POLICY FOR THE MANAGEMENT OF POLICIES AND STANDARD OPERATING PROCEDURES

POLICY FOR THE MANAGEMENT OF POLICIES AND STANDARD OPERATING PROCEDURES

Subject and version number of document: Serial Number: Policy for the Management of Policies and V2 PFMPV2 Operative date: 1 April 2013 Author: Head of Business Review date: December 2015 For action by: Policy statement: Responsibility for dissemination to new staff: Further details and additional copies available from: Equality Analysis Completed? Consultation Process Approved by: All staff of the Clinical Commissioning Group (CCG) This document sets out the policy by which the policies and Standard Operating Procedures (including documents on procedures, protocols and guidelines) of the CCG will be prepared, approved, ratified, implemented and reviewed. This is a corporate policy. Head of Business www.southamptoncityccg.nhs.co.uk This document includes a section about Equality Analysis (previously called Equality Impact Assessment), the aim being to encourage and support policy developers to demonstrate due regard to the Equality Act 2010. This will be achieved if all new policies are assessed for equality impact at an early stage, and records kept of the equality analysis process and any actions identified. Senior Management Team Clinical Executive Group Governing Body Governing Body Date approved: 28 th January 2015 2

Intranet and Website Upload: Intranet Website Keywords: Electronic Document Insert the location of the document on the intranet Library Location: Location in FOI Publication Scheme Insert helpful keywords (metadata) that will be used to search for this document on the intranet and website Review Log: Include details of when the document was last reviewed: Version Review Number Date 2 October 2014 Name of Reviewer Rebecca Willis Ratification Process SMT, Governing Body Notes 3

POLICY FOR THE MANAGEMENT OF POLICIES AND STANDARD OPERATING PROCEDURES 1. INTRODUCTION & PURPOSE 1.1 Organisational documentation is an essential tool of governance, which helps to achieve the strategic objectives, operational requirements and brings consistency to everyday activity. A standard format and approved structure for such documents helps to ensure that policies and procedures are up to date and reflect the organisational approach. 1.2 All documents must undergo a rigorous process of development and be approved and monitored by the appropriate committee or subcommittee, who in turn provide assurance to the Governing Body on relevant legal and statutory requirements, NHS policy and guidance. 1.3 The purpose of this document is to create a standardised approach to the development, ratification, dissemination and review process of Policies and Standard Operating Procedures (SOPs) in accordance with the NHS Litigation Authority (NHSLA) Risk Management Standards 2012-2013. 2. SCOPE & DEFINITIONS 2.1 SCOPE 2.1.1 This policy applies to all directly and indirectly employed staff and other persons working within the CCG. 2.1.2 For the purpose of this policy, the word policy refers to policies, procedures, protocols, guidelines, integrated care pathways and patient group directions. 2.1.3 It is important that any members of staff who find it difficult or impossible to comply with a particular document or any aspect of it inform their manager at the earliest opportunity so that the document can be revised or action taken locally to make compliance possible. Where the policy is reviewed or revised as a result of a compliance issue, the document author must update the front cover and follow the process. 4

2.2 DEFINITIONS Strategy: An overall plan to achieve longer-term objective. Policy: A statement representing a principle adopted course of action. Standard Operating Procedures: Documents on procedures, protocols and guidelines. (SOPs) Procedure: The established form of conducting or performing an activity as a defined series of steps or actions to meet the requirements of a policy. Protocol: The rules of behaviour. Guidelines: Advisory or good practice principles put forward to set standards or determine a course of action. Clinical guidelines do not replace professional judgement and discretion. Standard: Specification of a required level of performance. Code of Practice: Code of Conduct: Document Author: Specification of standards which must be met within a legal framework. Specification of standards which must be met by members of that profession. For the purpose of this document the term document author will mean the original author and any subsequent person who is responsible for reviewing or revising the document. Stakeholder: A person group, or organisation that has direct or indirect input in an organisation because it can affect or be affected by the organisation s actions, objectives and policies. 5

3. PROCESS/REQUIREMENTS 3.1 A brief summary for the policy development, approval and ratification process has been provided in Appendix 1. 3.2 STATUTORY COMPLIANCE 3.2.1 All policies, protocols, guidelines and procedures will comply with the relevant statutory requirements, any subsidiary legislation and subsequent amendments, including but not limited to the following Acts: Health & Safety at Work Act 1974 Health and Social Care Act 2008 (Regulated Activities), Regulations 2010 Health Act 2009 Care Quality Commission (Registration), Regulations 2009 Equality Act 2010, Equality Act 2010 (Specific Duties) Regulations 2011 Human Rights Act 1998 Promoting Equality and Human Rights in the NHS: a guide for Non- Executive Directors of NHS Boards (2005) Department of Health Mental Health Act 2007 Mental Capacity Act 2005 Civil Contingencies Act 2005 Finance Act 2011 Freedom of Information Act 2000 Re-use of Public Sector Information Regulations 2005 Data Protection Act 1998 Environmental Information Regulations 2004 Corporate Manslaughter & Corporate Homicide Act 2007 3.2.2 All policies should take into consideration the requirements of the Care Quality Commission (CQC) and the NHSLA Risk Management Standards 2012-2013: NHSLA Acute, Community, Mental Health & Learning Disability and Non-NHS providers of NHS Care. The NHSLA standards are essentially about the reduction of incidents that give rise to high value claims (or their defensibility). 3.3 EQUALITY ANALYSIS (EQUALITY IMPACT ASSESSMENT): 3.3.1 The public sector Equality Duty (section 149 of the Equality Act 2010) came into force on 5 April 2011. The Equality Duty applies to public bodies and others carrying out public functions. It supports good decision-making by ensuring public bodies consider how different people will be affected by their activities, helping them to deliver policies and services which are efficient and effective; accessible to all; and which meet different people's needs. The Equality Duty is supported by specific duties, set out in regulations which came into force on 10 September 2011. The specific duties require public bodies to publish relevant, proportionate information demonstrating their compliance with the Equality Duty; and to set themselves specific, measurable equality 6

objectives. Source: The Advisory, Conciliation and Arbitration Service (ACAS). 3.3.2 In accordance with the CCG s commitment to Equality and Diversity, we aim to eliminate discrimination, harassment and victimisation, advance equality of opportunity, and promote good relations between groups. We need to do this for the 9 protected characteristics: age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex and sexual orientation. Appendix 5 shows the Equality Analysis Template and guidance which is designed to help you systematically analyse the needs and impact of your policy on each equality group or protected characteristic. 3.3.3 Document Authors are instructed to undertake an Equality Analysis for all new policies. Results of the assessment, consultation and monitoring process should be detailed under the section heading Equality, Diversity and Mental Capacity Act in the policy document. Existing policies should already have been Equality Impact Assessed and so only a review will be necessary where this is the case. 3.3.4 The completed Equality Analysis will need to be submitted as part of the policy approval process, and may be published to demonstrate compliance with the specific equality duty to publish equalities information 3.4 POLICY INITIATION 3.4.1 To avoid duplication, promote the involvement of all relevant stakeholders and to provide general support in the development of policies and SOPs a short checklist has been developed (see Appendix 3). 3.4.2 The intention to develop a policy must be registered with the CCG Head of Business who should maintain a central register of all policies. 3.5 POLICY STYLE AND FORMAT 3.5.1 All policies and standard operating procedures should be presented in accordance with the standard template (see Appendix 3). The basic style and format requirements are as follows; The policy title (on the cover page) should be written in black, capitals in font Arial Bold 14 or greater. The organisational logo should be at the top right corner of the title page. If the policy is a joint policy then the partner organisation logo should be on the top left side of the title page. It should be noted that joint policies will require ratification by all partner organisations concerned prior to implementation. The body text should be written using black Arial 11 font, with headings written in bold, capitalisation and/or underlined. 7

The policy should be written in plain English. Jargon should be avoided and abbreviations should be explained in their first use and subsequently where necessary. All sections of the document should be numbered sequentially, including paragraphs and appendices. All documents should include a footer (including the title of the document, page number and version number). 3.6 POLICY CONSULTATION 3.6.1 It is the responsibility of the document author to agree and undertake the appropriate consultation on the policy document, prior to passing the document through for ratification. This can be done by individual consultation and/or the use of committee meetings. 3.6.2 All documents should be reviewed by and commented on by the appropriate internal and external stakeholders prior to formal ratification by the CCG Governing Body. 3.6.3 Advice on groups/individuals to be consulted can be sought from the CCG Head of Business. 3.6.4 Any groups/individuals consulted throughout the development of the policy should be listed in the reference table at the front of the policy. 3.6.5 Any reviews or amendments as a result of the consultations must be listed in the review log at the front of the policy and will also require ratification. The process outlined in section 3.13.3 will need to be completed. 3.6.6 It is good practice to give consultation periods of at least one month to ensure that staff on leave and/or staff with prioritising workloads are able to give the document appropriate attention. At the end of a consultation period, where some staff have not responded, a view should be taken as to whether an appropriate proportion of those consulted have responded (given the nature of the policy) and/or whether particular individuals expected to have a key opinion have responded. 3.6.7 A trial or pilot of a policy may be the most suitable method of testing. Trials may be limited to particular sites or services and for a set period of time. Document Authors should be aware that approval of the basic policy should be given before a trial, as the service will be required to act within the requirements of the new policy rather than any existing policy. The policy document will have increased legal standing and will be relevant for any investigations. 3.7 SPECIAL CIRCUMSTANCES 3.7.1 Local Authority, Local NHS, NHS England or Department of Health policies do not need to be rewritten into the CCG format if the CCG is intending to adopt them. A separate front sheet should be attached to the policy showing the title and CCG policy reference. Details of the consultation process and the standard document control requirements must also be given on this sheet with 8

a nominated CCG Owner, rather than the Document Author, who would be responsible for reviews and CCG re-approval. 3.8 POLICY APPROVAL AND RATIFICATION 3.8.1 The policy should be presented to the appropriate CCG sub-committee for approval prior to final ratification by the CCG Governing Body. 3.8.2 The CCG Governing Body may wish to delegate the role of the CCG policy approval to one of its sub-committees. This should also be reflected in the CCG Scheme of Delegation. 3.8.3 Please see appendix 8 for the policy approval flowchart 3.8.4 The CCG Governing Body is responsible for the final ratification of policies for use within the CCG. 3.8.5 There is a requirement placed on the CCG by external agencies such as the NHS Litigation Authority, that some policies are formally approved by the CCG Governing Body and this may not be delegated (for example Risk Management Policy). The CCG Governing Body will also be expected to approve policies with significant public interest or where enactment would require a significant change in the way the CCG operates. Policies presented to the CCG Governing Body for approval should first have been considered and agreed at the appropriate sub-committee. 3.8.6 There is no requirement to formally agree Standard Operating Procedures (SOPs) although there may be some instances where SOPs require approval and ratification depending on the content, potential risk and impact. Further guidance can be obtained from the Head of Business. 3.8.7 It is highly recommended that the proforma in Appendix 6 Checklist for the review and approval of Policy Documents is used by the CCG Governing Body or delegated committee when approving policy documents. 3.8.8 Ratification is the point at which the approved policy is presented to the CCG Governing Body as final and accepted as ready for publication, and is signed by the Chair of the CCG. Please note that CCG Governing Body minutes must reflect the ratification by Policy Name and Policy Reference Number. 3.9 POLICY DISSEMINATION & ACCESS 3.9.1 The document author should consider how the policy or SOP will be communicated to staff and disseminated throughout the organisation. All approved policies and SOPs will be disseminated by means of shared computer drives and the intranet. Attention may also be drawn to new policies by newsletters and an intranet news section or staff news letter. 3.9.2 Document authors should consider whether additional dissemination routes, for example to stakeholders or partner organisations, would be appropriate. This should be detailed in the policy. 3.10 POLICY ROLES & RESPONSIBILITIES 3.10.1 The roles and responsibilities section should be presented in accordance with the standard template (see Appendix 3). 9

3.11 POLICY IMPLEMENTATION/TRAINING/AWARENESS 3.11.1 All policies must include a comprehensive Implementation Impact Assessment as detailed in Appendix 5. This should take full account of any associated costs related to implementing the policy in respect of manpower, training, equipment and provision of resources (both recurring and non-recurring). A policy will not be approved by the CCG Governing Body without such Impact Assessment being made and attached. 3.11.2 It will be the responsibility of the Document Author to ensure that any policy introduced within the organisation includes consideration for the provision of training or guidance for managers and staff. 3.11.3 The Impact Assessment will detail the requirements for training and awareness. This may be through the organisations training department which could offer advice and support on training issues, and where appropriate facilitate organisation wide training to accompany the implementation of policies. Alternatively, it may be considered more appropriate by the document author to visit departments or to meet individually with managers to offer general guidance or discuss specific aspects of the policy. 3.11.4 As part of the arrangements for the implementation of individual policies, the Document Author will need to detail the specific education and training requirements for the staff operating the policy/procedure, etc. including induction and mandatory training elements. 3.11.5 The Head of Business must maintain auditable logs/registers as evidence of staff awareness/training on each policy. Such records will help support the organisation s policy management systems and help demonstrate their effective implementation. Document authors may be required to request copies of implementation evidence to demonstrate levels of compliance and effectiveness and/or to identify problem areas or weaknesses. 3.11.6 The training section should be presented in accordance with the standard template (see Appendix 3). 3.12 POLICY SUCCESS CRITERIA / MONITORING THE EFFECTIVENESS OF THE POLICY 3.12.1 It is important to ensure that the policy document achieves its aims. The policy document must stipulate how implementation will be monitored / audited and evaluated giving timescales and/or frequency and detail what steps will be taken in response to the audit results. 3.12.2 Monitoring compliance (Auditing Standard) It is a requirement that all staff adhere to policies. To facilitate local Managers assessment of compliance within their department each policy should contain an Auditing Standard (or an appropriate alternative tool). This is a basic tool drawing out the main points of the policy, in the form of questions, which can be used to perform local audits on a regular basis. Document Authors will be expected to take local remedial action in response to audit findings and report as appropriate to Head of Business by completing Part 1 and 3 of Appendix 2. 10

Standards will vary in size and complexity dependant on the policy concerned. Document authors should aim to keep the tool as simple as possible to promote use and hence compliance. Please see Appendix 7 for the Standard for this policy which can be used as a template. This will need to be completed at least once during the 3 years of the life of the policy before the review date and the completed audit sent to the CCG Head of Business 3.12.3 Monitoring compliance (Implementation) The Document author must consider monitoring arrangements to assess general implementation of the policy. The document author should determine when implementation will be reviewed, by whom, using what tool and, where applicable, what sample size. The document author must state where the results of this monitoring will be taken and how any resulting actions will be taken forward and themselves monitored. 3.12.4 Achievement of aims The document author should, where possible, identify qualitative and quantitative outcome measures to identify whether the aims are being achieved by implementation of the policy. The document author should detail the method by which these measures are monitored, how often this will take place and where performance results will be taken. 3.13 POLICY REVIEW & REVISING DOCUMENTS 3.13.1 Documents will usually be current for a maximum of three years prior to review unless agreed otherwise when the document is approved. There are exceptions to this where some documents must be reviewed on an annual basis. 3.13.2 Upon review document author should ensure that any references or links used within the document are still relevant and current. 3.13.3 The CCG Head of Business will need to be notified of all reviewed policies. All reviewed policies where there have been significant amendments to the content of the policy must be re-approved by the committee. After review and reapproval the policy version number will be advanced by the document author and a complete copy of the reviewed policy will be distributed acting as a refresher to staff. 3.13.4 On occasion it may be necessary for a document to be reviewed earlier than the agreed review date, e.g. in the light of changing legislation or national guidelines. Document authors are responsible for ensuring that documents are reviewed following any changes to relevant legal and statutory requirements, NHS guidance and policy. Where the need for early review is identified the appropriate committee should be informed. 3.14 POLICY CONTROL & ARCHIVING 3.14.1 Record retention periods are defined in the Records Management: NHS Code of Practice. Document authors are responsible for any subsequent revisions to a document and archiving of all previous versions of documents electronically and/or hard copy and to notify the CCG Head of Business. 11

3.14.2 Document authors or other responsible person/s should ensure appropriate communication of any amended documents or revisions to the relevant service areas covered by the CCG. 3.14.3 As per section 3.13.3, after review and re-approval the policy version number will be advanced and a complete copy of the reviewed policy will be distributed acting as a refresher to staff. The CCG Business Manager will also need to be notified to update the policy register. 4. ROLES & RESPONSIBILITIES FOR THIS POLICY 4.1 CCG Chair The Chair of the CCG has ultimate accountability for the strategic and operational management of the organisation, including ensuring all policies are adhered to. 4.2 CCG Governing Body Has the responsibility for ensuring that all policies in use in the organisation are ratified by the CCG Governing Body. 4.3 Approving Committees - The Scheme of Delegation identifies the committee that has been delegated responsibility for approval of policies by the CCG Governing Body. This is also confirmed in appropriate committee terms of reference. 4.4 Stakeholders Are responsible for ensuring the following: to review this policy and provide feedback Ensure policy has been implemented. 4.5 Head of Business- Is responsible for ensuring the following: Maintaining a central policy register Contacting the document author when policy is nearing it s review date. 4.6 Document Author Is responsible for ensuring the following: Documents that they are responsible for (as determined by their role) are regularly reviewed and maintained. That the CCG Head of Business has been notified of any new policies or reviewed policies using the registration form in Appendix 1 and the central register updated. Policies that they are responsible for are formally ratified following the correct procedures. That documents are cascaded appropriately. That their local document index is maintained. That all documents follow the corporate format. That the effectiveness of the policy is monitored and evidenced. That any issues identified through the standard audit are followed up and appropriate actions taken. 5. TRAINING FOR THIS POLICY 5.1 No specific training is available to support this policy. Any specific queries should be addressed to the CCG Head of Business 5.2 All stakeholders involved in policy development should be aware of the contents of this Policy for the Management of Policies and Standard Operating Procedures document. 12

6. EQUALITY ANALYSIS RELATING TO THIS POLICY (See Appendix 6) 7. SUCCESS CRITERIA / MONITORING THE EFFECTIVENESS OF THIS POLICY 7.1 The Auditing Standard in Appendix 6 has been developed to provide assurance for monitoring compliance and effectiveness of any policy. 7.2 The Auditing Standard should be completed by the document author within the first 12 months of a new policy and thereafter on a 3 yearly basis. 7.3 A copy of the completed audit will need to be sent to the CCG Head of Business and any issues identified as a result of the audit will need to be followed up by the document author to ensure action has been taken. This may lead to an earlier review of the policy. 8. REVIEW OF THIS POLICY 8.1 This document may be reviewed at any time at the request of either staff side or management, but will automatically be reviewed after the first twelve months and thereafter on a 3 yearly basis. 9. REFERENCES AND LINKS TO OTHER DOCUMENTS FOR THIS POLICY The Medicines and Healthcare products Regulatory Agency (MHRA) Legislation.gov.uk Good Governance Institute The Advisory, Conciliation and Arbitration Service (ACAS) NHS South West London A Framework for the Development and Management of Policy and Procedural Documents Records Management: NHS Code of Practice The Department of Health 13

APPENDICIES APPENDIX 1: SUMMARY OF POLICY DEVELOPMENT / APPROVAL / RATIFICATION PROCESS STAGE 1: Development & Consultation STAGE 2: Approval STAGE 3: Ratification 1. Complete policy using standard template. See Appendix 4. 2. Complete Implementation Impact Assessment. See Appendix 5 (attach to completed policy). 3. Complete Equality Analysis template See Appendix 6 (attach to completed policy). 4. Consult stakeholders Appropriate committee to review policy for approval (see appendix 8) Completion of the Checklist for Review & Approval of Policy Documents (see APPENDIX 7) is highly recommended. Ratification by CCG Governing Body 5. Completion of the Policy & SOPs Pre- Approval Checklist is highly recommended. See Appendix 3. 6. Amend draft policy as appropriate after consultation with stakeholders. 7. Policy presented to appropriate committee with attachments Approved policy presented to CCG Governing Body STAGE 4: Review / Monitoring Following review or after completing an audit. If significant amendments are made consultation with stakeholders is required and the policy will then need to go to the appropriate committee for approval as per STAGE 2 of this summary and then onto STAGE 3 for ratification. 14

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APPENDIX 2: POLICY AND STANDARD OPERATING PROCEDURES (SOPS) PRE- APPROVAL CHECKLIST Checklist 1 Before Development To prevent duplication have you completed the policy registration form and sent it to the Business Manager? 2 Consultation Have you involved the appropriate stakeholders? Are other departments involved, communities or partnership agencies? 3 Format Has the corporate front cover been included and the appropriate sections of the reference table at the front of the document been completed? Serial Number / Operative date / Review date etc Does the document follow the organisations format? The body text should be written using black Arial 12 font etc Are the standard sections included? INTRODUCTION & PURPOSE SCOPE & DEFINITIONS PROCESS/REQUIREMENTS ROLES & RESPONSIBILITIES TRAINING EQUALITY ANALYSIS SUCCESS CRITERIA / MONITORING THE EFFECTIVENESS OF THE POLICY REVIEW REFERENCES AND LINKS TO OTHER DOCUMENTS Has a source been identified for queries? 4 Scope Does the document state what staff groups and patient/client group(s) it relates to? 5 Training Have the training and educational implications of Implications the document been considered and documented? 6 Impact Has an Implementation Impact Assessment been Assessment completed? Has an Equality Analysis template been completed? 7 References Is relevant national guidance/evidence present in the document? 8 Monitoring Has the process and timescales for monitoring Effectiveness the document s implementation and its effectiveness been identified? 9 Archiving If the document is a review/amendment of an existing document, have you retained the original copy and informed the Head of Business? 10 Intranet Uploading Have you identified a staff member to upload the document to the intranet once ratified? Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Name: 16

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APPENDIX 3: POLICY TEMPLATE Policy Title [Policy Version] 18

APPENDIX 3: POLICY TEMPLATE Subject and version number of document: Serial Number: Insert document title and version number. Insert your next sequential number. Operative date: Insert the date the document will be operational. Author: Review date: For action by: Insert the contact details of the document author. If the document is being reviewed by a different person, state the name of the reviewer/person taking responsibility for the revision (N.B. This may not be the same person as the original author). Insert the date the document will be reviewed (this is 1 year after the document is first written and then every 2 years thereafter unless the Document Manager stipulates a different timescale). State who the document applies to. Policy statement: Summarise the purpose of the document. Responsibility for dissemination to new staff: Training Implications: Further details and additional copies available from: Equality Analysis Completed? Consultation Process Approved by: Date approved: State who will responsible for informing new staff about this document. Insert who needs to be aware of the content of the policy and how they will be made aware. Insert website address or the name and contact details of where/who to contact to obtain additional copies and information. This document includes a section about Equality Analysis (previously called Equality Impact Assessment), the aim being to encourage and support policy developers to demonstrate due regard to the Equality Act 2010. This will be achieved if all new policies are assessed for equality impact at an early stage, and records kept of the equality analysis process and any actions identified. Insert names of persons/committees consulted during the construction of this policy. Insert name of group/committee that approved the policy. Insert the date the policy was approved. 19

APPENDIX 3: POLICY TEMPLATE Intranet and Website Upload: Intranet Website Keywords: Electronic Document Insert the location of the document on the intranet Library Location: Location in FOI Publication Scheme Insert helpful keywords (metadata) that will be used to search for this document on the intranet and website Review Log: Include details of when the document was last reviewed: Version Number Review Date Name of Reviewer Ratification Process Notes 20

INSERT POLICY TITLE It may be appropriate to insert a Contents Table to ease navigation through the document. 1. INTRODUCTION & PURPOSE 1.1 Insert text 2. SCOPE & DEFINITIONS SCOPE 2.1 It is essential that the document explicitly states who it applies to. DEFINITIONS 2.2 Insert any definitions for any terms used 3. PROCESS/REQUIREMENTS 3.1 There is no prescriptive way of detailing this section and the main body of the document will be unique depending on the subject matter. Include subsections as required. 4. ROLES & RESPONSIBILITIES 4.4 Outline here (subsections may be necessary) the different roles and responsibilities staff / users may have in relation to this document. 5. TRAINING 5.1 Outline here any training implications or issues as a result of this document. The Document Author must ensure that the Learning & Development Team have been engaged in the development of the document where any learning or training needs have been identified. Attendance at any training session carried out as a consequence of the policy implementation must be formally recorded and documented. 6. EQUALITY ANALYSIS 6.1 Include a statement summarising the outcome of the Equality Analysis that was conducted in relation to this policy, making reference to the Equality Analysis form which must be appended to the policy. 21

7. SUCCESS CRITERIA / MONITORING THE EFFECTIVENESS OF THE POLICY 7.1 The document author must be able to demonstrate the effectiveness of the policy at the point of review, for example by; carrying out audits, reviewing incidents that may have occurred related to the policy, discussing the policy at team meetings. Any subsequent issues/findings resulting from the review should be incorporated in the new version of the policy. 7.2 It will be necessary to formally document the results of the evaluation and keep records of any discussions relating to the monitoring of the policy for audit purposes. 7.3 This section should include details of the following (in accordance with NHSLA best practice); Monitoring arrangements for compliance and effectiveness i.e. audit, review etc Responsibilities for conducting the monitoring/audit Methodology to be used for monitoring/audit Frequency of monitoring/audit, i.e. quarterly, on a rolling basis Process for reviewing result and ensuring improvements in performance occur. 7.3 In relation to policies that support the NHSLA Risk Management standards 2012-2013, document authors should ensure they have referred to the NHSLA guidance to ensure that all the criteria requirements have been met. 8. REVIEW 8.2 Include the standard statement: This document may be reviewed at any time at the request of either staff side or management, but will automatically be reviewed after twelve months and thereafter on a bi-annual basis 9. REFERENCES AND LINKS TO OTHER DOCUMENTS 9.1 Where applicable, the document must contain a section detailing the Research/Evidence/References that were used to assist with the development of the Policy. Some of this information may be included at the beginning of the document as way of an introduction but should be referenced in full at the back of the policy. The Harvard Referencing System should be used as standard. 22

9.2 Signpost the reader to other relevant and supporting policies / Standard Operating Procedures. (Ensure these are cross referenced within the main body of the policy where appropriate). 23

APPENDIX 4: POLICY IMPLEMENTATION IMPACT ASSESSMENT (To be completed and attached to any policy submitted to an appropriate committee for consideration and approval) Summary of Impact Assessment (see next page for details) Policy Name Totals: WTE Recurring Non-Recurring Manpower costs Training staff Equipment & provision of resources Summary of Impact: Risk Management Issues: Benefits / Savings to the organisation: Equality Analysis template completed (See Appendix 4) Has this been appropriately carried out YES / NO Are there any reported equality issues? YES / NO If YES please specify: Has a copy of the completed Equality Analysis been submitted with this policy? YES / NO Use additional sheets if necessary. 24

APPENDIX 4: POLICY IMPLEMENTATION IMPACT ASSESSMENT Cont. Please include all associated costs where an impact on implementing this policy has been considered. A checklist is included for guidance but is not comprehensive so please ensure you have thought through the impact on staffing, training and equipment carefully and that ALL aspects are covered. Manpower WTE Recurring Non-Recurring Operational running costs Additional staffing required - by affected areas / departments Totals: Staff Training Impact Recurring Non-Recurring Affected areas / departments e.g. 10 staff for 2 days Totals: Equipment and Provision of Resources Recurring * Non-Recurring * Totals: Accommodation / facilities needed Building alterations (extensions/new) IT Hardware / software / licences Medical equipment Stationery / publicity Travel costs Utilities e.g. telephones 25

APPENDIX 4: POLICY IMPLEMENTATION IMPACT ASSESSMENT Cont. Process change Rolling replacement of equipment Equipment maintenance Marketing booklets/posters/handouts, etc Totals: *Capital implications 5,000 with life expectancy of more than one year. Funding /costs checked & agreed by finance: Signature & date of financial accountant: Funding / costs have been agreed and are in place: Signature of appropriate Executive or Associate Director: 26

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APPENDIX 5: EQUALITY ANALYSIS TOOL 1. Title of policy/ programme/ framework being analysed Policy on Policies 2. Please state the aims and objectives of this work and the intended equality outcomes. How is this proposal linked to the organisation s business plan and strategic equality objectives? 3. Who is likely to be affected? e.g. staff, patients, service users, carers Staff 4. What evidence do you have of the potential impact (positive and negative)? Step one: Gather evidence - List the main sources of evidence (including full references) reviewed to determine impact on each equality group or protected characteristic. This can include national research, census data, Joint Strategic Needs Assessment (JSNA), surveys, reports, research interviews, focus groups, engagement with stakeholders. Step two: Consider the impact On the basis of the evidence and findings from engagement activity, what is the impact of your work on each equality group/ protected characteristic? Identify whether the evidence shows potential for differential impact, if so state whether positive or negative and for which groups. This could be barriers to access, or different levels of needs, experiences or health outcomes. Identify how you will mitigate any negative impacts. Also how you will include certain protected groups in services or expand their participation in public life. How do the proposals impact on elimination of discrimination, harassment and victimization, advance the equality of opportunity and promote good relations between groups? (See Guidance Note) 4.1 Disability (Consider attitudinal, physical and social barriers) Opportunities can be made for staff to have alternative commission support. 4.2 Sex (Impact on men and women, potential link to carers below) There is nothing in the context of this policy that would appear discriminately. 4.3 Race (Consider different ethnic groups, nationalities, Roma Gypsies, Irish Travellers, language barriers, cultural differences). There is nothing in the context of this policy that would appear discriminately 4.4 Age (Consider across age ranges, on old and younger people. This can include safeguarding, consent and child welfare). There is nothing in the context of this policy that would appear discriminately 28

4.5 Gender reassignment (Consider impact on transgender and transsexual people. This can include issues such as privacy of data and harassment). There is nothing in the context of this policy that would appear discriminately 4.6 Sexual orientation (This will include lesbian, gay and bi-sexual people as well as heterosexual people). There is nothing in the context of this policy that would appear discriminately 4.7 Religion or belief (Consider impact on people with different religions, beliefs or no belief) There is nothing in the context of this policy that would appear discriminately 4.8 Marriage and Civil Partnership There is nothing in the context of this policy that would appear discriminately 4.9 Pregnancy and maternity (This can include impact on working arrangements, parttime working, infant caring responsibilities). There is nothing in the context of this policy that would appear discriminately 4.10 Carers (This can include impact on part-time working, shift-patterns, general caring responsibilities, access to health services, by association protection under equality legislation). There is nothing in the context of this policy that would appear discriminately 4.11 Additional significant evidence (See Guidance Note) Give details of any evidence on other groups experiencing disadvantage and barriers to access due to: socio-economic status location (e.g. living in areas of multiple deprivation) resident status (migrants) multiple discrimination homelessness 5 Action planning for improvement (See Guidance Note) Please give an outline of the key action points based on any gaps, challenges and opportunities you have identified. An Action Plan template is appended for specific action planning. 29

N/A Sign off Name and signature of person who carried out this analysis Date analysis completed 01/09/2014 Name and signature of responsible Director Date analysis was approved by responsible Director 30

Analysing the Impact on Equality Template ACTION PLAN Category Action Target Date Person responsible and their directorate Engagement with stakeholders (Involvement and consultation) Data collection and evidencing Analysis of evidence and assessment Monitoring, evaluating and reviewing Transparency (Including publication and dissemination to stakeholders) 31

Analysing the Impact on Equality Guidance Note Introduction Equality legislation has developed over several decades in response to the lack of equity experienced by individuals and groups in employment, education and the delivery/ receipt of goods and services. The Equality Act 2010 1 has strengthened and harmonised the law which now covers a range of 9 protected characteristics: Age Disabled people Gender reassignment (in terms of best practice this template covers all people who identify as Trans) Marriage and civil partnership Pregnancy and maternity Race Religion or belief Sex Sexual orientation The NHS itself has developed the Equality Delivery System 2 (EDS) which is a tool that assists both NHS commissioners and providers to: Comply with the Equality Act 2010, in particular the Public Sector Equality Duty such that they: Fulfill the first principle of the NHS Constitution - The NHS provides a comprehensive service, available to all irrespective of gender, race, disability, age, sexual orientation, religion or belief. It has a duty to each and every individual that it serves and must respect their human rights. At the same time, it has a wider social duty to promote equality through the services it provides and to pay particular attention to groups or sections of society where improvements in health and life expectancy are not keeping pace with the rest of the population Follow the five FREDA principles for human rights in relation to staff and service users i.e. Fairness, Respect, Equality, Dignity and Autonomy 3. Meet CQC s Essential Standards of Quality and Safety (2010) Deliver on the NHS Outcomes Framework (2010) APPENDIX 6: EQUALITY ANALYSIS TOOL Cont. 1 Details can be obtained on various websites including www.homeoffice.gov.uk/equalities/equality-act 2 For information on the EDS please access http://www.eastmidlands.nhs.uk/aboutus/inclusion/eds/ 3 Details about the Human Rights Act 1998 can be found at www.legislation.gov.uk/ukpga/1998/42/contents 32

Deliver on the Human Resources Transition Framework (2011) Reduce costs and improve quality (the QIPP agenda) The public sector equality duty 4 The public sector equality duty is made up of a general equality duty which is supported by specific duties. The public sector equality duty is the formal title of the legislation, the general equality duty is the overarching requirement or substance of the duty, and the specific duties are intended to help performance on the general equality duty. The general equality duty requires public authorities, in the exercise of their functions, to have due regard to the need to: Eliminate discrimination, harassment and victimisation and any other conduct that is prohibited by or under the Act. Advance equality of opportunity between people who share a relevant protected characteristic and people who do not share it. Foster good relations between people who share a relevant protected characteristic and those who do not share it. These are often referred to as the three aims of the general equality duty. The functions of a public authority include all of their powers and duties. This means everything that they are required to do as well as everything that they are allowed to do. Examples of this include: policy decisions, budgetary decisions, public appointments, service provision, statutory discretion, individual decisions, employing staff and procurement of goods or services. The Equality Act explains that having due regard for advancing equality involves: Removing or minimising disadvantages suffered by people due to their protected characteristics. Taking steps to meet the needs of people with certain protected characteristics where these are different from the needs of other people. Ensuring people with certain protected characteristics are able to participate in public life or in other activities where their participation is disproportionately low. It states that meeting different needs involves actions such as making adjustments to take account of disabled people s disabilities. It describes fostering good relations as tackling prejudice and promoting understanding between people from different groups. 4 Guidance on the public sector equality duty entitled Meeting the equality duty in policy and decision-making can be accessed at http://www.equalityhumanrights.com/adviceand-guidance/public-sector-equality-duty/guidance-on-the-equality-duty/ 33

The general equality duty and policy and decision-making Public authorities are required to have due regard to the aims of the general equality duty when making decisions and when setting policies. Understanding the effect of your policies and practices on people with different protected characteristics is an important part of complying with the general equality duty. This can help you to consider whether the policy will be effective for all sorts of different people. For example, does a particular policy meet the needs of people with protected characteristics? Does it minimise disadvantages faced by them? It can help you to identify any negative impacts or potential unlawful discrimination, as well as any positive opportunities to advance equality. Identifying these areas may help you to develop practical courses of action to mitigate negative consequences or to promote positive ones. The general equality duty does not set out a particular process that public authorities are expected to follow. It is up to each authority to choose the most effective approach for them, which will vary depending on the size of the organisation, the functions they carry out, and the nature of the particular decision. Having due regard to the aims of the general equality duty is about using good equality information and analysis, at the right time, as part and parcel of your decision-making processes. The law also requires transparency 5 about how you reached your decisions. This involves recording the evidence used and publishing records of your equality considerations with the relevant policy/proposal. It is useful to carry out this process when developing new policies as well as in the review of old policies. Since the actual, as opposed to predicted impact of policies and proposals may differ, they must undergo regular monitoring and review. This template has been designed for the use of the CCG to help staff, in particular those involved in developing policy and making decisions, to comply with the general duty. For assistance with Analysing the Impact on Equality and accessing evidence, please contact your Equality and Diversity Manager: Equality & Diversity Manager: Tel Number: The CCG gratefully acknowledges the work of NHS South of England who developed this template. 5 Please see http://data.gov.uk/blog/new-public-sector-transparency-boardand-public-data-transparency-principles 34

Supporting Guidance Notes for completing the template Guidance Note 4 The Government s commitment to transparency 6 requires public bodies to be open about the information on which they base their decisions and the outcomes of those decisions. Please list in section 4 the main sources of evidence that were reviewed to determine the impact on each equality group/protected characteristic. Wherever possible, provide references for each source. The evidence can include information from: engagement with stakeholders evaluation of pilot studies research interviews reports focus groups national research census data Everyone has at least five protected characteristics so it is important to think across the matrix of potential disadvantage when assessing the potential impact of decisions on access, experience and health outcomes e.g. older lesbian women, young black men, disabled children. It is also about looking for the potential to promote a positive impact, not just about mitigating against the negative impacts. Guidance Note 5 If there are gaps in evidence, state what you will do to fill them in the Action Plan on the last page of the template. For each protected characteristic also consider and detail how the policy/ proposal/ service will: 1. Impact on the elimination of discrimination, harassment and victimization and advance the equality of opportunity. 2. Remove or minimise disadvantages suffered by people due to their protected characteristics. 3. Take steps to meet the needs of people with certain protected characteristics where these are different from the needs of other people (e.g. making reasonable adjustments to take account of disabled people s impairments) Thus compliance with the general equality duty may involve treating some people more favourably than others to level the playing field 6 Please see http://data.gov.uk/blog/new-public-sector-transparency-boardand-public-data-transparency-principles 35

4. Ensure that people with certain protected characteristics are able to participate in public life or in other activities where their participation is disproportionately low. 5. Promote good relations between groups i.e. tackle prejudice and promote understanding between people from different groups and communities Also include any general actions to be taken to address specific equality issues and data gaps that need to be addressed through consultation or further research. Give an outline of your next steps based on the challenges and opportunities you have identified. Include any or all of the following, based on your assessment: 1. Plans already under way or in development to address the challenges and priorities identified. 2. Arrangements for continued engagement of stakeholders. 3. Arrangements for continued monitoring and evaluating the policy for its impact on different groups as the policy is implemented (or pilot activity progresses) 4. Arrangements for embedding findings of the assessment within the wider system, other agencies, local service providers and regulatory bodies 5. Arrangements for publishing the assessment and ensuring relevant colleagues are informed of the results 6. Arrangements for making information accessible to staff, patients, service users and the public 7. Arrangements to make sure the assessment contributes to reviews of CCG strategic equality objectives. 36

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APPENDIX 6: CHECKLIST FOR REVIEW AND APPROVAL OF POLICY DOCUMENTS (To be completed and attached to any policy submitted to an appropriate committee for consideration and approval) Document Title: 1 Title Is the title clear and unambiguous? Is it clear whether the document is a guideline, policy, protocol or standard? 2 Rationale Are reasons for development of the document stated? 3 Development Process Is the method described in brief? Are people involved in the development identified? Do you feel a reasonable attempt has been made to ensure relevant expertise has been used? Do you feel a reasonable attempt has been made to ensure relevant expertise has been used? Is there evidence of consultation with stakeholders and users? 4 Content Is the objective of the document clear? Is the target population clear and unambiguous? Are the intended outcomes described? Are the statements clear and unambiguous? 5 Evidence Base Is the type of evidence to support the document identified explicitly? Are key references cited? Are the references cited in full? Are supporting documents referenced? 6 Approval Does the document identify which committee/group will approve it? If appropriate have the joint Human Resources/staff side committee (or equivalent) approved the document?. Yes/No/ Unsure Comments 38

7 Dissemination and Implementation Is there an outline/plan to identify how this will be done? Does the plan include the necessary training/support to ensure compliance? 8 Document Control Is there an outline/plan to identify how this will be done? Does the plan include the necessary training/support to ensure compliance? 9 Process to Monitor Compliance and Effectiveness Are there measurable standards or KPIs to support the monitoring of compliance with and effectiveness of the document? Is there a plan to review or audit compliance with the document? 10 Review Date Is the review date identified? Is the frequency of review identified? If so is it acceptable? 11 Overall Responsibility for the Document Is it clear who will be responsible for co-ordinating the dissemination, implementation and review of the documentation? 39

APPENDIX 7: AUDITING STANDARD Policy Name: Policy Reference: TBC Standard statement The CCG will ensure that all policies meet the required format as stated in the Policy on the Management of Policies & Standard Operating Procedures. Criteria 1. Each policy gives complete document control information 2. All policies have a front sheet in the approved format and contain details against the 9 section headings although Not applicable is permitted where this is the case 3. All policies requesting approval follow the basic requirements of corporate identity and format 4. All policies detail where ultimate responsibility for adherence lies 5. Each policy considers the training needed to implement the policy and ongoing training commitments. 6. Each policy includes an auditing standard or similar tool 7. Each policy clearly details monitoring arrangements and identifies success criteria 8. An Equality Impact Assessment (EIA) for Equality and Diversity has been carried out prior to approval and details of the result, consultation and monitoring process are included in the Equality and Diversity section 9. Each policy details the consultation process that has been undertaken prior to seeking approval 40

Conclusion Please explain any discrepancies below: Please detail remedial action to prevent re-occurrence, giving details of monitoring arrangements to assess improvement: 41

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