AcademiWales

#PublicServiceWales

The Good Governance Pocket Guide for NHS Wales Boards

The Good Governance Guide for NHS Wales Boards: Pocket Guide 1 Contents

Introduction 5

What is Good Governance and Why Does It Matter? 6 What is Corporate Governance? 6 Importance and benefits of good corporate governance in the Welsh Public Sector 7 The Principles of Good Governance in the Public Sector 8

Values and Standards in Public Service Governance 10 The Nolan Principles of Public Life 10 Public Service Values and Behaviours for Wales 12 Citizen Centred Governance Principles for Wales 15 The principles of Citizen Based Governance 15 Managing Welsh Public Money 16 Information Governance 17 Integrated Governance 17

Values and Standards of Behaviour Framework for the NHS Wales 18

Governance Framework for the NHS in Wales 20 The Audit Committee 21 Quality and Safety Committee 22 Information Governance Committee 22 Charitable Funds Committee 22 Remuneration and Terms of Service Committee 22 The Mental Health Act Monitoring Committee 23 Committee Membership 23

2 The Good Governance Guide for NHS Wales Boards: Pocket Guide Holding NHS organisations to account 24

Effective Boards 25

Formulating Strategy 26 Effective Strategic Planning 26 Prudent Healthcare 27 The NHS Wales Planning Framework 28

Scrutiny and Assurance 32 What do Boards need assurance on? 33 Establishing an Effective Governance Framework 34 Where should your Board get its assurance? 35 Effective Scrutiny 36 Managing Risk 37 Quality Assurance and Clinical Governance 39 Being Open and Transparent About Quality and Performance 41 Clinical Audit 43 Health and Care Standards for Health Services in Wales 43 Putting Things Right 43 Intelligence 44

Engagement 46

Effective Partnership Working 47 The Well-being of Future Generations (Wales) Act 2015 47 Social Services and Well-being (Wales) Act 2014 49

The Good Governance Guide for NHS Wales Boards: Pocket Guide 3 Culture 50

Leadership of Organisations in Hard Times 51

Judgement and Dilemmas 53

Board Roles and Responsibilities 56 The Role and Responsibilities of the Board 56 The Role and Responsibilities of the Chair 56 The Role and Responsibilities of the Chief Executive 57 Separating the Roles of the Chair and Chief Executive 57 Roles and Responsibilities of Board Members 58 The Effective Non Executive Board Member 59 The Effective Executive Director 61 Due Diligence 63 Separating the Non-Executive Director/Independent Member and Executive Director Board Roles 63 Time Commitment 66 The Role and Responsibilities of the Board Secretary 67

Understanding the Environment 68 The Statutory Framework for NHS Bodies in Wales 68 The Welsh Language in Public Services 68 Structure of NHS Wales 69 Local Health Boards 69 NHS Trusts 70 Other Bodies 71 Sources of Further Help and Advice 73

References 74

4 The Good Governance Guide for NHS Wales Boards: Pocket Guide Introduction

This document has been designed to provide climate, and growing pressure on our services, some key principles of good governance that the role of NHS boards has never been more can aid good decision making at board level challenging and the need for good and in NHS Wales. The guide builds on previous effective governance so important. best practice guidance, but also recognises The guide is short to make for easy the major impact of recent legislation on the reading and reference, but is backed up related roles, responsibilities, and relationships by a wide range of material that is both of public service organisations across Wales signposted throughout this document and relating to health, wellbeing and social care. with useful links given at the end of the In this context, NHS Boards are extremely guide. This Pocket Guide should be read in important, they take decisions which are conjunction with “The Good Governance fundamental to improving health and in the Guide for NHS Wales Boards, Second Edition, planning, organisation and delivery of health Doing it Right, doing it better – a learning care for the benefit of the communities we resource for Board Members” all serve. Academi Wales 2017 The function of governance is to ensure that an organisation fulfils its overall purpose, achieves its intended outcomes for citizens and service users, and operates in an effective, efficient, and ethical manner. As we face ever more public scrutiny, a tough financial

The Good Governance Guide for NHS Wales Boards: Pocket Guide 5 What is Good Governance and Why Does It Matter?

What is corporate governance? having the means to verify and demonstrate ‘In simple terms, it refers to the way in the effectiveness of this direction and control. which public service bodies ensure that The principles for corporate governance apply they are doing the right things, in the right to all organisations; regardless of whether way, for the right people, in a manner that it is in the public or private sector. However upholds the values set for the Welsh public organisations within the public sector are sector. The effectiveness of governance subject to an array of different legislative arrangements has a significant impact on requirements and are significantly more how well organisations meet their aims and diverse in terms of their structure, scope and objectives’. objectives. As a result it is difficult to provide (Welsh Government, 2014c) one all-embracing definition that satisfies all those with a view on the matter, but one is: Governance is a wide-ranging term; it encompasses concepts such as leadership, ‘A system of accountability to citizens, stewardship, accountability, scrutiny, service users, stakeholders and the wider challenge, ethical behaviour, values and community, within which healthcare control. It is the process by which leaders organisations work, take decisions and lead execute their responsibilities and authority their people to achieve their objectives.’ and how they account for that authority in (Welsh Government, 2014c) relation to those that have entrusted them In the Independent Commission on Good with assets and resources. In particular it is Governance in Public Services (OPM and concerned with the potential abuse of the CIPFA, 2004), the Office for Public power and the need for openness, integrity Management and Chartered Institute of Public and accountability in the decision-making Finance and Accountancy asserted that the processes of the organisation. Fundamental function of governance is to ensure that an to effective corporate governance is therefore organisation or partnership fulfils its overall

6 The Good Governance Guide for NHS Wales Boards: Pocket Guide purpose, achieves its intended outcomes for is often seen (in hindsight) as creating the citizens and service users, and operates in an climate, structures and processes that lead effective, efficient, and ethical manner. to poor decisions. The more open and honest organisations are Importance and benefits of good corporate with themselves about their performance, governance in the Welsh Public Sector the more open and honest they can be with ‘Governance is not just a set of dry or service users and the public. This honesty is bureaucratic processes; it is the means by the foundation for deciding appropriate action which organisations identify and act on the to remedy poor performance. Better quality need for change in what they do and how services are then more likely; improved they deliver it’. performance and being more open will Summary Report of the Commission on increase public trust. Public Service Governance and Delivery The importance of effective leadership in (Welsh Government, 2014a) ensuring good governance is clear; ultimately, The quality of corporate governance is often leaders are responsible for achieving the reflected in the quality of decision-making. right balance of hard and soft factors and are Public sector bodies must combine reliable accountable for the decisions they take, or fail information produced by ‘hard’ systems and to take. They set the strategy for organisations processes with the ‘softer’ issues of openness and give it a sense of direction and purpose and integrity, to inform their judgement on and set the tone for the cultural aspects of key decisions. There are significant benefits organisations that can never be codified or to improved co-ordination of assurance. set out in detailed guidance, but which are Fundamental to these is the provision of immediately recognisable to those who work streamlined and synchronised information in or deal with them. Governance is dynamic; on organisational performance and the good governance encourages the public management of associated risks, helping trust and participation that enables services the organisation to operate efficiently and to improve; bad governance fosters the low effectively. Good governance supports morale and adversarial relationships that effective decision making; poor governance leads to poor performance or even, ultimately, to dysfunctional organisations.

The Good Governance Guide for NHS Wales Boards: Pocket Guide 7 Decision-making always involves risk, their intended outcomes while acting in although this risk is reduced when an open the public interest at all times. The diagram culture exists in which challenge is accepted overleaf illustrates how the various principles and supported. This challenge and openness for good governance in the public sector must be underpinned by robust performance, relate to each other. Principles A and B financial and information management permeate implementation of principles C systems, the effective use of risk management to G. The diagram also illustrates that good and an accountability framework that is based governance is dynamic, and that an entity as on a clear communication and understanding a whole should be committed to improving. across the organisation of roles and To deliver good governance in the public responsibilities. sector, both governing bodies and individuals working for public sector entities must try to The Principles of Good Governance in the achieve their entity’s objectives while acting Public Sector in the public interest at all times. This must be The International Federation of Accountants consistent with the requirements of legislation and the Chartered Institute of Public Finance and government policies, avoiding self-interest and Accountancy define governance as the and, if necessary, overriding a perceived arrangements put in place to ensure that organisational interest. Acting in the public the intended outcomes for stakeholders interest implies primary consideration of the are defined and achieved. The fundamental benefits for society, which should result in function of good governance in the public positive outcomes for service users and other sector is to ensure that entities achieve stakeholders.

8 The Good Governance Guide for NHS Wales Boards: Pocket Guide (IFAC AND CIPFA, 2014)

The Good Governance Guide for NHS Wales Boards: Pocket Guide 9 Values and Standards in Public Service Governance

Organisations in every sector benefit from The Nolan Principles of Public Life greater legitimacy when the public has Citizens have a right to expect that holders confidence in their integrity. High standards of public office who take decisions of behaviour are a matter of personal which affect their lives should do so with responsibility, but should also be embedded impartiality, should be truthful about what in organisational processes and actively they are doing and should use public and consistently demonstrated, especially money wisely. The basic building blocks for by those in leadership positions. This guide promoting high standards were identified focuses on three frameworks, central to by the original Nolan Committee as a set of ethical behaviour in public services in Wales: broadly expressed values, which everyone the ‘Nolan’ principles; the Welsh Public Service understands. Effective internal processes Values; and the Citizen-Centred Governance should then embed a culture of high Principles for Wales: standards, with leadership by example and proportionate, risk-based external scrutiny. These standards of behaviour matter and are particularly important where public money is being spent on public services or public functions.

10 The Good Governance Guide for NHS Wales Boards: Pocket Guide The Nolan Principles Selflessness: Holders of public office should act solely in terms of the public interest. Integrity: Holders of public office must avoid placing themselves under any obligation to people or organisations that might try inappropriately to influence them in their work. They should not act or take decisions in order to gain financial or other material benefits for themselves, their family, or their friends. They must declare and resolve any interests and relationships. Objectivity: Holders of public office must act and take decisions impartially, fairly and on merit, using the best evidence and without discrimination or bias. Accountability: Holders of public office are accountable to the public for their decisions and actions and must submit themselves to the scrutiny necessary to ensure this. Openness: Holders of public office should act and take decisions in an open and transparent manner. Information should not be withheld from the public unless there are clear and lawful reasons for so doing. Honesty: Holders of public office should be truthful. Leadership: Holders of public office should exhibit these principles in their own behaviour. They should actively promote and robustly support the principles and be willing to challenge poor behaviour wherever it occurs.

The Good Governance Guide for NHS Wales Boards: Pocket Guide 11 Public Service Values and Behaviours of Wales. The aim is to have a single set of for Wales values, which guide how Welsh public service The Welsh Government has set out an staff work, change culture and shape the way ambitious agenda to unify public service they behave. Living these values means being endeavour across Wales with a common autonomous yet accountable, being both brave set of values, bringing together the and bold and creating a culture that is open responsibilities of the Well-being of Future and transparent where people achieve their Generations (Wales) Act 2015. We need potential. All Welsh Board members and other to create a culture that cuts across leaders are expected to exhibit these values organisational boundaries and sectors; and behaviours when carrying out their Board where everyone involved in the delivery of roles. This will create a shared way of thinking public services in Wales is part of this common and behaving – developing a future where we endeavour, sharing common values and can all work together with a joint purpose, working together for the benefit of the people having a collective vision and values.

12 The Good Governance Guide for NHS Wales Boards: Pocket Guide One Welsh Public Service Improving the economic, social, environmental and cultural wellbeing of Wales

As One Welsh Public Service, we have a shared purpose and shared drivers to achieve a better and lasting quality of life for us all. Wellbeing goals: the responsibility of all public services

A Prosperous Wales A Resilient Wales A Healthier Wales A More Equal Wales

A Wales of Vibrant Culture A Wales of Cohesive and Thriving Welsh A Globally Responsible Communities Wales Language

Public service values: Wellbeing delivery principles: the beliefs we hold how we will work

Working for the Long Term: To safeguard the ability of future generations to meet their own needs, requires Long term: The importance of balancing short real longterm integration and collaboration addressing term needs with the need to safeguard the ability the wellbeing of people and communities, economic to also meet longterm needs. prosperity and the health of the natural environment.

Always Growing and Improving: We will be at our best for citizens and each other by choosing positive Prevention: How acting to prevent problems attitudes and behaviours, embracing learning and occurring or getting worse may help public bodies development and sharing ideas on ways to improve meet their objectives. and deliver public services.

Working Together: Where everyone involved in the Integration: Considering how the public body’s delivery of public services, values others contributions, wellbeing objectives may impact upon each of the shares common principles and collaborates for the wellbeing goals, on their other objectives, or on benefit of the people of Wales, within and across the objectives of other public bodies. organisational boundaries and sectors.

Treating Everyone With Respect: Recognising, Collaboration: Acting in collaboration with any valuing and respecting the diversity of the people of other person (or different parts of the body itself) Wales is central to seeing people as individuals and that could help the body to meet its wellbeing doing the right thing, at the right time and in the right objectives. place for citizens and each other.

Putting Citizens First: Our organisations need to be Involvement: The importance of involving people focussed on the needs of the people of Wales. This with an interest in achieving the wellbeing goals, requires us to genuinely involve people in decision and ensuring that those people reflect the diversity making which impacts them and their communities. of the area which the body serves.

The aim is to have a single set of values which guide how we work, change culture and shape the way we behave. Living these values means being autonomousThe Good Governance yet accountable, Guide for NHS Walesbeing Boards: both Pocketbrave Guide and bold13 and creating a culture that is open and transparent where people achieve their potential. • I will reflect honestly on my personal style and • I will maintain a realistic and positive attitude to its impact on others and I will develop my skills challenges, adversity and change and support so that I can adapt my style as appropriate. others to do the same. • I will learn from my successes and mistakes • I will pursue unpopular initiatives and plans if and develop new areas of knowledge and they represent progress and the ‘right thing expertise. to do’.

• I will encourage and support others to think differently, to question and to try new ways • I will continually reinforce a culture of inclusive of doing things, taking appropriate calculated decision making and shared leadership. risks. • I will demonstrate trust in others, knowing when • I will understand and embrace the benefits of to support and when to step back. new technology and implement their use for managing and delivering public services.

• I will communicate with citizens in a way they • I will work with others to generate a shared can understand and relate to using appropriate sense of purpose and a positive view of what channels, harnessing digital technology the future looks like. effectively. • I will act with agility to adapt my role and • I will seek to continually improve financial purpose in response to the anticipated needs of performance and deliver value for money the service. without compromising quality.

• I will seek to understand the different aims and • I will communicate openly, build credibility, and agendas of those with whom I am working, and be straightforward with people to generate trust use this knowledge to address any potential and confidence in me. conflict and to achieve a positive outcome. • I will lead across boundaries, see the public • I will plan ahead to identify and cultivate service as a single system and seek to break relationships that are likely to be important to down silo thinking. the successful delivery of services now and in the future.

14 The Good Governance Guide for NHS Wales Boards: Pocket Guide Citizen Centred Governance Principles The principles of Citizen Based Governance for Wales Putting the citizen first– putting the citizen The Welsh Government’s Citizen Centred at the heart of everything and focusing on Governance Principles embody what the their needs and experiences; making the Welsh Government want public services to be. organisation’s purpose the delivery of a high It is defined as“putting the citizen at the heart quality service. of everything and focusing on their needs Knowing who does what and why – making and experiences; making the organisation’s sure that everyone involved in the delivery purpose the delivery of a high quality service’’. chain understands each other’s roles and Governance encompasses culture and values responsibilities and how together they can as well as systems and processes. Citizens deliver the best possible outcomes. are engaged and involved in the development of services and receive services which are Engaging with others – working in efficient, effective and innovative in their constructive partnerships to deliver the best design and implementation. outcome for the citizen. Living public sector values – being a value-driven organisation, rooted in Nolan principles and Welsh public service values: High standards of public life and behaviour, including openness, customer service standards, diversity and engaged leadership. Fostering innovative delivery – being creative and innovative in the delivery of public services – working from evidence, and taking managed risks to achieve better outcomes. Being a learning organisation – always learning and always improving service delivery. Achieving value for money – looking after taxpayers’ resources properly, and using them carefully to deliver high quality, efficient services.

The Good Governance Guide for NHS Wales Boards: Pocket Guide 15 Managing Welsh Public Money whole of the Welsh public sector. Everyone The Welsh Government and the public sector who works in the public service in Wales in Wales rely on taxpayers’ money, and the shares a personal responsibility for the taxpayer rightly expects us to spend it wisely. stewardship of taxpayers’ money, whether they It is hugely important that people in Wales are manage budgets, assets or simply their own able to trust their public services, especially in time. Everyone working in public services in austere times when these services are relied Wales must be aware of the need to manage upon most heavily. and deploy public resources responsibly and in the public interest. This is all about Managing Welsh Public Money (Welsh delivering outcomes for the citizens of Wales. Government, 2016) sets out the main Looking after taxpayers’ money properly principles for managing resources in the means just getting two things right at the Welsh public sector and is primarily aimed same time; delivering the outcomes sought at organisations within the boundary of the by Ministers on behalf of the people for Wales Welsh Government’s consolidated accounts, and living up to the values demanded in the but the principles should hold true across the public service.

16 The Good Governance Guide for NHS Wales Boards: Pocket Guide Information Governance Integrated Governance Information Governance is a framework In order that the Board may discharge its related to how organisations and individuals duties with due rigour it has to be assured handle information; it applies to sensitive that the systems in place relating to integrated and personal information of employees and governance are closely intertwined. service users, and also to information related Each decision has to focus closely on the to the business of the organisation. It sits requirements of the different aspects of within corporate governance, and while the governance, in particular clinical governance, key focus is on ensuring that information is corporate governance, research governance, handled in a confidential and secure manner, information governance, and financial it is also very much about supporting the governance. provision of high quality services and care by The main features of an integrated governance ensuring the right information is available to model are: the right people, when and where it’s needed. • Integrating risk assessment with the initial Information Governance provides a objective setting process; framework for bringing together the requirements, standards and best practice • Developing a process for reporting that apply to the handling of information. progress against objectives; Caldicott is a key element of the Information • Aligning the various governance systems so Governance agenda in Wales, providing that they complement each other without organisations working in health and social overlap; care with a set of recommendations and • Developing an effective assurance principles to help ensure that person framework; identifiable information (including that of patients, staff and service users) is • Overhauling the committee structure to appropriately shared and protected. ensure that governance information was Each organisation should have a Caldicott properly integrated, and presented to the Guardian who has overall responsibility for Board as a coherent whole. establishing Information Governance policies and processes.

The Good Governance Guide for NHS Wales Boards: Pocket Guide 17 Values and Standards of Behaviour Framework for the NHS Wales

A values and standards of behaviour • Putting quality and safety above all else: framework, together with model standing providing high value evidence based care orders and standing financial instructions, for our patients at all times. form the key elements of the Governance • Integrating improvement into everyday and Accountability Framework for the NHS working and eliminating harm, variation in Wales. and waste. NHS Wales is a vital part of the public service • Focusing on prevention, health in Wales. Working together with its key improvement and inequality as key to partners, including local government and sustainable development, wellness and the Third Sector, public service values and wellbeing for future generations of the associated behaviours are and must be at its people of Wales. heart. NHS organisations must be value driven, rooted in high standards of public life and • Working in true partnerships with partners behaviour. The core values that underpin the and organisations and with our staff. NHS in Wales are: • Investing in our staff through training and development, enabling them to influence decisions and providing them with the tools, systems and environment to work safely and effectively.

18 The Good Governance Guide for NHS Wales Boards: Pocket Guide These core values support good governance • Invest time to develop constructive and help ensure the achievement of the relationships around the Board table highest possible standards in all that the • Reflect a drive to challenge discrimination, NHS in Wales does. Boards need to be seen promote equality, diversity, equity of access as champions of these values in the way they and quality of services. They respect and operate and behave. Effective Boards and their protect human rights in the treatment members: of staff, service users, their families and • Prioritise service quality and safety carers, and the wider community • Behave consistently in line with Nolan’s • Ensure that their approach to strategy, seven principles of public life accountability and engagement are • Model an open approach to learning consistent with the values they seek to promote for the organisation.

The Good Governance Guide for NHS Wales Boards: Pocket Guide 19 Governance Framework for the NHS in Wales

The Welsh Government’s Citizen Centred arrangements and in evaluating their Governance principles establish the standards effectiveness. Legislation for health and of good governance for the NHS in Wales and social care organisations requires them to are designed to ensure: have certain procedures in place to govern • Clarity for everyone working within the the behaviour of independent members and NHS system, those working in partnership staff and this contributes to the management with the NHS, those receiving NHS services of risks. It might appear that the structures themselves and carers and relatives of and processes are over-elaborate and those receiving NHS services; bureaucratic. However, Board members are accountable to the public in a stewardship role • Responsibility is placed with those and these measures help to protect Board who are best equipped to meet those members by ensuring there is openness responsibilities; and honesty in the business dealings of • Recognition for those achieving their NHS organisations. objectives; and The Code of Conduct for NHS Boards • Action to ensure activities remain on track. together with the Code of Accountability for NHS Boards is the basis on which The extent to which individual NHS NHS organisations in Wales should seek to organisations are able to demonstrate fulfil the duties and responsibilities conferred their alignment with the Citizen Centred upon them by the Welsh Ministers. All Board Governance Principles will contribute to members of NHS bodies in Wales are required, the Cabinet Secretary for Health, Wellbeing on appointment, to subscribe to the Codes of and Sport’s annual review of NHS bodies’ Conduct and Accountability for NHS Boards. performance. NHS bodies will need to A copy of the Codes of Conduct is available take account of these principles when from the NHS Wales Governance E-Manual developing their governance and assurance website.

20 The Good Governance Guide for NHS Wales Boards: Pocket Guide The Board will function as a corporate Committees with a primary scrutiny function, decision making body. Executive Directors membership is limited to Independent and Independent Members are full members Members, with Executive Directors in and share corporate responsibility for all attendance: the decisions of the Board. However, for

The Board

Quality Information Charitable Remuneration Mental Audit & Safety Governance Funds and Terms of Health Act Committee Committee Committee Committee Service Monitoring

The Audit Committee control over all activities requires a wider The Audit Committee supports the Board by focus. There are two key areas on which the critically reviewing governance and assurance Audit Committee should provide assurance processes on which the Board places reliance. to the Board: on the organisation’s assurance At the corporate level these will include a risk system; and on the public disclosure management system and a performance statements that flow from the assurance management system underpinned by an processes, including the Annual Governance effective system of assurance. Statement and the Annual Quality Statement. The Committee’s work will predominantly No Audit Committee can afford to limit itself focus upon the risks, controls and related to focus on internal financial control matters. assurances that make up the assurance The importance of financial scrutiny has system, which underpins the delivery of the not diminished but the need for rigorous organisation’s objectives. Therefore it has a

The Good Governance Guide for NHS Wales Boards: Pocket Guide 21 pivotal role to play in seeking and providing its provision of high quality healthcare; assurance on the organisation’s activities, and assurance to the Board in relation to the and delivery of its objectives. In particular arrangements for creating, collecting, storing, this covers the Governance Statement, safeguarding, disseminating, sharing, using which should come to the Committee before and disposing of information in accordance being submitted for approval and sign-off by with its stated objectives; legislative the Board. responsibilities, e.g. the Data Protection Acts 1998 and 2003 and Freedom of Information Quality and Safety Committee Act 2000; and any relevant requirements and standards determined for the NHS in Wales. The purpose of the Quality and Safety Committee is to provide accurate, evidenced (where possible) and timely advice to the Charitable Funds Committee Board to assist it in discharging its functions The purpose of the Charitable Funds and meeting its responsibilities with regard Committee is to ensure that the budget, to the quality and safety of healthcare. priorities and spending criteria determined It also seeks assurance in relation to the by the LHB as trustee are consistent with organisation’s arrangements for safeguarding the requirements of the Charities Act 1993, and improving the quality and safety of Charities Act 2006 (or any modification of healthcare and subsequently provide these acts). The Board, and Board Members, assurance to the Board. when they meet as Trustees, have a clear and distinctive role that is completely independent Information Governance Committee of their normal role as Board and Board Members of the LHB or Trust. The purpose of the Information Governance Committee is to provide evidence based and timely advice to the Board to assist it in Remuneration and Terms of Service discharging its functions and meeting its Committee responsibilities with regard to the: quality and The purpose of the Remuneration and integrity; safety and security; and appropriate Terms of Service Committee is to provide access and use of information (including advice to the Board on remuneration and patient and personal information) to support terms of service for the Chief Executive,

22 The Good Governance Guide for NHS Wales Boards: Pocket Guide Executive Directors and other senior staff Committee Membership within the framework set by the Welsh All Board committees normally have an Assembly Government. The committee also Independent Member as Chair. All committee provides assurance to the Board in relation members are Independent Members, to the LHB’s/Trust’s arrangements for the with Executive Directors in attendance remuneration and terms of service, including as appropriate, other than for Charitable contractual arrangements for all staff, Funds Committee where both Independent in accordance with the requirements and Members and Executive Directors can standards determined for the NHS in Wales; be committee members. At least one and to perform certain, specific functions Independent Member of the Audit Committee on behalf of the Board. The Committee has must have a financial background. Checks no powers to develop or modify existing pay and balances need to be maintained in schemes. committee membership. So, for example, the Board Chair cannot be a member of the The Mental Health Act Monitoring Audit Committee. Best practice suggests that Committee the Vice Chair of the organisation should not The purpose of the Mental Health Act chair the Audit Committee in order to avoid Monitoring Committee is to assure the Board potential conflicts of interest. Effective Boards that those functions of the Mental Health Act minimise the number of standing Board 1983, as amended, which they have delegated committees. However, Boards may establish to officers and staff are being carried out other committees such as finance committee, correctly; and that the wider operation of risk committees. the 1983 Act in relation to the LHB’s area is operating properly.

The Good Governance Guide for NHS Wales Boards: Pocket Guide 23 Holding NHS Organisations to Account

All NHS bodies in Wales will establish a clear • Independent scrutiny of activities by framework of accountability within which they Community Health Councils (CHCs) on conduct their business internally and work behalf of patients, and others such as the collaboratively with their NHS colleagues and Public Service Ombudsman. public service partners. They will develop and • Public sector partners, e.g. Local publish strategic and operational level plans Authorities, Public Services Boards with that define agreed outcomes and ways of regard to local well-being assessments and working with their community partners and plans and other ways within which public public sector partners. sector providers currently demonstrate They will be held accountable for their accountability to each other and to citizens performance in delivery of these plans in a within their communities; and ongoing variety of ways. They will be required to publish performance management led by the regular reports on activity and performance, National Delivery Group. including publication of an Annual Report and an Annual Quality Statement. Health organisations will also be subject to scrutiny at community and national levels, including: • Internal and external assurance work carried out by auditors, inspectors, regulators and others, e.g. Healthcare Inspectorate Wales (HIW), Wales Audit Office.

24 The Good Governance Guide for NHS Wales Boards: Pocket Guide Effective Boards

The behaviour and culture of a Board are key • Give priority to engagement with key determinants of the Board’s performance. stakeholders and opinion formers within Good Board governance cannot be legislated and beyond the organisation; the emphasis for but can be built over time. Sonnenfeld in here is on building a healthy dialogue his article for the Harvard Business Review, with, and being accountable to, patients, ‘What makes great boards great?’ (2002) the public, and staff, including clinicians. suggests that four characteristics of effective The three key roles through which effective Boards are: Boards demonstrate leadership within their • A focus on strategic decision-making. organisations are: • Board members who trust each other and • Formulating strategy. act cohesively/behave corporately. • Ensuring accountability by holding the • Constructive challenge by Board members organisation to account for the delivery of each other. of the strategy and through seeking • Effective chairs that ensure meetings have assurance that systems of control are clear and effective processes. robust and reliable. Effective Boards: • Shaping a positive culture for the Board and the organisation. • Are informed by the external context within which they must operate. • Are informed by, and shape, the intelligence which provides trend and comparative information on how the organisation is performing together with an understanding of local people’s needs, market and stakeholder analyses.

The Good Governance Guide for NHS Wales Boards: Pocket Guide 25 Formulating Strategy

Effective Strategic Planning Some of the hallmarks of an effective strategy In general, an effective strategic process include: ensures that: • A compelling vision for the future • The strategy, including identification of underpinned with clear strategic objectives strategic options, is demonstrably shaped that are reflected in an explicit statement and owned by the Board; of desired outcomes and key performance indicators. • It provides for the active involvement of and influence by staff; • An organisational vision that puts quality and service user/patient safety at its heart. • There have been open, transparent and accountable consultation, involvement • A clear statement of the organisation’s processes, collaborative engagement purpose. with partners, and the consultation and • An approach that takes appropriate involvement processes help to identify account of the external context in which the strategic choices, risks and proposed organisation is operating. ways forward; • A perspective which balances the priority • It is underpinned by regular strategic given to national and local performance discourse in the Board, throughout the indicators and targets. year; and • Evidence that the strategy has been shaped • It is dynamic in responding to changes by the ‘intelligence’ made available to in the external environment. the Board. • A longer term view (with at least a 3 to 5 year planning horizon), with a financial model and risk analysis, and a workforce

26 The Good Governance Guide for NHS Wales Boards: Pocket Guide model that sets out the organisational services are interacting with those of partner arrangements required to deliver the organisations. strategy and identifies the workforce The vision once agreed and fully articulated implications of strategic choices. is the reference point against which present • Demonstrable links to the needs of service and proposed performance is measured. users and communities. So Boards can ask questions like: How far have • An integrated approach to health and we got towards delivery so far? What else wellbeing. needs to be done to get us the rest of the way as easily, effectively and as quickly as possible? • Inclusion at its heart so that services that are commissioned or delivered produce Prudent Healthcare accessible, fair and equitable services and outcomes for all sections of the Wales is at the forefront of the movement to population served. provide a value-based approach to services and prudent healthcare is an important • Commitment to treating service users and concept now being used to shape Welsh staff with equity. Government policy. Boards in formulating • Explicit attention paid to the ability to strategy need to do so in the context of implement the strategy successfully. Welsh Government and Ministerial priorities. It is vital that the Board articulates a clear Prudent healthcare aims to create a patient- picture of what they want the future to look centred system. An NHS based on prudent like in as much detail as possible. This is healthcare principles will ensure patients not only restricted to being just about the receive the most appropriate agreed shape and style of the organisation, but treatments. This will reflect the contribution about what is happening in the outer world individuals can make to their own health and and how the organisation’s facilities and wellbeing.

The Good Governance Guide for NHS Wales Boards: Pocket Guide 27 Prudent healthcare as a key policy driver for the NHS in Wales and has four main principles:

The NHS Wales Planning Framework elements and describe, in both a qualitative Local Health Boards and Trusts in Wales have and quantitative way, how they will achieve a duty under their directed functions, flowing this vision over a three-year timeframe. from sections 1-3 of NHS Wales Act 2006, While this framework applies to both Local to continue the promotion in Wales of a Health Boards and Trusts, however as the comprehensive health service designed to statutory duties differ there will be recognised secure improvements in the physical and differences in approach and, ultimately, mental health of the people of Wales. detailed content. A market driven ideology does not apply to Collectively, the Welsh Government and NHS Wales. Planning is the main mechanism National Health Service (NHS) Wales have for Local Health Boards and Trusts to identified a need to raise the ambition and articulate how resources (financial, workforce effectiveness of planning in NHS Wales. and infrastructure) will be deployed to yield The need for effective medium term planning maximum benefit in order to: address areas is clear. NHS Wales faces some of the biggest of population health need and improve challenges and opportunities since its health outcomes; improve the quality of creation, including: care; and ensure best value from resources. • a rising elderly population The planning challenge for Local Health • inequalities in health Boards and Trusts is to align these key

28 The Good Governance Guide for NHS Wales Boards: Pocket Guide • enduring austerity finance and the public to delivering the • increasing numbers of patients with outcomes intended for the populations they chronic conditions serve over a medium term (three year) time frame. As well as demonstrating corporate • advancements in clinical practice, priorities and actions, Integrated Medium innovation and technology, with the Term Planning is also seen as the vehicle for associated increases in opportunities strengthening partnership working across the and also cost public and third sectors, acknowledging that • medical staffing pressures and securing many health outcomes will depend upon more than one organisation playing • some specialist services being spread their part. too thinly. All NHS organisations should have a strategy, In NHS Wales, planning is the agreed process approved by their Board, which clearly sets by which Health Boards and Trusts will work out their long-term vision for how they through their response to these and other will meet the needs of the communities challenges, without compromising their ability they serve. The long-term strategy of each to seize opportunities and deliver their vision. organisation is critical in setting the direction Addressing these challenges and creating of travel and in providing the context within a sustainable, effective 21st Century health which key strategic decisions about the service will require ambition, transformation, shape of services and the use of resources reconfiguration and innovation on a significant can be taken. These include decisions scale. The written Integrated Medium Term about service models, pathways, workforce Planning document (IMTP) is the formal planning, finance and infrastructure statement by which this is articulated but investment. Robust wellbeing and population planning is of course more than a document. needs assessments are essential to inform It is a discipline that should be embedded in strategies, and are a requirement of the every part of Local Health Boards and Trusts. Wellbeing of Future Generations and the Planning should be a dynamic process that Social Services and Wellbeing Acts (discussed allows Health Boards and Trusts to respond in detail later). NHS organisations must to day to day pressures without losing sight work closely with their Public Services of how they plan to align key services, staff, Boards, Regional Partnership Boards and

The Good Governance Guide for NHS Wales Boards: Pocket Guide 29 the communities they serve, as they develop Planning is a dynamic and continuous process their needs assessment, gap analysis and and it is not expected that IMTPs will set responses to inform their strategic plans. out a fixed picture for the next three years. The introduction of Integrated Medium It is however important that they are Term Plans (IMTPs) in 2014 signalled a sufficiently clear to provide confidence that move away from a focus on annual plans, the organisation understands its priorities, towards a medium-term approach linked opportunities and challenges over the to organisational strategies. IMTPs should medium-term, and that the actions it will take set out clearly what will be done over are linked to its longer-term strategy. the next three year period in pursuit of The Programme for Government Taking the organisation’s longer-term strategic Wales Forward clearly sets out four areas objectives and plans. Every organisation for development for Wales over the next must have a more immediate plan setting five years. It sets out an ambition for Wales out the actions it will take as it works towards to be: Prosperous and Secure, Healthy and its strategic objectives. A three-year focus Active, Ambitious and Learning, United and allows organisations to set out clearly what Connected. they intend to do in a medium-term period Plans need to demonstrate how they will and avoids the “stop/start” behaviours which deliver the key messages and aims within can be associated with a focus on a single Taking Wales Forward. From a health year. The IMTP should set out the aims perspective, provision of health care will need organisations will pursue in the achievement to be clearly focused on: of their long-term strategies, through measurable, clearly defined and resourced • Primary care, ensuring that patients receive actions which address key areas of population prompt, cost effective and high quality care health need, improve health outcomes and the as close to home as possible. quality of care, and ensure best value. • The provision of timely care, reducing the time that patients wait before treatment.

30 The Good Governance Guide for NHS Wales Boards: Pocket Guide • Mental health, at all levels of care, and also IMTPs are expected to demonstrate that within the workplace to ensure that we prudent principles underpin the work of the support our staff. organisation, building on our expectations • Improving integration between health and for a quality-driven service. Plans must use social services. the prudent healthcare principles to drive improved experience and outcomes for patients and citizens and the efficient and effective use of resources.

The Good Governance Guide for NHS Wales Boards: Pocket Guide 31 Scrutiny and Assurance

What is assurance? The concept guarantee; sureness; certainty; a measure of ‘assurance’ can be a source of of confidence; or as described by one Chief misunderstanding and mismatched Executive in the NHS “it’s about being able expectations within NHS organisations. to sleep at night”. Holding the organisation Most definitions of assurance centre around to account is at the heart of the Board’s common themes of confidence and certainty: role in pursuing high performance for its freedom from doubt; something said or organisation. It is important that Boards are done to inspire confidence, as a promise or not too readily assured or reassured.

Being assured is defined as the Board reviewing reliable sources of information and being satisfied with the course of action. Reassurance is defined as the Board being told by the executive or staff that performance or actions are satisfactory.

Where issues arise they need to be • Drawing on timely Board intelligence – addressed – swiftly, decisively and to monitor the performance of the knowledgeably – by the whole Board. organisation in an effective way and satisfy A robust but fair approach is important, itself that performance is continually particularly where there are problems improving and that appropriate action is of underperformance. Effective Boards taken to remedy problems as they arise. recognise that ‘the buck stops with the Board’. • Looking beyond written intelligence to The fundamentals for the Board in holding develop an understanding of the daily reality the organisation to account for performance for service users and staff, to make data include: more meaningful.

32 The Good Governance Guide for NHS Wales Boards: Pocket Guide • Seeking assurance that staff are clear about part of its annual accounts. The statement on their responsibilities and accountabilities internal control provides citizens and other and how these fit with the organisation’s stakeholders with a level of confidence on vision and purpose. the way in which an organisation is led, the • Triangulation which ensures that Board efficiency and effectiveness of its operations members are able to ‘test’ the intelligence and ultimately, its ability to deliver its strategic and seek assurance by looking at more vision, aims and objectives. However, Boards than one source and type of information, need to recognise that any assurance, including through direct engagement with whatever its source, will not be a guarantee the services. that offers absolute certainty, and that they must look to gain ‘reasonable’ assurance that • Seeking assurance of sustained their organisation’s ways of working enable improvement where remedial action has it to perform effectively across the full range been required to address performance of its activities and to deliver the strategic concerns. direction they have set. • Offering appreciation and encouragement Boards are also required to publish a public where performance is excellent or Annual Quality Statement. This statement sets improving. out clearly the achievements and challenges • Taking account of, and positively over the previous year, as well as the encouraging, independent scrutiny of improvements the Board has agreed to make performance. in the year ahead, to continuously improve the delivery of high quality and safe service. • Rigorous but constructive challenge from all Board members, executive and non- executive as corporate Board members. What do Boards need assurance on? NHS organisations in Wales are required Boards need to be confident that they are to produce an annual, formal statement of working towards fulfilling their aims and assurance known as the Annual Governance objectives in a manner that upholds the Statement, signed by the Chief Executive on highest standards of public service delivery behalf of the organisation, and published as and supports sustainable performance improvement.

The Good Governance Guide for NHS Wales Boards: Pocket Guide 33 In particular the assurance system will need for this lies firmly with the Board. They must to cover: first establish an effective governance • Compliance with relevant legislation, framework within their organisation that regulation, standards and other directions meets the standards set for the NHS in and requirements set by the Welsh Wales. The resulting framework should Government and others. ensure a strong focus on the culture and behaviours necessary for success as well as • The reliability, integrity, safety and security the introduction and operation of the right of the information collected and used by systems and processes: the organisation. • Establish a clear strategic vision for the • The efficiency, effectiveness and economic organisation, described within meaningful use of resources; and the extent to which strategic aims and objectives that the organisation safeguards and protects are clearly cascaded and understood all its assets, including its people to secure throughout the organisation. This is a the provision of high quality, safe healthcare principal role for Boards, and should set out for its citizens. what they are trying to achieve and where • This assurance extends not only to they are heading in the future. your organisation’s own arrangements • Put in place a sensible scheme of (including that of your Board itself), but delegation to the executive, committees and to e.g. working jointly, in partnership or others in line with the requirements set out through the provision of shared services. in its Standing Orders. • Highest standards of public service delivery • Establish and embed a clear, organisation and supports high quality, safe services and wide focus on actively identifying and sustainable performance. managing risks (both strategic and operational) so that the organisation is Establishing an Effective Governance able to maximise its opportunities and Framework at the same time mitigate any threats to The way in which your organisation is led is the achievement of its purpose, aims and critical to its likelihood of achieving success objectives. in the manner required – and responsibility

34 The Good Governance Guide for NHS Wales Boards: Pocket Guide Where should your Board get its plays in the overall framework of assurance, assurance? and the value they should place on it. NHS Boards may seek and receive assurance The Audit Commission (2009b) describes an from a wide range of sources within their approach to internal assurance as a “three organisation, both directly and through the lines of defence” assurance model which is operation of its committees, notably those illustrated below in RSM UK Group and NHS responsible for Audit & Quality and Safety. Providers publication – Board Assurance: The key challenge for Boards is understanding A toolkit for health sector organisations – each link in the assurance chain, what part it Do we really know what we think we know?

Application of controls

The first level of assurance comes from the department 1st Line Department that performs the day to day activity.

Other functions in the organisation such as quality, 2nd Line Organisation oversight Board finance and HR provide assurance.

Assurance provided from 3rd Line Independent assurance outside the organisation.

Board Assurance: A toolkit for health sector organisations (NHS Providers and RMS UK Group 2015)

The Good Governance Guide for NHS Wales Boards: Pocket Guide 35 1. First line of defence: Responsibility lies review activity to ensure the achievement of with healthcare staff and teams working at standards and compliance with policies and the ‘frontline’ to understand their roles and procedures. responsibilities and to carry them out properly 3. Third line of defence: This is independent and thoroughly. If working practices (the review, designed to assess the overall ‘systems and processes’) are well designed, adequacy and effectiveness of the first and and with staff are equipped to follow them, second lines of defence. The key source of this compliance with the arrangements should ‘independent’ assurance is through functions mean risks in day to day activities are routinely such as internal audit, although there are managed. other sources of independent review that 2. Second line of defence: This typically can also be used, including inspectorates and comprises executive/management review bodies. arrangements established to ensure compliance with the standards, policies and Effective Scrutiny working practices set through active oversight Effective scrutiny ensures that decision- of the operation of the first line of defence. making processes are clear and accessible to Typically, this includes holding them to account the public and that the people taking decisions for the effectiveness of their activities, and may are held accountable for those decisions. include routine assessment, inspection and

‘Scrutiny has a pivotal role in promoting improvement, efficiency and collaboration across public services and in holding those responsible for delivering services to account. The role of scrutiny is increasingly important at this time when public services are responding to the challenge of financial constraints, while continuously seeking to improve in response to rising public expectations.’ (Wales Audit Office, 2014)

36 The Good Governance Guide for NHS Wales Boards: Pocket Guide There are many sources of assurance in in particular, the proportionate management an organisation that can be harnessed to of risks that threaten the successful provide the body of evidence required to achievement of business outcomes and support the continuous assessment of the objectives. effectiveness of the management of risk As expectations of organisations increase and and internal control. Understanding the available resources become more restricted, sources of assurance and their scope means so do the constraints under which they internal audit can focus most effectively on operate and the risks that they face. the riskier areas. The structured mapping of assurances is one of the fundamental steps in building an assurance framework. The Chief Managing Risk Executive in their role as Accountable Officer, The Accounting Officer and the Board supported by the Board, is responsible for will need to ensure that they are receiving ensuring that there are robust governance, sufficient and timely assurance information risk management and internal control on the management of risk to enable them to arrangements across the whole organisation, exercise good oversight. This activity may take including any sponsored bodies. Authority, the form of reporting against a co-ordinated in terms of accountability and respective Assurance Plan or Programme. Information delegations, needs to be appropriately and provided should include routine reporting clearly established and monitored. on assurance arrangements and the body of evidence that supports this, together with Advice on and scrutiny of key risks is a any key points needing to be escalated to the matter for the Board. The Board will routinely Board. A particular focus should be the key monitor the mitigation of certain strategic strategic risks directly owned by the Board, risks. These will include risks of a sufficient any major ‘routine’ system and process magnitude to threaten organisational success risks should also be included. Risk is the and reputation, or a scenario of combined threat that an event or action will adversely risks that would have a similarly devastating affect an organisation’s ability to achieve impact. This supports the Accountable its objectives and to execute its strategies Officer in ensuring that there is regular successfully. Health and social care is, by its and timely assurance on the things that very nature, a risk activity. It is important that are important to organisational success; Board decisions are taken using all available

The Good Governance Guide for NHS Wales Boards: Pocket Guide 37 information on possible outcomes – this is in place to deliver the annual plan/ risk management. Without this, there is a very commissioning plan and comply with the real danger that patient care will suffer and, registration requirements of the quality as a consequence, give rise to the potential regulator. This includes systematically for adverse publicity and, for example, medical assessing and managing its risks. negligence cases. There are different types of These include financial, corporate and risk, but they are usually classified under the clinical risks. following main headings: Risk management by the Board is • Financial risks – for example, not having underpinned by four interlocking systems sufficient funding to meet all your of control: commitments, possibly resulting in deficit 1. The Board Assurance Framework: at year end. In their Board Assurance Toolkit, RSM UK • Clinical risks – for example, resulting from Group and NHS Providers point out that it mistakes in the treatment of patients. is common practice across the UK public • Reputational risks – for example, arising healthcare sector for the term ‘Board from adverse publicity about a failing within Assurance Framework (BAF)’ to be used to your organisation. refer to the key document used to record and report an organisation’s key strategic • Legal risks – for example, due to a lack objectives, risks, controls and assurances of understanding or implementation of to the Board. The development of Board legislation, or being sued by a patient. assurance arrangements should be a logical The role of the Board in risk management is extension of an organisation’s existing risk twofold: management arrangements. It is important therefore that Boards are satisfied with how • First, within the Board itself an informed they and their audit committees understand consideration of risk should underpin and implement risk management, and that organisational strategy, decision-making they maintain an informed engagement with and the allocation of resources. the risks and opportunities that they face. • Second, the Board is responsible for If these arrangements are effective they will ensuring that the organisation has help them understand the process and control appropriate risk management processes environment, and help them answer the core questions:

38 The Good Governance Guide for NHS Wales Boards: Pocket Guide • What do we want assurance over? Board to ensure that a robust body of evidence • How much assurance do we need? supports the assertions within it. 2. Organisational Risk Management: The approach to risk management needs Strategic risks are reflected in the Board to be systematic and rigorous. However, Assurance Framework. A more detailed it is crucial that Boards do not allow too operational risk register will be in use within much effort to be expended on processes. the organisation. The Board needs to be What matters substantively is recognition of, assured that an effective risk management and reaction to, real risks – not unthinking approach is in operation within the pursuance of bureaucratic processes. organisation. This involves both the design of Risk appetite is defined as ‘the amount and appropriate processes and ensuring that they type of risk that an organisation is willing are properly embedded into the operations to take in order to meet their strategic and culture of the organisation. objectives. Risk appetite and tolerance need 3. Audit: External and internal auditors play an to be high on any Board’s agenda and is a important role in Board assurance on internal core consideration of an organisations risk controls. There needs to be a clear line of management approach. sight from the Board Assurance Framework to the programme of internal audit. While Quality Assurance and Clinical Governance clinical audit is primarily a management As illustrated in the Francis Report (2013), tool, the advice in ‘Taking it on Trust’ (Audit failure to deliver the fundamentals of care can Commission, 2009b) suggests that ’it would bring down an NHS Board faster than failures be reasonable to expect it to appear (in the of either finance or performance, and there Board Assurance Framework) as a significant have been recent examples of this. Despite source of assurance’. this, there are still serious concerns about the 4. The Annual Government Statement: lack of attention some NHS Wales Boards pay This is signed by the Chief Executive as to the quality of clinical care. The Board has a Accountable Officer and comprehensively key role in safeguarding quality, and therefore sets out the overall organisational approach to needs to give appropriate scrutiny to the key internal control. It should be scrutinised by the facets of quality – effectiveness, patient safety, timeliness of care, and patient experience.

The Good Governance Guide for NHS Wales Boards: Pocket Guide 39 Effective scrutiny relies primarily on the of the staff and patient experience. It is provision of clear, comprehensible summary important to ensure that clinical leaders are information to the Board, set out for everyone properly empowered to lead on issues relating to see. This information should include to clinical quality. Boards benefit from regular services directly provided by the organisation, opportunities both to take advice from clinical and services provided by partner or leaders and to reflect on innovative practice commissioned organisations. Good practice in relation to quality improvement. Through suggests that: its National Governance Framework to enable • All Board members need to understand high quality care in NHS Wales Safe Care, their ultimate accountability for quality. Compassionate Care (Welsh Government, 2013c), the Welsh Government strives to • There is a clear organisational structure ensure our system is: that clarifies responsibility for delivering quality performance from the Board to the • Providing the highest possible quality and point of care, wherever it is provided, and excellent patient experience back to the Board. • Improving health outcomes and helping • Quality is a core part of main Board reduce inequalities meetings both as a standing agenda item • Getting high value from all our services. and as an integrated element of all major Whilst complex and multi-faceted, the one discussions and decisions. defining characteristic is that the Welsh • Quality performance is discussed in more NHS will put the patient, the family, the detail regularly by a quality and safety citizen, the community at the centre of all standing committee of the Board with a our work. We will listen to those who use our stable, regularly attending membership. services, we will engage with them as we plan • The Board becomes a driving force for improvements, we will address their concerns continuous quality improvement across the and we will respond to their personal as well full range of services. as clinical needs. The governance of quality can be improved if The term ‘Clinical Governance’ describes Board members periodically step outside of the range of systems that need to be in the Boardroom to gain first-hand knowledge place to provide assurance on the quality

40 The Good Governance Guide for NHS Wales Boards: Pocket Guide and safety of services. This is defined as: the • Listening to patients by having ways to system through which NHS organisations are understand and measure their experience accountable for continuously improving the and satisfaction and acting on it. quality of their services and safeguarding high • Listening to staff and students to standards of care, by creating an environment understand the concerns and challenges in which clinical excellence will flourish. they face in delivering care, and identify (Welsh Office, 1999). excellence in practice, so these findings can The Quality Delivery Plan (Welsh Government, be disseminated. 2012a) sets out a range of actions to help • Participating in national clinical audit and achieve this and has a dual purpose – driving clinical outcome reviews so that we can quality improvement and providing assurance. benchmark ourselves with others and see These two goals have much in common. where we need to improve. Each requires a strong commitment to do the right thing and to do it well, although both • Sharing good practice, participating in are essential to ensure good governance. research and encouraging innovation and Actions to drive quality improvement and use of new technologies. ensure high standards of care set within a • Making good use of data and information to system to provide robust quality assurance drive service improvement. include: • Ensuring that staff and teams have Being Open and Transparent About Quality access to learning and development to and Performance enable them to fulfil their roles safely and Managing risk effectively and being able to effectively. This includes being skilled in seek assurance that services are patient- quality improvement methodology, with centred, evidenced-based, safe and opportunities to put this into practice. good quality requires reliable and robust Continuously striving to improve what information, which must be thoroughly we do needs to be an integral part of understood at all levels in the organisation. everyone’s job, including that of Board A lack of information can lead to a tolerance members. The 1000 Lives Improvement of unknown risks and sub-standard care. Service is supporting the NHS in its efforts Robust risk management is an essential to continuously improve quality and safety.

The Good Governance Guide for NHS Wales Boards: Pocket Guide 41 element of good governance. The publication demonstrated if standards, experience and of an Annual Quality Statement by all NHS outcomes are improving and high value is organisations and the need to proactively being achieved within available resources. track quality indicators through the This is essential to show that no financial introduction of ‘Quality Triggers’ as an early decisions or workforce considerations are warning system will be an important addition made without considering the impact on to the governance framework for NHS Wales. service quality and safety. Publishing an Annual Key trigger questions provide a structure Quality Statement is first and foremost for the to triangulate information from a variety of public. It provides an opportunity for Boards sources, which cover all dimensions of quality. to routinely assess and inform their public and Are we: other stakeholders in an open and transparent • Providing safe care? way about: • Meeting required standards of effective • How well they are doing across all their care? services, including primary and community care and those provided by other • Improving user experience? organisations, including the third sector, • Providing efficient services within on their behalf resources? • Good practice that they wish to promote • Engaging the workforce? and share • Providing accessible and equitable • Areas that need to improve services? • Progress made over the past year • Improving population health? • Priorities and commitments going forward. Using quality triggers effectively will enable The Board is accountable for the all organisations to demonstrate that they organisation’s statement and must assure are truly listening and learning through itself that the information it publishes is strong and visible leadership of quality and accurate, accessible and representative safety. Ensuring Board reports integrate all across the breadth of its services. elements of performance so it can be clearly

42 The Good Governance Guide for NHS Wales Boards: Pocket Guide Clinical Audit Health and Care Standards for Health Clinical Audit is the systematic critical Services in Wales analysis of the quality of care involving the The Health and Care Standards procedures and processes used for diagnosis, (Welsh Government, 2015a) incorporate interventions and treatment, the use of revised standards for health care along with resources and the resulting outcome and revised Fundamentals of Care standards. quality of life as assessed by both professionals The revised standards are made up of and patients. It answers the questions: 7 themes comprising 22 specific standards. What are we trying to do? How well are we The Health and Care Standards have been doing? How do we know? How do we do designed so that they can be implemented in it better? all health care services, settings and locations. Audit must be regarded as tool within They establish a basis for improving the the armoury of clinical governance and quality and safety of healthcare services by effectiveness that must lead to improved providing a framework, which can be used in patient care and improved efficiency and identifying strengths and highlighting areas effectiveness. While it will be part of education for improvement. The public and patients and professional development, its main themselves must also take responsibility for purpose must be improved quality of care. helping the NHS help them through taking prudent action to protect and promote their When audits are carried out there are likely own health. The seven themes are: Staying to be lessons learned that will be applicable Healthy; Safe Care; Effective Care; Dignified elsewhere in the organisation or in the Care; Timely Care; Individual Care; and Staff wider NHS. There should be mechanisms and Resources. that encourage the sharing of learning. Clinical Audit should be reported through the Putting Things Right organisation’s structures to the Board and should form part of the way in which the Board The National Health Service (Concerns, exercises its responsibility for quality of care Complaints and Redress Arrangements) and patient safety. (Wales) Regulations 2011 (HM Government, 2011) set out the common arrangements

The Good Governance Guide for NHS Wales Boards: Pocket Guide 43 and duties that apply to NHS organisations open with patients, their families and carers in Wales in respect of the investigation and when things go wrong. Board members handling of situations where something has should ensure organisations have processes gone wrong. Under the Putting Things Right in place to support staff when concerns need arrangements (Welsh Government, 2011c), investigating as well as keeping patients and the NHS in Wales aims to ‘investigate once, their families involved throughout the process. investigate well’, ensuring that concerns It is equally important that organisations learn are dealt with in the right way, the first time. from concerns to ensure they do not recur Concerns should be taken to mean any and services are improved as a result. complaint, claim or patient safety incident. In order to gain a rounded picture of their It introduced arrangements for the handling organisation board members should request and investigating of concerns. The legislation the triangulation of information on complaints, also introduced the concept of “redress” patient safety incidents, patient experience for lower value claims worth up to £25,000, feedback, compliments, patient stories and drawing on powers set out in the NHS Redress third party surveys. This information may (Wales) Measure 2008. Organisations will also lead to the emergence of themes, which have to show how they have learnt lessons can provide learning and the opportunity for from the investigations they undertake. service improvements. The overriding message is that concerns should be investigated once and resolved to Intelligence the satisfaction of all parties in an open and Dr Foster in the paper The Intelligent Board constructive way which facilitates learning, (2006) asserts that the key tests of the i.e. a philosophy of ‘do it once, do it well’. success of any information resource for the Board members need to challenge their Board will be the extent to which it: organisations to the timeliness of dealing with concerns and emphasise the need to • Prompts relevant and constructive empower staff to ‘nip concerns in the bud’ challenge. before they escalate into formal complaints. • Supports informed decision-making. The principles of Being Open are at the heart of Putting Things Right and staff need to be • Is effective in providing early warning of potential financial or other problems.

44 The Good Governance Guide for NHS Wales Boards: Pocket Guide • Develops all directors’ understanding of the issues with a request for more information is organisation and its performance. widespread. Using information intelligently • Enables Board members to perform all means that Boards need to distinguish their roles and responsibilities within the between: limited time they have available. • Issues that need to be reported routinely to The challenge is to select, from the hundreds the Board at a certain level of detail. of statistics produced in the organisation, • Issues that need to be reported only if there those that are relevant, and to identify what is demonstrably a problem, for example, additional information is required. Dr Foster where performance significantly diverges also observes that Board members often from that achieved by peer organisations. suffer from information overload where • Issues that change relatively slowly and quantity wins over quality when it comes to that should therefore be looked at only on Board papers. The habit of responding to a quarterly or six-monthly basis.

The Good Governance Guide for NHS Wales Boards: Pocket Guide 45 Engagement

Engagement in public services is not new, stakeholders. These include Local Health and has long been a priority of senior leaders Boards and NHS Trusts, local government, in public service organisations. Recent universities and further education, research has however begun to identify the the voluntary sector, independent sector role that direct interaction between the Board, and of course regulators. This stakeholder professional staff, service users and the public engagement is most often led by the Chair can play in effective governance. Boards as and Chief Executive. a whole generally receive and consider the Section 183 of the National Health Service results of these processes in the form of (Wales) Act 2006 (in relation to Health reports and papers. The effective Board gives Boards), and section 242 of the Act (in relation priority to engaging with key stakeholders to NHS Trusts) set out the requirement to and opinion formers within and beyond involve and consult with citizens in: planning the organisation. Engaging effectively is an to provide services for which they are important way that a Board and organisation responsible; developing and considering demonstrates its openness and transparency proposals for changes in the way those and ultimately its accountability. There are services are provided; and making decisions some circumstances where there is a legal that affect how those services operate. Under obligation on public service organisations to the Community Health Councils (Constitution, involve the public. A wide range of guidance is Membership and Procedures) (Wales) available for Boards on service user and public Regulations 2010 (as amended), CHCs are engagement. The three main aspects for allocated a particular role in NHS planning, Boards to consider are: empowering people; in essence comprising the right to be involved putting service user experience centre stage; and consulted from inception and throughout and accountability to local communities. all stages of the planning process. Boards are advised to develop a coherent strategy for engagement with key institutional

46 The Good Governance Guide for NHS Wales Boards: Pocket Guide Effective Partnership Working

All in the public sector understand the need to people and communities and each other, look work together, although this often produces to prevent problems and take a more joined- tensions at organisational boundaries. up approach. It will expect them to: work In these ‘white spaces’ it can be unclear where together better; involve people reflecting the accountability lies and who is in charge or diversity of our communities; look to the long responsible. It is important to remember that term as well as focusing on now; and take setting up and managing partnerships is about action to try and stop problems getting worse delivering change. Its success depends on: - or even stop them happening in the first a shared sense of purpose; clear ownership place.To make sure we are all working towards and commitment; strong governance and the same vision, the Act puts in place seven inter-organisational relationships; jointly well-being goals. These goals and the five owned and focused agendas and business things that public bodies need to think about plans; effective interagency and community to show that they have applied the sustainable wide engagement and communications. development principle are shown in the two diagrams below. The Well-being of Future Generations (Wales) Act 2015 In Wales, the Well-being of Future Generations (Wales) Act 2015 is about improving the social, economic, environmental and cultural well-being of Wales. It sets out to make the public bodies listed in the Act think more about the long term, work better with

The Good Governance Guide for NHS Wales Boards: Pocket Guide 47 Well-being Goals

A globally responsible A prosperous Wales Wales

A Wales of vibrant culture A resilient and thriving Wales Welsh Language

A Wales of cohesive A healthier communities Wales

A more equal Wales

Well-being Delivery Principles

Long term

The importance of balancing short-term needs with the need to safeguard the ability to also meet long-term needs.

Prevention

How acting to prevent problems occurring or getting worse may help public bodies meet their objectives.

Integration

Considering how the public body’s well-being objectives may impact upon each of the well-being goals, on their other objectives, or on the objectives of other public bodies.

Collaboration

Acting in collaboration with any other person (or different parts of the body itself) that could help the body to meet its well-being objectives.

Involvement The importance of involving people with an interest in achieving the well-being goals, and ensuring that those people reflect the diversity of the area which the body serves.

48 The Good Governance Guide for NHS Wales Boards: Pocket Guide The Act establishes a statutory Future preventative approach to meeting care and Generations Commissioner for Wales, whose support needs. The purpose of these plans role is to act as a guardian for the interests of is to provide a description of the range and future generations in Wales, and to support level of services to be provided, or arranged, the public bodies listed in the Act to work to respond to the care and support needs towards achieving the well-being goals. It also identified in the combined population establishes Public Services Boards (PSBs) for assessment report. These plans should each local authority area in Wales, at which inform, and be informed, by the wider local partners must work together to assess the well-being plans provided for by the Well-being wellbeing of its local area and agree a plan to of Future Generations Act. Both plans should improve the economic, social, environmental similarly inform and be informed by Integrated and cultural well-being of its area. Medium Term Plans (IMTPs). Regional Partnership Boards are required Social Services and Well-being (Wales) to establish pooled funds in relation to the Act 2014 exercise of their family support functions and A key principle of the Act is the need for in relation to any functions they exercise jointly integrated and sustainable care and support in response to the population assessment. services. Under the Act, seven Regional Pooled funds will also be required in relation Partnership Boards have been established at to the provision of care home accommodation a Local Health Board area level. These Boards for adults from April 2018. bring together Local Health Boards, local Statutory guidance sets out the requirement authorities, third sector and other partners to for Regional Partnership Boards to prioritise deliver integrated health and social services the integration of services in relation to: older in Wales. Their purpose is to improve the people with complex needs and long term outcomes and well-being of people and conditions, including dementia; people with improve the efficiency and effectiveness of learning disabilities; carers, including young service delivery. carers; integrated family support services; and Regional Partnership Boards will be expected children with complex needs due to disability to respond to the population assessment or illness. (via an area plan), specifically, taking a

The Good Governance Guide for NHS Wales Boards: Pocket Guide 49 Culture

The third core role of the Board is shaping the organisation’s relationship and reputation a positive culture for the Board and the with service users, the public and partners as organisation. This recognises that good the primary means by which it meets policy governance flows from a shared ethos or and/or regulatory requirements. As such culture, as well as from systems and due it holds the interest of service users and diligence for the organisation and its staff. communities at its heart. It is important for Boards to develop a If shaping the culture of the organisation is good understanding of the current values, a vital role for Boards, then embedding the behaviours and attitudes operating within culture, so that it becomes a lived reality, the organisation, and to work with the staff is equally important and arguably the most to shape the desired values, behaviours challenging part of the role. Embedding and attitudes. The challenge then is how to a healthy culture across an organisation achieve change. requires sustained effort and consistency The organisation and its leaders must be of approach, often over a number of years. mindful of the cultural messages that they Dialogue and engagement with staff and send, intentionally or passively. For example: service users ensures that Board members by the Board’s agenda; by the nature of the take back to the Boardroom an enriched debate in the Board; by the relative emphasis understanding of the lived reality for staff, given to different performance criteria; by how service users and partners. An outward visible Board members are in the organisation; looking Board leadership culture that actively by where leaders choose to invest time and embraces change, fosters innovation, resource. Effective Boards shape a culture for encourages learning and maintains an the organisation, which is caring, ambitious, unswerving commitment to quality and safety self- directed, nimble, responsive, inclusive of service users offers the best prospect of and encourages innovation. A commitment to navigating effectively through a demanding openness, transparency and candour means and rapidly changing environment. that Boards are more likely to give priority to

50 The Good Governance Guide for NHS Wales Boards: Pocket Guide Leadership of Organisations in Hard Times

Leadership of organisations in hard times very senior roles, whether Executive or Non- poses new challenges and requires different Executive. While short term actions will be thinking. In their paper Tough times, tough needed, organisations must also ensure that choices – Being open and honest about they develop medium and long term strategies NHS Finance 2013, the NHS Confederation and plans. The overriding challenge will be to point out that all health systems across the have a clear sense of the journey which must developed world face increasing demand and be travelled over the next few years and of cost pressures. There is mounting evidence the nature of the organisation and services to support the need for redesigning services which will emerge when a ‘post-rebalancing’ to unlock more sustainable efficiencies, destination is reached. while remodelling services around the needs This is an agenda that poses a unique blend of of patients. This would make it possible to challenges. Major long term reforms will need reduce the need for patients to be treated to be planned, resourced and implemented in the acute sector and allow them to be while also coping with near-term budget more appropriately cared for in their own reductions. Adjustments will be required communities. Making this choice and that change existing ways of working and delivering this vision will not be easy and will challenge preconceived views, both within not be achieved without public support, which and beyond the organisation. Priorities will has proved difficult to win. The Chartered need to be articulated more clearly than ever Institute of Public Finance and Accountancy before and resources allocated with greater has prepared a paper, Leading in Hard precision. Leaders will have to navigate high Times – Guidance for everyone involved in levels of uncertainty and anxiety, listening and the leadership of public services (CIPFA, engaging with the views of the public, service 2010) that is tailored explicitly for the very users, staff, partners and other stakeholders, difficult conditions which are likely to prevail and charting a way forward which is in the for the next few years. It focuses in particular public interest. Leadership of organisations in on the leadership responsibilities of those in

The Good Governance Guide for NHS Wales Boards: Pocket Guide 51 hard times poses new challenges and requires their leaders approach the challenges of the different thinking. new environment and that ten key actions CIPFA suggests that seven key principles will enable leaders to direct organisations’ should underlie the way public bodies and responses to the new challenging climate with real focus and purpose:

Having a shared understanding of what ‘efficiency’ means

Thinking creatively and acting innovatively

Being open to a range of skills and techniques

Recognising the ‘wicked’ nature of the problem

Responding to local needs and priorities

Getting people engaged

Being pro-active and starting early CIPFA 2010

Engage and communicate

Know where your Understand where Build a vision for costs are now value lies how you will look Identify options for change Build a balanced portfolio Understand funding scenarios of change projects Actions

Build the capacity to change

Implement effective financial and risk management

Ensure governance is fit for purpose CIPFA 2010

52 The Good Governance Guide for NHS Wales Boards: Pocket Guide Judgement and Dilemmas

Exercising judgment is key to building There are examples from both inside and an effective Board. Here a spectrum of outside of public service where culture has dilemmas that many Boards are grappling been successfully changed over a period of with are set out, and yet are not amenable time. Learning the leadership and governance to uniform guidance. They are provided here lessons from these case studies may provide to encourage Boards to set aside the time important pointers for Boards. to debate and explore them as part of their Building trust with local people in a developmental journey. financially constrained environment: Paying attention to culture: beyond Most Boards would wish to support an exhorting a person-centred culture: approach which suggests that ‘if organisations While the emerging consensus about the concentrate on quality – the resources will critical importance of organisational culture follow’ but evidence of the extent to which this in delivering safe and effective high quality is the case in practice seems inconsistent. services is to be welcomed; it prompts a range Although there are some salutary examples, of questions for Boards: Boards are often called upon to balance • Public service organisations are complex competing priorities where the ‘high quality and multi-faceted and rarely have a single services can be more cost effective’ mantra culture. How does the Board really ‘know’ is more difficult to see. In the financially what the culture is – especially in the light of constrained environment within Boards the lively academic debate about the extent delivering are operating or public service to which culture can be ‘measured’? Boards, the challenge is for organisations to work with service users, the local community, • To what extent can the Board really shape and across the public services divide to culture in a deliberate and purposeful way? identify opportunities for service integration • What sorts of approaches will help the and redesign to deliver better outcomes for Board to move beyond exhorting the service users in a more cost effective way culture that it aims to shape? in the longer term. More often than not,

The Good Governance Guide for NHS Wales Boards: Pocket Guide 53 delivering these longer term improvements and conduct that matter most to them, will require significant service change and to service users and the public – and that this these can trigger anxiety, opposition and thinking is reflected in the broader suite of concern in the community. It is important standards that are set and monitored in the that Boards are able to work with partners, organisation. local people and local political leaders to help Achieving a balance between managing risk to build understanding of the choices and and encouraging innovation: A systematic ‘trade-offs’ and thereby build public trust and approach to the management of risk is one confidence. way that Boards can build public confidence. Maintaining the balance between holding However, it is clear that the future sustainability to account and being accountable: Boards of public service values will require creative and organisations devote a great deal of time and innovative solutions. Boards must ensure and resource responding to the demands that risk and innovation aren’t seen as mutually and expectations of external regulators. exclusive and should ensure that individuals This brings the risk that ‘accountability’ comes and teams within the organisation take full and to mean accounting for what the organisation active responsibility for the management of has done rather than taking meaningful risk without creating a straightjacket of anxiety responsibility for the performance of the that stifles creativity? Boards should know organisation and its adherence to standards. about and act on good practice emerging Robust assurance processes begin with from the literature, encourage innovation and the intrinsic motivation of the Board to set, engage with the academic networks as well exemplify and monitor organisational values as tapping into other networks as sources of and fundamental standards and support staff innovative practice. to deliver them. External regulation should Zero tolerance of poor services... in a be seen as a ‘failsafe’ rather than a primary learning organisation: The appropriate source of assurance and it is important that Board response to flagrantly poor services Boards model and encourage an approach is beyond debate and prevarication, but that makes it clear and that adherence to questions about care that is simply sub- external standards is not enough. Rather, staff optimal – the services that are persistently are expected to give robust and thoughtful mediocre – can be more challenging. attention to the standards of quality, service The dilemma for Boards is to identify the point

54 The Good Governance Guide for NHS Wales Boards: Pocket Guide at which they need to move from working reduce the likelihood that staff will be open collaboratively to gain improvement on an about mistakes so that the learning can be issue to the ‘zero tolerance’ point – and, having surfaced and disseminated. If organisations made that judgment, what that means the are to respond to resource constraints and Board does in practice. encourage innovation, there will be a need An open culture that encourages for experimentation with new services and transparency and learning in response to Boards must maintain a commitment to ‘zero adverse events is a key pre-requisite for avoidable mistakes’ whilst allowing space for reliably high quality safe and effective services. innovation and experimentation. They should However Boards must ensure that in pursuing also consider what extent are staff rewarded a policy of ‘zero avoidable mistakes’ they do for bringing forward and/or implementing not, inadvertently, drive a climate of fear and innovative ideas which improve quality.

The Good Governance Guide for NHS Wales Boards: Pocket Guide 55 Board Roles and Responsibilities

The Role and Responsibilities of the Board • Provide leadership to the Board, the The Board’s role is to provide leadership of the other Non-Executives, the Chief Executive organisation within a framework of prudent and Executive Directors; and ensure the and effective controls which enables risk to be effectiveness of the Board in all aspects of assessed and managed. its role and agenda; including directing the organisation towards achieving its and the The Board should: Government’s objectives. • Set the organisation’s strategic aims, • Ensure the provision of accurate, timely • Ensure conformance to statutory duties and clear information to the Board and and responsibilities, directors to meet statutory requirements. • Ensure that the necessary financial and • Ensure effective communication with the human resources are in place for the Board, staff, service users and the public organisation to meet its objectives, in a changing public service environment. • Review management performance, • Arrange the regular evaluation of the performance of the Board, its committees • Set the organisation’s values and standards, and individual Non-Executives, Directors, and and the Chief Executive. • Ensure that its obligations to its • Plan and conduct Board meetings, with stakeholders are understood and met. the Chief Executive. Facilitate the effective contribution of Non-Executive Directors The Role and Responsibilities of the Chair and ensure constructive relations within Chairs are accountable for giving leadership the organisation and between executive to the Board and delivering value for money and Non-Executive Directors. in terms of quality of service and financial • Share and use relevant expertise of all balance. They will: members of the Board.

56 The Good Governance Guide for NHS Wales Boards: Pocket Guide • The Chair is responsible for ensuring the leadership role in effective communication organisation’s policies and actions support and building strong partnerships with the Welsh Ministers’ strategic priorities and patients, public, staff key partners and that its affairs are conducted with probity. regulators. The Chair is appraised by the relevant • Ensures that the executive team has Minister/Cabinet Secretary. the right balance and diversity of skills, knowledge and perspectives. The Role and Responsibilities of the Chief Executive • Supports the Chair in ensuring that development programmes are in place The Chief Executive is the most senior for Board members – uses the Board manager of the organisation, the Accountable performance evaluations as the basis Officer and: for determining individual and collective • Leads the organisation in the development professional development programmes for and delivery of the organisation’s strategy. Executive Directors relevant to their duties as Board members. • Is ultimately responsible for performance, establishes effective performance management arrangements and controls. Separating the Roles of the Chair and Chief Executive • Provides visible leadership in developing a healthy culture for the organisation, In essence the accountability of the Chair is to and ensures that this is reflected in their manage the performance and development own and the executive’s behaviour and of the Board whilst the accountability of decision-making. the Chief Executive is to lead and manage the performance and development of the • Ensures all Board members are well briefed organisation. The Chair is the figurehead on external context. and ambassador for the purpose and vision • Ensures provision of accurate, timely and of the organisation. This means that the clear information to Board/Directors. Chair can always go out and champion what the organisation stands for and is trying to • Acts as the organisation’s chief internal achieve and when it comes to questions and external communicator, playing a key about the performance of the organisation

The Good Governance Guide for NHS Wales Boards: Pocket Guide 57 or its detailed implementation plans they • Help to clarify which decisions are reserved can rightly say “you will need to ask the Chief for the Board and then ensure that the rest Executive”. This enables the Chair always to are clearly delegated. stay on the high ground and not be forced • Hold management to account for its onto the defensive. This is a crucial attribute performance in meeting agreed goals and when representing their organisation to objectives through purposeful challenge stakeholders and partners. It is absolutely vital and scrutiny; and to monitor the reporting that somebody is standing back independently of performance. and objectively so that ideas, proposals, plans, activities, performance, competence and Quality behaviour can be sensibly and appropriately • Set organisation wide expectations and reviewed in context. lt is the job of the Chair accountability for high performance and to ensure that the quality of this independent ensure that all staff understand their role viewpoint and objectivity is sustained in all the in the effective and high-quality provision Board’s activities. of care in a governance framework that ensures a balance between trust, Roles and Responsibilities of Board constructive debate and effective challenge Members and in a culture of openness and learning. The role of the Board member including Risk Executives and Non Executives focuses on • To ensure that financial information is four key areas: accurate and that financial controls Strategy and systems of risk management and • Contribute to strategic development and assurance are robust and defensible. decision-making. Behaviour Performance • To live up to the highest ethical standards • Ensure that effective management of integrity and probity and comply fully arrangements and an effective team are in with the Code of Conduct. Board members place at the top level of the organisation. should also demonstrate through their behaviour that they are focusing on their responsibilities to citizens, the organisation and its stakeholders.

58 The Good Governance Guide for NHS Wales Boards: Pocket Guide When appointed to a Board, members should The Effective Non Executive Board Member be provided with an appropriate programme Non-executive director are also referred to as of induction training. This should include independent members on health boards/trust guidance on what members have to do and boards. the standards that they must meet. Non-Executive Directors will work alongside Specific roles will vary depending on the role other Non-Executives and Executive Directors of the Board and the capacity in which you as an equal member of the Board. They share have been appointed, but generally you will be responsibility with the other directors for expected to: the decisions made by the Board and for • Understand the environment in which your the success of the organisation in leading public body operates; the local improvement of healthcare • Contribute to decision-making and share services. Non-executives use their skills and responsibility for the Board’s decisions; personal experience as a member of their community to: • Attend Board meetings on a regular basis and be well prepared by reading relevant • Commit to working to, and encouraging papers in advance and, if necessary, within the organisation, the highest seeking further information; standards of probity, integrity and governance and contribute to ensuring • Attend training events and keep up-to-date that the organisation’s internal governance with subjects relevant to the organisation’s arrangements conform with best practice work; and statutory requirements. • Contribute to the work of any committees • Provide independent judgement and advice that have been established by the Board; on issues of strategy, vision, performance, and resources and standards of conduct and • Represent the Board at meetings and constructively challenge, influence and help events when required. the executive board develop proposals on such strategies to enable the organisation to fulfil its leadership responsibilities for healthcare of the local community.

The Good Governance Guide for NHS Wales Boards: Pocket Guide 59 • Ensure the Board sets challenging • Assist fellow directors in providing objectives for improving its performance entrepreneurial leadership to the across the range of its functions. organisation within a framework of prudent • In accordance with agreed Board and effective controls, which enable risk to procedures, monitor the performance be assessed and managed. and conduct of management in meeting • Assist fellow directors in setting the agreed goals and objectives and statutory organisation’s values and standards responsibilities, including the preparation and ensure that its obligations to its of annual reports and annual accounts and stakeholders and the wider community are other statutory duties. understood and fairly balanced at all times. • Ensure that financial information is Non-Executive Directors and Independent accurate and that financial controls and Members are appointed to bring a particular risk management systems are robust perspective, skill or area of expertise to the and defensible and that the Board is kept Board. They are not appointed to directly fully informed through timely and relevant represent the particular interests of any one information. group or sector, and all individual members • Accept accountability for the delivery of the are responsible for contributing across the organisation’s objectives and ensure that breadth of the Board’s responsibilities. the Board acts in the best interests of its An effective Non-Executive Director or local community. Independent Member: • Participate in the committees established • Supports executives in their leadership of by the Board to exercise delegated the business while monitoring performance responsibility and take an active part • Questions intelligently, debates in other activity such as the Board’s dispassionately and constructively, and programmes of engagement and challenges rigorously partnership. • Listens sensitively to the views of others, • Bring independent judgement and inside and outside the Board experience from outside the organisation and apply this to the benefit of the • Gains the trust and respect of other Board organisation, its stakeholders and its wider members community.

60 The Good Governance Guide for NHS Wales Boards: Pocket Guide • Maintains a focus on strategy and The Effective Executive Director performance and is not distracted by detail. All Executive Directors have a dual set of roles They must: and responsibilities: • Ensure that they understand the role of the • Firstly, as a result of their management organisation and the sector within which it relationship to their Chief Executive. In this operates. respect, their accountability is defined by • Support the Chair in being clear about the their job description and by the personal information they need in order to discharge objectives and standards of performance their role, including assurance and scrutiny. they have agreed with their Chief Executive. • Aside from attending Board and committee • Secondly, as a result of being a Board meetings, always ensure they have read Member. In this respect, when they are all papers they are sent and have a operating in the Board they are also good understanding of the work of the accountable to the Chair for the same organisation. 18 accountabilities as other Board Members. • Actively participate in all aspects of assurance and scrutiny and not absent Executive Directors must be able to view themselves from particular discussions. both their own and the organisation’s work from above, as an independent objective • Properly declare all areas of potential or observer. This enables them to rigorously perceived conflict of interest. and objectively scrutinise all proposals, • Discuss matters they feel uncomfortable offer dispassionate comments and identify with or uncertain about with the Chair. potential improvements to all areas of work, including their own. • Go through an annual development appraisal discussion with the Chair. • Undertake their important ambassadorial role for their organisations.

The Good Governance Guide for NHS Wales Boards: Pocket Guide 61 Hold the vision - To improve the health and wellbeing of Ensure your Board sets a definite direction - By the population of Wales. You need to really understand the providing clear purpose, vision, goals and priorities to Welsh Government’s vision for Wales and to keep drawing enable your organisation to drive forward improvements your organisation, your Board, your partner organisations in health, improve the quality and availability of services and NHS Wales back to the key things we need to do to and reduce health inequalities within and between the make it a reality. communities you serve.

Ensure clarity and action - Ensure that your executives Hold executives and managers to account - For pull together effective plans and have resources and the delivery of the organisation’s plans, and to help systems in place to deliver the vision and goals effectively. them ensure high standards of regularity, propriety Ensure that the purpose, vision, goal and objectives are and excellence. Participate skilfully in time-effective clearly communicated to and engage all who are involved clinical, financial, managerial and corporate governance in, or affected by their delivery. activities in your Board to review their stewardship of the organisation, its practices, and its people. Ensure probity and governance - Is appropriately Learn and practice discharged in all corporate, managerial, clinical and Use time well - Time effectiveness and results focus, your role financial affairs. preparation and skilfulness are key attributes you will need. Develop yourself and Make sure you can your colleagues deliver it effectively in Do your own due diligence - Make sure you complete all your Board activities your induction training and understand your organisation, Be diligent and probing - Take the time to properly find Society and technology its context, your role and stay alert to your responsibilities out and understand what is happening in your organisation are both changing Complete sufficient and effectiveness. and the context in which it is working. rapidly. due diligence prior to Be disciplined and methodical - Use effective starting your role Be objective and logical - With your Board colleagues, Every one of us will methodologies to get results, to evaluate and measure you will be responsible for deploying and making decisions need to learn new progress, to review your own performance and Maintain your due about significant amounts of public money and services. skills. contribution as a Board. diligence to a level Be rational and objective in your approach, evaluate and that enables you to measure, seek evidence of effectiveness and delivery. Boards and their participate effectively members will need to Separate your role from that of executives and in setting direction develop. Be skilful - Work with all your colleagues on your Board managers - Retain the integrity of your role as a Board for your organisation as a team. Continuously develop yourself, your colleagues member and don’t get lost in the work of the organisation, and assessing the and your Board so that maximum impact and effectiveness which is the work of your executives. If you were all It is vital that we build performance of the is achieved. This may mean you and your colleagues engaged working in the organisation, who would be on our successes. organisation and its employ innovative and creative practices and techniques working on the organisation? executives. in order to maximise effectiveness and delivery. This is to be encouraged so that we can raise our standards and Guard against your own conflict of interest- In the achieve new levels of competence and delivery. more obvious ways where you have personal gain or vested interest issues that are relevant, but also in the less Use your experience to contribute - To strategies where obvious ways when you have emotional capital or strong you can and tap into your network of contacts to get opinions that will reduce your objectivity and logic. things done - though in so doing recognise that you are there as Board members and not representatives of your professional or interest group. You will sometimes need Collaborate with partners - Collaborate and commuicate your Board colleagues to help you stay objective and do with all your partners in this endeavour, whether that the due diligence on your activities. be with your organisation’s partner organisations, staff, patients or the public. Communicate the vision and what is possible through all of us working together to achieve the Bring equality and respect diversity - Hear the needs common aim of better health, better services and quality of of minority groups and find ways to look after and address life for all who live in Wales. the needs of the least served and most disadvantaged.

62 The Good Governance Guide for NHS Wales Boards: Pocket Guide Due Diligence achievement of the organisation’s short, Due diligence is the act of making sure that medium and long-term goals? How is everything is the way it is supposed to be. our performance compared with that It involves doing all the necessary homework, of others? background checks, and analyses to identify • What specific underlying forces determined problems, offer solutions, and document those results? procedures. In terms of corporate governance • Constituency protection – what in general, Peter Morgan, former Director mechanisms are in place to ensure that the General Institute of Directors suggested that interests of all stakeholders are addressed, the following twelve questions “The Diligent and that the appropriate statutory or Dozen” are important for Board members to regulatory requirements are met? assess whether things are as they should be. • What litigation and disputes risks and • What is the strategic purpose and vision of arrangements do we have? the organisation? • How well are we able to respond to crises, • What are short, medium and long-term and what contingency plans and processes objectives for achievement for us to are in place? strive for? • How are resources allocated to bring Separating the Non-Executive Director/ it about, in particular, the financial and Independent Member and Executive human resources? Director Board Roles • How is the management organisation All Board members, executives, managers and geared to the achievement of the strategy? staff in your organisation need to understand • Financial controls – how do they work? the work of the Board and Board members, and how it is different from the work of • Operational controls – how do they work? executives, managers and staff. The work of • What are the management priorities in the the Board and Executives/Managers can be near, intermediate and long term? broadly separated by looking at the Board’s • Past and present performance – what responsibility as to state ‘what’ is required and progress has been made towards the measuring progress towards its achievement.

The Good Governance Guide for NHS Wales Boards: Pocket Guide 63 The Executives/Managers’ and Team’s advice on issues and constructively challenge, responsibility is to come up with “how” this can influence and help the executives develop be achieved and then to implement action to proposals to enable the organisation to fulfil achieve it. its leadership responsibilities for healthcare The flow chart below shows the Board’s first of the local community. When satisfied that task is to provide or approve the strategic the plans are as good and coherent as they vision and goals for the organisation. Once the can be, they are approved by the Board and Board has provided or agreed the vision, goals passed back to the Executive Team for the and priorities, the Executive Team will develop preparation of detailed plans and personal the strategy for how these can be achieved. objectives for implementation. The Board’s Once the strategy is prepared it should be role, then, is to regularly measure progress submitted to the Board, which then acts as and performance and seek assurance a test bed where Non Executive Directors through the accountability and governance can provide independent judgement and arrangements put in place for this purpose.

64 The Good Governance Guide for NHS Wales Boards: Pocket Guide WORK OF THE BOARD WORK OF EXECUTIVE “WHAT” “HOW”

PURPOSE

Provide strategies to achieve Set or agree vision, goals and vision, strategic goals and priorities long and short term priorities

Test bed to rigourously examine and test strategies before real world implementation

Devise and implement detailed Approve strategies plans and objectives

Measure and monitor progress

Measure and monitor performance Revise and update plans to reflect progress Ensure accountability and governance and provide ongoing due diligence and probity

Implementation

The Good Governance Guide for NHS Wales Boards: Pocket Guide 65 As a Board member, are you able to answer the following questions relating to your organisation’s progress and performance? Progress – did people do what they said they would do by when they said they would do it? lf not, why not? Have the strategy and the plan been amended to show the new way forward? Performance – is what is being done by the organisation being completed to the standards and quality required?

lt is the Board’s role to see that the plan is chairing appeals panels). Experience has regularly amended to keep it up to date. shown that the higher the time commitment The Board is there to ensure accountability expected of Non-Executive Directors, the and governance. Throughout the process it less likely Boards are to attract and retain is important that sufficient due diligence and candidates with a diverse background (such probity is carried out to ensure excellence, as people who are younger, of black and regularity, and propriety is maintained to the minority ethnic origin, women). There is a highest standards. balance to be struck between developing a good understanding of the organisation and Time Commitment how it is functioning, and getting too involved in operational matters. It is important that IMs Chairs, in their Board leadership role, have maintain objectivity and independent scrutiny. a key responsibility to plan and manage the Newly appointed IMs may find that they need time commitment required of Independent and want to spend more time initially as they Members (IMs) in line with their role on the learn about the organisation, its people and its Board in relation to strategy, accountability context. In times of significant organisational and culture. Some tasks that IMs are asked to or service change, more time is likely to be do can be undertaken by other appropriately required of IMs for a limited period. selected and trained lay people (for example

66 The Good Governance Guide for NHS Wales Boards: Pocket Guide The Role and Responsibilities of the ongoing development of a governance and Board Secretary assurance framework for the organisation The Board Secretary has a pivotal role within and ensures that it meets the standards of LHBs and Trusts in Wales. As principal good governance set for the NHS in Wales. advisor to the Board and the organisation As advisor to the Board, the Board Secretary as a whole on all aspects of governance, is not a Board member, and the role does not the Board Secretary – on behalf of the Chair affect the specific responsibilities of Board and Chief Executive – leads the design and members for governing the organisation.

The Good Governance Guide for NHS Wales Boards: Pocket Guide 67 Understanding the Environment

The Statutory Framework for NHS Bodies The Welsh Language in Public Services in Wales The Welsh Government is committed to The statutory framework for NHS Wales delivering high quality public services that comprises three core components: are centred on users’ needs. The Welsh • Primary legislation: setting the statutory Language (Wales) Measure 2011 establishes powers and duties of the NHS a framework of imposing Welsh Language standards on organisations, eventually • Statutory instruments: detailing the replacing Welsh Language Schemes functions of NHS Bodies; and established under the Welsh Language • Standing orders: providing the rules by Act 1993. The Welsh Language Commissioner which health boards and trusts work and is tasked with providing compliance notices make decisions. to organisations that will require them to comply with specified standards, and will be Please refer to the full summary of the primary regulating their compliance. The Regulations legislation for NHS Wales and other relevant that specify Welsh Language standards for legislation provided in. The Good Governance bodies are being introduced gradually and are Guide for NHS Wales Boards, Second Edition, prepared with the aim of being reasonable, Doing it right, doing it better – A learning proportionate and relevant to the bodies resource for Board members. named in the Regulations.

68 The Good Governance Guide for NHS Wales Boards: Pocket Guide Structure of NHS Wales

Local Health Boards There are seven Local Health Boards in Wales as shown on the map below: WALES Local Health Boards

ISLE OF ANGLESEY

FLINTSHIRE CONWY BETSI CADWALADR UNIVERSITY DENBIGHSHIRE WREXHAM GWYNEDD

POWYS Local Health Board Boundary TEACHING

Local Authority Boundary CARDIFF

POWYS POWYS CEREDIGION TEACHING

HYWEL DDA UNIVERSITY

PEMBROKESHIRE CARMARTHENSHIRE MERTHYR BLAENAU TYDFIL GWENT

MONMOUTHSHIRE

NEATH TORFAEN PORT TALBOT ABERTAWE BRO CWM TAF ANEURIN BEVAN MORGANNWG UNIVERSITY UNIVERSITY SWANSEA UNIVERSITY RHONDDA CAERPHILLY CYNON TAF NEWPORT

BRIDGEND CARDIFF CARDIFF & VALE UNIVERSITY VALE OF GLAMORGAN

© Crown Copyright and database right 2014. Ordnance Survey 100021874 Cartographics • Welsh Government March 2014

The Good Governance Guide for NHS Wales Boards: Pocket Guide 69 The principal role of a Local Health Boards based information service, and a telephone is to ensure the effective planning and advice in relation to other agreed services. delivery of healthcare for people for whom The Public Health Wales NHS Trust it is responsible, within a robust governance framework, to achieve the highest standards The Public Health Wales NHS Trust aims to of patient safety and public service delivery, protect and improve health and wellbeing and improve health and reduce inequalities and reduce health inequalities in Wales. It delivers achieve the best possible outcomes for its four statutory functions: citizens, and in a manner that promotes • Provide and manage public health, human rights. The Local Health Boards health protection, healthcare improvement, (Constitution, Membership and Procedures) health advisory, child protection and (Wales) Regulations 2009 on the link below: microbiological laboratory services and www.legislation.gov.uk/wsi/2009/779/pdfs/ services relating to the surveillance, wsi_20090779_mi.pdf prevention and control of communicable diseases. NHS Trusts • Develop and maintain information There are currently 3 NHS Trusts in Wales about matters related to the protection with an all – Wales focus. These are the and improvement of health in Wales Welsh Ambulance Services Trust, the Velindre available to the public; to undertake and NHS Trust and Public Health Wales. commission research into such matters and to contribute to the provision and The Velindre NHS Trust provides specialist development of training in such matters. cancer and blood services across South and Mid Wales through the Velindre Cancer Centre • Undertake the systematic collection, and the Welsh Blood Service and a range of analysis and dissemination of information national support services. about the health of the people of Wales in particular including cancer incidence, The Welsh Ambulance Services NHS Trust mortality and survival; and prevalence of provides high quality pre-hospital emergency congenital anomalies. care and treatment throughout Wales: a 24 hour telephone service to provide the • Provide, manage, monitor, evaluate and public and practitioners with advice, a web- conduct research into screening of health

70 The Good Governance Guide for NHS Wales Boards: Pocket Guide conditions and screening of health related and strategy agreed by the NHS Wales Shared matters. Services Partnership Committee. The Shared Services Portfolio includes: Procurement Other Bodies Services; Primary Care Services; Employment Services; Workforce, Education and Specialised and Tertiary Services Development Services; Student Awards Unit The seven Local Health Boards in Wales have (NHS Bursaries); Facilities Services; Legal & established the Welsh Health Specialised Risk Services; Welsh Risk Pool Services; Services Committee (WHSSC) to ensure that Audit and Assurance Service; and Counter the population of Wales has fair and equitable Fraud Services (National Team). access to the full range of specialised The Emergency Ambulance Services services. This followed a consultation on Committee plans and secures the provision specialised services for Wales in 2009, of emergency ambulance services in line with which recommended improvements on both the Welsh Government directions and how the NHS plans and secures specialised NHS Planning Framework and is dedicated services. In establishing WHSSC to work to planning and securing the provision of on their behalf, the seven LHBs recognised emergency ambulance services. that the most efficient and effective way of planning these services was to work together The Wales Audit Office’swork covers all to reduce duplication and ensure consistency. devolved public sector organisations in Wales WHSSC receives funding from the LHBs to pay – including health and social care, local and for specialised healthcare for everyone who central government, fire service, national lives in Wales and is entitled to NHS care and parks, agriculture, education and community to obtain the best value for this money. councils. Its aim is that the people of Wales know whether public money is being managed NHS Wales Shared Services Partnership wisely, and public bodies in Wales understand The LHBs and Trusts in Wales have how to improve outcomes. The Auditor collaborated over the operational General is the independent statutory auditor arrangements for the provision of NHS Wales of most of the Welsh public sector. They are Shared Services Partnership and have agreed responsible for the annual audit of the majority the terms of a Co-operation Agreement in of public money spent in Wales, including order that it operates effectively by collective the NHS. decision making in accordance with the policy

The Good Governance Guide for NHS Wales Boards: Pocket Guide 71 Healthcare Inspectorate Wales is the of the health service within its district as independent inspectorate and regulator of all the Council thinks fit. The Board of CHCs healthcare in Wales. Its core role is to review in Wales is a statutory body established by and inspect NHS and independent healthcare the Welsh Government to advise CHCs with organisations in Wales to provide independent respect to the performance of their functions; assurance for patients, the public, the Welsh to represent collective views of councils on Government and healthcare providers, that an all-Wales basis; to promote collaborative services are safe and of good quality. HIW is working and information sharing; and to the regulator of independent healthcare monitor the performance of the CHCs as well providers in Wales. as the conduct of members and performance Community Health Councils – There are of officers. seven Community Health Councils in Wales: The Public Services Ombudsman for Wales 1. Aneurin Bevan Community Health Council is independent of all government bodies and has legal powers to look into complaints about 2. Abertawe Bro Morgannwg Community public services in Wales and to: consider Health Council complaints about public bodies; put things 3. Betsi Cadwaladr Community Health Council right and to secure the best possible outcome where injustice has occurred; recognise and 4. Cardiff and Vale of Glamorgan Community share good practice; help people send their Health Council complaint to the right public service provider; 5. Cwm Taf Community Health Council consider complaints that members of local 6. Hywel Dda Community Health Council authorities have broken the code of conduct; and build confidence in local government 7. Powys Community Health Council in Wales by promoting high standards in The duty of each of the seven Community public life. Health Councils (CHCs) in Wales is to The Equality and Human Rights Commission scrutinise the operation of the health service is a public body set up to challenge in its area, to make recommendations for the discrimination, to protect and promote improvement of that service and to advise equality and to promote human rights. relevant Local Health Boards and NHS Trusts It enforces equality legislation on age, disability, upon such matters relating to the operation gender reassignment, marriage and civil

72 The Good Governance Guide for NHS Wales Boards: Pocket Guide partnership, pregnancy and maternity, race, Sources of Further Help and Advice religion or belief, sex and sexual orientation. The Good Governance Guide for NHS Wales It regulates the Public Sector Equality Duty Boards, Second Edition, Doing it right, doing and encourages compliance with the Human it better – A learning resource for Board Rights Act 1998. The Commission in Wales has members, Academi Wales, 2017 a statutory Wales Committee with decision www.gov.wales/academiwales making powers to develop its own work programme and provides independent advice NHS Wales Governance e-Manual to the Welsh Government on the effect of its www.wales.nhs.uk/governance-emanual/ legislation on equality and human rights in home Wales. The Commission operates as a catalyst 1000 Lives Improvement for change and improvement on equality and www.1000livesplus.wales.nhs.uk human rights. Bevan Commission Commissioners www.bevancommission.org/ The Older People’s Commissioner, Future Generations Commissioner, Children’s Commissioner for Wales and the Welsh Language Commissioner act as independent champions and have regular interface with NHS organisations in Wales. The Health and Safety Executive (HSE) is part of the Department for Work and Pensions. It is the body responsible for the encouragement, regulation and enforcement of workplace health, safety and welfare, and for research into occupational risks.

The Good Governance Guide for NHS Wales Boards: Pocket Guide 73 References

Academi Wales (2017) Academi Wales, Welsh Government, www.gov.wales/academiwales Audit Commission (2009a) A review on how Boards of NHS trusts and foundation trusts get their assurance Audit Commission (2009b) National Report ‘Taking it on Trust – A review of how boards of NHS trusts and foundation trusts get their assurance’, published in April 2009 CIPFA (2010) Leading in Hard Times: Guidance for everyone involved in the leadership of public services, Chartered Institute of Public Finance & Accountancy, www.cipfa.org/policy-and-guidance/reports/leading-in-hard-times Committee on Standards in Public Life (2013), ‘Nolan Committee’,Standards matter – a review of best practice in promoting good behaviour in public life, Fourteenth Report, January 2013 Dr Foster (2006) The Intelligent Board Good Governance Institute (2015) Good Governance Handbook, January 2015, www.good-governance.org.uk/wp-content/uploads/2017/04/Good-Governance-Handbook.pdf Higgs, D. (2003) Review of the role and Effectiveness 0f Non Executive Directors HM Government (2011) The National Health Service (Concerns, Complaints and Redress Arrangements) (Wales) (Amendment) Regulations 2011, www.legislation.gov.uk/wsi/2011/1706/pdfs/wsi_20111706_mi.pdf HM Treasury (2012) Assurance Frameworks, December 2012 IFAC and CIPFA (2014) International Framework: Good Governance In The Public Sector, July 2014, International Federation of Accountants and Chartered Institute of Public Finance and Accountancy, www.cipfa.org/policy-and-guidance/standards/international-framework-good- governance-in-the-public-sector

74 The Good Governance Guide for NHS Wales Boards: Pocket Guide Institute of Internal Auditors (2013) The Three Lines of Defence in Effective Risk Management and Control, IIA Position Paper, January 2013, www.iia.org.uk/media/1042665/three-lines-of- defence-march-2015.pdf Institute of Risk Management (2011) Risk Appetite and Tolerance, September 2011 Institute of Risk Management (2012) Risk culture – Under the Microscope Guidance for Boards MacLeod, D. and Clarke, N. (2009) Engaging for success: enhancing performance through employee engagement, London: Crown National Assembly for Wales (2015) Senedd.tv, Plenary 16 June 2015, www.senedd.tv/Meeting/Archive/e989aa5c-c04e-4725-91fb-11c47f614f08 NHS Confederation, Tough times, tough choices – Being open and honest about NHS Finance, 2013 NHS Leadership Academy (2013) The Healthy NHS Board 2013 – Principles for Good Governance, www.leadershipacademy.nhs.uk NHS Providers and RSM UK Group – Board Assurance: A toolkit for health sector organisations – Do we really know what we think we know? Social Care Institute for Excellence (2004) Learning Organisations Resource Pack Sonnenfeld (2002) What makes great boards great? Harvard Business Review, September 2002 Wales Audit Office (2014)Scrutiny in the spotlight, June 2014, www.wao.gov.uk/good-practice/governance/scrutiny Welsh Government Codes of Conduct and Accountability for NHS Boards and the Code of Conduct for NHS Managers Directions 2006 Welsh Government (2009) Our healthy future Welsh Government (2010a) Doing Well, Doing Better – Standards for Health Services in Wales Welsh Government (2010b) Setting the Direction – Primary & Community Services Strategic Delivery Programme

The Good Governance Guide for NHS Wales Boards: Pocket Guide 75 Welsh Government (2011c) Putting Things Right, www.wales.nhs.uk/sites3/home.cfm?orgid=932 Welsh Government (2012a) Achieving Excellence – The Quality Delivery Plan for the NHS in Wales 2012-2016, http://gov.wales/topics/health/nhswales/plans/excellence/?lang=en Welsh Government (2012c) More than just words – Strategic Framework for Welsh Language Services in Health, Social Services and Social Care Welsh Government (2012d) NHS Audit Committee Handbook Welsh Government (2013b) NHS Wales Planning Framework – Developing an Effective Planning system in NHS Wales – Supporting the Development of Local Health Boards’ and Trusts’ 2014/15 – 2016/17 Integrated Plans Welsh Government (2013c) Safe Care, Compassionate Care A National Governance Framework to enable high quality care in NHS Wales, January 2013 Welsh Government (2014a) Commission on Public Service Governance and Delivery, http://gov.wales/topics/improvingservices/public-service-governance-and-delivery/ report/?lang=en Welsh Government (2014c) NHS Wales Governance E-Manual, www.nhswalesgovernance.com Welsh Government (2015c) Listening and Learning from Feedback Framework for Assuring Service User Experience 2015, WHC/2015/061, 18 December 2015, http://gov.wales/topics/health/nhswales/circulars/quality/?lang=en Welsh Government (2016) Managing Welsh Public Money, January 2016, http://gov.wales/funding/managing-welsh-public-money/ Welsh Office (1999)Quality Care and Clinical Excellence

76 The Good Governance Guide for NHS Wales Boards: Pocket Guide © Crown copyright 2017 WG31231 Digital ISBN 978 1 4734 8729 1 Print ISBN 978 1 78859 578 0

Mae’r ddogfen yma hefyd ar gael yn Gymraeg. / This document is also available in Welsh.

The Good Governance Guide for NHS Wales Boards: Pocket Guide 77 78 The Good Governance Guide for NHS Wales Boards: Pocket Guide