PROCUREMENTPOLICY

October2013

Authorship:GaryMetcalfe–Procurement Manager

CommitteeApproved:NHSNorthLincolnshireClinicalCommissioningGroup GoverningBody

Approveddate:12December 2013 ReviewDate:

Equality ImpactAssessmentCompleted- Screening

SustainabilityImpact Assessment:Completed

TargetAudience: PolicyReferenceNo: VersionNumber:

The on-lineversionistheonlyversionthat is maintained. Any printedcopies should,therefore,be viewedas ‘uncontrolled’andas suchmay not necessarilycontainthelatest updates and amendments.

POLICYAMENDMENTS

AmendmentstothePolicywill be issued fromtime totime.Anewamendment history will be issuedwith each change.

New
Version Number / Issuedby / Nature of Amendment / Approvedby& Date / Date on
Intranet
1.0 / Procurement
Manager / - / NHS North
LincolnshireCCG GoverningBody– 12.12.13
1.1 / Procurement
Manager / 10.2
Public Contracts Regulations2006–From1 January2012 updatedto Public Contracts Regulations2006–From1
January2014

Contents

1.Overview ...... 4

2.PolicyStatement ...... 4

3.KeyProcurementPrinciples ...... 4

4.KeyDriversandConsiderations ...... 5

5.PrimeFinancialPolicies/ProcurementApproval ...... 7

6.KeyAccountabilities ...... 8

7.KeyResponsibilities ...... 8

8.ConflictsofInterest ...... 8

9.SignificantProcurementthresholds(CCG) ...... 10

10.OJEUProcurementThresholds ...... 10

11.Non-HealthCareProcurement ...... 11

12.National/RegionalFrameworkContracts ...... 11

13.TenderWaivers ...... 12

14.HealthandSocialCareProcurement ...... 12

Appendices……………………………………………………………………………………………………………………….19

1.Overview

1.1Procurementistheprocessbywhichservices,goods,productsand infrastructureareacquired from externalorganizationsandproviders.The procurementprocessstarts withtheidentificationofneedandcontinuesthroughtotheendoftheagreedcontractorendoftheusefullifeoftheacquiredasset.

1.2Procurementcancoverarangeofpurchasingmethods:

  • Spot,lowcostpurchasing
  • Quotations
  • Full-scaleTenders
  • AnyQualifiedProvider
  • FrameworkAgreements
  • PublicPrivatePartnerships

1.3Procurementplaysakeyroleindeliveringhighquality,valueformoney,customer/patientcenteredservices.ThisdocumentoutlinesNorthLincolnshireClinicalCommissioningGroup’sprocurementpolicy,includinggeneralpurchasingandtenderprocess,legalobligations,environmentalissues,andgivesdetailsof EuropeanUniontenderingtimetables

1.4ThisProcurementPolicyisanintegralpartofthecommissioningcycleandfully observesestablishedPrimeFinancialPoliciesandasaresultshouldnotbereadin isolation.

1.5ThisProcurementPolicywillberefreshedasfurtherNHSProcurementPolicyGuidanceisissued.ThisPolicywillalsoberefreshedtotakeaccountofthescheduled2014EUProcurementRulechanges.

2.PolicyStatement

2.1NorthLincolnshireCCGiscommittedtothe provisionandmaintenanceofhigh qualitycareandservicesforitslocalcommunity.Thispolicyisdesignedtoprovideguidanceandinstructionsontheprocurementofallgoodsandservicesprovidedto NorthLincolnshireCCG.

2.2To support the policya series of practice guides will be established to providedetailed guidanceontheprocurementprocess.

3.KeyProcurement Principles

3.1Thekeyprinciplesofgoodprocurement,aslaiddownbytheDepartmentofHealth,areshownbelowand willactasatouchstonefordevelopingprocurementpractice.

  • Transparency–includingtheuseofsufficientandappropriateadvertisingof tenders,transparencyinmakingdecisionstotenderor nottotender,andthedeclarationandseparation ofconflictsofinterest.
  • Proportionality–makingprocurementprocessesproportionatetothevalue,complexityandriskoftheservicescontracted,andcriticallynotexcludingpotentialprovidersthroughoverlybureaucraticorburdensomeprocedures.
  • Non-discrimination–ensuringconsistencyofprocurementrules,transparencyontimescaleandcriteriaforshortlistandaward.
  • Equalityoftreatment–ensuringthatallprovidersandsectorshaveequal opportunitytocompetewhereappropriate;thatfinancialandduediligencechecksapplyequallyandareproportionate;andthatpricingandpaymentregimesaretransparentandfair.

4.KeyDrivers and Considerations

4.1Indevelopingthisprocurementpolicyitisclearthatprocurementbestpracticeshouldbeappliedtoallfunctionalareas,specificallyforHealthcareprocurementthefollowingbusinessareas/driversareimportant.

ServiceQuality,SafetyandEffectiveness

Providersmustbeabletodemonstrate,viathecompletionofadetailed questionnaireregarding theservicesto beprocuredthattheservicestobeprovidedaredeliveringtherequiredoutcomesandareofthehighestpossible quality, aresafeandeffective.NorthLincolnshireCCG requiresprovidersto demonstratecompliancewithbestpractice,(includingallclinicalguidelinesand advice),thattheyhaveclearclinicalleadership,aplannedclinicalauditprogrammeinplaceandtoprovideclinicaldatashowingthesafetyand effectivenessoftheirservices.NorthLincolnshireCCGwillnotcommission servicesfromprovidersthatcannotdemonstratecompliancewithestablished qualityassuranceframeworks.

Choice

Wheneverpossible,andappropriate,patientsandservicesshouldbeoffereda choiceofprovider. NorthLincolnshireCCGwillworkwithkeystakeholdersto ascertainthoseservicesthatwillbedeliveredbyasingleprovider,andthosewhichwillofferchoiceinthelocalareaandwillbeexplicitaboutthereasonsforthis.ThisprocesswillneedtocomplyfullywithUKandEUcompetition requirementsandwillincorporateappropriate stakeholderconsultation.

PotentialforServiceDe-stabilisation

NorthLincolnshireCCGrecognisesthatcertainservicesmustproperlybereviewedintheirtotality.Theimpactofchangesinaserviceonotherservicesprovidedbytheorganisationmustbeconsidered.Examplesoftheseincludeemergencyservices.Thisdoesnotprecludecompetitionperse;howeverNorth LincolnshireCCGwillneedtoconsidertheextenttowhichthelossofcertain servicesfromaprovidermayjeopardisetheoverallprovisionofservices.Equally, NorthLincolnshireCCGwillensurethatimportantareassuchastraining,

localemploymentopportunitiesandsoundpoliciesandproceduresareincorporated intoallspecifications.

PluralityandInnovation

NorthLincolnshireCCGiskeentoencouragetheinnovativeapproachesthatcouldbeofferedby newproviders–includingindependentsector,voluntaryand thirdsectorproviders.NorthLincolnshireCCGiscommittedtothedevelopmentoflocalprovidersthatunderstandtheneedsoflocalcommunities.ItwillbeimportanttoensurethatNorthLincolnshireCCG’sapproachtohealthcare procurementis openandtransparentandthatitdoesnotactasabarriertonewproviders.

ServiceDevelopment–TrialsandPilots

Inits drivetofacilitateplurality andinnovationNorthLincolnshireCCGmayneed toconducttrialsandpilots ofnew servicesorspecificationstoderivelessons and orrefineoutcomespecifications.Withthisinmind,NorthLincolnshireCCGwill berequiredtoestablish clearly thattheprojectis apilotviathedefinition and/ordeliveryof:

  • Specific goal
  • Clearlydefinedtimelines
  • Volumelimits
  • Datedefinitionandrequirementincludingtrackingshiftinactivityto assesslessonslearnt
  • Clearcontractincludingobligationstoadvisepatientsofthepotential conflict,allowingforalternativesandgivingthepatientoptionstogo elsewhere
  • Robustprocessofevaluation
  • Rightsofterminationifdeterminedthatpilotisunsafeorfailingin termsofoutcome

NetworksandLinks

NorthLincolnshireCCGrecognisestheimportanceofstrongandeffective clinical andservicenetworksandonthevalueplacedbymanypatients,carersand othersonhavingalong-standingrelationshipwithaclinicianorservice.Itwillbevitaltoensure thatNorthLincolnshireCCG’sapproachdoesnotunderminethesenetworksandlinks.

EquityandEquality

NorthLincolnshireCCGwillneedtoensurethatitsapproachdoesnotwiden healthandserviceinequalitygapsandthatitsapproachservestoimproveboth healthandaccesstoservicesandtoaddressinequalitiesgaps.

PartnershipswithCommissioners

ItwillbevitaltoensurethatwherepossibleNorthLincolnshireCCG’sapproach complementsandsupportstheapproachadoptedbyPartneringOrganisations.

PartnershipswithProviders

NorthLincolnshireCCGrecognisestheimportanceofmaintainingpositiveand ongoingrelationshipswithprovidersso thatservicesaresustainedandimprovedcontinuously.Subjecttoitsoverridinglegalobligationstoadvertiseand/ortenderservices,NorthLincolnshireCCGwill,aspartofitsassessmentprocess,seekproviders,whetherNHSorNon-NHS,thatarecommittedtothehealthand wellbeingof thelocal population.

ValueforMoney

Providerswillneedtodemonstratethatservicesofferthebestpossiblevalueformoneyforthe investmentmade.

Significance

NorthLincolnshireCCGrecognisesthathealthcareprocurementprocesseswill requiresignificanttime,attentionandresourcestoorganiseandmanage.Decisionswillneedtobetakenastowhetherandwhencompetitiveprocessesareadopted.Keytothesedecisionswillbethesignificanceandmaterialityof theserviceinquestion(whethercurrentornew),theopportunitiesthatcompetitionwillbringandtherisksofadoptingsuchanapproach.Such opportunitiesandriskswillincludetherequirementsofpatients,riskstoservicequality,servicecontinuityandgeneralimpact.

Legal

AsapublicbodyNorthLincolnshireCCG’scommissioningdecisionsmustfully complywithEUandUKRegulations.

5.Prime Financial Policies/Procurement Approval

5.1TheCCGPrimeFinancialPolicieshaveestablishedspecificprocurementrequirements,whichmustbeobservedduringallprocurementactivities.

5.2AnumberofkeyprocurementgatewaysmustobtainNorthLincolnshireCCGGoverningBodyapprovalpriortocommencement.Theseinclude:

  • Decisionsonwhichservicestocompetitivelyadvertise,ornotto advertise
  • Approvalofindividualprocurementprojectstrategyincludingtheprocurementapproachtobeadopted
  • Approvalofcompetitiveprocurementevaluationreportsandtheawardof preferredsupplierstatus

5.3NorthLincolnshireCCGmustmaintainarecordofallofthehealthcarecontractsitawards.This informationwillbepublishedona websitewhichwillbemaintained bytheNHS England.Thefollowinginformation willberequiredforeachcontract:

  • thenameoftheproviderandtheaddressofitsregisteredofficeorprincipal placeofbusiness
  • adescriptionofthehealth careservicesto beprovided
  • thetotal amounttobepaidor,wherethetotalamountisnot known,theamountspayabletotheprovider underthecontract
  • thedatesbetween which thecontractprovides for the servicestobeprovided,and
  • Adescription oftheprocessadoptedforselectingtheprovider

6.KeyAccountabilities

  • Lead CCG Officer:Overall responsibility for Procurement lies with theDirectorofCommissioning
  • ProcurementSupport:ProcurementandDeliverySupportwillbeprovided byNorth Yorkshireand HumberCommissioningSupportUnit

7.KeyResponsibilities

7.1NorthLincolnshireCCGwillberesponsiblefor:

  • ApprovingthecommencementofProcurementActivities
  • ApprovingthepreferredProcurementprocess
  • Approvingfinalservice specifications,evaluationcriteriaandadvertisements
  • Approvingthefinallist ofprovidersinvitedtotender
  • Approvingthefinalaward decision

8.ConflictsofInterest

8.1Inordertoensureafairandcompetitiveprocurementprocess,NorthLincolnshireCCG requiresthat allactualor potentialConflictsofInterestareidentifiedand resolvedappropriately.Intermsofprocurement,twokeyareasof potential concernexist:

  • TenderingProcessesandBidderBehaviour

PotentialbiddersshouldnotifyNorthLincolnshireCCGofanyactualorpotentialConflictsofInterestintheirresponses.Ifthepotential providerbecomesawareofanactualorpotentialConflictofInterest followingsubmissionitshouldimmediatelynotify NorthLincolnshireCCG.

NorthLincolnshireCCGreservestherighttoexcludeatanytimeanypotentialproviderfromtheprocessshouldanyactualorpotential ConflictsofInterestbeidentified.

Eachpotentialprovidermustneitherdiscloseto,nordiscusswith,anyotherpotentialprovider,anyaspectoftheprocurement.

Eachpotentialprovidermustnotcanvassorsolicitorofferanygiftorconsiderationwhatsoeverasaninducementorrewardtoanyofficeror

employeeof,orpersonactingasanadviser toNorthLincolnshireCCGin connectionwiththeselectionofProviders.ConflictsofInterest,CollusionandCanvassing issuesapplyequallytoNorthLincolnshireCCGemployeesorothersengagedbyNorthLincolnshireCCGintheprocurementanddecisionmakingprocesses.Atthecommencementof allprocurementprojects,officersscheduledtoparticipateintheprocurementwillberequiredtodiscloseanyactualorpotential ConflictsofInterest.

  • PotentialNorthLincolnshireCCGandGPPracticeConflictsofInterest

ApotentialareaforconflictsofinterestexistswhereNorthLincolnshireCCGcommissionsservicesthatcouldbepotentiallyprovidedbylocal GPPractices.

NorthLincolnshireCCGBusinessConductPolicysetsouttheoverall approachtodealingwithpotentialconflictsofinterestandshouldbefullyobserved.BusinessConduct Policy

Intermsofprocurementapotentialconflict ofinterestcouldexist where:

  • Anindividualiscurrentlyemployedbyabidderorganisationoroneofitssubsidiaries
  • Anindividualiscurrentlyemployedbyabidderorganisationoroneofitssubsidiaries
  • Aclosefamilymemberorpartnerorclosefriendiscurrently employedbya bidder organisationor oneof itssubsidiaries
  • Anindividual iscurrentlyadirector or ownerorcontrollerofa bidderorganisation,orhavesharesinabidderorganisationortheir

family, partner, or close relative has such shares in a bidderorganisation

  • Anindividualhasbeendismissedbyabidderorganisationorhavebeensubjecttoadisciplinaryprocessbyabidderorganisation
  • Anindividual/organisationwillderivefinancialbenefitfromtheawardofcontractresultingfromthetenderprocess

Specificallyforprocurement,whereaGP,practiceofficerand/orGPpracticehasapotentialmaterialinterestinaprocurementprocessordecision,thefollowingstepsshould beobserved:

  • Theleadprocurementofficershouldbenotifiedassoonasit becomesapparentthatapotentialconflictofinterestexists.This informationwillbeincludedontheprocurementprocessconflictof interesttemplate
  • TheGP,practiceofficerand/orGPpracticewheretheconflictof interestrests,willbeexcludedfromtheformalprocurementprocessanddecisionmakingprocess
  • TheProcurementLeadwillensurethatallinterestedandbiddingpartiesaretreated equitablyandfairly

Furtherpracticalguidanceandspecificcasescenarioswillbeissuedto allofficers/staffinvolvedintheprocurement process.

9.SignificantProcurement thresholds (CCG)

9.1NorthLincolnshireCCGobservesthefollowingprocurementthresholds:

Up to £5000 / Wherethe procurement of goodsservices over thelifeof
a contract is reasonablyestimated to cost less than £5,000- competitive quotes arenot mandatory, but still remain good practiceif cost effectiveto obtain.
£5001 to £50000 / Wherethe procurement of goodsservices is reasonably
estimated to cost £ 5,000 or more, but less than £50,000- the procurement decisionmust bebased on obtainingand evaluating3 competitivequotes.
£50001 to European
Procurement Threshold / Wherea contract valueisreasonablyexpected to equal or
exceed £50,000, a formaltender exercise needs tobe undertaken in conjunction with procurement specialists, as appropriate.
AboveEuropean
Procurement Thresholds / Wherea contract valueisreasonablyexpected to exceed
European Commissionthresholds, contracts must be let in accordancewith the relevant EUdirective(seesection 10).

9.2Anumberofnationalandregionalagencieshaveestablishedframeworkcontracts whichcanbeaccessed bytheCCG.Astheseframeworkshavealreadybeensubjecttoaformaltenderingexercisetheycanbeaccessedasan alternative toundertakingaformal quotationortenderingexercise.Seesection12.

9.3ThePrimeFinancialPoliciesestablishclearregulationsandanapprovalprocessforthewaivingofinternalprocurementthresholds,thesemustbeobserved.UKand EuropeanCompetitionrequirementscannotbewaivedunderanycircumstance.

10.OJEUProcurement Thresholds

10.1Certaintypesofpublicprocurementforgoodsandservicesaboveacertainvalue(Threshold)areobligedtobeadvertisedacrosstheEuropeanUniontoprovidefair opportunitiesforcompaniesinmemberstatestobid.TheadvertsappearintheOfficialJournaloftheEuropeanUnionandarereferredtoasOJEUnotices. Thresholdvaluesarereviewedannually.DetailsofcurrentOJEUThresholdscanbeobtainedfromthefollowingwebsite:

10.2ThetablebelowliststheOJEUProcurementThresholdswhichapplyfromthe1st

January2012untilthe31stDecember2013(thresholds arenetofVAT).

PUBLICCONTRACTSREGULATIONS2006-FROM1JANUARY2014

SUPPLIES / SERVICES / WORKS
Entities listed inSchedule 11 / £111,676 / £111,6762 / £4,322,0123
(€134,000) / (€134,000) / (€5,186,000)
Other public sector contracting / £172,514 / £172,514
£4,322,0123
(€5,186,000)
authorities / (€207,000) / (€207,000)
Indicative Notices / £625,050 / £625,050 / £4,322,012
(€750,000) / (€750,000) / (€5,186,000)
Smalllots / £66,672 / £66,672 / £833,400
(€80,000) / (€80,000) / (€1,000,000)
11. / Non-Health Care Procurement
11.1 / All non-health care procurements will follow UK and RegulationsandobservePrimeFinancialPolicies. / European / Competition
12. / National/Regional FrameworkContracts

12.1Anumberofnationalandregionalagencieshavedevelopedframeworkcontracts whichcanbeaccessedbyNHSorganisations.Theseframeworkagreementshavebeenappropriatelytenderedforbytherelevantagencieswhichinclude:

  • Government Procurement Service
  • NHS England
  • Regional NHS Procurement Agencies
  • RegionalLocal AuthorityProcurement Agencies
  • NorthLincolnshireCouncil

12.2Thefollowingconsiderations shouldbemadebeforeutilisingaframeworkcontract:

  • Theoverallvalueofthecontract
  • Theavailabilityofarobustservicespecificationandisitapplicabletothetermsoftheframeworkagreement
  • IstheframeworkavailabletoCCG's
  • Isamanagementfeechargeableforaccessingtheframeworkagreement
  • Dotheterms oftheframeworkrequireaminicompetitiontobeundertaken
  • Dotheagreedfinancialandservice termsrepresentvalueformoney

13.TenderWaivers

13.1Inveryexceptionalcircumstances,FormalTendering proceduresmaybewaived.The

circumstances where this is applicable are outlined in the CCG Prime Financial Instructions.

13.2ItshouldbenotedthatitisnotpossibletowaiveEuropeanandUKCompetition Requirements.

14.Health and Social Care Procurement

14.1NHSProcurement

14.1.1In2012theDepartmentofHealthhasissuedfurtherguidanceonNHSprocurement‘NHSProcurement-RaisingOurGame’setsoutguidanceandproposedactionsfor NHSorganisations’toimproveprocurementstandards.Specificallysixkeyareasfor improvementsareidentified:

  • leversforchange
  • transparencyanddatamanagement
  • NHSstandardsofprocurement
  • leadership,clinicalengagementandreducingvariation
  • collaborationanduseofprocurementpartners
  • suppliers,innovationandgrowth

14.1.2NorthLincolnshireCCGwiththesupportofNorthYorkshireandHumberCSUwill ensureprocurementprocessesadoptthekeyrecommendations.

14.1.3NorthLincolnshireCCGinpartnershipwithNorthYorkshireandHumberCSUwill alsoensurethatallprocurementactivityisfullycompliantwiththelatestNHS ProcurementRegulations.The2013NHSProcurementRegulationsspecificallyplaceanyobligations onNorthLincolnshire CCGto:

  • Ensurethatallhealthcareprocurementsaimtomeettheneedsofpatients andservicesusers.Improvethequalityandefficiencyofservicedelivery.Treatallproviders(regardlessofsizeandsector)equallyandinanon- discriminatorymanner.Beundertakeninatransparentmanner
  • The regulationsplacea requirementon NorthLincolnshireCCGtoconsiderwhetherhealthservicescanbeprovided inanintegratedmannerwithotherhealth andsocialcareservices
  • TheRegulations states thatin circumstances whereonlyonecapableproviderexists thennorequirementwouldexisttoadvertise
  • NorthLincolnshireCCGmustnotundertakeanyactionswhichareanti- competitiveunlesstodosowouldbeclearly intheinterests ofthepeople

whousetheservice.Theregulationreferstotheareas ofintegrationandco- operationtoimprove servicequalityaspotentialexceptions

  • NorthLincolnshireCCGmustmaintainarecordofallofthehealth carecontractsitawards.Thisinformationwillbepublishedona website which

willbemaintained bythe NHS England

  • TheRegulationsclearlystatethatNorthLincolnshireCCGmustnotawarda contractiftheintegrityandrobustnessoftheprocurementandaward processhasbeen(orappearstohavebeen)compromisedbyconflictsof interest

14.2GeneralApproach

14.2.1NorthLincolnshireCCGwillundertakeallhealthandsocialcareprocurementsin accordancewithUKandEUCompetitionrequirements.ItwillalsoobserveDepartmentofHealthserviceguidanceanditsPrinciplesandRulesforCooperation andCompetition.

14.2.2NorthLincolnshire CCGapproachtohealth andsocialcareprocurementwillbeunderpinnedbythefollowingprinciples:

  • NHSandexistingprovidersshouldbeengagedatanearlystageofservicedevelopment
  • Earlyandsubstantialengagement ofexistingprovidersis expected
  • Earlyandsubstantialengagementofstaffandtheirtradeunion representativeswhereapplicableisexpected
  • Earlyandsubstantialpublicconsultation willtakeplacewhereappropriate
  • Decisionsaretakenlocallybutwithin clearnationalguidelines
  • Commissionersmustdemonstrate:
  • Fairnessandtransparencyofprocess
  • Clearrationalefordecisionmaking
  • Needs–driven
  • Proportionality(thatthecommissioneractsproportionatelyto thesizeandseriousnessofanyproblem
  • Commissionersareexpected tosecure best valueand qualityforpatientsand taxpayers.
  • Commissionersareexpectedtoactivelymonitorthequalityoftheserviceandinitiateaprocesswithprovidersifservicesarenotadequate.
  • RobustoversightandassuranceofalltheabovethroughNorthLincolnshireCCGGoverningBody.

14.3When toTenderServices

14.3.1Thekeydriverforanydecisiontotenderornottotenderahealthorsocialcareservicewillbetheneedtocommissionservicesfromtheproviderswhoarebestplacedtodeliver theneedsofpatientsand thelocalpopulation.

14.3.2Suchdecisionswillfallintotwotypes,eitherexistingservicesornewservices(includingsignificantlychangedservices).

  • ExistingServices

Ifanexistingserviceiscoveredbyanin-datecontract,isdeliveringeffectivevalueformoneyserviceswhich meetscurrentservicerequirements,thentheexistingprovider(s)mayberetained.

Whereanexistingservice contracthascometotheendofitscontractperiod,andthiscontracthasbeenpreviouslycompetitivelytendered,thenanewcompetitiveprocessislikelytobeundertaken.

Whereanexistingserviceisprovidedonaproviderlistbasis andhascometo theendofitscontractterm,NorthLincolnshireCCGwillconsiderthepotential forusingAQPtoincreasetheavailableprovider pool.

Whereanexistingservicecontracthascometo theendofitscontractperiod,andthis contracthas notbeenpreviously competitivelytendered,thenNorth LincolnshireCCGwillexaminetheservicetoseeifitissuitableforcompetitivetenderobservingtherequirementssetoutinthelatestNHS ProcurementRegulations.

  • NeworSignificantly ChangedServices

Wherepatientchoiceisakeydriver,NorthLincolnshireCCGwilllookatthepotential forincreasingtheavailableproviderpool throughtheuseofAQP.

InsituationswhereGPPracticesaretheonlyavailableandcapableprovider,thenNorthLincolnshireCCGwilllookconsiderasingletenderwaiverforpurchasingtheservicefromGPPractices.Insuchcircumstancestheconflictofinterestprinciplesmustbeobserved.

Forserviceswhereacompellingreasondoesnotexisttoawardonsingletenderbasis,competitivemarketexistsanditisnotsuitableforAQP,thenNorthLincolnshireCCGpreferencewillbeforacompetitivetenderprocess.

14.4ProviderChecks

14.4.1DuringAQP or competitivetenderprocesses, assurance checkswill be carriedouton potential providers.Thesecheckswillexamine:

  • Financialviabilityand standing
  • LegalStanding
  • Clinical capacityandcapability
  • ClinicalandProfessionalGovernance
  • InsuranceCover
  • QualityFramework

14.4.2For potential providers not sourced through AQP or a competitive process,additionalchecksmustalsobeperformedon:

  • ViabilityoftheDeliveryProposal
  • ValueforMoneyoftheProposal
  • AffordabilityoftheProposal

14.5AnyQualifiedProvider(AQP)

14.5.1AnyQualifiedProviderisaprocurementmodelthatCCG’scanusetodevelopa registerofprovidersaccreditedtodeliverarangeofspecifiedserviceswithina communitysetting.Themodelaimstoreducebureaucracyandbarrierstoentryforpotentialproviders.

14.5.2UnderAQP,anyproviderthatdemonstratesthatitmeetstheassuranceandspecific servicerequirements,andalsoagreestothepredeterminedAQPpricewillbeapprovedand can compete foractivitywithinthatspecificmarket.ThekeytoAQPis that therearenoguaranteesprovidedonpaymentorvolumelevels.

14.5.3AQPopportunitieswill beadvertisedusing Supply2Health.

14.5.4AQPmaynotbeappropriateinthefollowingcircumstances:

  • Wheretheapprovedclinicalpathwayandservicerequirementdictatesa singleorlimitednumberofproviders
  • Wherelimitedactivitylevelsexistandwouldnotsupportmultipleproviders
  • WhereoverallservicecostswillbesignificantlyincreasedbyadoptingAQP
  • Wheresomeformcompetitiveprocessisrequiredtodeterminecorrectand appropriatepricinglevels
  • Where no fair and reasonable method of selecting between approvedproviderscanbedetermined

14.6CompetitiveTenders

14.6.1NorthLincolnshireCCGwillpursueandmanagecompetitivetendersforhealthand socialcarethroughensuringthatchoice,cooperationandcompetitionareappropriatelyadopted.ThecompetitivetendersundertakenbyNorthLincolnshireCCGwillseektofullyobserve thefollowingkeyprinciples:

Transparency–CompetitiveTendersshouldbefairandopen andincludeasufficientlevel ofadvertising.Specifically:

  • North Lincolnshire CCGwill endeavour to publish proposed procurementplans that will provide providers with information about commissioning

intentions andfuturetenderingopportunities

  • NorthLincolnshireCCGwillselectthe mostappropriatemedia for advertisingtenders.TheSuppy2Healthprocurementportalwillbetheprimaryadvertmedia
  • NorthLincolnshireCCGwillonlycommissionservicesfromtheproviderswho are bestplacedtodelivertheneeds ofourpatientsandpopulation
  • NorthLincolnshireCCGwillprocureservicesfromsuppliersthatofferbest valueformoney
  • NorthLincolnshireCCGwillfairlymanageandbetransparentabout potential conflictsofinterest
  • NorthLincolnshire CCGwillbetransparentaboutitsservice requirements andhowit willevaluatetenderbids
  • NorthLincolnshireCCGwillbetransparentindisclosingtheproposedaward ofcontractsandprovidingdebriefinformationtounsuccessfulbidders

Objectivity -Keydecisions mustbe basedondocumentedobjective dataandcriteriaaspart oftheprocurementprocess.

Proportionality–Thecompetitivetenderingprocessshouldbeproportionatetothevalueandcomplexityoftheservices tobeprocured.

Non-discrimination–Thecompetitivetenderingprocessmustnotdiscriminateamongproviders,andensurethatinthedeliveryofservices,providersdonotdiscriminateamongpatientsorpatientgroups.Specifically:

  • Servicespecificationsandevaluationcriteriawillbedevelopedsoastobegenericandnotfavourspecificproviders.
  • NorthLincolnshireCCGwillensurethatevaluationsprocessesarefairanddo notdiscriminateagainstparticularbidders.

Accountability–Officersinvolvedincompetitivetendersshouldstrivetoaligntheirauthorityandlegalpowers withtheiraccountabilityandlegalduties.

Subsidiarity-DecisionsshouldbemadebythelowestcompetentauthorityandnotunnecessarilyescalatedtoBoard.

Consistency-Formulationandimplementationofpolicymust beinternallycoherentandconsistent.

Interdependency-Whenassessingspecificissues,commissionersandprovidersshouldunderstandandminimise thepotentialunintended consequencesofany

actions.Aspartoftheoverallapproachtotheaboveprinciplessystemswillbeadoptedthatassistin:

  • Thedesignoflocalincentivesanddrivers.
  • Drivingqualityinprovision.
  • ProcurementandContractingincludingmanagementofchange,failureand disputes.
  • Marketdevelopmentandmanagements.
  • Enablingand improvingchoice.
  • Patient,publicandmarketinformation.

14.6.2NorthLincolnshireCCGmayalsoactivelyengagewiththirdpartyorganisations whereappropriatetoengagesupportorguidancewithinthecommissioningand procurementprocess.

14.7EUDirectivesandProcurementRegulations

14.7.1TheProcurementRegulationsrequirecompetitionasthemechanismbywhich contractingauthoritiesensureequalityoftreatment,transparencyand non- discrimination.ThisisreinforcedbythelatestNHSProcurementRegulations.TheNationalHealthService(Procurement,PatientChoiceandCompetition)Regulations2013

14.7.2ThisPolicycomplieswiththerequirementssetoutintheNorthLincolnshireCCGcurrentStandingOrders,ReservationandDelegationofPowersandStandingFinancialInstructions.

14.7.3AllprocurementswillcomplywiththeEuropeanUnion(EU)ProcurementDirectives(asenactedby theUKProcurement Regulations).Underthe currentEUProcurementRegulationsHealthcareServicesaretreatedasPartB Services.However,thereisstill arequirementtoadheretotheprinciplesoftheProcurementRegulations.Pleasenote:SignificantchangestoEUregulations,includingPartBservicesarecurrently beingfinalisedNorthLincolnshireCCGProcurementPolicywillbeupdatedwhentheEUregulationshavebeenfinalised.

14.8Consultation

14.8.1Healthservicechangesmaybesubjecttopatientandpublicconsultation.WhereapplicableNorthLincolnshireCCGwillagreeaconsultationprocess at theoutset ofa procurementprojectonacasebycasebasis.

14.8.2MajorServicechangeproposalshavebeensubjecttotheServiceChangeAssuranceProcessmanagedbySHA’s.Fromthe1stApril2013arevisedassuranceprocesswill beundertakenbyNHSEngland.NorthLincolnshireCCGwillensurefullcompliancewiththerelevantnationalServiceChangeAssurancerequirements.

14.9EthicalandSustainableProcurement

14.9.1NorthLincolnshireCCGtakessocialandenvironmentalfactorsintoconsideration alongsidefinancialfactorsinmakingdecisionsonthepurchaseofgoodsandthecommissioningofservices.Ourpurchasingdecisionswherepracticableconsiderwholelifecostandtheassociatedrisksandimplicationsforsocietyandtheenvironment.

14.9.2Theethicalprocurementprincipleistoensurethatallpeopleinvolvedinoursupply chainaretreatedfairlyandreasonably,arenotdiscriminatedagainstandworkina safe environment.

14.9.3Thesustainability/environmentalprocurementprincipleistodeliversustainablesocialandenvironmentalactivitiesbothwithin our organisationbutalsoin oursupply chain.

14.9.4Whereveritispossible,anddoesnotcontradictorcontravenetheCCG’s procurementprinciplesortheprovisionsallowableunderthePublicServices(Social Value)Act2012,theCCGwillworktodevelopandsupportasustainablelocalhealth economy.

14.9.5TheseoverarchingEthicalandSustainableProcurementprinciplesareembodiedin theCCG’s SustainablePolicy Framework.

APPENDICES-EqualityImpactAnalysis

1. EqualityImpactAnalysis
Policy/Project/Function: / Procurement Policy
NHS North LincolnshireCCG
Date of Analysis: / November2013
ThisEqualityImpact Analysiswas
completedby:
(Name andDepartment) / GaryMetcalfe(Headof Procurement)
North Yorkshireand HumberCSU
What aretheaimsandintended effects of this policy,project or function? / ThisdocumentsetsouthowNHS NL CCGprocurement will be in proportiontoriskand will be used tosupport
clinicalpriorities,healthand well-beingoutcomesand
widerCCGobjectives.
Tofacilitateopen andfair,robustandenforceable contractsthatprovide valueformoneyand deliver requiredqualitystandardsand outcomes,with effective performancemeasuresand intervention protocols.
Please listany other policies that arerelatedto orreferred toas part of thisanalysis? / Prime Financial Policies Sustainable ProcurementPolicy
BusinessConduct Policy
Whodoes thepolicy,project or functionaffect?
Please Tick / Employees
Service Users
MembersofthePublic Other(ListBelow)
2. EqualityImpactAnalysis:Screening
Couldthis policyhave a positive impacton… / Couldthis policyhave a negativeimpacton… / Is thereanyevidencewhichalreadyexists fromprevious
(e.g. fromprevious engagement) toevidence this impact
Yes / No / Yes / No
Race /  / 
Age /  / 
Sexual Orientation /  / 
DisabledPeople /  / 
Gender /  / 
Transgender People /  / 
Pregnancy andMaternity /  / 
MaritalStatus /  / 
ReligionandBelief /  / 
Reasoning / Thispolicydocumentdoes notdirectly impactonanyspecificservices,butsetsaframeworkthatwill influencetheselection ofservice providersonceservice requirementshave been identified.Assuch,there is no impactonanyprotectedgroupfromthe procurementpolicy-the impacton protectedgroupsofindividual services will be assessed asthe needarises.
A wide range ofstakeholdershave beenconsulted onthispolicy;anyequality issuesraised bythemwill reviewed and actedupon asappropriate,with thisEQIA amended accordingly.
If thereis nopositive ornegative impact onanyof theNineProtectedCharacteristicsgoto Section7

20

3. EqualityImpactAnalysis:LocalProfileData
Local Profile/Demographyof theGroups affected(populationfigures)
General
Age
Race
Sex
Gender reassignment
Disability
Sexual Orientation
Religion,faithandbelief
Marriageandcivil partnership
Pregnancy andmaternity
4. EqualityImpactAnalysis:EqualityDataAvailable
Is anyEqualityDataavailablerelating to theuse or implementation of thispolicy, projector function?
Equalitydataisinternalorexternalinformationthatmayindicatehowtheactivity beinganalysedcan affect differentgroupsofpeoplewhosharethe nineProtectedCharacteristics–referredtohereafteras ‘Equality Groups’.
ExamplesofEquality Datainclude:(thislistis notdefinitive)
1.ApplicationsuccessratesEqualityGroups
2.ComplaintsbyEquality Groups
3.Serviceusageandwithdrawalofservices by
EqualityGroups
4.Grievancesor decisionsupheldanddismissed by
EqualityGroups
5.PreviousEIAs / Yes
No
Whereyouhaveansweredyes,pleaseincorporatethisdatawhenperformingtheEqualityImpactAssessmentTest(thenextsectionofthisdocument).
ListanyConsultatione.g.withemployees, serviceusers,Unions ormembers of the
publicthat has takenplaceinthe development orimplementation of this policy,project orfunction / Thispolicydocumentdoes notdirectly impacton anyspecificservices,butsetsaframeworkthatwill
influencetheselection ofservice providersonce
service requirementshave been identified.Assuch, there isno impactonanyprotectedgroupfromthe procurementpolicy-the impacton protectedgroups ofindividualserviceswillbe assessed asthe need arises.
A wide range ofstakeholdershave beenconsulted on thispolicy;anyequality issuesraisedbythem will reviewed and actedupon as appropriate,with thisEQIA amendedaccordingly.
Promoting Inclusivity
Howdoes theproject,service orfunction contribute towardsour aims of eliminating discriminationandpromoting equality and

diversitywithin our organisation

22

5. EqualityImpactAnalysis:AssessmentTest
Whatimpactwilltheimplementationofthispolicy,projectorfunctionhaveonemployees,serviceusersorotherpeoplewhosharecharacteristicsprotectedbyTheEqualityAct2010?
ProtectedCharacteristic: / NoImpact: / PositiveImpact: / NegativeImpact: / Evidenceofimpactandifapplicable,justificationwhereaGenuineDeterminingReasonexists
Gender
(MenandWomen) / 
Race
(AllRacialGroups) / 
Disability
(MentalandPhysical) / 
ReligionorBelief / 
SexualOrientation
(Heterosexual,Homosexualand
Bisexual) / 
Whatimpactwilltheimplementationofthispolicy,projectorfunctionhaveonemployees,serviceusersorotherpeoplewhosharecharacteristicsprotectedbyTheEqualityAct2010?
ProtectedCharacteristic: / NoImpact: / PositiveImpact: / NegativeImpact: / Evidenceofimpactandifapplicable,justificationwhereaGenuineDeterminingReasonexists
PregnancyandMaternity / 
Transgender / 
MaritalStatus / 
Age / 
6. ActionPlanning
Asaresultof performingthis analysis,what actions areproposedtoremoveorreduceanyrisks of adverse outcomesidentified onemployees,service users orother peoplewhosharecharacteristics protectedbyThe EqualityAct2010 ?
Identified Risk: / RecommendedActions: / Responsible Lead: / CompletionDate: / ReviewDate:
NoneIdentified
7. EqualityImpactAnalysisFindings
AnalysisRating: /  / Red /  / Red/Amber /  / Amber / Green
Actions / WordingforPolicy/Project /Function
Red
Stopandremovethepolicy / Red:As a resultofperformingthe
analysis, itis evidentthat ariskof discriminationexists(direct, indirect,unintentionalor otherwise) tooneormoreof the nine groupsof peoplewhoshare ProtectedCharacteristics.It is recommendedthat the useofthe policy be suspended until further workoranalysisis performed. / Removethepolicy
Completetheactionplanabove to identifythe areasof discriminationand the workoractions whichneeds tobe carriedout tominimisetheriskof discrimination. / Nowordingneeded as policy is beingremoved
RedAmber
Continuethepolicy / As a resultofperformingthe
analysis, itis evidentthat ariskof discriminationexists(direct, indirect,unintentionalor otherwise) tooneormoreof the nine groupsof peoplewhoshare ProtectedCharacteristics. However, a genuinedetermining reasonmay existthat could legitimiseor justify the useofthis policyandfurther professional adviceshouldbetaken. / ThepolicycanbepublishedwiththeEIA
List the justificationofthediscrimination andsourcetheevidence(i.e. clinicalneed as advisedbyNICE).
Consider ifthereareany potential actions whichwouldreducethe risk of discrimination.
AnotherEIAmust becompleted ifthe policy is changed, reviewed or iffurther discriminationis identifiedat a later date. / As a resultofperformingthe analysis,itisevident that a
risk ofdiscriminationexists(direct,indirect,unintentional orotherwise) tooneormore ofthe ninegroupsof peoplewhoshareProtectedCharacteristics.However,a genuine determiningreasonexistswhichjustifiestheuseof this policy andfurtherprofessional advice.
[Insertwhat thediscrimination isand the justificationof thediscriminationplus any actionswhichcouldhelp what reduce the risk]
EqualityImpactFindings(continued):
Actions / WordingforPolicy/Project /Function
Amber
AdjustthePolicy / As a resultofperformingthe
analysis, itis evidentthat ariskof discrimination(asdescribedabove) existsandthis riskmayberemoved or reduced by implementingthe actions detailedwithinthe Action Planningsectionof thisdocument. / ThepolicycanbepublishedwiththeEIA
The policy canstill be publishedbut the ActionPlanmustbemonitored toensure that workis beingcarried out toremove or reduce thediscrimination.
Any changesidentified andmade tothe service/policy/strategyetc. shouldbe included inthe policy.
AnotherEIAmust becompleted ifthe policy is changed, reviewed or iffurther discriminationis identifiedat a later date. / As a resultofperformingthe analysis,itisevident that a
risk ofdiscrimination(as described above)existsandthis riskmaybe removed or reduced by implementingthe actions detailedwithinthe ActionPlanningsectionof this document.
[Insertwhat thediscrimination isandwhatworkwill be carriedouttoreduce/eliminatethe risk]
Green
Nomajorchange / As a resultofperformingthe
analysis, the policy, projector functiondoesnot appear tohave any adverseeffectsonpeople who shareProtected Characteristicsand nofurtheractions are recommended at thisstage. / ThepolicycanbepublishedwiththeEIA
AnotherEIAmust becompleted ifthe policy is changed, reviewed or ifany discriminationis identifiedat a later date / As a resultofperformingthe analysis,the policy, project
or functiondoesnot appear tohaveanyadverseeffects onpeoplewho shareProtectedCharacteristicsandno further actions are recommended at thisstage.

Brief Summary/Furthercomments

Approved By
JobTitle: / Name: / Date:
Head ofprocurement / GaryMetcalfe / 16November2013

27

Appendix3

SUSTAINABILITYIMPACTASSESSMENT

StaffpreparingaPolicy/BoardReport/CommitteeReport/ServicePlan/ProjectarerequiredtocompleteaSustainabilityImpactAssessment.Sustainabilityisone oftheTrust’skeyStrategiesandtheTrusthasmadeacorporatecommitmenttoaddresstheenvironmentaleffectsofactivitiesacrossTrustservices.Thepurposeof thisSustainabilityImpactAssessmentistorecordanypositiveornegativeimpactsthatthisactivityislikelytohaveoneachoftheTrust’sSustainabilityThemes.For assistancewithcompletingthe Sustainability Impact Assessment,pleaserefer tothe instructions below.

Policy/Report/ServicePlan/ProjectTitle:
Theme(Potentialimpactsoftheactivity) / PositiveImpact / NegativeImpact / Nospecificimpact / Whatwilltheimpactbe?Iftheimpactisnegative,howcanitbemitigated?(action)
ReduceCarbonEmissionfrombuildingsby12.5%by
2010-11then30%by2020 / X
Newbuildsandrefurbishmentsover£2million(capital
costs)complywithBREEAMHealthcarerequirements. / X
Reducetheriskofpollutionandavoidanybreachesin
legislation. / X / Stipulates compliance with key sustainable/ethical procurement
legalframework,inparticulartheSocialValueAct2012.
Goodsandservicesareprocuredmoresustainability. / X / Stipulates compliance with key sustainable/ethical procurement
legalframework,inparticulartheSocialValueAct2012.
Reducecarbonemissionsfromroadvehicles. / X
Reducewaterconsumptionby25%by2020. / X
Ensurelegalcompliancewithwastelegislation. / X
Reducetheamountofwasteproducedby5%by2010
andby25%by2020 / X
Increasetheamountofwastebeingrecycledto40%. / X
Sustainabilitytrainingandcommunicationsfor
employees. / X
Partnershipworkingwithlocalgroupsandorganisations
tosupportsustainabledevelopment. / X / Stipulates compliance with key sustainable/ethical procurement
legalframework,inparticulartheSocialValueAct2012.
Financialaspectsofsustainabledevelopmentare
consideredinlinewithpolicyrequirementsandcommitments. / X / Stipulates compliance with key sustainable/ethical procurement
legalframework,inparticulartheSocialValueAct2012.

Appendix 4

BriberyAct2010Guidance

Introduction

OnJuly2011theBriberyAct2010cameintoforce,makingitacriminaloffencetogive,promise, orofferabribeandto request,agreeorreceiveabribe.Itincreasedthemaximumpenaltyforbriberyto10years’imprisonment,withanunlimitedfine.Furthermoretheactintroducesa‘corporateoffence’offailingtopreventbriberybytheorganisationnothaving adequatepreventativeproceduresinplace.Anorganisationmayavoidconvictionifitcan showthatithadsuchproceduresandprotocolsinplacetopreventbribery.

TheMinistryofJusticeinitsconsultationandguidance setoutsixbroadmanagementprincipleswherebyanorganisationcandemonstrateaneffectivedefencebyshowingthatithadeffectivebriberyprevention measuresinplace.

RiskAssessment–thisisaboutknowingandkeepinguptodatewiththebriberyrisksyou faceinyoursectorandmarket;

Top levelcommitment–this concernsestablishing aculture across theorganisationinwhich briberyis unacceptable.Ifyourbusinessissmallormediumsizedthismaynotrequiremuch sophisticationbutthethemeismakingthemessageclear,unambiguousandregularlymadetoallstaffandbusinesspartners;

Duediligence–thisisaboutknowingwhoyoudobusinesswith;knowingwhy,whenandto whomyouarereleasingfundsandseekingreciprocalanti-briberyagreements;andbeingin apositiontofeelconfidentthatbusinessrelationshipsaretransparentandethical;

Clear,PracticalandAccessiblePoliciesandProcedures–thisconcernsapplyingthemto everyoneyouemployandbusinesspartnersunderyoureffectivecontrolandcoveringall relevantriskssuchaspoliticaland charitable contributions,giftsandhospitality,promotional expenses,andrespondingtodemandsforfacilitationdemandsorwhenanallegationof briberycomestolight.

Effectiveimplementation–thisisaboutgoingbeyond‘papercompliance’toembeddinganti-briberyinyourorganisation’sinternalcontrols,recruitmentandremunerationpolicies, operations,communicationsandtrainingonpracticalbusinessissues.

Monitoringandreview–thisrelatestoauditingandfinancialcontrolsthataresensitiveto briberyandaretransparent,consideringhowregularlyyouneedtoreviewyourpoliciesand procedures,andwhetherexternalverificationwouldhelp.

RelevancetotheNHS

NHSorganisationsareincludedintheBriberyAct’sdefinitionofa“relevantcommercial organisation”.Any senior managerorexecutive whoconsentstoorconnives inany active or passivebriberyoffencewill,togetherwiththeorganisation,beliableforthecorporateoffenceundertheact.

Appendix 4

Anyindividualassociatedwithanorganisationwhocommitsactsoromissionsformingpartofabriberyoffencemaybeliableforaprimarybriberyoffenceundertheactorforconspiracytocommittheoffence withothers–including,forexample,theiremployer.

RisksinbreachingtheBriberyAct

ThereareanumberofrisksentailedinbreachingtheBriberyAct.Theseinclude:

  • Criminal sanctionsagainst directors,board members andother senior staffasa corporate offence–Section7oftheAct.
  • Convictionsofbriberyorcorruptionmayalsoleadtotheorganisationbeingprecludedfromfuturepublicsectorprocurementcontracts.
  • Damagetotheorganisation’sreputationandnegativeimpactonpatient/stakeholder perceptions.
  • Potentialdiversionand/orlossofresources.

WhatdoNHS organisation’sneedtodo?

ThereareanumberofstepsNHSorganisationscantake:

  • TheBoardneeds tounderstanditsresponsibilityinrespectoftheact.
  • Beclearthat,asNHSorganisations,youarecoveredbycorporateliabilityforbriberyonthepartoftheiremployees,contractorsand agents.
  • Takestepstomakeyouremployees,contractorsandagentsawareofthestandards ofbehaviour thatareexpectedofthem: this mayinclude trainingfor employees who mightbeaffected –for example,employeeswithresponsibilityforprocurement.
  • Reviewexistinggovernance,procedures,decisions-makingprocessesandfinancial controls,introducethemifnotalreadyinplaceand,wherenecessary,provideappropriatetrainingforstaff.
  • Recordthefactthatthesestepshavebeentaken,astheyprovidethedefenceagainstcorporateliabilityundertheact.

AreasforAction

  • Onceriskshavebeenassessedtheorganisationmustputinplaceproceduresthatareproportionatetobriberyrisksthatareidentified.
  • Thechecklistbelowprovidesdetailsofareasforactionstoassistinensuringproportionatestepstoensurepreventionanddefenceagainstcorporateliabilityundertheact.ThechecklistisbasedonbestpracticeguidancedocumentsissuedbyNHSProtectinMay2011,MinistryofJusticeandotheranti-briberyandcorruption NGOs.
  • InternalAuditandCounterFraudTeamswillprovidesupporttotheorganisationto helpensurethatassurancecanbegivenagainstthepointsinthefollowingchecklist during2012/13.

Appendix 4

BriberyAct2010GuidanceandBriberyPreventionChecklist

Areasforaction / ExpectedAction / EvidenceofCompliance/Assurance
1.GovernanceandTop
LevelCommitment / TheChiefExecutiveshouldmakeastatementinsupportofthe
anti-briberyinitiativeandthisshouldbepublishedontheorganisation’s website.
The boardofdirectorsshouldtakeoverallresponsibility fortheeffectivedesign,implementationandoperationoftheanti- briberyinitiatives.TheBoardshouldensurethatsenior managementisawareofandacceptstheinitiativesandthatit isembeddedinthecorporateculture.
2.DueDiligence / This is a key element of good corporate governance and
involvesmakinganassessmentofnewbusinesspartnerspriortoengagingtheminbusiness.Duediligenceproceduresarein themselvesaformofbriberyriskassessmentandalsoameans ofmitigatingthatrisk.Itisrecommendedthatattheoutsetof anybusinessdealings,allnewbusinesspartnersshouldbemade awareinwritingoftheorganisation's anti-corruption andbriberypoliciesandcode of conduct.
3.Codeofconduct / Theorganisationshouldeitherhaveananti-briberycodeof
conductorageneralcodeofconductforstaffwithananti- briberyandcorruptionelement.
TheorganisationshouldrevisetheStandardsofBusiness ConductPolicy(orequivalent)andDeclarationofInterests guidance(seepoint4below)toreflecttheintroductionoftheBriberyAct.

Appendix 4

Areasforaction / ExpectedAction / EvidenceofCompliance/Assurance
4.Declaration of
Interests/Hospitality / Theorganisationshouldhaveinplaceadeclarationofbusiness
interests/giftsandhospitalitypolicywhichclearlysetsoutacceptablelimitsandalsoamechanismtomonitorimplementation.
5.Employee
employmentprocedures / Employeesshouldgo through the appropriate proprietychecks
e.g.CRB(CriminalRecordsBureau)and/oracombinationof other checks before theyareemployedtoascertain, asfar asis reasonable,thattheyarelikelytocomplywiththeorganisation’santi-briberypolicies.
6.Detectionprocedures / TheorganisationshouldensureInternalAudit/CounterFraud
checkprojects,contracts,procurementprocessesandanyotherappropriatesystemswherethereisariskthatactsof briberycouldpotentiallyoccur.
7.Internalreporting
procedures / Theorganisationshouldhaveinternalproceduresforstaffto
reportsuspiciousactivitiesincludingbribery.
8.Investigationof Briberyallegations / TheorganisationshouldhaveproceduresforstafftoreportsuspicionsofbriberytoNHSProtect(previouslyNHSCounterFraudandSecurityManagementService)andtheorganisation’sLocalCounterFraudSpecialistfor investigation/referraltotheappropriateauthorities.
9.Riskassessment / MoJ (Ministry of Justice) guidance states”…organisations
shouldadoptarisk-basedapproachtomanagingbriberyrisks…[and]aninitialassessmentofriskacrosstheorganisation isthereforeanecessaryfirststep”.Theorganisationshould, onaregularbasis,assesstheriskofbriberyandcorruptionin itsbusinessandassess whetherits proceduresandcontrolsareadequatetominimisethoserisks.

Appendix 4

Areasforaction / ExpectedAction / EvidenceofCompliance/Assurance
10.Recordkeeping / The organisationshouldkeepreasonablydetailed recordsofits
anti-fraudandcorruptioninitiatives,includingtraininggiven,hospitalitygiven andreceivedandotherrelevantinformation.
11.Internalreview / Theorganisationshouldcarryoutanannualinternalreviewof
theanti-briberyandcorruptionprogramme.
12.Independent
assessmentand certification / Proportionate to risks identified, the organisation should
commission, at least every three years, an independentassessmentandcertificationofitsanti-briberyprogramme.
13.InternalandExternal communications / TheorganisationshouldpublicisetheNHSFraudand CorruptionReportingLine(FCRL)andon-linefraudreportingfacility.
Theorganisation shouldpublicisetheSecurityManagementrole(theftandgeneralsecurityissues)andreportingarrangements.
Theorganisationshouldworkwithitsstakeholdersinthepublicandprivate sectorto helpreduce briberyandcorruption in thehealthindustry.
14.Awarenessand training / Theorganisationshouldprovideappropriateanti-briberyand corruptionawarenesssessionsandtrainingonaregularbasis toallrelevantemployees.

Appendix 4

Areasforaction / ExpectedAction / EvidenceofCompliance/Assurance
15.Monitoring:
  • OverallResponsibility
  • Financial/Commercial Controls
/ Asenior managershould bemade responsiblefor ensuring
thattheorganisationhasaproportionateandadequateprogrammeof anti-fraud,corruptionandbribery initiatives.
Theorganisationshouldensurethatitsfinancialcontrols minimisetheriskoftheorganisationcommittingacorruptact.
Theorganisationshouldensurethatitscommercialcontrols minimisetheriskoftheorganisationcommittingacorruptact. Thesecontrolswouldincludeappropriateprocurementand supplychainmanagement,andthemonitoringofcontractexecution.