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STAFF GUIDE SUMMARY OF STANDING ORDERS, FINANCIAL INSTRUCTIONS AND CORPORATE GOVERNANCE POLICIES Introduction The rules and regulations setting out how NHS Calderdale, Kirklees and Wakefield District Cluster must be managed are set out in two comprehensive documents: the Standing Orders (SOs), which incorporate; the Standing Financial Instructions (SFIs). A revised set of SOs and SFIs have now been approved by the Cluster Board and these will be reviewed on an annual basis. The policies set out in these documents now apply across NHS Calderdale, Kirklees and Wakefield District. The SOs and SFIs are available to view on the Cluster intranet or our website. Hard copies sit with your local governance and finance leads. This is a summary of the key requirements including; scheme of delegation – this sets out who can sign up to each level; decision making processes; and standards of business conduct. Ensuring that there are adequate processes and controls in place and that these are followed consistently throughout the organisation is essential in order to demonstrate effective use of resources and value for money. These policies will be subject to regular review by both the Internal and External Auditors. It is the responsibility of all staff to be aware of and comply with the SOs, SFI’s and relevant associated policies. FAILURE TO COMPLY WITH STANDING FINANCIAL INSTRUCTIONS AND STANDING ORDERS WILL BE REGARDED AS A SERIOUS MATTER THAT COULD RESULT IN DISCIPLINARY ACTION INCLUDING DISMISSAL

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Support and Contacts The general rule when dealing with commitment of expenditure, procurement of goods and services, or any of the areas covered by the SOs and SFIs is that if you are unclear, you must ask for clarification. Any queries regarding the SOs, SFIs and business cases can be referred to the following staff: Finance lead for NHS Calderdale; Finance lead for NHS Kirklees; and Finance lead for NHS Wakefield District. Any queries in relation to the SOs and code of conduct should be raised with: Governance lead or Chief Operating Officer for NHS Calderdale Governance lead or Chief Operating Officer for NHS Kirklees; and Governance lead or Chief Operating Officer for NHS Wakefield District. A list of the current staff involved is set out in Appendix 1.

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STANDING FINANCIAL INSTRUCTIONS Key issues The critical stage in the process of managing and approving expenditure is the part before a commitment is made, or an order placed - not when an invoice is received. The following information and approval levels refer only to expenditure within budget. Any expenditure outside budget will be subject to approval by the Director of Finance and the Board. Projects that are approved in principle as part of the annual budget are not approved as a commitment. In general a business case will be required and this will need to be approved in line with limits set out in this document. Through the governance arrangements, decision making has been delegated to relevant groups and committees. It should be noted that although these groups can make decisions, the SFIs require that commitments are formally signed off by individual officers in line with the limits set out in Appendix 2. The commitment of any expenditure over £500K (except under an NHS SLA contract) must be approved by the Board. All figures quoted and approval limits include VAT. The amount to be approved must be the total cost of the project, in the case of a 5 year contract it would be the total cost for 5 years, not just the annual cost. Under no circumstances must any transaction be split into smaller parts in order to reduce the amount to be approved. If the total cost of a number of consecutive phases of a project, using one supplier, takes the project over the tender or another authorisation limit, advice must be sought from the Finance lead. This is particularly relevant for service development, IT and consultancy costs. Where in exceptional circumstances these policies are varied, authority must be obtained in writing from the Director of Finance. A list of named contacts is set out in Appendix 1. A list of Directors / delegated officers is set out in Appendix 2B General Goods and Services – Revenue Expenditure Page 3 of 16 Jonathan Molyneux Director of Finance and Efficiency 10 November 2011 V6 / VP / 14 NOVEMBER 2011 C:\Documents and Settings\Rabinder.Bhachu\Local Settings\Temporary Internet Files\Content.Outlook\2QJSAY7R\SOs___SFIs_Summary_for_all_staff_-_2011-11-14_V6.doc


The designated budget holder is responsible for ensuring that there is sufficient budget available, completing the authorisation form accurately and checking that authorisation of the expenditure is within the required delegated authorisation limits before expenditure is committed. A list of delegated limits and cost centre managers is maintained by leads in each of the PCTs as set out in Appendix 1. Where there is not a revenue budget available a business case must be completed and submitted through the agreed local arrangements for approval by the Director of Finance before the expenditure can be committed. NHS Supply Chain must be used wherever possible for procurement of all consumable goods unless the Chief Executive or nominated officers deem it inappropriate. The decision to use alternative sources must be documented. Where public sector contracts or Buying Solutions Agreements (formerly PASA) are in place and have been approved by the Cluster Board this can preclude the need for a formal competitive quotation or tender process. However, where there is more than one approved supplier or contractor in the Buying Solutions Agreements process then a “mini tender” may be required. Tenders and competitive quotations are required for: the supply of goods, materials and manufactured articles outside NHS Supply Chain or public sector agreement; the tendering of services including all forms of management consultancy services (other than specialised services sought from or provided by the Department of Health); and the design, construction and maintenance of building and engineering works (including construction and maintenance of grounds and gardens); for disposals. Quotations for the following limits are required: 3 (three) or more quotes for expenditure between £20,000 and £50,000; formal tendering for expenditure over £50,000; and full OJEC* rules and the prevalent limits should be observed. *OJEC is the Official Journal of the European Community (or Union – OJEU). This is the publication in which all tenders from the public sector, which are valued above a certain financial limit, according to EU legislation, should be published.

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Tender Waivers No exemptions can be made to these Standing Orders relating to tenders, unless authorised appropriately (see SFI 1710.5). A written record of the reasons for the decision must be retained and reported to the Cluster Audit Committee. The waiving of a formal tendering process is limited and full details of the circumstances that are appropriate for a tender waiver is detailed in Paragraph 17.11 of the Standing Financial Instructions. Any potential waiver must be discussed with the relevant Finance lead – see Appendix1. Service Level Agreements (NHS) Service Level Agreements (SLAs) are annual contracts entered into by NHS Calderdale, Kirklees and Wakefield District PCTs with other NHS bodies for provision of healthcare. The top five contracts by value and contingency reserve must be reported to and reviewed by the Board. All contracts with a value of over £1M < £5M must be authorised by a Director. Any contracts over £5M must be authorised by the Chief Executive or the Director of Finance. Contract Variations If an SLA requires a contract variation within the year it must be approved as follows: Up to £250,000

-

Authorised by a Director

Up to £500,000

-

Authorised by the Chief Executive

Over £500,000

-

Authorised by the Board

Contract Over Performance If an SLA over performs, the impact on the available contingency and the overall financial position must be notified to the Board. Individual overtrade invoices must be approved as follows: Up to £250,000

-

Authorised by a Director

Up to £500,000

-

Authorised by the Chief Executive

Over £500,000

-

Authorised by the Board

Staff Appointments

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The engagement or re-banding of employees, either on a permanent or temporary basis, must always be subject to the authorisation of the Chief Executive, the Director of Finance or a Director. This applies also to the hiring of temporary agency staff and to any changes to contract that result in a change in remuneration. Forms must be completed and authorised by the relevant line manager and are available from the Human Resources Department. Current employment legislation dictates that all employees must be issued with a contract of employment within 13 weeks. Variations to, or termination of, contracts of employment are the responsibility of line managers supported by the Human Resources Department. Temporary and Agency Staff It is essential that hours worked by agency or bank staff are recorded accurately and authorised by the appropriate designated manager who should ensure that timesheets are regularly checked. Expenses Expenses incurred exclusively on Trust business must be claimed through completion of the Trust expenses form which must be authorised by the line manager and submitted for payment. Claims must be submitted on a monthly basis and any claims over 3 months old may not be reimbursed. Petty Cash Where staff are required to spend relatively small amounts of their own cash on Trust business they are entitled to recover this through petty cash. The maximum value of a claim is ÂŁ50. All petty cash claims must be supported by a receipt and authorised by a line manager. Legal Advice The commitment to any legal advice (except HR issues) must be approved in advance by the Governance leads and a log maintained. All commitments to HR legal advice will be managed by the HR department and a log maintained by HR.

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Capital Expenditure Capital funding is expenditure over ÂŁ5000 on specific items. These will generally be large items of expenditure with a useful life over several years. This expenditure is charged to the revenue financial accounts over the estimated life of the asset through depreciation, usually 5 to 10 years, rather than all being charged in the year of purchase. Capital expenditure includes the acquisition of land and premises, individual works for the provision, adaptation, renewal, replacement and demolition of buildings, items or groups of equipment and vehicles. All capital items will be included on the asset register and will attract capital charges for the duration of their life. There are strict controls over the procedures to incur expenditure over this limit. All capital expenditure must be supported by an approved business case. Quotations are required under the same circumstances and limits as for revenue expenditure. Business Cases Any expenditure over an approved budget, any capital expenditure and any other new investments must be covered by a business case and approved via the local arrangements and within the limits referred to in this document. For further advice please contact the Business Case leads (see Appendix 1)

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STANDARDS OF BUSINESS CONDUCT It is a long established principle that public sector bodies, which include the NHS, must be impartial and honest in the conduct of their business, and that their employees should remain beyond suspicion. As a publicly funded body, the Trusts have a duty to set and maintain the highest standards of conduct and integrity. The standards of business conduct policy requires all board members and senior staff to declare interests which are relevant and material to their work and position within the NHS as well as requiring all staff to make declarations of any material gifts and hospitality. Where these declarations have been made they are retained in a register which is a public document and subject to audit. The Cluster supports a culture of openness and transparency in its business transitions. The following guidance and policies describe the standards expected of public service employees and how to raise concerns in circumstances of improper conduct: The Nolan Principles on Conduct in Public Life Selflessness:

Holders of public office should take decisions solely in terms of the public interest. They should not do so in order to gain financial or other material benefits for themselves, their family, or their friends.

Integrity:

Holders of public office should not place themselves under any financial or other obligation to outside individuals or organisations that might influence them in the performance of their official duties.

Objectivity:

In carrying out public business, including making public appointments, awarding contracts, or recommending individuals for rewards and benefits, holders of public office should make choices on merit.

Accountability:

Holders of public office are accountable for their decisions and actions to the public and must submit themselves to whatever scrutiny is appropriate to their office.

Openness:

Holders of public office should be as open as possible about all the decisions and actions that they take. They should give reasons for their decisions and restrict information only when the wider public interest clearly demands.

Honesty:

Holders of public office have a duty to declare any private interests relating to their public duties and to take steps to resolve any conflicts arising in a way that protects the public interest.

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Leadership:

Holders of public office should promote and support these principles by leadership and example.

Code of Conduct for NHS Managers The NHS Code of Conduct sets out the core standards of conduct expected of NHS managers. It serves two purposes: to guide NHS managers and employing health bodies in the work they do and the decisions and choices they have to make; and to reassure the public that these important decisions are being made against a background of professional standards and accountability. Standards of Business Conduct for NHS Staff Health Circular HSG 93 5 set out the standards of conduct for NHS staff and is still applicable. This is supplemented by a local standards of business conduct policy in each PCT. Staff are advised to read the circular and their own PCT policy on standards of business conduct and ensure that they complete the relevant forms to record: receipt of gifts and hospitality; outside employment / private practice; sponsorship; and declaration of outside interests. The following link to the national code of conduct is below: http://www.dh.gov.uk/en/AdvanceSearchResult/index.htm?searchTerms=HSG%2893%295 +Standards+of+business+conduct+for+NHS+staff Senior managers in particular have a leadership role in demonstrating expected behaviours. The National Leadership Council is developing a new statement of professional ethics defining core values and standards expected of senior managers.

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Commercial Sponsorship â&#x20AC;&#x201C; Ethical Standards for the NHS (2000) This document issues guidance on the appropriate use of commercial sponsorship within the NHS. It applies to all health professionals working under NHS terms and conditions and extends to all forms of collaborative partnership, including charitable. It outlines considerations to be taken into account before entering into a sponsorship agreement. It sets parameters for the provision and receipt of hospitality and cites examples of potential conflicts of interest. Special provisions cover partnerships involving pharmaceutical companies and research and development based sponsorship. NHS Constitution In 2009 the NHS Constitution became law. This establishes the principles and values of the NHS and the rights to which patients, public and staff are entitled. It also sets out our responsibilities to help the NHS work effectively and ensure resources are used responsibly. The rights of staff and the NHS pledges and commitments can be found in the NHS constitution handbook. In early 2012 changes to the NHS Constitution are expected to protect staff who raise concerns about poor patient care. It will be a duty of all NHS workers to report bad practice or any mistreatment of patients receiving care from the health service and NHS organisations must ensure that concerns raised are fully investigated, with someone independent to talk to and clarity around the legal right of staff to raise concerns without suffering any detriment. The Code of Practice on Openness in the NHS This code of practice sets out the basic principles underlying public access to information about the NHS. It reflects the Government's intention to ensure greater access by the public to information about public services and complements the code of access to Information which applies to the Department of Health. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuida nce/DH_4050490 Conflicts of Interest and Registering Declarations The PCT holds a register of Interests for Board and CCE members which is available for public inspection. Senior Managers are also required to declare any conflict of interest between their personal and professional interests. Managers should discuss this with their Director and notify the Corporate Affairs Manager of any interests that need to be recorded in the register. If any budget holder identifies a pecuniary interest in any supplier being engaged in a business capacity with the Trust, then any requisition or order should be Page 10 of 16 Jonathan Molyneux Director of Finance and Efficiency 10 November 2011 V6 / VP / 14 NOVEMBER 2011 C:\Documents and Settings\Rabinder.Bhachu\Local Settings\Temporary Internet Files\Content.Outlook\2QJSAY7R\SOs___SFIs_Summary_for_all_staff_-_2011-11-14_V6.doc


referred to an independent officer for authorisation. In addition, in the event that a potential conflict of interest exists, Board Directors must exclude themselves from all tendering processes. Gifts and Hospitality Every employee has a duty not to accept gifts and hospitality resulting from their professional duties without the prior permission of the Trust. Managers are asked to ensure that the Trust’s policy is brought to the attention of their direct line staff. The acceptance of small promotional gifts such as stationery is permitted. Acceptance of a light meal, such as sandwiches, fruit and non alcoholic refreshments, at a meeting or event extending through a normal refreshment break is also permitted. Any employee offered gifts or hospitality of a more material nature must seek the prior approval of their Director before accepting and register acceptance of the gift in the Trust’s Register maintained by the Corporate Affairs. Such offers will include alcohol, gifts, meals or visits to sporting events. All gifts received must be declared. Those of £25 or more will require authorisation. An offer of money should not be accepted in any circumstances, and the intending donor should be directed towards making a contribution to the PCT charitable funds. Further information is contained in the PCT Policy “Standards of Business Conduct Policy” available from the intranet or Head of Corporate Governance / Corporate Affairs. The Bribery Act 2010 Bribery is not tolerated. All staff are required to avoid activity that breaches the anti–bribery policies in place in each organisation. Everyone has a responsibility to help detect, prevent and report instances of bribery. Staff can raise their concerns through: the Whistleblowing Policy; the Local Counter Fraud Specialist (Telephone: 01924 816098); and the NHS Fraud and Corruption Reporting line (0800 028 4060) / or online fraud reporting form at www.reportnhsfraud.nhs.uk. Bribery is: “an inducement or reward offered, promise or provided to gain personal, commercial, regulatory or contractual advantage.”

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Under the Bribery Act 2010, it is an offence for employees, individually or in partnership, to: pay bribes: to offer or give a financial or other advantage with the intention of inducing that person to perform a relevant function or activity improperly or to reward that person for doing so; and/or to receive bribes: to receive a financial or other advantage intending that a relevant function or activity should be performed improperly as a result; and fail to prevent bribery: an organisation is guilty of an offence if an associated person, ie someone who performs services on behalf of the organisation, bribes another person intending to obtain or retain business or a business advantage. Individuals are personally liable under the Bribery Act 2010. As well as the possibility of civil and criminal prosecution (conviction under the Act is punishable by imprisonment for a maximum term of 10 years) staff that breach this policy will face disciplinary action, which could result in dismissal for gross misconduct. In certain circumstances, these offences could be committed as a result of a gift consideration being accepted by a friend or relative as well as by a member of staff. Whistleblowing The aim of the Whistleblowing Policy is to encourage staff to come forward to raise concerns in circumstances of improper conduct which are in the public interest, and be confident in the knowledge that they will be listened to, the matter taken seriously, investigated fairly and properly, a response given, action taken and that they will be protected from victimisation and not fear that they may be putting their job, career or training opportunities at risk. To discuss any concerns, in confidence, please contact Human Resources and Organisational Development. Staff are advised to read their own PCT policy on Whistleblowing. Counterfraud Falsifying financial statements or other records to gain financial benefit constitutes fraud. Establishing a false identity is also a fraudulent action. The Standing Orders, Standing Financial Instructions, documented policies and procedures, systems of internal control and risk management are all procedures which protect the Trustâ&#x20AC;&#x2122;s assets by reducing the likelihood of fraud occurring. The Cluster Board supports a risk and fraud awareness culture through its counter fraud arrangements and has contractual arrangements with the Local Counter Fraud Service and Page 12 of 16 Jonathan Molyneux Director of Finance and Efficiency 10 November 2011 V6 / VP / 14 NOVEMBER 2011 C:\Documents and Settings\Rabinder.Bhachu\Local Settings\Temporary Internet Files\Content.Outlook\2QJSAY7R\SOs___SFIs_Summary_for_all_staff_-_2011-11-14_V6.doc


participates in the national programme of action to combat fraud and corruption. All counterfraud activity is reported to the Cluster Board through the Cluster Audit Committee. The policy ensures that the Cluster’s Local Counter Fraud Specialist (LCFS) is notified and the appropriate action taken. The LCFS specialist at the West Yorkshire Audit Consortium (who are also the Trust’s internal auditors) can be contacted in confidence – see appendix 1.

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APPENDIX 1 KEY CONTACTS Finance Leads Neil Smurthwaite for NHS Calderdale Steve Brennan for NHS Kirklees Kay Hughes for NHS Wakefield District Budget / Cost Centre Information Mike Dollman for NHS Calderdale Kirstie Gallant for NHS Kirklees Elizabeth Goodson for NHS Wakefield District Business Case Leads Neil Smurthwaite for NHS Calderdale Alex Wilson for NHS Kirklees Gill Wainwright for NHS Wakefield District Governance Leads or Chief Operating Officers (Including General Legal Advice) Any queries in relation to the SOs, code of conduct and general legal advice Victoria Pickles or Julie Lawreniuk for NHS Calderdale Terry Service (legal advice), Victoria Pickles or Carol McKenna NHS Kirklees Andrea McCourt or Gill Galdins for NHS Wakefield District Local Counter Fraud Specialist (LCFS) Telephone: 01924 816098

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APPENDIX 2A Calderdale, Kirklees & Wakefield District Cluster Authorised Financial Limits Schedule of levels of authorisation to commit expenditure and delegated powers approved by the Cluster Board of Directors.

FINANCIAL LIMIT ÂŁ 1 Commitment of expenditure, with the exception of NHS contracts for health care -

Authorised by Trust Board if greater than

500,000

-

Authorised by the Chief Executive and Director of Finance acting jointly if between

250,000 and 500,000

-

Authorised by a Director and either the Chief Exective or the Director of Finance

100,000 and 250,000

-

Authorised by a Director, up to (the definition of directors includes Executive Directors, Cluster Directors, Accountable Officers, Chief Operating Officers and Chief Financial Officers where appropriate)

-

Authorised by Budget Holders

100,000

10,000

2 Commitment of NHS contracts and expenditure -

Chief Executive and/or Director of Finance (with the top 5 contracts by value must be reported to the Board)

NO LIMIT

-

A Director (the definition of directors includes Executive Directors, Cluster Directors, Accountable Officers, Chief Operating Officers and Chief Financial Officers where appropriate)

1,000,000

-

All other Budget Holders (Heads of Service)

3

10,000

Tenders and quotations -

Competitive quotations to be obtained for contracts not exceeding

-

Competitive quotations must be invited where estimated contract value is between

-

Formal tendering procedure must be applied where estimated contract value exceeds

-

European Union (OJEU) limits and requirements must be followed - current limit must be confirmed

20,000 20,000 & 50,000 50,000 140,000 (Approx)

4 Losses and Compensations Authorisation limits -

Audit Committee

No limit

The above limits include VAT The above limits only apply to expenditure within agreed budgets. Any expenditure over budget has to be agreed by the Board. The limits must be applied to the cumulative cost of a project and must take into account the potential whole lifetime cost of a contract When a contract or order is properly approved the budget manager may subsquently sign invoices for any amounts due under that contract. This will be reflected in the detailed Authorised signatory Lists These limits and further information are set out in the detailed Standing Financial Instructions

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APPENDIX 2B

LIST OF DELEGATED OFFICERS AS AT 1.11.11 Post

Current Post Holder

Chief Executive Executive Director of Finance Executive Medical Director Executive Director of Commissioning Executive Director of Quality and Governance (Executive Nurse)

Mike Potts Jonathan Molyneux Matt Walsh Ann Ballarini Sue Cannon

Director of Public Health - Calderdale Director of Public Health - Kirklees Director of Public Health - Wakefield

Graham Wardman Judith Hooper Andrew Furber

Cluster Cluster Cluster Cluster

Peter Flynn Sheila Dilks Sue Ellis Chris Dowse

Director Director Director Director

of Performance for Transformation for HR & OD for Transition

Accountable Officer - Calderdale Accountable Officer - Kirklees Accountable Officer - Wakefield

Matt Walsh Carol McKenna Jo Webster

Chief Operating Officer - Calderdale Chief Operating Officer - Kirklees Chief Operating Officer - Wakefield

Julie Lawreniuk Carol McKenna Gill Galdins

Chief Finance Officer - Calderdale Chief Finance Officer - Kirklees Chief Finance Officer - Wakefield

Julie Lawreniuk Steve Brennan Gill Wainright

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/v6_SOs___SFIs_Summary_for_all_staff_-_2011-11  

http://www.kirklees.nhs.uk/uploads/tx_galileodocuments/v6_SOs___SFIs_Summary_for_all_staff_-_2011-11-14.pdf

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