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    APRIL 2005




1.1 Purpose of report

    This paper puts forward proposals to revise the Terms of Reference for each of the Committees that have been established by the Trust in order to reflect the requirements placed on the Trust to meet and achieve the new Standards for Better Health (SfBH).

    These revised arrangements will ensure that the Trust’s corporate committee structure explicitly reflects the need to progress the work required in achieving the SfBH as well as providing the Trust Board with further sources of corporate assurance when it comes to signing-off and agreeing the self-assessment statement on the level of compliance with the SfBH.

1.2 Other changes

It is important to bear in mind that this is very much a first phase to ensure that the Trust’s

    corporate governance arrangements, particularly those relating to its Committees and Sub-Committees has been reviewed and revised to reflect the requirements for meeting the new SfBH.

    The Committee structure will also need to be reviewed in the light of what emerges from the work being led by the NHS Appointments Commission on developing integrated governance arrangements. The guidance on integrated governance is anticipated to be published in late Spring.

    This exercise also needs to be viewed alongside the work in hand to revise the reporting format for performance reporting against the SfBH and the objectives in the Trust’s Business Plan, and work that will be undertaken later in the year to review the current Standing Orders and Standing Financial Instructions for the Trust, as well as the Scheme of Delegation and Schedule of Matters Reserved to the Board for taking decisions.


    The Standards for Better Health (SfBH) were published by the Healthcare Commission in their report ‘National Standards, Local Actions’.

    A consultation exercise has recently been conducted by the Healthcare Commission entitled ‘Assessment for Approval: Our Approach’ on how Trusts and NHS bodies will be monitored and assessed against the new Standards. It has been made clear that NHS bodies as part of the new monitoring regime will be required to produce a self-assessment of their compliance against the Standards. The SfBH and the implications for the Trust have been the subject of discussions at recent Joint Trust Board/PEC/Management Board meetings.

The Trust Board needs to ensure that its corporate governance arrangements particularly

    in relation to its Committees have been reviewed in order to enable it to meet the requirements of the SfBH. This paper sets out the implications for the various Committees which the Trust Board has established.

EPCT April 2005 1


3.1 Role of Audit Committee and Clinical and Organisational (COG) Committee

    The two Committees most affected by the introduction of SfBH are the Audit Committee and the Clinical Organisational and Governance (COG) Committee. Both of these Committees are responsible for overseeing the Trust’s programme of risk management and the systems in place to provide corporate assurance to the Trust Board about the PCT’s management systems.

    The Audit Committee remains the responsible Committee for providing the necessary ‘Assurance’ to the Trust Board on the Trust’s system of internal controls and risk management arrangements to enable the ‘signing-off’ of the Statement of Internal Control

    (SIC) together with the Trust’s Annual Statutory Accounts. The Audit Committee’s Terms of Reference were revised at the Trust Board meeting on 23 February 2005 to reflect the replacement of the Controls Assurance Programme with the new SfBH.

    The Clinical and Organisational and Governance (COG) Committee also retains its central role in overseeing the detail of the Trust’s programme of risk management and control systems with its clear line of reporting to the Audit Committee.

    The roles and relationship of these two Committees does not need to alter, but their Terms of Reference need to be revised to reflect that they are now overseeing the achievement of the SfBH and to reflect the fact that they can also draw on the work of other Committees which will be monitoring aspects of the 7 Domains of the SfBH. Attached as Appendix 1 is a set of a revised Terms of Reference for the Clinical Organisational and Governance (COG) Committee to reflect this change.

3.2 Implications for other Trust Board Committees

    Each of the Trust Board’s Committees have clear Terms of Reference. What this exercise will do is to make it explicit that the role of that Committee is to monitor and review those elements of SfBH which directly apply to its area of work and sphere of responsibility.

    It is proposed that the clause set out in Appendix 2 be inserted into each Committee’s Terms of Reference. Each Committee will be required to note that its Terms of Reference have been amended and to note the implications involved. Further work will of course be undertaken to produce for each Committee a schedule which carefully dissects the individual elements of SfBH which relate to the respective Committee.

    It is suggested that the Audit Committee be asked to report on the completion of this exercise.


It is important to note that this is not just a paper exercise.

The need to revise all the Trust’s various Committees and Sub-Committees respective

    Terms of Reference in order to clarify explicitly their responsibilities for overseeing and monitoring aspects of SfBH is an essential first step in ensuring that SfBH is properly embedded into the Trust’s Committees structures. It is also extremely important in terms of

    demonstrating good corporate governance and the Trust’s commitment to meeting the requirements of SfBH.

    However, of far more importance will be the cultural change, in seeing how the individual Committees tackle their responsibilities and the assurance the Trust Board will be able to place on the work that they will undertake. The whole process will provide a very sound


Corporate Governance Review Revising Existing Committee arrangements to reflect the new Standards for Better Health (SfBH)

    underpinning and foundation for being able to sign-off the SfBH self-assessment in September 2005.

    The measures will also place the Trust in good shape for whatever guidance emerges on developing integrated governance arrangements.


The Trust Board is asked to NOTE:

1. the background to the review and the need to ensure that the Trust’s corporate

    governance arrangements particularly in relation to its Committees, have been

    reviewed to enable it to meet the requirements of the new SfBH, and to ensure that

    the Trust’s Committee structures will be able to add to the level of assurance that the

    Trust Board will be required to have to adopt the self-assessment on the SfBH in

    September 2005;

    2. that a further review of the Committee structures will be needed in the light of what

    emerges in the way of guidance, either from the Department of Health or the NHS

    Appointments Commission on developing integrated governance arrangements;

    3. that the roles and duties of Committees may be further affected by the review of the

    Trust’s Standing Orders and Standing Financial Instructions, and the Scheme of

    Delegation which will be taking place later in the year.

The Trust Board is asked to AGREE:

    1. that the clause set out in Appendix 2 be inserted into the Terms of Reference for

    every Board Committee;

    2. that an appropriate list of relevant SfBH core and developmental standards that apply

    to each Committee is prepared;

    3. that the Audit Committee be asked to review the completion of this exercise.

Nick Curtiss

    Director of Corporate Governance

EPCT April 2005 3

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