NHS South West London Governance Handbook (4MB pdf)

Introduction

The Governance Handbook (the ‘Handbook’) has been produced in line with NHS England (NHSE) guidance and fulfils the requirements set out in NHS South West London ICB’s (the ‘ICB’) Constitution and is published on the ICB’s website.

The Handbook will be reviewed annually with oversight from the Audit and Risk Committee, and any changes to the content of the Handbook will be recommended for adoption by the ICB Board.

Scope

The Handbook is intended as a reference guide for members of the public and is applicable to all individuals working for, or on behalf of the ICB.

Purpose

The purpose of the Handbook is to bring together a range of statutory and corporate documents and information in a format that is easy for interested people to navigate. It includes:

1. The Scheme of Reservation and Delegation & Operational Scheme of Delegation (SoRD) – sets out those decisions that are reserved to the Board of the ICB and those decisions that have been delegated in accordance with the powers of the ICB and which must be agreed in accordance with and be consistent with the constitution. The SoRD identifies where, or to whom, functions and decisions have been delegated to;
2. Functions and Decision map – a high-level structural chart that sets out which key decisions are delegated and taken by which part or parts of the system. The Functions and Decision map also includes decision making responsibilities that are delegated to the ICB (for example, from NHSE);
3. Functions and Decision map – a high-level structural chart that sets out which key decisions are delegated and taken by which part or parts of the system. The Functions and Decision map also includes decision making responsibilities that are delegated to the ICB (for example, from NHSE);
4. Standing Financial Instructions – which set out the arrangements for managing the ICB’s financial affairs;
5. Terms of Reference for all committees and sub-committees of the Board that exercise ICB functions;
6. Where applicable, any delegation arrangements for all instances where ICB functions are delegated, in accordance with section 65Z5 of the 2006 Act, to another ICB, NHSE, an NHS trust, NHS foundation trust, local authority, combined authority or any other prescribed body; or to a joint committee of the ICB and one of those organisations in accordance with section 65Z6 of the 2006 Act;
7. Where applicable, any Terms of Reference of any joint committee of the ICB and another ICB, NHSE, an NHS trust, NHS foundation trust, local authority, combined authority or any other prescribed body; or to a joint committee of the ICB and one or those organisations in accordance with section 65Z6 of the 2006 Act;
8. The up-to-date list of eligible providers of Primary Medical Services – the list of practices that nominate the Partner Member for Primary Medical Services;
9. Links to key policy documents including Standards of Business Conduct, Conflicts of Interest and Public Involvement and Engagement

Scheme of Reservation and Delegation & Operational Scheme of Delegation (SoRD)

Appendix One provides the ICB’s Scheme of Reservation and Delegation & Operational Scheme of Delegation (SoRD) which sets out those decisions that are reserved to the Board of the ICB, and those decisions that have been delegated in accordance with the powers of the ICB. The SoRD identifies where, or to whom, functions and decisions have been delegated to.

Functions and Decision map

The Functions and Decisions map on the website provides a high-level structural chart that sets out which key decisions are delegated and taken by which part or parts of the system. The Functions and Decision map also provides an overview of delegated decision-making responsibilities.

Standing Financial Instructions

Appendix Two provides the ICB’s Standing Financial Instructions which set out the arrangements for managing the ICB’s financial affairs.

Committees of the Board

1. The functions and decisions of the ICB are discussed and considered at statutory and non-statutory committees in line with the ICB’s constitution. All committees have a responsibility to operate within their individual Terms of Reference which support effective decision making. Terms of Reference for committees and sub-committees of the Board that exercise ICB functions can be found in Appendix Three. These committees are:
   • Audit and Risk Committee;
   • Remuneration Committee;
   • Finance and Planning Committee; and
   • Place Committees

Key policies

Key policy documents including Standards of Business Conduct and Conflicts of Interest can be found in Appendix Five.

Providers of Primary Medical Services

Appendix Six provides an up-to-date list of eligible providers of Primary Medical Services. These are the list of eligible practices that nominate the Partner Member for Primary Medical Services of the Board.

ICB Code of Conduct and Behaviours

1. The ICB will, at all times, observe generally accepted principles of good governance. This includes the Nolan Principles of Public Life and any governance guidance issued by NHS England.
2. The ICB has agreed a code of conduct and behaviours which sets out the expected behaviours that members of the Board and its Committees will uphold whilst undertaking ICB business.
3. As a publicly funded organisation, we have a duty to set and maintain the highest standards of conduct and integrity. We expect the highest standards of corporate behaviour and responsibility from Board members and everyone who works for or on behalf of the ICB. The Standards of Business Conduct Policy, found in Appendix Two, sets out the principles, public service values and behaviours that will guide decision making in the ICB.

Petitions

Where a valid petition has been received by the ICB it shall be included as an item for the agenda of the next meeting of the Board.

 Review

The Handbook will be reviewed annually, with oversight from the Audit and Risk Committee

Equality Impact Assessment

1. An Equality Impact Assessment (EIA) must be carried out as part of the development of each Policy, Strategy, and Framework document. All public authorities have a legal responsibility to assess their activities, and to set out how they will monitor any possible negative impact upon equality in terms of the protected characteristics of age, disability, gender, gender identity, marriage or civil partnership, pregnancy and maternity or paternity, race, religion or belief, and sexual orientation. If a negative impact is identified, mitigating action will need to be taken to reduce that impact.
2. The Handbook will be reviewed annually, with oversight from the Audit and Risk Committee

Appendix One Scheme of Reservation and Delegation & Operational Scheme of Delegation

Introduction

The arrangements made by NHS South West London Integrated Care Board (ICB) for the reservation and delegation of decisions are set out in this Scheme of Reservation and Delegation (SoRD). The ICB remains accountable for all its functions, including those that it has delegated.

This SoRD may be amended from time to time to reflect changes in legislation, ICB policy or operational requirements.

The ICB will coordinate regular reviews of financial, procurement and contracts signing financial delegations for positions and limits. A revised version is submitted to the Senior Management Team and Audit and Risk Committee for endorsement before submitting it to the ICB Board for approval.

Purpose

The purpose of this document is to consolidate the guiding principles, functions, level and restrictions or conditions of delegated authority for Committees (or other bodies), Executives and / or other staff within the ICB.

The types of financial delegation outlined in this document include:

• Expenditure approval delegations.
• Invoices and credit note requests.
• Business case approval delegations.
• Procurement delegations.
• Contracts signing delegations.
• Other non-financial delegations.

Decisions and functions reserved to the Board

• Consideration and approval of applications to NHS England (NHSE) on any matter concerning changes to the ICB’s constitution or standing orders.
• Approval of the ICB’s Scheme of Reservation and Delegation (SoRD)
• Approve detailed financial policies with detailed review by the Audit and Risk Committee.
• Set out who can execute a document by signature / use of the seal.
• Agree the vision, values, and overall strategic direction of the ICB.
• Approval of the ICB’s operating structure.
• Approval of the ICB’s system plan.
• Approval of the ICB’s corporate budgets that meet the financial duties as set out in the main body of the constitution.
• Approval of the ICB’s annual report and annual accounts.
• Approve the ICB’s arrangements for business continuity and emergency planning.
• Approval of the arrangements for ensuring appropriate safekeeping and confidentiality of records, and for the storage, management and transfer of information and data.
• Approve decisions delegated to joint committees established under section 75 of the 2006 Act.
• Approval and review of significant investments.
• Approval of the arrangements for discharging the ICB’s statutory duties associated with its commissioning functions, including but not limited to promoting the involvement of each patient, patient choice, reducing inequalities, improvement in the quality of services, obtaining appropriate advice and public engagement and consultation.
• Approve the NHS Joint Forward Plan.

Decisions and functions delegated by the Board to ICB committees

Audit and Risk Committee

• Review the adequacy and effectiveness of the system of integrated governance, risk management and internal control across the whole of the ICB’s activities that support the achievement of its objectives, and to highlight any areas of weakness to the Board.
• Ensure that financial systems and governance are established which facilitate compliance with DHSC’s Group Accounting Manual.
• Review the adequacy and effectiveness of the assurance processes that indicate the degree of achievement of the ICB’s objectives, the effectiveness of the management of principal risks.
• Oversight of system risks where they relate to the achievement of the ICB’s objectives.
• Ensure that the ICB acts consistently with the principles and guidance established in HMT’s Managing Public Money.
• Oversight of urgent decisions exercised by the Board.
• Ensure that there is an effective internal auditfunction that meets the Public Sector Internal Audit Standards and provides appropriate independent assurance to the Board.
• Review the work and findings of the external auditors and consider the implications and management’s responses to their work.
• Review the findings of assurance functions in the ICB, and to consider the implications for the governance of the ICB.
• Review the assurance processes in place in relation to financial performance across the ICB including the completeness and accuracy of information provided.
• Review the findings of external bodies and consider the implications for governance of the ICB.
• Approve the ICB’s counter fraud arrangements.
• Ensure adequate and secure Freedom to Speak Up arrangements.
• Review the annual Senior Information Risk Owner (SIRO) report, the submission for the Data Security & Protection Toolkit and relevant reports and action plans.
• Provide assurance to the Board that there is an effective framework in place for the management of risks associated with information governance.
• Monitor the integrity of the financial statements of the ICB and any formal announcements relating to its financial performance.
• Ensure that the systems for financial reporting to the Board, including those of budgetary control, are subject to review as to the completeness and accuracy of the information provided.
• Review the annual report and financial statements (including accounting policies) before submission to the Board.
• Ensure that the ICB’s policy, systems and processes for the management of conflicts, (including gifts and hospitality and bribery) are effective.

Remuneration and Nominations Committee

• Ensuring the ICB follows national pay and terms and condition frameworks to set the pay policy for ICB employees.
• Setting remuneration, allowances and terms and conditions for the Chief Executive and Very Senior Managers (VSMs) in line with national guidance.
• Setting remuneration, allowances and terms and conditions for Integrated Care Board members.
• Agreeing any discretionary payments or terms and conditions for staff employed by the ICB. 
• Approving any termination or redundancy payments.
• Approving TUPE or other staff transfers into or out of the ICB.
• Setting the ICB pay policy and standard terms and conditions of employment for all individuals appointed by the ICB as clinical leads, workers, office holders (this may include pensions, remuneration, fees, travelling or other allowances payable), and any pay awards for these individuals.

Finance and Planning Committee

• Provide assurance to the Board of performance against system control total by scrutiny of financial and planning strategy, strategic and operational financial and non-financial plans, and the current and forecast financial position of the overall ICS.
• As part of the ICB’s performance management role, alongside the Quality and Oversight Committee operate an ICS Performance Framework that enables the Committee to proactively manage the financial, broader performance, and savings agenda across the system, and to assess the performance against the system control total.
• Oversight and approval of the process by which the ICS allocates the annual resource to stakeholders (partners), including both revenue and capital.
• Ensure oversight of financial and planning performance, focusing on oversight of the delivery of ICB-wide efficiency savings, performance and system control total.
• Oversee the arrangements in place for the allocation of resources and the scrutiny of all expenditure.
• Review ongoing Financial Reports (capital and revenue) and the Annual Statement to be presented to the Board.
• Review delivery of savings plans and initiatives through regular reports.
• Provide assurance to the Board and the Audit and Risk Committee of the completeness and accuracy of the financial information provided to the Board.
• Review, by exception, performance report summaries as required, and consider performance issues in so far as they impact on financial resource.
• Review, scrutinise, approve and / or recommend business cases for approval to the Board for both ICB investment and the wider system priorities.
• Review, and agree, procurement decisions as appropriate, in accordance with Standing Financial Instructions and make recommendation to the Board.
• Review tender waivers and tenders from firms not on approved lists and ensure these are reported to the Board and Audit and Risk Committee.
• Review the financial policies of the ICB and make appropriate recommendations to the Board.
• Review and monitor those risks on the ICB’s BAF and Corporate Risk Register which relate to finance. Ensure the ICB is kept informed of significant risks and mitigation plans, in a timely manner.
• Review and agree termination of leases in line with the Scheme of Delegation.

Quality and Performance Oversight Committee

• Ensure that there are robust processes in place for the effective management of Quality and Performance oversight across the system.
• Review governance that supports quality planning, performance oversight, control and improvement, to be assured that the organisation is operate effectively, and timely action is taken to address areas of concern
• Recommend the key quality and performance priorities that are included within the ICB strategy / annual plan, including priorities to address variation / inequalities in care.
• Oversee and monitor delivery of the ICB key statutory / mandatory requirements.
• Review and monitor those risks on the BAF and Corporate Risk Register which relate to quality and system performance, and high-risk operational risks which could impact on care.
• Oversee and scrutinise the ICB’s response to all relevant (as applicable to Quality and Performance oversight) Directives, Regulations, national standard, policies, reports, reviews and best practice as issued by the DHSC, NHSE/I and other regulatory bodies / external agencies (e.g. CQC, NICE) to gain assurance that they are appropriately reviewed and actions are being undertaken, embedded and sustained.
• Oversight of changes in the methodology employed by regulators and changes in legislation/regulation.
• Oversee and seek assurance on the effective and sustained delivery of the ICB Quality Improvement Programmes and broader improvement plans.
• Ensure that mechanisms are in place to review and monitor the effectiveness of the quality of care delivered by providers and place.
• Receive assurance that the ICB identifies lessons learned from all relevant sources.
• Scrutinise the robustness of the arrangements for and assure compliance with the ICB’s statutory responsibilities for safeguarding adults and children.
• Scrutinise the robustness of the arrangements for and assure compliance with the ICB’s statutory responsibilities for infection prevention and control.
• Scrutinise the robustness of the arrangements for and assure compliance with the ICB’s statutory responsibilities for medicines optimisation and safety with operational oversight by the Senior Management Team.
• Develop the ICB Performance Oversight Framework and review this framework annually to ensure that is meets the needs of our system to support delivery of our strategic objectives.
• Oversight of NHS System Oversight Framework reviewing mitigations and assessing risk where appropriate
• Oversee the development and implementation of the system of targeted intervention, ensuring that all issues are considered and review the level and depth of intervention required.
• Oversee the triangulation of performance oversight ensuring that the right balance is struck with workforce, quality, finance and system operational metrics and risks have been fully assessed.
• Ensure that there is accurate alignment of the BAF risks and the performance risks.
• Review the proposed contracting CQUINS on an annual basis and ensure these are aligned to drive forward system quality and transformation objectives.

Decisions and functions delegated by the board to groups, individual board members and employees

Senior Management Team

• Provide assurance to the Finance and Planning Committee of performance against system control total by scrutiny of financial and planning strategy, strategic and operational financial and non-financial plans, and the current and forecast financial position of the overall ICS.
• Oversee the process by which the ICS develops a plan to allocate the annual resource to stakeholders (partners), including both revenue and capital.
• Review ongoing Financial Reports (capital and revenue), including savings plans.
• Review, by exception, quality and performance report summaries as required, and consider mitigations for any issues identified
• Review, scrutinise approve and / or recommend business cases/procurement processes to the Finance and Planning Committee/ Board in line with the Scheme of Delegation. Ensuring expertise and guidance has been sought from the relevant groups recommending any investment/disinvestments, including but not limited to Capital investment group, Primary Care Executive Group, SWL Digital Delivery Board.
• Review the joint working model with NHSE for Specialised Services.
• Oversight and assurance on the productivity of all Delivery, Programme and Transformation Boards, including deployment of funding initiatives.
• Oversight of any statutory workforce responsibilities (e.g. Workforce Race Equality Standard and Workforce Disability Equality Standard.
• Oversight of the delivery of the Provider Collaboratives and Place Partnership Delivery Agreements
• Approve corporate (non-statutory) policies and procedures and recommend adoption to the respective Committee where appropriate.
• Oversees the design of staffing structures and determines the recruitment processes and governance.
• Recommend for approval any non-audit based professional services to be delivered by the ICB’s external auditor.
• Review and approve the acquisition, disposal or change of the use of land / buildings and oversight of Tenancy Agreements across the ICB in line with the Scheme of Delegation.

Contracts & Procurement Group

• Oversight and management of the organisation’s contract register.
• Oversight and management of the organisation’s procurement register.
• Oversight of procurement governance for the ICB.
• Review and award contracts up to agreed delegated limit where funding is identified within budgets.
• Advise of commissioning and decommissioning decisions.

Chief Executive Officer

• Approval of the ICB’s contracts for any commissioning support.
• Approval of the ICB’s contracts for corporate support (for example finance provision).
• Approve arrangements for co-ordinating the commissioning of services with other ICBs and or with the local authority(ies), where appropriate.
• Ensuring that the allocated annual revenue and capital resource limits are not exceeded, jointly, with system partners.
• Approve proposals for actions on litigation and claims handling on behalf of the ICB.
• Approve and determine arrangements for handling FoI requests.
• Approve Publication Scheme.

Chief Financial Officer

• Ensure that the ICB is in a position to produce its required monthly reporting, annual report, and accounts, as part of the setup of the new organisation.
• Ensure that the ICB in each financial year, prepares a report on how it has discharged its functions in the previous financial year.
• Responsibilities in relation to the ICB preparation and audit of annual accounts.
• Responsibilities in relation to the ICB adherence to the directions from NHS England in relation to accounts preparation.
• Ensuring that the allocated annual revenue and capital resource limits are not exceeded, jointly, with system partners.
• Ensuring that there is an effective financial control framework in place to support accurate financial reporting, safeguard assets and minimise risk of financial loss.
• Ensuring the ICB meets statutory requirements relating to taxation.
• Ensuring that there are suitable financial systems in place.
• Responsibilities in relation to the ICB meeting the financial targets set for it by NHS England.
• Use of incidental powers such as management of ICB assets, entering commercial agreements.
• Ensuring the Governance Statement and Annual Accounts & Reports are signed.
• Ensuring planned budgets are approved by the relevant Board; developing the funding strategy for the ICB to support the Board in achieving ICB objectives, including consideration of place-based budgets.
• Making use of benchmarking to make sure that funds are deployed as effectively as possible.
• Executive Members (Partner Members and Non-Executive Members) and other Officers are notified of and understand their responsibilities within the SFIs.
• Financial leadership and financial performance of the ICB.
• Identification of key financial risks and issues relating to robust financial performance and leadership and working with relevant providers and partners to enable solutions.
• Support a strong culture of public accountability, probity, and governance, ensuring that appropriate and compliant structures, systems, and process are in place to minimise.
• Prepare the ICB’s operational scheme of delegation, which sets out those key operational decisions delegated to individual employees of the ICS, not for inclusion in the ICB’s constitution.
• Prepare detailed financial policies that underpin the ICB’s prime financial policies.

Chief People Officer [CPO] (or equivalent people role in the ICB)

Lead the development and delivery of the long-term people strategy of the ICB ensuring this reflects and integrates the strategies of all relevant partner organisations within the ICS.

Other statutory duties and roles delegated to individuals within the ICB include:

• Executive lead for children and young people;
• Executive lead for children and young people with Special Education Needs and Disabilities (SEND);
• Executive lead for safeguarding;
• Executive lead for learning disability and autism; and
• Executive lead for Down’s syndrome.
• Conflicts of Interest Guardian.
• Non-Executive Member with responsibility for Freedom to Speak Up.
• Oversight and assurance to the Board on the Emergency Preparedness, Resilience and Response function.
• ICB Senior Information Responsible Officer – Executive Director of Transformation and People.
• ICB Caldicott Guardian – Chief Medical Officer.
• Nominated responsibility as the Freedom to Speak Up Guardian.

Decisions and functions delegated to the Board by other organisations

• Primary medical care commissioning.
• Pharmacy, Optometry and Dentistry.
• Specialised Commissioning on confirmation of delegation from NHSE.

Section B – Operational scheme of delegation

Introduction & Purpose

1. This schedule of matters delegated to Committees. Groups and Officers (scheme of delegation) has been developed in conjunction with the organisation’s Standing Financial Instructions and will provide guidance for the ICB.
2. The delegation shown below is the lowest level to which authority is delegated. Authority can be delegated upwards with no further action being required. However, delegation to lower levels is only permitted with written approval of the Chief Executive Officer. Decision making with a financial impact must be carried out in accordance with the ICB’s Standing Orders, Prime Financial Policies and detailed financial procedures. All financial limits in this schedule of matters delegated to Officers are subject to sufficient budget being available.
3. The Standing Financial Instructions set out the financial responsibilities of the various Committees, Groups and individuals within the ICB.

Levels of Delegation

• The Scheme of Delegation covers only matters delegated by NHSE/I to the ICB and those matters reserved for the ICB Board its committees, Executive Officers and/or Partners.

• Further delegation may be approved:
  • by the ICB Board in approving specific management policies
  • by the ICB Chief Executive
  • as part of Financial Procedures approved by the Chief Finance Officer (CFO)

• Each Executive Director will need to consider the arrangements for authorisation of expenditure against delegated budgets and further delegation of management/professional responsibilities.

• In accordance with The Scheme of Delegation the ICB Board exercises financial supervision and control by:
  • Authorising the operational plan;
  • Requiring the submission and approval of budgets within approved allocations / overall income;
  • Defining and approving essential features in respect of important procedures and financial systems (including the need to obtain value for money); and
  • Defining specific responsibilities placed on members of the ICB Board, its Committees, Partners and employees as indicated in the Scheme of Delegation.

• Once the ICB Board, has reviewed and approved the Operating Plan and any supporting financial plan / budget, the Board, will delegate approval to the Chief Executive; the Chief Finance Officer and other Executive Directors and employees to commit these resources for the purpose set out in the plan subject to the financial thresholds set out in this document.

• Levels of Sub-Delegation
  • The Delegation of financial limits are also linked to the position/role of the staff member  and the Levels outlined in Schedule 1 will be those set on the financial system.

• Types of Delegation Authority
• The types of financial delegation outlined in this document include:
  • Expenditure approval delegations
  • Invoices and credit note requests
  • Business case approvals and delegations
  • Procurement delegations
  • Contracts signing delegations
  • Other non-financial delegations

Principles

General Delegation Principles

• Delegates Must:
  • Act within your authority by ensuring you hold the relevant delegation
  • Understand your authority by referring to relevant guidance, limitations and directions
  • Act with the ICB’s values in mind
  • Avoid conflicts of interest
  • Consider the ICB’s business needs
  • Seek expert advice when making a decision
  • Make decisions objectively, reasonably and fairly.

• Delegates Must Not:
  • Exercise delegations in respect of someone outside of your immediate line of control
  • Exercise powers in respect of a position higher than your own
  • Exercise a delegation in respect of yourself (i.e. confer a personal benefit)
  • Exercise a delegation on behalf of an absent employee unless it is within the scope of your delegated authority, or you are officially acting in the position.
• Compliance
  • All delegates are required to comply with manuals and directives issued by the ICB
  • Delegated authority is subject to internal controls and to any overriding National laws
• Responsibility
  • Delegations are made to positions, not to persons, and are specific to the position’s work unit and/or role. Ultimate responsibility for performance of the functions or exercise of the authority or power rests with the authority holder.
  • Where an authority holder delegates an authority to an individual position, the person occupying that position becomes personally accountable for the delivery of that authority.
  • The delegation to a position is unique and is not transferable by the delegate.
  • Delegations extend to the Officer substantively appointed to that position and any person acting in that position for a specified period unless otherwise excluded in the terms of the temporary appointment. Delegations do not extend to volunteers.
  • Where the Scheme of Delegation specifies a delegate, the position to which the delegate reports is also deemed to have the delegated authority except where otherwise determined by legislation, policy or a Chief Executive instruction.
  • Where the permanent Officer takes leave, it is their responsibility to instruct the relieving Officer (and the finance department) of the level of delegation that is attached to the position and the responsibilities associated with the delegation for the agreed period. In case of the Chief Executive Officer their responsibility would be delegated to the Deputy Chief Executive Officer in the first instance for any leave.

• Application
  • Delegates are expected to exercise their powers, authorities, duties or functions delegated to them in a responsible, efficient, consistent and cost-effective manner.
  • Discretion is to be utilised by the delegate in determining whether to exercise a delegation or refer the matter to a higher authority.
  • When an Officer is exercising their financial delegation, they are required to clearly provide their name, position and date when signing.

• Financial Delegation Principles

• Delegates Must:
  • Only approve expenditure in cost centres under the delegate’s authority
  • Only approve expenditure where there is sufficient budget to cover the cost
  • Only approve expenditure on goods and services related to official work and business use
  • Only approve expenditure where all relevant ICB’s procedures and policies have been followed
  • Only approve expenditure to the financial limit of the delegation
  • Only approve expenditure where evidence exists that goods have been received and/or services have been performed in accordance with and at the rate/s of an agreed contract or arrangement
  • Employees are to note that an expenditure approval is to be given prior to any commitment being made, contract signed, or purchase order raised.

• Delegates Must Not:
  • approve a gift or settlement of any legal claim unless specifically delegated this authority
  • transfer the financial delegation granted by the ICB Chief Executive to another employee
  • break one purchase down into several smaller items to avoid breaching the financial limit of the delegation
  • approve expenditure on capital works, contracts or special payments unless specifically delegated this authority
  • exceed their delegation limits even if automated systems permit this to occur
  • Approve any expenditure incurred by the delegate on travel, meals, conferences and other similar expenditure
  • Assume the financial delegation of an absent delegate if you are not authorised to do so.
• Suspension, Revocations and Reductions in Financial Delegations
  • The terms of any financial delegation cannot be exceeded under any circumstances.
  • Financial delegations cannot be sub-delegated once granted by the ICB Chief Executive.
  • Improper performance of responsibilities may result in disciplinary action being taken against the employee concerned.
  • The power to revoke, suspend or reduce financial delegations granted to positions within the ICB rests with the Chief Executive in respect of delegations made.
  • If circumstances arise which warrant the suspension, revocation or reduction of a financial delegation, full details must be forwarded to the ICB’s Chief Finance Officer. The ICB’s Chief Finance Officer will submit an appropriate recommendation to the Chief Executive for consideration.
  • If the recommendation is approved, the delegation will be amended to reflect that reduction, suspension or revocation.

• Reviewing and Maintaining the Scheme of Delegations
  • This Scheme of Delegation may be amended from time to time to reflect changes in legislation, ICB policy or operational requirements.
  • The ICB will coordinate regular reviews of financial, procurement and contracts signing financial delegations for positions and limits. A revised version is submitted to  the Senior Management Team (SMT) and Audit and Risk Committee for endorsement before submitting it to the ICB Board for approval.

Summary of Expenditure Approval Financial Delegations

This section will summarise the delegated responsibilities and the associated delegated Officer, linked to the Standing Financial Instructions.

• Management of budgets and approval to spend revenue funds (non-pay)

• The ICB’s annual Budget Plan is approved by the ICB Board at the commencement of the financial year following a review by the Finance & Planning Committee.

• This delegation has application in respect of the management and approval to spend revenue funds for non-pay expenditure included within the annual approved ICB budget plan (for example, approval of purchase orders and sign-off of invoices).

• It should be noted that any spend over £25,000 will need approval from NHSE as part of the ‘triple lock’ process.

• In addition, the ICB has a ‘no PO, no pay’ principle in place. Therefore all expenditure commitments should be through a Purchase Order (PO) except in a pre-agreed limited number of circumstances.

• Delegations relating to the approval of a business case, procurement or the signing of a contract are outlined separately (in Sections 5 and 6).

• The detailed instructions are outlined in SFI section 4 Management Accounting & Business Management

• Management of budgets and approval to spend ICB Capital funds (non-pay)

• The ICB capital plan is developed by the Capital Investment Group, reviewed by Senior Management Team, the Finance and Planning Committee before being approved by the ICB Board prior to publication.

• ICB capital includes:
• Primary care improvement grants
• Primary care ICT grants
• Buildings and equipment
• Leases (under IFRS16) – including the authority to extend or exit tenancy agreements for ICB offices
• It excludes tenancy agreements and void costs that should be managed in line with non-pay revenue investments/spends.

• ICB capital projects are subject to the DHSC and Cabinet office rules for approval as in the Procurement Section.

• Invoice requests (to receive income)

• This delegation has application in respect of the raising of an invoice requesting payment from an external organisation.

• All invoices for NHS commissioning services must go via the SWL ICB Director of Finance.

• Expense claims and Leave Requests

• This delegation has application in situations where an employee is claiming reimbursement for an expense they have incurred personally. The ICB’s detailed policy covering expense claims is outlined in the NHS Terms and Conditions of Service Handbook.

• Management of budgets and approval to spend ICB revenue funds (pay)

• This delegation has application in respect of the management and approval to spend revenue funds for pay expenditure included within the annual approved ICB budget plan – in other words, this delegation applies to recruitment to fully funded staff posts that are included within the existing HR establishment. Note, any proposed increases to the HR establishment or new posts will require a business case to be approved (refer paragraph 4.32).

• The detailed process to be followed when seeking to appoint temporary or permanent staff is outlined in the Vacancy Approval Process, including the role and membership of the Recruitment Sub Committee, and the requirement for the relevant Recruitment Form to be signed off and approved.

• Approval of business cases requesting funding for ICB programmes of work

• A business case (also known as an investment proposal) is a document that provides the rationale for why the ICB should agree to fund a particular project. This delegation has application when a business case requesting funding  is required to be prepared and approved. Note, delegations relating to procurement, or the signing of a contract are outlined separately (refer Sections 5 and 6).

• A business case is required in the following situations:
• When funding is requested in excess of allocated budget OR
• A change to the model of service delivery or model of care is proposed OR
• A change to the HR establishment is proposed OR
• An existing contracted service is required to be re-tendered.

This would include business cases for:

• Entering into a legally binding tenancy or licence agreement with one or more other parties under which each party assumes an obligation.
• There is a change to an existing tenancy or licence agreement held by the ICB or GP practice; 
• The ICB, a Trust, GP practice or other organisation is entering into a new tenancy or licence agreement that is to be underwritten by the ICB with respect to the payment of void costs;
• There is a change to existing tenancy or licence arrangements underwritten by the ICB with respect to the payment of void costs.
• Dispersal of a GP patient list
• All business cases requesting funding should be locally reviewed prior to the case going to the SMT and the SWL Capital Investment Group (where relevant) for endorsement, and then F&PC or ICB Board (dependent on the financial value) for final approval. Further to this any investment, over £25,000 would need to be approved by NHSE as part of the ‘triple lock’ process.

• Determining the appropriate approval process

• The appropriate approval process for a business case is determined by the value of the business case. The following principles should be applied to calculate the value of the business case:
• For non-pay or capital expenditure business cases, the value of the business case should be calculated on the basis of the total cost over 5 years
• For pay expenditure business cases, the value of the business case should be calculated based on the yearly cost, and
• For business cases combining non-pay, capital and pay expenditure, the value of the business case should be calculated on the basis of the total cost over 5 years.
• New revenue budgets can only be funded from reserves; additional capital budgets can only be funded from within the approved capital plan or from an increase in the system capital delegated expenditure limit (CDEL).
• Escalating the business case approval process

• There will be situations where a business case is relatively low value but of strategic importance to the ICB. Accordingly, any Executive Director has the right to override these delegations to escalate approval up the approval process. Example situations include:
• Politically or commercially sensitive, novel or contentious
• Outsourcing of a service with implications on staffing
• Deemed of strategic importance and intrinsically linked to the ICB’s strategic direction and priorities, or
• Where the Place is not meeting its budget control total.
• An Executive Director cannot override these delegations to de-escalate approval down the approval process.

• Review and support for ICS NHS partner business cases

• The ICB is required to have oversight of significant investment (no matter whether they are revenue or capital or a combination) made by partners in the system to ensure they align with the ICS and ICP strategy and provide value for money. These business cases typically relate to additional funds made available by NHSE for specific projects and the strategic investments as part of the system-wide capital plan. On agreeing they align to the system priorities, are affordable and value for money the ICB will be expected to write a letter of support for the scheme.

• Where the NHS makes allocations to individual organisations within the ICS/allocation values are updated in year e.g. pay awards. These would be excluded from requiring a business case

• Prior to the ICB reviewing and agreeing its support to any cases it is expected these will have been through individual partner organisations governance (in line with their SFIs and Scheme of Delegation). Any investment, over £25,000 would need to be approved by NHSE as part of the ‘triple lock’ process and that for significant investment the Cabinet Office rules and DHSC approval thresholds are followed.

• The appropriate approval process for a business case is determined by the value of the business case. Business cases should follow national guidance in their construct:

• Condemnations & Disposals

• The detailed instructions are outlined in SFI10 Losses & Special Payments.

• Losses, Write Offs & Compensation

5.   Summary of Procurement Delegations

• All UK Public Sector organisations are subject to either the Public Procurement Regulations 2015 or the Provider lection Regime Regulations 2023 which stipulate how goods and services should be purchased fairly and transparently with evidence of good value for money.

• The requirements for tendering and contracting by or on behalf of the ICB are outlined in SFI 7 Procurement & Purchasing. The table below summarises the detail in line with the Procurement Policy and any investments above £25,000 would be subject to NHSE approval as part of the ‘triple lock’.

Procurement under the Public Procurement Regulations 2015

These rules apply to all non healthcare services and goods.  The current Public procurement regulation limits are quoted below  – these should be updated when the new limits are issued

• Waiving of Formal Competitive Tendering relating to Public Procurement Regulations 2015
  •  Formal competitive tendering can be waived only in limited circumstances, and these are outlined in SFI 7. In instances where formal competitive tendering is to be waived, an ‘SFI Waiver Form’ must be completed and approved by those with delegated authority. It is important to note that processes cannot be waivered under the Provider Selection Regime Regulations 2023.

This delegation has application when:

• The total contract value is over £25,000 and up to £75,000, and a minimum of three (3) quotations have not been received, OR
• The total contract value is over £75,000 and up to the  limit set out in the Public Contracts Regulations 2015 (PCR), and a minimum of three (3) formal competitive tenders have not been received, OR
• The total contract value is either over the limit set out in the Public Contracts Regulations 2015, a compliant tender process has not been conducted OR a minimum of three (3) formal competitive tenders have not been received.

5.6      Procurement under the Provider Selection Regime Regulations 2023 (PSR)

5.7      From 1 January 2024, healthcare services (defined via Common Procurement Vocabulary Codes, details of which can be found at NHS England » The Provider Selection Regime: statutory guidance) are subject to a new regime of regulations called the Health Care Services (Provider Selection Regime) Regulation 2023 (PSR).

5.8      Unlike Public Procurement Regulations, there is no minimum threshold for procurements subject to the PSR and the process cannot be waived. Where there is a non-compliant award this will need to be approved by Finance and Planning Committee.

5.9      Under PSR, relevant healthcare services can be procured by following one of the five available routes:

• direct award process A – the existing provider is the only provider that can deliver the health care services
• direct award process B – patients have a choice of providers and the number of providers is not restricted by the relevant authority
• direct award process C – the existing provider is satisfying its existing contract, will likely satisfy the new contract to a sufficient standard, and the proposed contracting arrangements are not changing considerably
• most suitable provider (MSP) process – This involves awarding a contract to providers without running a competitive process, because the relevant authority can identify the most suitable provider.
• competitive process – This involves running a competitive process to award a contract.

5.10    PSR allows provision for urgent award or modification in exceptional circumstances where the ICB may need to act urgently and award or modify contracts to address immediate risks to patient or public safety. These circumstances include where:

• a new service needs to be arranged rapidly in an unforeseen emergency or local, regional or national crisis, e.g., to deal with a pandemic
• urgent quality/safety concerns pose risks to patients or the public and necessitate rapid changes
• an existing provider is suddenly unable to provide services under an existing contract (for example, a provider becomes insolvent or experiences a sudden lack of critical workforce) and a new provider needs to be found.

5.11    In line with the requirements of the PSR the ICB shall have a Provider Representation Panel (‘Panel’) to act in an advisory capacity to the Board of Members, its committees, sub-committees and those officers or employees making decisions pursuant to the NHS Provider Selection Regime (‘PSR’).  The purpose of the Panel is to consider representations by eligible providers against procurement decisions made by the ICB under Direct Award Process C, the Most Suitable Provider Process and/or the Competitive Process of the PSR. 

5.12    The Panel cannot override the Original Decision Maker but can identify where there are defects in the process or where decisions were not made on a rational basis and make recommendations to fix any errors.  The Panel can remit a decision back to the Original Decision Maker and ask for the decision to be reconsidered with any defects remedied and Panel recommendations being taken into account.

5.11    All contract awards processes should follow the detailed guidance in the ICB Contracts and Procurement Policy

5.12    Selection of preferred tenderer(s)/compliant direct contract award under either the Public Procurement Regulations 2015 or the Provider lection Regime Regulations 2023

5.13    This delegation has application when a formal competitive tender process is conducted. At the conclusion of the tender evaluation stage, the evaluation team will make a decision on the award of contracts and will prepare a recommendation report that recommends the preferred tenderer(s). The report will detail the factors (including price, quality, and timing) that define the tender that provides the best overall value for money, and provide a comparison with the details of the nearest competing bids, where appropriate, with reasons for their rejection.

5.14    The Delegated Officers have authority to approve the recommendation report. Following approval award, post-tender negotiations can be initiated with the successful tenderer to improve the successful offer, where appropriate, and the formal contract should be prepared.

5.15    Where a purchase exceeds the limit set in the Public Contracts Regulations 2015, but only a single provider is identified having advertised our requirements, approval must be sought from the Chief Finance Officer together with one other executive prior to award of the contract.

5.17    Acceptance of late tenders under either the Public Procurement Regulations 2015 or the Provider lection Regime Regulations 2023

5.18    This delegation has application when a formal competitive tender process is conducted. The Invitation to Tender documentation will specify the date and time by which tenderers must submit a tender response. Late tenders should not be accepted unless in exceptional and genuine circumstances – including, issues outside of the tenderer’s control such as ICT difficulties uploading to the tendering portal, or where acceptance of the tender would ensure adequate competition.

5.20    Continuing Healthcare and Mental health Placement/care package award process (including adults, children and special educational needs and disability placements)

5.21    All placements must be awarded under PSR processes based on national NHS eligibility criteria. However, value for money for the placements should be evidenced and reviewed on a regular basis (see ICB Contracts and Procurement policy). 

5.22    The table below details the delegation limits for all placements. The value relates to the period of award up to the next review point. With the individual/group responsible for ensuring value for money of each award.  This could be as an individual or as part of a wider review panel.

6.   Summary of Contracts Signing Delegations

A contract is an agreement between two or more parties under which each party assumes an obligation (for example, to provide a service) which they intend will be legally binding (that is, it can be enforced by a court). A contract can be reflected in a formal document or can be formed by an exchange of correspondence or even verbal communication.

SWL ICB is a body corporate established under the Health Services Act 2006 according to the laws of England and Wales on 1 March 2012, and may sue and be sued in its corporate name. The legal entity by which SWL ICB contracts with external organisations is the “NHS South West London Integrated Care Board,” with its principal place of business at 120 The Broadway, Wimbledon, SW19 1RH.

There are no values or limits assigned to the Contracts Signing Delegations.

•  Signing healthcare funding contracts and service agreements

This delegation has application when the ICB is entering into a legally binding contractual agreement with a third-party organisation for the provision of NHS healthcare services.

• Signing commercial contracts

This delegation has application when the ICB is entering into a legally binding contractual agreement with one or more other parties under which each party assumes an obligation. A commercial contract could relate to one of the following:

• the supply of goods (including equipment, consumables and consignment stock), services, maintenance or design services
• provision of “works” (as defined in the Public Contracts Regulations 2015)^[2]
• research
• commercial intellectual property.
• Better Care Fund

A commercial contract could take the form of a deed, contract, agreement, release, discharge, indemnity, guarantee, consent, instrument, and any other documents which binds the ICB legally to another party by imposing an obligation on each party. The process should be in line with SFI 7 Procurement & Purchasing.

Before exercising this delegation, the Delegated Officer must ensure that the essential prerequisites have been completed – these include:

• Manager/Director has reviewed the contract specification to confirm it contains the correct scope, reflects any subsequent agreements or negotiations with the supplier, and that specific input has been obtained throughout the drafting process from relevant areas within the ICB (e.g. ICT, information governance and security, clinical service delivery, facilities, data protection including application of the Data Protection Act 2018/UK General Data Protection Regulation)
• Senior Finance Manager OR Director of Finance (ICB) has reviewed the commercial and pricing schedule to confirm the pricing and budgetary aspects are appropriate.
• Where the contract relates to specific goods and/or services obtained through a tender process conducted by the ICB or its external procurement partner (NEL ICB/SBS), have been reviewed to confirm all applicable procurement rules have been complied with and that the terms and conditions are appropriate.
• Contract & Procurement Group has reviewed the procurement governance to confirm it is appropriate and seek further input from specific areas in the ICB and / or legal review from external legal providers, where appropriate.

This contract review and approval process is outlined in the Standard Operating Procedure form which must be completed prior to contract signature and execution.

•  Custody of Seal

The common seal of the ICB shall be the responsibility of the Senior Governance Advisor and kept in a secure place.

• The ICB shall have a Seal. All deeds executed by the ICB shall, unless otherwise so determined, be signed by two duly authorised members of the ICB. The Chief Executive Officer shall keep a register in which s/he, or another manager of the ICB authorised by him/her, shall enter a record of the sealing of every document.
  • In land transactions, the signing of certain supporting documents will be delegated to managers and set out clearly in the Scheme of Reservation and Delegation but will not include the main or principal documents effecting the transfer (e.g. sale/purchase agreement, lease, contracts for construction works and main warranty agreements or any document which is required to be executed as a deed).
  •  Signing non-legally binding administrative arrangements

This delegation has application when the ICB is entering into non-legally binding administrative arrangement with one or more other parties. The non-legally binding administrative arrangements could relate to one of the following:

• Memoranda of Understanding (either intra-ICB, with other NHS organisations, or with a commercial third party)
• Service level agreements (intra/Inter ICB, other NHS Organisations)
• Operating level agreements (intra/Inter ICB, other NHS Organisations)

7.   Summary of Non-financial Delegations

7.1     Risk management and insurance

This delegation has application in respect of the management of risk across the ICB

8.   Schedule 1 – Delegated Expenditure Approval and Invoice Request Limits

The following levels are created for the purposes of linking a position level to a level of authorisation in the electronic financial system for the ICB.

Where a significant contract is approved by the Board, the Chief Finance Officer will have the delegation to raise any purchase orders required related to the approved contract. Evidence of Board approval must be provided with the requisition.

[1] ‘Total Contract Value’ is inclusive of VAT and relates to the whole of life cost of the contract.

[2] Activities constituting “works” are defined in Schedule 2 of the Public Contracts Regulations 2015 to include: construction of new buildings and works, restoring and common repairs; site preparation; building of complete constructions or parts thereof; building installation; building completion; renting of construction or demolition equipment.