NEATH PORT TALBOT LOCAL HEALTH BOARD CORPORATE GOVERNANCE HANDBOOK

NEATH PORT TALBOT LOCAL HEALTH BOARD CORPORATE GOVERNANCE HANDBOOK Purpose of this Handbook This handbook sets out, in broad terms, the Corporate Governance arrangements in place within Neath Port Talbot Local Health Board and highlights the key issues that everyone needs to be aware of, including responsibilities of the Board, Directors and individual members of staff. This handbook is written in the belief that staff are already achieving high standards of conduct in their work. The handbook is provided as a way of: Informing staff, particularly new staff, of roles and responsibilities; Reinforcing the key messages and requirements of policy and other documents produced on Corporate Governance issues within Neath Port Talbot Local Health Board. What is Corporate Governance? Corporate Governance refers to the mechanisms that are put in place to ensure that the three public services values at the heart of the NHS are fulfilled. These values are: Accountability: Everything done by those who work in the NHS must be able to stand the test of parliamentary scrutiny and public judgments on proprietary and meet the requirements of professional codes of conduct. Probity: Openness: There should be an absolute standard of honesty and integrity. There should be sufficient transparency about NHS activities to promote confidence between the NHS and its staff, patients and the public. The Role of Neath Port Talbot Local Health Board Corporate Governance need to be viewed against the backcloth of the overall purpose of Neath Port Talbot Local Health Board. This purpose is Working to Secure Better Health through: Neath Port Talbot LHB Staff Handbook Corporate Governance 1

Working with others to put health on their agendas; Preventing disease, protecting public health and promoting healthy lifestyles. Shaping and supporting primary, community and secondary care services; Ensuring timely access to health care services; Developing an enabling, responsive organization to work with people; Ensuring probity, value for money, and first class stewardship of resources; Effective auditing, regulation and accreditation of health care services. ACCOUNTABILITY In what ways is Neath Port Talbot Local Health Board accountable to the National Assembly for Wales for what it does? Overall accountability is held by the Board, with the Chief Executive having particular responsibility as the accountable officer. The Board The Board consists of a Non-Executive Chairman, Non-Executive Directors, the Chief Executive and three Executive Directors. The Board is held accountable to the National Assembly for six key functions. Broadly these are: Setting the strategic direction of the LHB and preparing plans to achieve this, e.g. through agreeing Local Strategies for Health and annual Health Plans; Monitoring performance, e.g. receiving reports on the overall contract performance, complaints received, etc; Ensuring effective financial stewardship, e.g. regular reports to the Board, Audit Committee; Ensuring high standards of Corporate Governance, e.g. by agreeing a fraud policy statement; Appointing, appraising and remunerating senior executives; Ensuring effective dialogue with local communities. The activities of the Board are underpinned by Standing Orders and Standing Financial Instructions. Corporate Governance issues included in these are: Neath Port Talbot LHB Staff Handbook Corporate Governance 2

The requirement for the Board to meet regularly, and that their meetings are open to the public; The terms of reference of all sub-committees including audit and remuneration committees; The requirement for Directors to declare formally any interest in companies or organizations in which they have an interest and that may do business with Neath Port Talbot Local Health Board; The appropriate tendering procedure for goods and services; The details of the type of decisions that only the Board can take and what authority is delegated to the Executive. Copies of Standing Orders and Standing Financial Instructions can be obtained from your Director. The Chief Executive The Chief Executive of Neath Port Talbot Local Health Board: Implements the policies of the Board; Is responsible for the financial stewardship of all public monies for which she/he is accountable; Ensures the Authority s financial affairs are conducted legally, effectively, efficiently and economically. In this she/he acts as The Accountable Officer. Further details of the responsibilities and accountabilities of the Chairman, Non-Executive and Executive Directors are available from the Director of Finance. PROBITY By probity we mean maintaining the highest standards of honesty and integrity in carrying out our duties. Neath Port Talbot Local Health Board have several policies and procedures that can help you understand more fully how this can be achieved. These are summarised below. The overriding principles that underpin these policies and procedures are that we are all expected to: Ensure that the interests of patients remain paramount at all times; Be impartial and honest in the conduct of official business; Use the public funds entrusted to us to the best advantage for the NHS, always ensuring value for money. Neath Port Talbot LHB Staff Handbook Corporate Governance 3

Standards of Business Conduct for Staff Policy on Conflict of Interest This policy is to ensure that none of us: Abuses our official position for personal gain or to benefit our family or friends; Seek to advantage or further private business or other interests in the course of our official duties. A short guide of do s and don ts are: DO Make sure you understand the guidelines on standards of business conduct and consult your manager if you are not sure; Make sure you are not in a position where your private interests and NHS duties may conflict; Declare to your manager any relevant interests. If in doubt ask yourself: Am I, or might I be in a position where I (or my family or friends) could gain from the connection between my private interests and my employment? Do I have access to information which could influence purchasing decisions? Could my outside influence be in any way detrimental to the NHS or to patient s interests? Do I have any other reasons to think I may be risking a conflict of interests? If unsure declare it! A register of staff interest is held by the Secretary to the Board. Seek your manager s permission before engaging in any other employment if there is a question of it adversely affecting your NHS duties; Obtain your manager s permission before accepting any commercial sponsorship. Neath Port Talbot LHB Staff Handbook Corporate Governance 4

Do Not Accept any gifts, inducement or inappropriate hospitality; Abuse your post or present official position to obtain preferential rates for private deals; Unfairly advantage one competitor over another or show favoritism in awarding contracts; Misuse or make available official commercial in confidence information. A copy of the policy is contained within the Corporate Health Programme file held in each Directorate. Relationship with the Pharmaceutical Industry A Code of Conduct on how relationships within the Pharmaceutical Industry should be conducted was agreed by the Board. This Code sets out activities that are acceptable and not acceptable in accepting sponsorship or funding from drug companies. The Code is available within each Directorate. Fraud Policy This policy exists to ensure that we all act with propriety in the use of official resources and in the handling of and use of public funds and resources, whether involved with cash or payment systems, receipt or dealing with contractors, suppliers or any other aspect of business. If you believe a fraud is being attempted or is occurring: You should tell your manager immediately; The manager will check the basic facts, and if it is possible that a member of staff may be involved in fraud, must inform the Executive Director of Resources; The Executive Director of Resources will decide on the appropriate course of investigation in conjunction with the Chief Executive; Other than reporting the facts as you know them to your manager, you should not discuss matters with anybody else unless formally instructed to do so; There may be instances when you feel unable to tell your manager of your concerns. In such an instance you could contact the Executive Director of Resources directly or you could write to the Head of Internal Audit. Neath Port Talbot LHB Staff Handbook Corporate Governance 5

Theft of NHS Property Theft means taking anything that does not legally belong to you. NHS resources should not be used for personal benefit. Examples of unacceptable practices are: Taking stationary for personal use; Private use of telephones or photocopying facilities, without paying. Everyone should be aware that theft is considered gross misconduct and will normally result in summary dismissal. Information, Management and Technology (IMT) Security The Local Health Board holds information relating to many aspects of individuals in and around the area, from personal medical records through to financial data. The confidential nature of this data means that staff should exercise extreme caution when managing them, and should on no account misuse their rights of access to such items. There are a number of legal responsibilities in addition to moral duties of care in this area, which are summarised in the LHB s Information Management and Technology Security Policy and associated documents, available from the IT. Department at the Business Service Centre or the Secretary to the Board. I.T. Equipment Staff should exercise extreme care when using the I.T. equipment made available to them to ensure that they do not make inappropriate use of these facilities. This applies particularly to the use of E-mail, and to access to the Internet. The LHB has clear policies governing these areas. Authorised use of NHS Property There may be occasions when a member of staff needs to use NHS property when working at home, or carrying out duties outside NHS premises. This is acceptable as long as permission has been received in advance from the Line Manager. In order to avoid any misunderstanding, this permission should be given in writing and the equipment returned ads soon as possible. Neath Port Talbot LHB Staff Handbook Corporate Governance 6

Surplus Equipment From time to time equipment may become surplus to requirements. In these cases details will be circulated inviting sealed bids from anyone interested in buying the equipment. The highest bidder will be advised if they are able to purchase the item and a receipt given to the buyer as proof of purchase. Financial Control Procedures Underpinning Standing Financial Instructions, the Board has agreed detailed financial control procedures. These are wide ranging procedures covering such things as ordering, requisitioning and receipt of goods. Copies are available within each Directorate. OPENNESS It is extremely important that the LHB conducts its business in an open way in order to keep people fully informed of our role and engender confidence within partner organisations and the wider public that we are opting in an honest and accountable way. Within the LHB, this means: The Board holds all its formal meetings in public, to which the press are invited; We produce an Annual Report and Annual Accounts which are widely available; We provide information to the public within the context of the Code of Practice on Openness in the NHS and will comply with the future Freedom of Information requirements We undertake public consultation on any plans for major service changes including the annual commissioning intentions; Directors declare their interested annually; A formal complaints procedure exists; There is open competition for jobs; We have adopted the Welsh Language Scheme. Neath Port Talbot LHB Staff Handbook Corporate Governance 7

The procedure for dealing with requests for information under the Code of Practice on Openness in the NHS is available. If you have any queries, contact the Secretary to the Board. Freedom of Speech Neath Port Talbot LHB has a procedure in place where staff can raise concerns about any aspect of Corporate Governance or other ethical issues. Such concerns should, in the first instance, be raised with individual line managers. If in doubt, advice can be sought from the Secretary to the Board or the Director of Resources. The procedure has been widely circulated and copies are available on the LHB network. AUDIT ARRANGEMENTS Neath Port Talbot LHB received audit advice from its Internal Auditors, who undertake VFM studies and provide an independent appraisal of internal control systems, and also from the External Auditors (currently the Audit Commission in Wales) who provide an independent assessment of the financial stewardship of the LHB by giving an opinion on the Annual Accounts and producing an annual management letter setting out any concerns. The process is overseen by the Audit Committee, made up of 4 Non- Executive Directors. The Terms of Reference of the Audit Committee are set in the Standing Orders. CONTACT POINTS If you want further information about any of the issues, contact the Director of Finance. BREACHES Any member of staff found to be in breach of any aspect of corporate governance may be subject to disciplinary action. V:\LHB\Chief Executive (CE)\LHB Office & Admin\LHB policies & Procedures (CEOA 3)\Current Policies - from Mar '04\Finance & Commissioning Directorate\CORPORATE GOV HANDBOOK3.doc Neath Port Talbot LHB Staff Handbook Corporate Governance 8