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KIRKLEES PCT. GOVERNANCE COMMITTEE TERMS OF REFERENCE. 1. BACKGROUND The prime governance tasks for a PCT are the effective management of risk, ensuring the provision of quality services, and the effective stewardship of public funds in providing those services. ‘Risk’ should be considered holistically to include:  Financial  Business  Operational  Clinical  Litigation In addition, the PCT is required to ensure probity when commissioning services from its provider arm. 2. PURPOSE OF THE GOVERNANCE COMMITTEE. The Trust Board has delegated authority to the Governance Committee to ensure on its behalf that appropriate systems and processes are in place to achieve and maintain the highest standards of governance and public accountability across the whole spectrum of the PCT’s work. The Board Assurance framework will be used as a tool for monitoring progress. The Governance Group will assure Trust Board that the level of acceptable risk (as determined by Trust Board) is managed as far as reasonably practicable. This will be achieved by working to deliver the following key objectives: 3.      

OBJECTIVES To design a robust system for management of the Board Assurance Framework and review that this is working effectively. To review, challenge and prioritise issues that are important regarding the management of risk within the PCT’s internal and external environments. Monitor compliance against the Standards for Better Health, RPST and Information Governance Toolkit standards and report any exceptions to the Trust Board To own the PCT’s Risk Management and Clinical Governance strategies and ensure that their contents meet national standards and are complimentary. To give direction in the development of polices, procedures and audit across all of the PCT’s activities and to ratify those policies that Trust Board has delegated authority to the committee to do so. To work with senior management to ensure that these strategies and policies are embedded in the daily work of the PCT.


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To set key performance indicators for the management of risk and improvement of quality and monitor progress against these indicators. To ensure that the Practice Based Commissioning practices and consortia have implemented robust corporate and clinical governance arrangements that meet national targets. To approve clinical governance aspects of business cases submitted to the PCT from practices within practice based commissioning arrangements. To ensure that service providers in contract with the PCT, including the primary care provider arm, have effective systems of corporate and clinical governance that meets national targets To ensure that agents commissioning on behalf of the PCT have in place effective corporate and clinical governance arrangements To receive and consider reports the following reports o incident trends, health and safety, security on a quarterly basis o significant incidents ad hoc and annually o the risk register on a quarterly basis o activity, manpower and finance o legal claims, insurance matters ad hoc and annually o complaints and PALs contacts on a quarterly basis o clinical and corporate governance reports regarding commissioned and provided services on a quarterly basis o research governance & information governance on a quarterly basis To receive and consider the minutes of the sub-committees listed in Section 10 to respond appropriately to matters referred to the committee by the Board and Professional Executive Committee

4; ORGANISATION OF THE AGENDA & REPORTS In order to ensure transparency of probity and management of risk by the separate Provider and Commissioner arms of the PCT, the meeting will be divided into two distinct parts. The agenda will be drawn up in such a way that matters pertinent to the Commissioning arm are considered at the start of the meeting and matters pertinent to the Provider arm will be considered at the end of the meeting. This will enable members of the committee to attend only for the relevant part of the meeting.


5; MEMBERSHIP Commissioning Agenda Chief Executive (Chair) NED PEC Risk Management lead. PEC Clinical Governance lead Director of Corporate Affairs Director of Finance Medical Director Internal Auditor Head of Risk Management Head of Clinical Governance

Provider Agenda As for commissioning agenda plus Director of Provider Services

In attendance as appropriate Director of Commissioning Strategic Development Director of Patient Care & Professions Director of Performance & Information Director of Public Health Complaints manager H&S Risk Manager HR Senior Manager Head of PDT Pharmacy lead External advisors Head of Estates The minutes and agenda will be circulated for information to the non-core members, who will be requested to attend according to the subject matter of the agenda. 6; QUORUM The separate halves of the meeting will be quorate on the attendance of one third of the membership which must include the Chair (or their deputy) NB: If a member is unable to attend a meeting, their deputy should attend on their behalf. 7; FREQUENCY OF MEETINGS Meetings of the Governance Committee will normally be on a six weekly cycle, there will be a minimum of 7 meetings per year. The Chief Executive may request additional meetings to address specific items. 8; SUPPORT TO THE COMMITTEE The committee will be supported by the Trust Board Secretary. 9; REPORTING 1; This committee is a sub-committee of the Trust Board and hence directly accountable to the Trust Board. The minutes of each meeting to be presented to the Trust Board for receipt and discussion as appropriate. 2; The minutes and a bullet pointed highlight report to be presented to the Audit Committee


3; Annual Risk Management and Clinical Governance reports will be presented to the Trust Board. These report will be compliant with the criteria contained within the Risk Pooling Scheme for Trusts standards and other external audits as required. 4; Relevant articles will be produced for PCT newsletter and the Team Brief. These will also be posted on the internet / intranet. 10; SUB-COMMITTEES  Operational Risk Management group  Infection Control Committee  Clinical Audit group  Clinical effectiveness group  Supporting Primary Care Practitioners Advisory Group  Information Governance  Accreditation panel for new services 11; CONDUCT OF BUSINESS  Agendas and papers will be circulated to committee members at least 7 calendar days before the meeting.  Minutes of the meeting will be circulated no later than 14 Calendar days after the meeting  This Committee will observe the requirements of the Freedom of information Act 2000, which allows a general right of access to recorded information held by the PCT, including minutes of meetings, subject to specified exemptions.  This committee will operate in accordance with the PCT’s guidance for Chairs and Minute Takers.  All members must declare any conflict of interest they may have regarding an agenda item at the start of the meeting. 12; REVIEW DATE These Terms of Reference will be reviewed on an annual basis. Approved by Trust Board 25th October 2006 Review Date October 2007


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