SCHEDULE OF THIRD PARTIES WITH WHOM THE TRUST HAS A DUTY OF CO-OPERATION

Directorate of Clinical and Quality Assurance & Trust Secretary SCHEDULE OF THIRD PARTIES WITH WHOM THE TRUST HAS A DUTY OF CO-OPERATION Reference: CEM004 Version: 1.4 This version issued: 14/12/12 Result of last review: Minor changes Date approved by owner (if applicable): 12/12/12 Date approved: 27/06/12 Approving body: Trust Board Date for review: June, 2015 Owner: Director of Clinical and Quality Assurance & Trust Secretary Document type: Miscellaneous Number of pages: 10 (including front sheet) Author / Contact: Alison Hurley, Membership Manager Northern Lincolnshire and Goole Hospitals NHS Foundation Trust actively seeks to promote equality of opportunity. The Trust seeks to ensure that no employee, service user, or member of the public is unlawfully discriminated against for any reason, including the protected characteristics as defined in the Equality Act 2010. These principles will be expected to be upheld by all who act on behalf of the Trust, with respect to all aspects of Equality.

The Code of Governance (paragraph G.2.1) requires that the Board of Directors of a Foundation Trust maintains a schedule of third party organisations in relation to which the trust has a specific duty of co-operation. This document has been produced specifically to fulfil that requirement. Overall, the responsibility for ensuring co-operation with third parties lies with the Chief Executive. Nevertheless, for specific organisations, that responsibility may be delegated to the appropriate director or senior manager. This list is split into third parties with a remit specific to healthcare, and those with a more general remit. The principal functions of the bodies are shown, along with the delegated responsibility within the trust to ensure co-operation, if applicable. Third parties with statutory enforcement powers over NHS Foundation Trusts Third parties with a remit specific to healthcare Care Quality Commission (Chief Executive / Director of Clinical and Quality Assurance & Trust Secretary) The Care Quality Commission registers all care providers in England, including NHS foundation trusts, and monitors providers compliance with its standards on an ongoing basis. The Care Quality Commission has a range of enforcement powers available to it to address failure to maintain compliance with these requirements. In the case of an NHS foundation trust failing to meet these standards, the Care Quality Commission will liaise with Monitor and, taking account of their respective powers, Monitor and the Care Quality Commission will work together to ensure these requirements are met. Health Protection Agency (Chief Executive) The Health Protection Agency is a statutory body set up to: identify and respond to health hazards and emergencies; anticipate and prepare for emerging and future threats; alert and advise the public and Government on health protection; provide specialist health protection services; and support others in their health protection roles. Human Fertilisation and Embryology Authority (Medical Director) The Human Fertilisation and Embryology Authority is a non-departmental government body that regulates and inspects all UK clinics providing IVF, donor insemination or the storage of eggs, sperm or embryos. Regulators of individual health professionals Currently, there are nine regulators of individual health professionals, covering a range of professions. They are the: General Chiropractic Council (Chief Nurse) General Dental Council (Chief Nurse) General Medical Council (Medical Director) Printed copies valid only if separately controlled Page 2 of 10

General Optical Council (Medical Director) General Osteopathic Council; (Medical Director) Health Professions Council (Chief Nurse) Nursing and Midwifery Council (Chief Nurse) Pharmaceutical Society of Northern Ireland (N/A) General Pharmaceutical Council (Chief Nurse) Each has the power to demand the release of information where it relates to a hearing about the fitness to practice of a health professional. Some regulators may also have powers in relation to the accreditation of courses, education or training for health professionals wishing to register. Third parties with a general remit Charities Commission (Director of Finance, Planning & Performance) The Charities Commission is a statutory regulator and registrar for charities in England and Wales. Equality and Human Rights Commission (Director of Organisational Development and Workforce / Director of Operations) The Equality and Human Rights Commission is an independent statutory body established to promote and monitor human rights, and to protect, enforce and promote equality across the nine protected grounds age, disability, gender, race, religion and belief, pregnancy and maternity, marriage and civil partnership, sexual orientation and gender reassignment. Environment Agency (Director of Facilities and Information) The Environment Agency is the leading public body for protecting and improving the environment in England and Wales. It grants licences for waste management services, including clinical waste. Fire Authorities (Director of Clinical and Quality Assurance & Trust Secretary) Fire Authorities are responsible for firefighting and fire safety and may require NHS foundation trusts to make changes to buildings or operations to prevent fires. Health and Safety Executive (Director of Clinical and Quality Assurance & Trust Secretary) The Health and Safety Executive is responsible for the regulation of almost all the risks to health and safety arising from work activity. Human Tissue Authority (Chief Executive / Director of Operations) The Human Tissue Authority (HTA) is a regulator that licenses organisations that store and use human tissue for, for example, research, teaching, treatment, and post-mortem examination and gives approval for organ donations from living people. The HTA, as the Competent Authority for England and Wales for the EU Organ Donation Directive, will set standards for the quality and safety of transplant organs Printed copies valid only if separately controlled Page 3 of 10

across the UK and will develop the first formal regulatory framework and its implementation into legislation by August 2012. Information Commissioner (Trust Secretary) The Information Commissioner oversees and enforces compliance with the Data Protection Act 1998 and Freedom of Information Act 2000. Public Accounts Committee (Chief Executive) The Public Accounts Committee is a parliamentary committee with the power to call any accounting officer of a public body (including NHS foundation trusts) before it. Secretary of State for Health (N/A) NHS foundation trusts are not generally subject to direction by the Secretary of State for Health. However, the Secretary of State has specific duties in respect to safety and security in connection with the provision of high security psychiatric services, and may issue directions which will be applicable to NHS foundation trusts. Third parties with statutory role but no enforcement powers Third parties with a remit specific to healthcare Commissioners (Director of Operations / Director of Finance, Planning and Performance) Commissioners specify in detail the delivery and performance requirements of NHS foundation trusts, and the responsibilities of each party, through legally binding contracts with NHS foundation trusts. NHS foundation trusts are required to meet their obligations to commissioners under their contracts. Any disputes about contract performance should be resolved in discussion between commissioners and NHS foundation trusts, or through their dispute resolution procedures. Commissioners should raise with Monitor serious and persistent concerns regarding an NHS foundation trust s willingness to attempt to agree contracts or ability to remain compliant with its Authorisation. NHS foundation trusts should similarly keep Monitor informed where disputes or potential disputes with commissioners may have an impact on an NHS foundation trust s ability to remain compliant with its Authorisation. Monitor does not expect to be involved in specific contractual disputes. Primary care trusts ( PCTs ) commission secondary care services from NHS trusts, NHS foundation trusts and independent sector treatment centres, controlling 80% of the NHS budget. Each is responsible for monitoring compliance by NHS foundation trusts with their contractual obligations. PCTs play a crucial role in the management of the quality of care delivered, as Printed copies valid only if separately controlled Page 4 of 10

measured by national and local agreements, through contractual arrangements with providers. The independent NHS Commissioning Board, currently a Shadow Special Authority, will be established as a statutory body from October 2012. Its roles will include both the delivery of its own commissioning functions and ensuring that all NHS commissioning is coordinated, comprehensive and effective, supported by clinical networks and senates. It will also take on the safety functions of the National Patient Safety Agency (NPSA). PCTs will be abolished by April 2013 and the NHS Commissioning Board will start considering applications for the establishment and authorisation of Clinical Commissioning Groups (CCGs) from October 2012. Formed by GP practices, these will be responsible for commissioning the majority of healthcare services. Transitional PCT Clusters will support the development of these successor organisations. Health and Wellbeing Boards (Chief Executive) Each top tier and unitary authority will have its own Health and Wellbeing Board. Each will be a forum for health and social care service representatives to collaborate to understand local needs and agree priorities in order to address the broader determinants of health and wellbeing and reduce health inequalities for their local population. Boards will operate in shadow form during 2012/13 and take on their statutory functions from April 2013. Public Health England (N/A) Public Health England (PHE) will be established as part of the Department of Health. It will be responsible for the delivery of improvements in public health outcomes and incorporate functions from the Health Protection Agency from April 2013, the National Treatment Agency for Substance Misuse, Public Health Observatories and cancer registries and will work closely with local authorities. PHE will take on full responsibilities, budgets and powers from April 2012 and public health budgets will be allocated directly to local authorities from April 2013. NHS Blood and Transplant (Director Diagnostics and Therapeutics / Medical Director) NHS Blood and Transplant is a special health authority with responsibility for providing a range of essential health services, including blood and tissue related services across England and transplant related services across the whole of the UK. Printed copies valid only if separately controlled Page 5 of 10

Parliamentary and Health Service Ombudsman (Director of Clinical and Quality Assurance & Trust Secretary) The Parliamentary and Health Service Ombudsman investigates complaints made by or on behalf of people who may have suffered because of unsatisfactory treatment or service by the NHS. Co-operation and Competition Panel (CCP) (Director of Finance, Planning & Performance) The CCP investigates potential breaches of the Principles and Rules for Cooperation and Competition, and makes independent recommendations to strategic health authorities, the Department of Health and, in relation to NHS foundation trusts, Monitor, on how such breaches may be resolved. On receipt of advice from the CCP, Monitor will decide what, if any, action is required on the part of the NHS foundation trust(s) concerned. From April 2012, Monitor will incorporate the CCP and its function. NHS Information Centre for Health and Social Care (Director of Facilities and Information) The NHS Information Centre is a special health authority that collects analyses and presents national data and statistical information about health and social care. NHS foundation trusts are required to report information specified by Schedule 6 of their Authorisation to the NHS Information Centre. Overview and scrutiny committees of local authorities (Trust Secretary) The overview and scrutiny committees of local authorities inquire into all matters of local concern, including, for example, health inequalities and access to services in the NHS. NHS foundation trusts must consult with the relevant overview and scrutiny committees before making any material changes to service offerings that will result in a change to mandatory services, and must provide the overview and scrutiny committees with any information requested. A number of overview and scrutiny committees, some non-local, may take an interest in provision where NHS foundation trusts offer a tertiary referral service on a regional or national basis. Local Involvement Networks (LINks) and HealthWatch England (Trust Secretary) The role of LINks is to give local communities a voice in commissioning health and social care. The Local Government and Public Involvement in Health Act 2007 which established LINks sets out their role and function and also gives the Secretary of State power to make regulations, imposing duties on commissioners and certain providers of health and social care services. HealthWatch England will be established in October 2012 as a sub-committee of the Care Quality Commission. LINks will evolve into local HealthWatch bodies that will: continue LINks current role in shaping the planning and delivery of local health and social care services; help people makes choices; and provide an advocacy service regarding complaints. HealthWatch England will be able to Printed copies valid only if separately controlled Page 6 of 10

advise the Secretary of State for Health, the NHS Commissioning Board, local authorities, Monitor and the Care Quality Commission about concerns raised by local HealthWatch bodies for possible investigation. Third parties with a general remit Ofsted (Chief Nurse) Ofsted is the inspectorate for children and learners in England. It is Ofsted s job to contribute to the provision of better education and care through effective inspection and regulation. HM Inspectorate of Prisons (N/A) HM Inspectorate of Prisons for England and Wales is an independent inspectorate which reports on conditions for and treatment of those in prison, young offender institutions and immigration detention facilities. National Audit Office (Director of Finance, Planning & Performance) The NAO is an independent body headed by the Comptroller and Auditor General and scrutinises public spending on behalf of Parliament. The NAO audits the accounts of all government departments and agencies as well as a wide range of other public bodies, and reports to Parliament on the economy, efficiency and effectiveness with which government bodies have used public money. Third parties with no statutory role but a legitimate interest The third parties on the following list have no statutory powers over NHS foundation trusts. However, Monitor expects that NHS foundation trusts will generally cooperate with such bodies, and a failure to cooperate may, under certain circumstances, constitute a breach of the Authorisation and grounds for intervention. Monitor expects such bodies to influence NHS foundation trusts through the advice they give and NHS foundation trusts to report to Monitor any issues raised by such bodies that could indicate a significant breach of their Authorisation. Monitor will review any reports of non-cooperation, failure to take account of relevant advice (e.g. safety alerts from the NPSA and the organisations to which its functions are transferred) or serious or persistent concerns from such third parties with the NHS foundation trust and make its own judgement on how to proceed. Monitor may choose to intervene if it believes this to be necessary. Third parties with a remit specific to healthcare Clinical Pathology Accreditation (UK) Ltd (Director Diagnostics and Therapeutics) Clinical Pathology Accreditation (UK) Ltd is a private organisation which provides a nationally recognised accreditation service for clinical laboratories. Printed copies valid only if separately controlled Page 7 of 10

Committees, working groups and forums advising the Department of Health on topics across health and social care (Chief Executive) There are about 40 groups which advise the Department of Health on a range of topics across health and social care. Of these, about half may work with foundation trusts from time to time and include: the NHS-wide Clearing Service; the National Specialist Commissioning Advisory Group; and the Specialist Advisory Committee on Antimicrobial Resistance. Confidential enquiries (Medical Director) Confidential enquiries research the way patients are treated, to identify ways of improving the quality of care. They publish reports summarising key findings and recommendations arising from the information they gather. They aim to identify changes in clinical practice that will improve quality of care and ultimately improve patients outcomes. There are three enquiries, each undertaking research in different areas: The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness examines all incidences of suicide and homicide by people in contact with mental health services in the UK. It also examines cases of sudden death in the psychiatric inpatient population; The Centre for Maternal and Child Health Enquiries carries out national confidential enquiries into maternal and child health and a range of other audit and research related activities designed to improve maternal and child health in the UK; and The National Confidential Enquiry into Patient Outcome and Death assists in maintaining and improving standards of medical and surgical care for the benefit of the public by reviewing the management of patients, undertaking confidential surveys and research, and publishing the results of such activities. Medical Education England (Medical Director) Medical Education England is a non-departmental public body that provides independent, expert advice on education and training and workforce planning in the fields of medicine, dentistry, pharmacy and healthcare science. National Patient Safety Agency (Director of Clinical and Quality Assurance & Trust Secretary) The National Patient Safety Agency coordinates the reporting of, and learnings from, mistakes and problems that affect patient safety. It also incorporates the National Clinical Assessment Service, which provides a support service where there are concerns over the performance of an individual doctor or dentist. The NPSA is due to be abolished in July 2012. However, its functions such as patient safety, NCAS, the National Research and Ethics Service and the National Reporting and Learning Service (NRLS) will continue in other ways. NHS organisations should continue to submit their patient safety incident reports to the NRLS to support ongoing learning. Printed copies valid only if separately controlled Page 8 of 10

NHS Business Services Authority (Director of Finance, Planning & Performance) The NHS Business Services Authority is responsible for policy and operational matters relating to prevention, detection and investigation of fraud and corruption in the NHS. NHS Litigation Authority (Director of Clinical and Quality Assurance & Trust Secretary) The NHS Litigation Authority is responsible for handling negligence claims made against NHS bodies in England. It helps to manage clinical risks (via the Clinical Negligence Scheme for Trusts) and non-clinical risks (via the Risk Pooling Scheme for Trusts) and manages claims and litigation for both. Royal Colleges (Medical Director / Director of Operations) Royal colleges aim to ensure high quality care for patients by improving standards and influencing policy and practice in modern healthcare. They set standards for clinical practice, conduct examinations, define and monitor education and training programmes for their members, support clinicians in their practice of medicine, and advise the Government, public and the profession on healthcare issues. The list of Royal colleges includes the: Royal College of Anaesthetists (Medical Director) Royal College of General Practitioners (Medical Director) Royal College of Midwives (Chief Nurse) Royal College of Nursing (Chief Nurse) Royal College of Obstetricians and Gynaecologists (Medical Director) Royal College of Ophthalmologists (Medical Director) Royal College of Paediatrics and Child Health (Medical Director) Royal College of Pathologists (Medical Director) Royal College of Physicians (Medical Director) Royal College of Psychiatrists (Chief Executive) Royal College of Radiologists (Medical Director) Royal College of Speech and Language Therapists (Chief Nurse ) Royal College of Surgeons (Medical Director). Universities and post-graduate deaneries (Medical Director / Chief Nurse / Director of Organisational Development and Workforce) NHS foundation trusts may offer professional education or training in conjunction with universities or other professional bodies. The accreditation process for such education or training may include a requirement for inspection and monitoring of provision. For NHS foundation trusts with cross-border activities in Wales, the list also includes the Welsh Assembly, local health boards, Health Commission Wales and Healthcare Inspectorate Wales. Printed copies valid only if separately controlled Page 9 of 10

The electronic master copy of this document is held by Document Control, Directorate of Clinical and Quality Assurance & Trust Secretary, NL&G NHS Foundation Trust. Printed copies valid only if separately controlled Page 10 of 10