

professional advice and to secure the attendance of outsiders with relevant experience and

expertise if it considers this necessary.


This Committee will;

Ensure that an Audit highlight report is submitted to all Herefordshire CCG Governing Body

meetings.

Provide minutes of meetings to Herefordshire CCG Governing Body .


Body.

The Committee will report to the Governing Body annually on its work in support of the Annual

Governance Statement, specifically commenting on the fitness for purpose of the Assurance

Framework, the completeness and embeddedness of risk management in the organisation, the

integration of governance arrangements and the appropriateness of the self-assessment against the

Care Quality Commission Standards.


The Audit & Assurance Committee is a committee of the Governing Body and is accountable to it. As a

committee of the Governing Body it has the delegated authority to make recommendations on any

matters of audit and to act where there is a pressing need. It also has the authority to approve

business cases, guidelines and polices on behalf on the Herefordshire CCG Governing Body, in line

with the CCGs scheme of delegation.

8. Policy and Practice

The Committee will apply best practice in the decision making processes it uses in its work.

The Committee will have full authority to commission any reports or surveys it deems necessary to help

it fulfil its obligations.


These Terms of Reference supersede all previously issued versions; they shall be reviewed by the

Committee annually as part of the Audit & Assurance Committee’s planning process.

These Terms, and any subsequent amendment, shall be subject to approval by the Governing Body.


OVERVIEW

Chair: Lay Member – Public and Patient Involvement

Vice Chair Director of Corporate Development


CCG Executive Lead Director of Corporate Development

Frequency of Meetings The Committee will meet every other month





Quorum Chair/Vice Chair plus at least 3 CCG members of the

Committee


Lay Member – PPI (Chair)

Director of Corporate Development

CSU Communications Lead (Co-opted)

CSU PPI Local Communications Lead

(Co-opted)

Communications & Involvement Committee Terms of Reference Last reviewed at Committee: 03 March 2016

Approved at Governing Body: 24th

January 2017




Public Health Representative (Co-opted)

Practice Manager Board Representative

Chief Nurse or Deputy

Director of Primary Care


HCCG GP Clinical Leads as appointed from time to time

HCCG COST Team programme managers/Medicines Optimisation Team

HCCG GP practices: clinicians and practice managers





to:


1. Introduction

The Herefordshire CCG Communications & Involvement Committee (C&I) is established in accordance with

the CCG’s constitution, standing orders and scheme of delegation. These terms of reference set out the

membership, remit, responsibility and reporting arrangements of the group, and shall have effect as if

incorporated into the CCGs constitution and standing orders.


NHS Herefordshire CCG is intent on ensuring that it has effective communications and engagement

channels in place with a range of stakeholders in order to ensure that the organisation can receive and use

intelligence to inform commissioning decisions. This will help the CCG make sure that health services in

Herefordshire are shaped to meet patient and service user needs, both now and in the future. The

Committees role is to ensure and seek assurance that this principle is central to the CCGs service resign,

transformation and planning work. It will do this by:

Ensuring the CCG Governing Body receives, hear and considers the patients and public view

Monitoring and evaluating the success of the CCG’s Patient and Public engagement and

Communication work

Review and consider how patient and public feedback should be used and employed by the CCG to

inform its plans

This Committee also ensures that the CCG has a regular and systematic focus on external

Communications and this Committee will receive Communication policies/procedure notes etc for

consideration

Ensuring the CCG’s Commissioning Plan is considered and takes account of stakeholders and

residents views

3. Conduct of the Communications & Involvement Committee

The Communication and Involvement Committee will conduct its business in accordance with any

national guidance relevant codes of conduct and good governance practice including Nolan’s seven

principles of public life

The Communication and Involvement Committee will, at least annually, review its own performance,

membership and terms of reference. Any resulting changes to the terms of reference will be

submitted to Herefordshire CCG Governing Body for approval


The Committee Chair will ask at the beginning of each meeting whether any member has a conflict

of interest to declare about any cases being discussed at the meeting



as to whether it is appropriate or not for this member to remain involved

If a member has been approached and offered advice on the management of a case then this must

be declared to the Chair


5. Authority

In order to facilitate the achievement of good portfolio management the group is authorised by the

governing Body to investigate any activity within its terms of reference.

Minutes of the Communications & Involvement Committee will be provided for information to the

HCCG board

Matters for consideration by the Communications and Involvements Committee may be nominated

by any member of the group or HCCG Governing Body.

The Communications & Involvement Committee is authorised by the HCCG Board to obtain outside

legal or other independent professional advice and to secure the attendance of advisers with

relevant experience and expertise if it considers this necessary.

The Communications & Involvement Committee is authorised by the HCCG board to commission

any reports or surveys it deems necessary to help it fulfil its obligations.


The Communications and Involvement Committee shall act on behalf of Herefordshire CCG in

accordance with powers delegated by Herefordshire CCG Governing Body as follows:

To receive and consider the CCGs Communications and Involvement strategy and plans and

monitor delivery of the plan

Review and assesses Patient and Public feedback and ensure that the CCG takes appropriate

account of this within its planning and service transformation work, and feedback is systematic

Seek assurance that significant change or service improvement projects that could impact on health

outcomes or changes to service levels are properly consulted on/involve public and patients

appropriately

Promote the principle of co-production in the design and delivery of commissioning plans and

strategies

Ensure that Patient and Public Involvement and communications capacity and capability provided

internally or externally is of a quality that will support delivery of the CCGs strategic objectives

Review Communications mechanisms and process designed to engage stakeholders and

Herefordshire CCG members and evaluate their success, to provide assurance to the Governing

Body of the robustness of these systems

Horizon scan to promote best practice and innovation across commissioned services

Review and provide assurance to the Governing Body that Equality & Diversity is embedded into the

CCG and ensure we provide equality of opportunity to all our patients, their families and carers to

proactively eliminate direct or indirect discrimination of any kind.

7. Relationship with Providers

The Communication and Involvement Committee will facilitate Herefordshire CCG to establish and link

into provider organisations:


Wherever possible the committee will aim to work with existing networks of providers in gathering

their views and the views of their service users. This will include co-hosting events and being more

visible within the provider network.

The committee will work with providers in the co-production of engagement exercises and plans to

maximise the feedback and its value.

The committee will use social media to link in to and share the communications of providers


This committee will;

Ensure that a Communication and Involvement highlight report is submitted to all Herefordshire

CCG Governing Body meetings

Provide minutes of meetings to Herefordshire CCG Governing Body and Audit Committee


Body


This is Committee of the HCCG Governing Body. As such the Committee has delegated authority from

the HCCG Governing Body to make recommendations on any matters relating to service improvement

and transformation. It also has the authority to approve business cases, service improvement and

transformation projects, guidelines and polices on behalf of the HCCG Governing Body, in line with the

CCGs scheme of delegation.

10. Policy and Practice

The Committee will apply best practice in the decision making processes it uses in its work.


These terms of reference will be reviewed by the committee no later than 1 year from approval of

current Terms of Reference.


OVERVIEW

Chair: GP Clinical Lead

Vice Chair Lay Member – Audit & Governance


CCG Executive Lead Accountable Officer

Frequency of Meetings Minimum of 6 meetings a year to be held in public

Agendas and papers will be distributed at least five working days

in advance of the meeting.

Minutes to be distributed seven working days after the meeting.

Quorum Meetings of the Governing Body will be quorate when there are

a minimum of six voting members present, which must include

representation from the following groups:

o the chair or deputy chair;

o two GPs from the membership (which may include the

Chair of the Governing Body);

o one of either the chief officer or the chief financial officer;

and

o two of the following:

lay members

secondary care clinician

registered lead nurse (Chief Nursing Officer)

practice manager representative

Quorum with declared conflicts of interest: in situations where

the four GP representatives (including the chair) have conflicts

of interest the chair or deputy chair (if the chair is conflicted) will

decide whether they can take part in discussions prior to being

Herefordshire CCG Governing Body Terms of Reference Last reviewed at Committee:

Approved at Governing Body: Nov 17

Next Review: May 2018

Master copy saved:


excluded for voting. In the case of these four members being

excluded because of conflict of interest the quorum is five, which

must include the Deputy Chair, AO (or nominated deputy) or

CFO (or nominated deputy), a lay member (in addition to the

deputy chair), the secondary care clinician or the practice

manager (if not conflicted).

If quoaracy is not met: where it is known before a meeting or

due to exceptional circumstances at the start of a meeting that

quoracy requirements cannot be met the Chair of the meeting in

liaison with the Accountable Officer, will decide to

either formally postpone the meeting or hold the meeting as an

informal briefing

If the latter takes place no formal decisions can be taken or

minutes of previous meeting be approved. However the meeting

may continue to meet to allow those present to be briefed and

discuss key items but no decisions can be taken.

If there is a time-limited decision that was due to be made at the

committee, and due to exceptional circumstances quoracy

requirements are not made, then an e-vote can be undertaken,

as permitted under the CCGs constitution, with Committee and

Governing Body members.

Membership Responsibility to cascade

information to:

Voting Members

Chair Governing Body (Elected Member Representative) GP Leads

Clinical Vice Chair (Elected Member Representative) GP Leads

Governing Body GP Lead (Elected Member Representative)

Governing Body GP Lead (Elected Member Representative)

Practice Manager (Elected Member Representative)

Secondary Care Clinician

Lay member – Audit & Governance (Deputy Chair)

Lay member – Patient and Public Involvement

Lay member – Primary Care


Accountable Officer Key Managers

Chief Nursing Officer (registered lead nurse) Key Managers

Chief Finance Officer Key Managers

Non-Voting Key Managers

Director of Public Health (Herefordshire Council) Key Managers



place at the agreement of the Chair. Members of the Committee may nominate deputies as long as these

are arrangements are recorded formally in the Committees minutes

The following Executive member of the CCG will also be represented at the meeting to aid and support

decision-making:

o Director of Operations

o Director of Corporate Development

o Director of Primary Care

o Director of Transformation


Public (for Public Meetings)

Local Authority Councillors




3. Introduction

The CCG Governing Body is established in accordance with NHS Herefordshire Clinical Commissioning

Group’s (the CCG) Constitution, Standing Orders and Scheme of Delegation. These terms of reference set

out the membership, remit responsibilities and reporting arrangements of the Governing Body and shall

have affect as incorporated into the Constitution and Standing Orders.

The Governing Body members will be active leaders of change, promoting a compelling vision for health

improvement for its local community. The purpose of the Governing Body will be to embed clinical

leadership at the heart of commissioning in Herefordshire and drive transformation and service redesign by

putting people and patients of Herefordshire at the heart of everything the CCG does and commissions.

The Governing Body will put patient safety at the forefront of its work, whilst also ensuring prudent financial

management is at the core of its commissioning strategies and plans.

4. Purpose of the Governing Body

The Governing Body has been delegated all decision making by the CCGs members council (‘GP

Parliament), accept those exceptions as outline din the constitution. Its role and purpose includes:

to lead the development and delivery of the CCGs vision, strategy and plans;

to act as the body that will discharge its commissioning responsibility on behalf of its constituent

members ensuring local health services meet the needs of its resident population and offer best

value for money in spending NHS resources;

improve and develop the principles and practices of good safe quality care to its patients and local

community;

foster and improve collaborative working between CCGs, secondary care and the local authority to

meet the health needs of patients;

lead the development and delivery of commissioning and be accountable for decisions and actions

within the power and authority delegated to it by the Secretary of State for Health;

lead on all governance assurance, openness and transparency matters which will include managing

conflicts of interest, corporate governance, integrated risk management and assurance,

be responsible for demonstrating the delivery of the CCGs financial plans;

be responsible for ensuring a programme engagement of all of its constituent practices to support

the delivery of commissioning plans;

use the power it derives from its clinical leadership to lead and communicate with clinicians across

the health community;

use effective communication methods to involve and share its business to all stakeholders and

partners involved in the local health system; and

work closely with the health and wellbeing arrangements to ensure service design and development

is pooled and aligned effectively.

continue meaningful engagement with our patients, their carer’s and the community;

ensure there is proper constitutional and governance arrangements, with the capacity and capability

to deliver all our duties and responsibilities including financial control, as well as effectively

commission all the services for which we are responsible;


put in place collaborative arrangements for commissioning with other CCG’s, local authorities and

the NHS England; and

have great leaders who individually and collectively will make a real difference

3. Conduct of the Governing Body

The CCG Governing Body will conduct its business in accordance with any national guidance and

relevant codes of conduct and good governance practice including Nolan’s seven principles of

public life.

The Governing Body will work in accordance with the CCGs constitution, scheme of delegation and

conflict of interest policy and procedures.

The Governing Body will, at least once annually, review its own performance, membership and

terms of reference. Any resulting changes to the terms of reference will be submitted to the CCG


The Governing body will meet in public at least 6 times a year, press and members of the public will

only be excluded where publicity would be prejudicial to the public interest.










in situations where the four GP representatives (including the chair) have conflicts of interest the

chair or vice chair (if the chair is conflicted) will decide whether they can take part in discussions

prior to being excluded for voting. In the case of these four members being excluded because of

conflict of interest the quorum is four, which must include the chief officer or formally nominated

representative, and the chief financial officer or formally nominated representative, and a lay

member.

5. Authority and delegation (as outlined in the CCGs constitution)

The GP Parliament has delegated all decision making to the Governing Body with the following exceptions:

Discussions and recommendations to change the Constitution

Electing the GP Members to the Governing Body, including the Chair

Expanding the geographical area of the CCG

Final approval of annual commissioning plans and CCG Annual report

Those matters reserved for joint committees established by the group

The Governing Body has responsibility for:


ensuring that the group has appropriate arrangements in place to exercise its functions effectively,

efficiently and economically and in accordance with the groups principles of good governance (its

main function);

determining the remuneration, fees and other allowances payable to employees or other persons

providing services to the group and the allowances payable under any pension scheme it may

establish under paragraph 11(4) of Schedule 1A of the 2006 Act, inserted by Schedule 2 of the 2012

Act;

approving any functions of the group that are specified in regulations;

ensuring that the register of interests is reviewed regularly, and updated as necessary;

ensuring that all conflicts of interest or potential conflicts of interest are declared;

overseeing the discharge of the public sector equality duty as delegated under section 5.2.;

the Governing Body shall have the authority to delegate any of its activities to a committee or sub-

committee of the Governing Body. Such committee or sub-committee shall be made up of members,

employees, members of the Governing Body or any other person approved by the Governing Body.

That means a committee or sub-committee of the Governing Body may have people on it who are

not members or employees of the group.

Additionally the Governing Body also has authority to

obtain outside legal or other independent professional advice and to secure the attendance

of advisers with relevant experience and expertise if it considers this necessary

to commission any reports or surveys it deems necessary to help it fulfil its obligations

Matters for consideration by the Governing Body may be nominated by any member of the Team or the

CCG Governing Body.


The Governing Body will:

Receive updates and reports from the following committees:

Finance, Resources and Performance

Quality and Patient Safety

Communications and Involvement

Joint Commissioning Board

Audit & Assurance

Remuneration Committee

Minutes of the Governing Body will be made publically available in the CCG’s website


These terms of reference will be reviewed by the Governing Body no later than 1 year from approval of

current Terms of Reference.


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Herefordshire CCG Governance Framework

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