NHS Grampian

Scheme of Delegation

Schedule of Reserved Decisions

(a partner document in conjunction with the Operational Scheme of Delegation)

C O N T E N T S
Page
Scheme of Delegated Authority
3
/
Introduction
4
/
NHS Grampian
4
/
Meetings
4
/
Code of Conduct and Code of Accountability
4
/
Other Matters
5
/
Decisions Reserved for the Board
6
/
Management of NHS Grampian Assets

7

/

Financial Plans and Projections

7

/

Service Agreements for the Provision of Services

8

/

Budgets

8

/

Income

8

/

Annual Accounts and Reports

8

/

Bank and OPG Accounts

9

/

Capital Approvals, Capital Investments, PFI, Fixed Asset Registers and Security of Assets

10

/

Security of Cash, Cheques and other Negotiable Instruments

10

/

Staff Contracts of Employment

10

/

Payment of Accounts

11

/

Primary Care Contractors

11

/

Procurement and Tendering

11

/

Ordering, Stores and Receipt of Goods

12

/

Patients’ Property

12

/

Information Technology

12

/

Internal Audit

13

/

Disposals and Condemnations, Losses and Special Payments

13

/

Endowment Funds

13

/

Risk Management and Insurance

13

/

Legal Matters

13

/

Retention of Documents

14

/

Delegated Limits and Authorised Signatories

14

/

Quotations, Tendering and Contract Procedures

16

/

Endowment Projects and Payments

16

/

Endowment Investments

16

/

Authorisation of Losses, Compensation and Ex-Gratia payments

17

/

Bank Accounts

19

/

Compensation Payments Under Legal Obligation (CNORIS delegated limits)

20

/

Fixed Asset Disposals

20

/

Professional Consultancy Commitment and Payment

20

/

Travel/Conference/Course/Training/Expenses Payment

20

/

Establishment of Cash Floats

20

/

Leased Car Ordering

21

/

Virement between Revenue Budget Headings

NHS Grampian Schedule of Reserved Decisions

Introduction

The Schedule of Reserved Decisions (SORD) is a corporate governance protocol that did not exist previously in either the trusts or Grampian Health Board. The purpose of the protocol is to provide a high level summary of delegated responsibilities within NHS Grampian. The SORD complements the Operational Scheme of Delegation that details all officers within NHS Grampian who have delegated authority according to the standard categories that have been agreed on a NHS Grampian basis.

It is intended that the SORD will be a key reference document for senior personnel in relation to their delegated duties and delegated authority levels. It also details the decision-making powers of the Board and the responsibilities of committees that report into the Board.

The Board Secretary is the officer responsible for the SORD. Any queries that you may have should be directed in the first instance to either Kay Smart, Assistant Director of Finance on ext 56211 or Andrew Jackson, NHS Grampian legal adviser, on ext 58496.

1

June 2004

Review Date December 2004 NHS Grampian Reserved Decisions and Delegated Authority

DELEGATED TO

/ DUTIES DELEGATED
NHS Grampian-Chief Executive
-Chairman / -Overall responsibility that the organisation meets its obligation to perform within the available financial resources
-Final authority in interpretation of Standing Orders
Meetings-Chairman
-Deputy Chairman
-Chairman
-Deputy Chairman / -Calling meetings
-Calling meetings in the absence of the Chairman
-Chair all Board meetings and assume associated responsibilities
-Chair Board meetings and assume associated responsibilities in the absence of the Chairman
Code of Conduct and Code of Accountability-Board Secretary / -Register of Interests
Other Matters-Audit Committee
-Board Secretary
-Director of Finance
-Audit Committee
-Chairman and Chief Executive, or delegated deputy (being Deputy Chair or Chief Operating Officer) / -Examine every decision to suspend Standing Orders and make recommendations to the Board
-Responsible for preparation and regular review and update of the Standing Orders
-Responsible for preparation and regular review and update of the Standing Financial Instructions
-Review Standing Orders and Standing Financial Instructions regularly and make recommendations to the Board on amendments to the Standing Orders and Standing Financial Instructions
-Take decisions where, because of urgent time constraints, the Board and/or Committees cannot be consulted. The decision must be reported back to the next Board meeting for homologation.

DELEGATED TO

/ DUTIES DELEGATED
Decisions Reserved for the Board
-Board Members / Approval of:-
-Regulation and control of Standing Orders and Standing Financial Instructions
-Regulation and control of the establishment, remit and reporting arrangements for any other committee or sub committee acting on behalf of the Board
-Appointments of members to Standing Committees
-Appointments of executive Directors; membership to other statutory bodies as representing the Board
-Local Health Plan, including financial plans
-Corporate objectives as advised by the Performance Governance Committee
-Operational decisions committing revenue resources in excess of approved budget
-Setting thresholds for obtaining quotations and tenders
-Acceptance of tenders above £1 million
-Disposal of Capital Assets over £500,000, as advised by SSRC
-Awarding Consultants and Associate Specialists Discretionary Points, as advised by the Remuneration Committee
-Financial and Performance Reporting Arrangements, as advised by the Performance Governance Committee
-All Insurance Arrangements
-Audit Arrangements
-Clinical Governance Arrangements
-Staff Governance Arrangements
-Responsibility for and delegation of exercising financial supervision and control
-Approval of the Annual Accounts
-Approval of variations that exceed the greater of £100,000 or 10% of approved capital schemes
-Approval of non-ehealth projects with a capital cost below £5million, as detailed in the NHG Grampian Capital Plan (>£5million – SEHD approval required)
-Approval of e-health projects with a project life cost of less than £1million over the first 4 years of the project, as detailed in the NHS Grampian Capital Plan (or the project life if shorter) (>£1million – SEHD approval required)

DELEGATED TO

/ DUTIES DELEGATED
Management of Organisation’s Assets -Director of Finance
-Chief Executive and Director of Finance
-Chief Executive and Director of Finance
-Chief Operating Officer
-Chief Executive and Director of Finance
-Chief Executive and Director of Finance or Chief Operating Officer and Director of Finance
-Chief Operating Officer
-Audit Committee
-Director of Finance
-Endowment Committee / -Maintenance of register of assets and register of leases
-Delegation of budgets approved by the Board to appropriate officers
-Confirm to the officer responsible the authority to proceed with the approved Capital Plan
-Responsible for ensuring tenders prepared in accordance with SFIs
-Approve post-tender negotiations, where the movement is the Lower of £25,000 or 10% of the contract value
-Condemnations, Losses and Special Payments
-Delegation of responsibility for stock control
-Undertake to review the audit of the Patients Funds
-Procedural instructions for the management of Endowment Funds
-Review the audit reports of the Endowment Funds and review the adequacy of action taken as a result of audit
-Endowment Committee
-Director of Performance Improvement
-Chief Operating Officer
-Clinical Director of e-Health
-Chief Executive
-Director of Finance / -Appointment of Statutory External Auditors for Endowment Funds.
-Ensure that Risk Management Framework is in place and fully implemented
-Delegation of responsibility for physical Security Arrangements
-Responsible for the preparation of E-health Strategy and procedures for the Control of Computer Systems and Facilities, including e-health security arrangements
-Delegation of responsibility for preparing and implementing procedures for Data Protection Arrangements to the Data Protection Officer
-CNORIS Insurance Arrangements

DELEGATED TO

/ DUTIES DELEGATED
-Director of Finance
-Board
-Chief Executive
-Director of Finance
-Director of Finance
-Director of Finance
-Director of Finance
-Director of Finance / -Approve all Financial Operating Procedures
-Responsibility for and delegation of exercising financial supervision and control.
-Ultimately accountable to the Board for overall responsibility to ensure the organisation meets its obligation to perform within the available financial resources, overall Executive responsibility for the organisation’s activities, responsible for ensuring that the organisation’s financial obligations and targets are met and overall responsibility for the organisation’s systems of internal control.
-Ensure that existing Directors and all new appointees are notified of and understand their responsibilities within the Standing Financial Instructions
-Implement financial policies and coordinate any corrective actions where necessary to further the policies
-Prepare the organisation’s financial plans and policies and co-ordinate any corrective action necessary to further these plans and policies
-Maintain an effective system of internal financial control
-Ensure that effective records are maintained to show and explain the organisation’s transactions
Financial Plans & Projections-Director of Finance
-Director of Finance
-Director of Finance / -Compile a 5 year financial plan, as an integral part of the Local Health Plan
-Report to and advise the Board of any significant variance from the financial plan and remedial actions to be taken
-Compile and submit to the Board financial projections on both revenue and capital
Service Agreements for the Provision of Services-Chief Operating Officer / -Establish proper arrangements for the provision of services in to and out of NHS Grampian

DELEGATED TO

/ DUTIES DELEGATED
Budgets-Director of Finance
-Director of Finance and Chief Operating Officer
-Director of Finance
-Budget Holders
-Director of Finance
-Director of Finance
-Chief Operating Officer and Director of Finance
-Chief Executive
-Director of Finance / -Lead on preparation of budgets and submit to Board for approval
-Agree level of delegation to budget holders
-Monitor financial performance against budget and Local Health Plan
-Provide information as required by the Director of Finance to enable compilation of budgets
-Ensure that adequate training is delivered to budget holders to help them manage effectively
-Devise and maintain systems of budgetary control
-Identify and implement efficiency savings and income generation initiatives
-Lead on strategy to reduce cost base to funding levels
-Ensure appropriate financial monitoring forms are submitted to the Scottish Executive
Income-Director of Finance
-Director of Finance
-Director of Finance
-Director of Finance / -Design and maintain systems for the proper recording and collection of all monies due
-Ensure that full cost recovery is achieved when setting prices for services
-Approve and regularly review the level of all fees and charges other than those determined by the Scottish Executive or by statute
-Take appropriate recovery action on all outstanding debts
Annual Accounts and Reports-Director of Finance
-Audit Committee
-Board
-Chairman and Chief Executive and Director of Finance / -Prepare Annual Accounts and related returns
-Review of the Annual Accounts and present to the Board for approval within agreed timetables
-Approval of the Annual Accounts
-Certify the Annual Accounts in accordance with national guidance
Bank and OPG Accounts-Director of Finance / -Responsible for the systems, procedures and operation of the organisation’s bank accounts

DELEGATED TO

/

DUTIES DELEGATED

Capital Approvals, Capital Investments, PFI, Fixed Asset Registers and Security of Assets
-Chief Executive
-Board
-Board
-Chief Executive
-Chief Executive
- Director of Planning
-Chief Executive
- Asset Investment Group
-Director of Planning
-Director of Finance
-Board
-Chief Operating Officer
-Director of Finance
-Chief Executive
-Director of Finance
-Strategic Services Redesign Committee, as a committee reporting to the Grampian NHS Board / -Responsible for ensuring a Property Strategy is in place, and that plans for capital investments are only agreed where a robust business case has been developed in line with Local Health Plan objectives
-Approval of non-ehealth projects with a capital cost below £5 million, as detailed in the NHS Grampian Capital Plan (>£5million– SEHD approval required)
-Approval of e-health projects with a project life cost of less than £1 million over the first 4 years of the project, as detailed in the NHS Grampian Capital Plan (or the project life, if shorter) (>£1million – SEHD approval required)
-Responsible for ensuring all Capital Planning guidance is followed
-Responsible for ensuring:
-there is an adequate appraisal and approval process in place for determining capital expenditure priorities and the effect of each proposal upon financial plans and also operational service plans;
-that a Capital programme is brought to the Board for approval;
-that capital investment is not undertaken without confirmation of Board support in terms of the Capital Plan and the availability of resources to finance all revenue consequences, including capital charges
-the management of all stages of capital schemes and that the schemes are delivered on time and within budget;
-Ensure that for every capital expenditure proposal over £500,000 a business case is produced for approval by the Board
- Approval of capital expenditure proposals less than £500,000
-Management of capital schemes stage payments in compliance with PROCODE and SCIM
-Ensure reporting procedures are in place on capital expenditure
-Approval of variations that exceed the greater of £100,000 or 10% of approved capital schemes.
-Approval of variations of approved capital schemes < £100,000
-Responsible for demonstrating the use of PFI/PPP represents value for money
-Approval of disposal of fixed assets between £250,000 and £500,000
-Approval of disposal of fixed assets below £250,000
-Approval of disposal of fixed assets above £500,000

DELEGATED TO

/ DUTIES DELEGATED
Security of Cash, Cheques and other Negotiable Instruments
-Director of Finance / -Responsibility for development of systems to ensure the security of cash, cheques and other negotiable instruments throughout the organisation
Staff Contracts of Employment
-Director of Human Resources
-Director of Human Resources andDirector of Finance
-Director of Finance
-Director of Human Resources and Director of Finance
-Director of Human Resources and Director of Finance -Director of Finance / -Ensure that each employee shall be issued with a contract, which shall comply with current employment legislation
-Approve all variations to agreed rates of pay and conditions of service on behalf of the Board through the Remuneration Committee where these do not relate to nationally agreed settlements
-Ensure that all payments of staff are properly authorised in accordance with national agreed pay scales or formally approved local agreements.
-Agree any local agreements in support of changes in local working practices, which involves new rates of pay leading to additional remuneration
-Responsible for ensuring procedures governing the early retirement and redundancy in compliance with extant guidance
-Reporting the financial performance of the overall impact of early retirement/redundancies to the Board
Payment of Accounts
-Director of Finance
-Director of Finance
-Director of Finance / -Responsible for the prompt payment of all accounts and claims
-Ensure all payments are made in accordance with the Scheme of Delegation
-Design and maintain systems for the verification, recording and payment of all amounts payable by the organisation

DELEGATED TO

/ DUTIES DELEGATED
Primary Care Contractors-Director of Primary Care
-Director of Finance and Director of Primary Care / -Responsible for preparing, documenting and maintaining systems to control the registers of those who are entitled to provide general dental, medical, ophthalmic or pharmaceutical services under the NHS in Grampian
-Ensure the preparation, documentation and maintenance of systems, including lines of accountability for:
-Payment to Primary Care Contractors;
-Receipt of income from Primary Care Contractors;
-Recording and verification of all payments under agreed contractual obligations including the quality and outcomes framework;
-Budgetary control of all income streams to support the development of Primary Care
-Agree the SLA with Practitioner Services Division for the agency to support the payment and verification process
Procurement and Tendering
-Director of Finance
-Chief Operating Officer and Director of Finance
-Director of Finance
-Chief Executive or nominated officer
-Director of Finance
-Director of Planning and Director of Facilities / -Advise the Board on the setting of thresholds above which quotations or formal tenders must be obtained
-Set thresholds above which quotations or formal tenders for obtaining goods, services and works must be obtained
-Prepare procedural instructions incorporating the thresholds set for obtaining goods, services and works
-Evaluate quotations and select using a best value for money criterion
-Ensure arrangements for financial control and financial audit of building and engineering contracts and property transactions comply with guidance contained in PROCODE and SCIM
-Responsible for the technical audit of building and engineering contracts
Ordering, Stores and Receipt of Goods
-Director of Finance
-Director of Finance
-Chief Operating Officer
-Chief Operating Officer
-Chief Operating Officer
-Chief Operating Officer
-Director of Finance
-Chief Operating Officer and Director of Finance
-Chief Operating Officer / -Preparation, documentation and maintenance of procedures governing the requisitioning of goods and services from whatever source of funds
-Preparation and maintenance of operational scheme of delegation listing managers authorised to requisition goods and services including authorised limits
-Responsible for the system of control of stores
-Delegation of responsibility for stock control
-Delegation of responsibility for security arrangement and custody of keys for all stores locations
-Set out procedures and systems to regulate the stores
-Ensure stocktaking arrangements confirmed with Chief Operating Officer and Auditors
-Approval of system for reviewing slow moving/obsolete/unserviceable items for condemnation, disposal and replacement
-Implementation of the system for reviewing slow moving/obsolete/unserviceable items for condemnation, disposal and replacement

DELEGATED TO

/

DUTIES DELEGATED

Patients’ Property-Chief Operating Officer
-Director of Finance
-Director of Finance
-Director of Finance
-Director of Finance / -Responsible for informing patients or their guardians about patients’ property procedures on admission
-Provide detailed written instructions for the receipt, custody, recording, safekeeping and disposal of patients’ property
-Preparation of an abstract of receipts and payments of patients’ private funds in the form laid down in the SEHD’s Manual for Accounts.
-Ensure that the abstract of receipts and payment of patients’ private funds is independently audited
-Present the audit report on the abstract of receipts and payment of patients’ private funds.
Information Technology-Director of Finance
-Director of Finance
-Director of Finance and Clinical Director of e-Health
-Chief Operating Officer
-Chief Executive
-Caldicott Guardian / -Ensure the accuracy and security of the computerised financial data of the organisation
-Ensure that new financial systems and amendments to current systems are developed in a controlled manner and thoroughly tested prior to implementation
-Ensure adequate controls, including financial, are in place for contracts for computer services with external agencies
-Devise and implement any necessary procedures to protect the organisation and individuals from inappropriate use or misuse of information held on computer files taking account of the Data Protection Acts 1984 and 1998 and other relevant guidance
-Ensure that the organisation is fully compliant with the requirements of the Freedom of Information (Scotland) Act 2002 with effect from 1 January 2005
-Ensure the protection of patient confidentiality throughout NHS Grampian in accordance with patients legal rights.
Internal Audit -Director of Finance
-Director of Finance
-Director of Finance
-Chief Operating Office and Director of Finance
-Director of Finance
-Director of Finance / -Establish and maintain an effective internal audit service
-Responsible for the arrangements to review, evaluate and report on the effectiveness of internal financial control
-Responsible for ensuring the adequacy of internal audit and that it meets NHS mandatory audit standards
-Responsible for investigating cases of fraud, misappropriation or other irregularities in accordance with Board policy
-Responsible for ensuring that the Chief Internal Auditor prepares the required plans for approval
-Responsible for ensuring that an annual audit report is prepared by the Chief Internal Auditor

DELEGATED TO