Item 6.2.2B for 5 April 2011 Schedule of Reserved Decisions

SCHEDULE OF RESERVED DECISIONS

Aim

The purpose of this paper is to seekGrampian NHS Board approval of theorganisation’s revised Schedule of Reserved Decisions (SORD).

Strategic Context

The Schedule of Reserved Decisions is a key component of the organisation’s overall financial governance and internal control arrangements.

Discussion

The current SORD requires to be updated to reflect a number of changes in managerial responsibilities. The Audit Committee considered the proposed changes at its meeting on 9thMarch 2011 and agreed to recommend the revised SORD included at Appendix 1, for approval by the Grampian NHS Board.

Key Risks

That the proposed SORD is not fit for purpose or is not adhered to by the organisation’s officers in carrying out day to day responsibilities. Regular internal and external audit reviews of arrangements and how effectively they are applied in practice are essential in minimising potential risks.

Recommendation

The Grampian NHS Board is asked to approve the revised Schedule of Reserved Decisions as set outinAppendix 1.

Executive Lead:

Alan Gall, Director of Finance/Deputy Chief Executive

Paper submitted by:

Garry Kidd

Interim Assistant Director of Finance

28th March 2011

Appendix 1

NHS Grampian

Scheme of Delegation

Schedule of Reserved Decisions

C O N T E N T S

Page

/
/

Scheme of Delegated Authority

4 Introduction

5 NHS Grampian

5 Meetings

5 Code of Conduct and Code of Accountability

5 Other Matters

6 Decisions Reserved for the Board

7 Management of NHS Grampian Assets

Financial Plans and Projections

Service Agreements for the Provision of Services

Budgets

Income

Annual Accounts and Reports

Bank and OPG Accounts

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

Security of Cash, Cheques and other Negotiable Instruments

Staff Contracts of Employment

Payment of Accounts

Primary Care Contractors

Procurement and Tendering

Ordering, Stores and Receipt of Goods

Patients’ Property

Information Technology

Internal Audit

Disposals and Condemnations, Losses and Special Payments

Endowment Funds

Risk Management and Insurance

Legal Matters

Retention of Documents

Delegated Limits and Authorised Signatories

Quotations, Tendering and Contract Procedures

Endowment Projects and Payments

Endowment Investments

Authorisation of Losses, Compensation and Ex-Gratia payments

Bank Accounts

Compensation Payments Under Legal Obligation (CNORIS delegated limits)

Fixed Asset Additions and Disposals in relation to Property

Professional Consultancy Commitment and Payment

Travel/Conference/Course/Training/Expenses Payment

Establishment of Cash Floats

Leased Car Ordering

Virement between Revenue Budget Headings

NHS Grampian Schedule of Reserved Decisions

Introduction

The Schedule of Reserved Decisions (SORD) is a corporate governance protocol that provides 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, The Assistant Director of Finance (Financial Services) on ext 56211 orthe NHS Grampian legal adviser, on ext 58496.

NHS Grampian Schedule of Reserved Decisions

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 Deputy Chief Executive ) / -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 the Asset Investment Group
-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 – SGHD approval required)
-Approval of e-health projects with a project life cost of less than £2million over the first 4 years of the project, as detailed in the NHS Grampian Capital Plan (or the project life if shorter) (>£2million – SGHD 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 are 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 Nursing
-Chief Operating Officer
-Chief Operating Officer
-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 Risk Sharing 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 Delivery 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
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 Delivery 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 Government
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 charges for services
-Approve and regularly review the level of all fees and charges other than those determined by the Scottish Government 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 Government Banking Service 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 and Director of Public Health
-Chief Executive and Director of Public Health
-Director of Public Health and Director of Finance
-Chief Executive
-Asset Investment Group
-Director of Public Health and Director of Finance
-Director of Finance
-Board
-Director of Public Health and Director of Finance
-Director of Finance
-Director of Finance
-Chief Executive
-Asset Investment Group / -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– SGHD approval required)
-Approval of e-health projects with a project life cost of less than £2 million over the first 4 years of the project, as detailed in the NHS Grampian Capital Plan (or the project life, if shorter) (>£2million – SGHD 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
-Approval of Business Cases for the development of GP premises
-Approval of the acquisition of property, whether by purchase, lease or excambion up to a value of £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 alternative sources of finance represents value for money
-Approval of disposal of fixed assets below £250,000
-Approval of disposal of fixed assets between £250,000 and £500,000
-Approval of disposal of fixed assets above £500,000
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 HR & Strategic Change
-Director of HRStrategic Change andDirector of Finance
-Director of Finance
-Director of HR& Strategic Change and Director of Finance
-Director of HR& Strategic Change and Director of Finance -Director of Finance
-Grampian Area Partnership Forum / -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 to 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 early retirement and redundancy in compliance with extant guidance
-Reporting the financial performance of the overall impact of early retirement/redundancies to the Board
-Development and agreement on NHS Grampian wide employee relations matters, subject to approval by the Board and the relevant trade unions.
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-Designated CHP General Manager
-Director of Finance and Designated CHP General Manager / -Responsible for preparing, documenting and maintaining systems to control the registers, professional accreditation and service quality 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 and Chief Operating Officer
-Chief Executive or nominated officer
-Director of Finance
-Director of Finance and Chief Operating Officer / -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 and Chief Operating Officer
-Director of Finance and Chief Operating Officer
-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 arrangements 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
Patients’ Property-Chief Operating Officer
-Chief Operating Officer
-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 SGHD’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 Chief Operating Officer
-Chief Operating Officer
-Chief Executive
-Chief Executive and 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
-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
-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