Download Scheme of Delegation

APPENDIX 1: DETAILED SCHEME OF DELEGATION
1 BUDGETARY CONTROL
1.1 Schedule of Budgetary Responsibility
Each Divisional Clinical Director and Divisional General Manager is responsible for maintaining a
Schedule of Budgetary Responsibility to be approved by the Chief Financial Officer. The Schedule
indicates who within each Directorate fulfils the roles identified throughout the Scheme of
Delegation. The Divisional General Manager is also responsible for ensuring that the Finance
Department is kept informed of any amendments to the Schedule, within his/her delegated limits.
The Procurement Department will maintain a record of any ordering limits for users of the
electronic ordering system that are set lower than the overall budgetary responsibility limits.
The Schedule and any subsequent amendments must be approved by the Chief Financial Officer
and notified to the Trust Board.
1.2 Business Case Approval
A business case is required for all service and capital developments and must be completed using
the Trust’s business case template. The template is reviewed annually by the Finance Department
and is located on the intranet. The business case approval process is applicable for business
cases requiring capital investment, revenue funding, a combination of capital and revenue funding
or business cases that are self- funding/income generating.
All business cases will for consideration/approval be signed-off by the Divisional General Manager
or Executive Director responsible for the Directorate.
Business cases requiring capital investment must receive approval from the relevant Executive
Director (refer to table below) before then following the same approval process as revenue
business cases. Depending on the specifics of the business case, this approval by the relevant
Executive Director may be sufficient to secure the capital funding. If not then the next stage, ie
approval by the Chief Executive Officer, Capital Executive Group, Finance, Investment and
Estates Committee and Trust Board, will be followed as appropriate.
A Business Case register will be maintained by the Chief Financial Officer.
A full description of the process to secure capital investment is detailed in the table below as
expressed in SFI 24:
Equipment business cases up to £200,000
within an overall capital programme
approved by the Trust Board
IM&T equipment or systems business
cases up to £200,000 within an overall
capital programme approved by the Trust
Board
Approved by Chair of Equipment Sub
Group within delegated budget and
reported to the Capital Executive Group.
Approved by IMT Strategy Chair within
delegated budget and reported to the
Capital Executive Group.
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Any urgent capital business cases less than
£200,000 outside the capital programme
approved by the Trust Board.
Approved by Chief Financial Officer and
reported to Capital Executive Group.
All capital business cases over £200,000
within a capital budget allocation approved
by the Trust Board.
Approved by relevant Executive Director,
and then submitted to the Capital
Executive Group.
All capital business cases up to £4,000,000
where no capital budget allocation has
previously been approved by the Trust
Board and none of the above categories
applies.
To Chief Executive Officer, then Capital
Executive Group Capital Executive Group
and the Finance, Investment and Estates
Committee.
Any urgent capital business cases in this
category (i.e. greater than £200,000 and
with no capital budget) must be approved
by the Chief Financial Officer for
Chairman’s action.
To Chief Executive Officer, then Capital
Executive Group Capital Executive Group
and the Trust Board.
Any urgent capital business cases in this
category (i.e. greater than £4,000,000 and
with no capital budget) must be approved
by the Chief Financial Officer for
Chairman’s action.
All capital business cases over £4,000,000
where no capital budget allocation has
previously been approved by the Trust
Board and none of the above categories
applies.
Capital business cases are defined as urgent where they are so deemed by the Chief Executive
Officer and Chief Financial Officer. Reference should also be made to the section on Single Tender
Waivers in the Standing Orders - see SFI 17.5.3. However, it should be noted that urgency of
requirement may not obviate the need to follow the required procurement process, especially where
the procurement is in excess of the EU thresholds.
The approval process for Revenue only or Revenue and Capital business cases is outlined in the
table below:
Divisional funded business cases
revenue expenditure up to £50,000.
of
Divisional approval by Divisional General
Manager up to an annual limit of £50,000.
Divisional funded business cases of
revenue expenditure up to £50,000 and
requiring capital investment.
Divisional approval by Divisional General
Manager for revenue costs up to an
annual limit of £50,000 and then follow the
capital process as described in the table
above. If the aggregate is exceeded then
the Chief Executive Officer or Chief
Financial Officer must approve the
business case.
Business cases requiring up to £200,000
revenue funding.
Approved by relevant Chair of Capital
Project Group (if case contains a capital
element), then Chief Financial Officer or
Chief Executive Officer for approval,
within relevant capital and revenue
budgets approved by Trust Board.
Reported to the Capital Executive Group
Capital Executive Group if case contains
capital investment.
Business cases up to £4,000,000 revenue
funding.
Approved by relevant Chair of Capital
Executive Group (if it contains a capital
element), submitted to Chief Executive
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Officer, then Capital Executive Group for
approval (if it contains capital investment).
Revenue element of case should be
approved by Divisional General Manager,
then Chief Financial Officer and the
Finance,
Investment
and
Estates
Committee.
Business cases over £4,000,000 revenue
funding or costs.
Board approval required.
Business case applicants are required to demonstrate that they have involved Finance, HR and
Procurement and Contracting where appropriate at the start of the activity for support and advice on
costing and procurement strategy.
Business case applicants are not permitted to talk directly with suppliers about costs and must
instead obtain guide costs and quotations from the Procurement Department, IM&T Directorate or
Estates Management Department, as appropriate, for inclusion in business cases. At all points of
the business case or procurement process, business case applicants must not discuss commercial
issues such as prices with suppliers unless a representative from the Procurement Department is
present.
In order to provide indicative costs to inform business cases the Estates Department and IT
Department must comply with the Trust’s legal obligations and ask the required number of suppliers
as outlined in the SO, to provide a quote against an independently drafted specification. Any third
parties commissioned to undertake any part of the business planning or procurement process must
comply with the Trust’s scheme of delegation and standing financial instructions.
1.3 Management of Budgets
The budgets agreed annually by the Board are to be treated independently and should not be
aggregated for the purposes of monitoring.
With the exception of the Chairman, Chief Executive Officer and Chief Financial Officer no other
officer of the Trust is empowered to incur expenditure beyond their budgeted limits.
Budget Holders must confirm either in writing or via online confirmation that they have read the
Trust’s Standing Orders, Standing Financial Instructions and Scheme of Delegation before they are
approved as authorised signatories within the appropriate delegated limits. This confirmation must be
renewed annually to take into account the annual revision to these documents.
2 REVENUE EXPENDITURE
2.1 Requisitions for Goods, Works & Services
Authorisation limits for requisitioning goods, works & services (excluding Pharmacy)
Up to £5,000
Up to £15,000
Up to £25,000
Up to £50,000
Between £50,000 and
£150,000
Between £150,000 and
£250,000
Over £250,000
Budget Manager or other Designated Signatory
General Manager or equivalent
Divisional Clinical Director or Divisional General Manager
Executive Director
Chief Financial Officer
Chief Executive Officer
Chief Executive Officer & Chairman or Vice Chairman after
Board approval
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All above values are exclusive of VAT
Authorisation limits for the requisitioning of Pharmaceutical Drugs; Pharmacy Department
Up to £10,000
Pharmacy Purchasing Co-ordinator
Pharmacy Payments Administrator
Pharmacy Invoicing Manager
Pharmacy Buying Office & Stores Manager
Homecare Administrator (For Healthcare at Home only)
Principal Purchasing Technician
Up to £50,000
Pharmacy Purchasing & Distribution Manager
Principal Pharmacist Patient Service
Up to £300,000
Deputy Chief Pharmacist
Head of Pharmacy / Chief Pharmacist
Up to £500,000
Chief Executive Officer &Chief Financial Officer
Over £500,000
Trust Board
All above values are exclusive of VAT
The delegated limits shown above for all departments including Pharmacy do not confer any rights
to avoid the duty to comply with EU directives governing public procurement, formal tendering or
competitive quotations requirements as instructed in section 17 of the SFIs. The Procurement
Department should initially be consulted for guidance and support to ensure Trust compliance.
2.2 Confirmation of Goods Received
All Orders
Appropriate staff member as nominated by Budget Manager
and receipt and delivery staff on their behalf
2.3 Contracts for Goods and Services
The following are the authorisation levels for entering into contracts for Goods & Services:
The Procurement Department should initially be consulted for guidance and support to ensure Trust
compliance prior to any new purchase as per the below threshold levels:
Contract Value Up to £ 10,000
Contract Value Up to £ 50,000
Contract Value Up to £ 100,000
Contract Value Up to £300,000
Contract Value Up to £750,000
Contract Value Up to £4,000,000
Contract Value over £4,000,000
Budget Holder
General Manager
Non-Board Director, Divisional Clinical Director
Executive Director
Chief Executive Officer &Chief Financial Officer
Finance & Investment Committee
Trust Board
Budget holders are reminded that only Procurement Department members of staff have the
delegated authority to enter into contracts negotiations with suppliers however agreement of the
contract remains subject to a budget holder’s approval in line with the limits above.
2.4 Variations to Revenue Contracts
Note – for all construction projects, authorisation is the responsibility of the relevant Project
Board or Executive Director.
Contract Value Up to £100,000
Contract Value Up to £200,000
Contract Value Up to £750,000
Non-Board Director, Clinical Director
Executive Director
Chief Executive Officer &Chief Financial Officer
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Contract Value Up to £4,000,000
Contract Value over £4,000,000
Finance & Investment Committee
Trust Board
2.5 Call-off Orders Against Existing Contracts including Pharmacy
The following are the authorisation levels for signing call-off orders against existing contracts:
Up to £ 10,000
Up to £ 50,000
Up to £100,000
Up to £300,000
Up to £750,000
Over £750,000
Budget Holder
General Manager
Non-Board Director, Divisional Clinical Director
Executive Director
Chief Executive Officer &Chief Financial Officer
Trust Board
2.6 Invoices Against Existing Service Contracts (All departments excluding Pharmacy)
The following are the authorisation levels for signing off invoices against existing service contracts:
Up to £ 10,000
Up to £ 50,000
Up to £100,000
Up to £300,000
Up to £750,000
Over £750,000
Budget Holder / Manager
General Manager
Non-Board Director, Clinical Director
Executive Director
Chief Executive Officer &Chief Financial Officer
Trust Board
2.7 Invoices Against Existing Service Contracts – Pharmacy
The following are the authorisation levels for signing off invoices against existing service contracts
specific to the Pharmacy Department:
Up to £ 7,500
Pharmacy Invoicing Manager
Pharmacy Buying Office Manager
Pharmacy Payments Administrator
Pharmacy Operational Dispensary Manager
Lead Clinical Dispensary Pharmacist
Chief Technician Technical Services
Up to £ 50,000 Pharmacy
Purchasing & Distribution Manager
Lead Directorate Pharmacist Medicine
Lead Directorate Pharmacist W&C
Lead Directorate Pharmacist HIV/GUM
Up to £300,000
Deputy Chief Pharmacist, Head of Pharmacy, Chief
Pharmacist, Non-Board Director
Over £300,000
Chief Executive Officer &Chief Financial Officer
Over £500,000
Trust Board
2.8 Non-Budgeted Non-Pay Expenditure
Non pay expenditure for which no specific budget has been set up and which is not subject to
funding under delegated powers of virement (as specified in the budget manual) may only be
authorised by the Chief Executive Officer or the Chief Financial Officer.
The Chief Financial Officer is responsible for maintaining a register of occasions when the power
above is used.
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3 QUOTATION,
EXPENDITURE
TENDERING
AND
CONTRACT
PROCEDURES
–
REVENUE
The following procedures relate to all revenue expenditure and should be followed in conjunction
with the authorisation limits stated in Section 2. All tendering activity is to be processed through the
Trust’s e-tendering system. Paper tenders will not be accepted, and will be deemed to be noncompliant.
3.1 Expenditure Under £10,000 excluding VAT
There is no formal quotation or tendering procedure relating to expenditure below £10,000. There is,
however, a duty upon those responsible for the expenditure to achieve the best value for money –
this means the optimisation of both cost and quality. A minimum of one written quotation must be
obtained from the supplier.
1.2 Expenditure Between £10,000 and £50,000 excluding VAT
There is a requirement to request a minimum of 3 written quotations, of which a minimum of two
must be returned. Proposed purchases must first be verified by authorised staff from the
Procurement Department prior to the order being placed.
3.3 Acceptance of Quotation
The best value for money quotation should be accepted, that is the bid, which in the opinion of the
independent evaluators, represents the most economically advantageous outcome and which under
this condition is therefore deemed to be the offer that represents the best combination of quality and
price. This may not, therefore, be the lowest priced quotation.
3.4 Waiving of Quotations
The requirement to obtain quotations may be waived with the approval of the Chief Executive Officer
or the Chief Financial Officer on a formal Single Tender Waiver document, and clear reasons for
such being provided. All such instances must be recorded and reported to the Audit, Governance
and Risk Committee in line with 5.3.7
3.5 Expenditure over £50,000 excluding VAT
3.5.1 The Formal Tendering Process
The formal tendering process applies to all revenue expenditure over £50,000 excluding VAT and
must be adhered to unless the expenditure fits the criteria under which formal tendering may be
waived in line with the procedures in 5.3.7.
Standing Orders state “The Board shall ensure that invitations to tender are sent to a sufficient
number of firms/individuals to provide fair and adequate competition as appropriate and in no case
less than three firms/individuals, having regard to their capacity to supply the goods or materials or to
undertake the services or works required.”
At least 6 tenders must be requested, of which at least 3 must be returned.
If the proposed expenditure for the whole term of the contract is likely to exceed the prevailing OJEU
threshold then the Procurement Department must be consulted.
The process from the opening of tenders onwards applies to both capital and revenue
expenditure and is detailed in section 5.2.2.
4 CAPITAL PROJECTS/EXPENDITURE AND PRIVATE FINANCE SCHEMES
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4.1 Management
All capital expenditure must be within the agreed capital programme approved by the Board. A
business case submission must be completed for every capital project. The financial monitoring and
reporting of all capital scheme expenditure is the responsibility of the Chief Financial Officer. Capital
expenditure should be reported monthly to the Capital Executive Group, to the relevant Capital
Project Board, Finance, Investment and Estates Committee and the Trust Board.
4.2 Capital Schemes SOD no.9 and no.4
Selection of architects, quantity surveyors, consultant
engineer and other professional advisors within EU
regulations
Chief Executive Officer or Chief
Financial Officer
or Director of Estates & Facilities
Financial monitoring and reporting on all capital
scheme expenditure
Chief Financial Officer or Nominated
Deputy or Director of Estates & Facilities
Granting and termination of leases with an annual
rental less than £100,000
Chief Executive Officer or Chief Financial
Officer
Granting and termination of leases with an annual
rental greater than £100,000
Chief Executive Officer and Chief Financial
Officer
5 QUOTATION, TENDERING & CONTRACT PROCEDURES - CAPITAL
5.1 Expenditure Under £10,000 excluding VAT
There is no formal quotation or tendering procedure relating to expenditure below £10,000 excluding
VAT. There is, however, a duty to achieve the best value for money, therefore the capital must be
procured through the Procurement Department and a quotation must be obtained and approved
before the order is placed. The nominated Capital Project Manager can authorise expenditure up to
£10,000.
1.2
Expenditure Between £10,000 and £50,000 excluding VAT
The nominated Capital Project budget holder is responsible for the authorisation of all expenditure up
to £50,000 excluding VAT. There is a requirement to request a minimum of 3 written quotations, of
which a minimum of 2 must be returned. All formal communication to initiate the procurement
process should be undertaken by the Procurement Department.
5.2.1 Acceptance of Quotation SOD no.5
Best Value for Money quote:
If quote does not vary from pre-quote
estimate by more than 20% and there is
sufficient funding
Executive Director
If quote does vary from pre-quote
estimate by more than 20%
Chief Executive Officer or Chief Financial Officer
A quote other than the best value for money
Chief Executive Officer or Chief Financial Officer
5.2.2 Waiving Of Quotations
The requirement to obtain quotations may only be waived with the approval of the Procurement
Department in conjunction with either the Chief Executive Officer or the Chief Financial Officer.
5.3 Expenditure Over £50,000 excluding VAT
5.3.1 Formal Tendering Process
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The formal tendering process applies to all capital expenditure over £50,000 excluding VAT and
must be adhered to, unless the expenditure fits the criteria under which formal tendering may be
waived. In addition, the OJEU process must be complied with; refer to the Procurement department
for the prevailing OJEU thresholds and the application of such to the whole life of the contract.
In line with the provisions of SFI 17.5.4, it is a requirement to ensure that invitations to tender are
sent to a sufficient number of firms or individuals to provide fair and adequate competition. In no
case should fewer than three firms or individuals be requested to provide tenders.
A minimum of 3 tenders should be requested and 2 should be returned.
All tendering activity must be conducted through the electronic tendering system; paper submissions
will not be accepted and may be deemed non-compliant.
THE FOLLOWING SECTION IS APPLICABLE TO BOTH CAPITAL AND REVENUE TENDERS:
5.3.2 Opening Tenders
Tenders will not be accepted in paper format.
Where tenders are received via the Trust’s online Tender Management system: These need
only be verified by representatives from the Legal Department and Procurement, as the system has
built in security and is fully compliant with all relevant legal obligations.
5.3.3 Insufficient Tenders SFI 17.6.6
If insufficient tenders returned,
decision whether to re-tender
or to continue.
Chief Executive Officer/Chief Financial Officer
reporting to the Board.
5.3.4 Receipt of Late Tenders SFI 17.6.5
In the event that a tender is received by the Trust beyond the official deadline, only the Chief
Executive Officer or his nominated officer is authorised to decide if the tender can still be included
for consideration. Valid reasons for inclusion would include evidenced delivery to the Trust before
the deadline where the Trust’s internal postal system caused the delay in receipt.
5.3.5 Acceptance of Tender
Tenders should be evaluated in accordance with the guidance contained in the Purchasing
Handbook (see the Trust intranet).
The best value tender should be accepted. In the case of variations from the pre-tender estimate, the
following rules apply:


If the tender does not vary from the pre-tender estimate by more than 20% and there is
sufficient funding – Executive Director is authorised to accept it.
If the tender does vary from the pre-tender estimate by more than 20% - it may only be
accepted with the agreement of the Chief Executive Officer or Chief Financial Officer.
Where a tender other than the best value is accepted, the following should apply;
Tender value under £500,000
Chief Executive Officer must approve & report reasons to
the Trust Board.
Tender value over £500,000
This power is reserved to the Trust Board. The Chief
Executive Officer should make a recommendation as
appropriate.
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5.3.6 Reporting Of Tenders
Reporting of all tenders including companies invited to tender, dates and values of tenders received.
Over £50,000
Chief Financial Officer
5.3.7 Waiving Of Formal Tendering Process
Formal tendering procedures for expenditure over £50,000 may be waived under SFI 17.5.3 (d) to
(m) under the circumstances set out below. The SFI specifically prohibit the use of these waivers for
the purpose of avoiding competition or for administrative convenience. Single Tender Waivers must
be sought and approved PRIOR to any procurement taking place. All waivers must be reported to the
Audit, Governance and Risk Committee.
Supply under special arrangements
negotiated by Dept. of Health which must therefore be complied
with.
Chief Financial Officer or
Chief Executive Officer
& reported to the Board
Timescale precludes competitive tendering
Chief Financial Officer or
Chief Executive Officer
& reported to the Board
Specialist expertise is required and is available from only one
source.
Chief Financial Officer or
Chief Executive Officer
& reported to the Board
Task is essential to complete project AND
arises as a consequence of a recently completed
assignment and engaging different consultants
for the new task would be inappropriate.
Chief Financial Officer or
Chief Executive Officer
& reported to the Board
There is a clear benefit from continuity with an
earlier project.
Chief Financial Officer or
Chief Executive Officer
& reported to the Board
5.3.8 Recording Of Tender & Quotation Waiving
The Chief Financial Officer is responsible for maintaining a record of the occasions when the
requirement for tenders and quotations has been waived.
6 SIGNING OF CONTRACTS
The following are the authorisation levels for the signing of contracts for both revenue and capital
expenditure:
Contract Value Up to £ 10,000
Contract Value Up to £ 50,000
Contract Value Up to £ 100,000
Contract Value Up to £300,000
Contract Value Up to £750,000
Contract Value Over £750,000
Budget Holder / Manager
General Manager
Non-Board Director
Executive Director
Chief Executive Officer & Chief Financial Officer
Trust Board
In addition to the budget holder’s signature on a contract, all contracts with a value of up to £100,000
must be countersigned by the following people:

Associate Director of Procurement – in order to review all of the legal aspects of the contract
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

Assistant Director of Finance (Financial Control) – in order to review the financial aspects of
the contract and ensure that budget exists for the related expenditure.
Chief Information Officer (for ICT related contracts).
Healthcare Contracts
All healthcare contracts and contracts for private or new business ventures regardless of value must
be approved by the Chief Financial Officer and Associate Director of Contracting.
Grants
All grant applications should be reviewed and signed off by the relevant Finance Managers in the first
instance. All applications for grants exceeding £50,000 should also be counter signed by the Chief
Financial Officer and the above rules on the signing of contracts would apply.
7 FINANCIAL CONTROL
7.1 Bank Accounts SFI 15
Maintenance & operation of bank
accounts and Government Banking Service
Chief Financial Officer
Approval of cheque signatories
Chief Executive Officer and Chief Financial Officer
Signing cheques or approval of direct
electronic payments up to £50,000
Two approved signatories
Signing cheques or approval of direct
electronic payments over £50,000
Two approved signatories including at
least one Executive Director
Electronic authoriser of direct electronic
approved as above by two
approved signatories
Assistant Director of Finance (Financial Controller)
or Senior Financial Accountant
The only exception to the limits for approval of direct electronic payments over £50,000 is in the case
of the transmission of funds to the National Loans Fund for short term (7 days) deposits. In this case
ONLY, the transmission of funds can be approved by two approved signatories and this does not
have to include at least one Executive Director.
7.2 BACS Payments Transmission
BACS payments transmission of approved invoices is authorised by the Accounts Payable Manager
or Deputy Accounts Payable Manager and Assistant Director of Finance (Financial Control) or Senior
Financial Accountant.
BACS payments transmission of salaries is authorised by the Payroll Manager or Deputy Payroll
Manager and Assistant Director of Finance (Financial Control) or Senior Financial Accountant.
7.3 Fees and Charges SFI 16 SOD 6
The responsibility for setting fees and charges lies with the Chief Financial Officer, however in some
cases the value may be set externally, e.g. by the Department of Health or legislation.
Price of NHS Service Agreements
Chief Financial Officer and Associate Director of
Contracting
Charges for all NHS Service Agreements
Chief Financial Officer and Associate Director of
Contracting
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Price of Non-NHS activities:
Income generation including Private
Patients, Overseas Visitors Income
Generation and other patient related
services.
Chief Financial Officer or Nominated Deputy
7.4 Losses, Write-Offs & Compensation SOD 11 SFI 26
Authorisation Limits
7.4.1 Losses and cash due to theft, fraud,
overpayment and others
up to £50,000
Over £50,000
Chief Executive Officer and Chief Financial Officer
Audit, Governance and Risk Committee
7.4.2 Fruitless Payments (including
abandoned Capital Schemes)
up to £50,000 per case
Over £50,000 per case
Chief Executive Officer and Chief Financial Officer
Audit, Governance and Risk Committee
7.4.3 Bad Debts and Claims Abandoned. Private
Patients, Overseas Visitors and other
Up to £1,000 per case
Assistant Director of Finance (Financial Control)
Up to £5,000 per case
Director of Financial Operations
Up to £10,000 per case
Chief Financial Officer
Up to £50,000 per case
Chief Executive Officer
Over £50,000
Audit, Governance and Risk Committee
7.4.4 Damage to buildings, fittings, furniture &
equipment and loss of equipment & property in
stores and in use due to Culpable causes (eg
fraud, theft, arson) or other.
Up to £50,000
Chief Executive Officer and Chief Financial Officer
Over £50,000
Audit, Governance and Risk Committee
7.4.5 Compensation payments made under
legal obligation.
Up to £50,000
Over £50,000
Chief Executive Officer and Chief Financial Officer
Audit Governance and Risk Committee
7.4.6 Ex-gratia Payments to Patients and Staff
for loss of personal effects
Up to £1,000
Up to £5,000
Up to £10,000
Up to £50,000
Over £50,000
Assistant Director of Finance (Financial Control)
Director of Financial Operations
Chief Financial Officer
Chief Executive Officer
Audit, Governance and Risk Committee
7.4.7 For clinical negligence all cases are
referred to the NHS Litigation Authority
Trust agreement to settle
Medical Director and Chief Financial Officer
7.4.8 For personal injury claims all cases
are referred to the NHS Litigation Authority
7.4.9 Other, all cases are referred to the
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NHS Litigation Authority
7.5 Petty Cash Disbursements (not applicable to central Cashiers Office) SOD 13
The overall responsibility for Petty Cash Floats held within a Department lies with the General
Manager.
7.5.1 Expenditure up to £50 per item
Petty Cash Holder
7.5.2 Reimbursement of patients’ monies up
to £50 in cash
Patient Affairs Officer
7.5.3 Reimbursement of patients’ monies in
excess of £50 by cheque
Patient Affairs Officer
Approval for Petty Cash Float
Assistant Director of Finance (Financial Control)
or Senior Financial Accountant
Costs incurred by staff in the ordinary course of business, e.g. travel costs, must be reclaimed
through an expenses application form and paid to the employee in the salary to ensure the tax
implications are correctly accounted for.
7.6 Purchasing Cards
Overall responsibility for the security and use of a purchasing card is the named holder of the card.
Each card must only be used for the purpose for which it is authorised, for example, travel and
subsistence costs. Each cardholder must comply with the administrative requirements of the Trust’s
Purchasing Cards User Manual.
Approval for issue of new cards
Chief Financial Officer or Chief Executive Officer.
7.7 Patients’ Monies and Valuables SFI 28
The General Manager/Divisional Clinical Director is responsible for the control and safe-handling of
patients’ monies and valuables up to the point of receipt by the Cashiers Office after which the Chief
Financial Officer is responsible for their safe-keeping and recording.
Withdrawals of patients’ monies
(Maximum £100 per day)
Ward Manager
Reimbursement of closing balance of
Patients’ monies and valuables
Ward Manager
(These transactions must also be authorised by the Patient).
In the event of a patient’s death where no next of kin is known then the claimant must provide
evidence that he/she is the executor of the patient’s estate. If there is no such evidence available
but the claimant can show the original death certificate, the monies and valuables will be given to
the claimant. Probate see SFI 28.
7.8 External and Internal Audit Recommendations SOD 15 SFI 11
Implementation of recommendations
Relevant Executive Director
Follow up of recommendations to ensure
effective implementation
Audit, Governance and Risk Committee
7.9 Trust Financial Procedures SOD 16
Maintenance & update on Trust
Chief Financial Officer
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Financial Procedures
7.10 Investment of Funds SOD 17
Approval of organisations in which the
Treasury Management department of
the Trust may invest and of the types
of investment permitted.
Chief Financial Officer and approved
by the Trust Board
Authorisation of individuals
responsible for making investments.
Chief Financial Officer
7.11 External Borrowing SFI 22
The authority to sign loan draw-downs against approved loans is delegated to the Chief Financial
Officer or the Chief Executive Officer.
1.12 Charitable Donations SOD 8 &17 SFI 15 & 29
The following criteria must be considered when making charitable donations from Trust funded
budgets:


Whether the donation is an appropriate use of NHS funds
Whether the donation directly supports the department’s objectives
Any donation for an amount greater than £5,000 must be countersigned by an Executive Director
and donations may only be made to arm’s length charities, i.e. charities that are not controlled by the
budget holder making the donation.
8 HUMAN RESOURCES SOD 18 SFI 20
8.1 Engagement of Staff on the Establishment
Authority to fill funded post on the
establishment with permanent staff
Divisional General Manager or equivalent
Authority to appoint staff to post not on the
formal establishment
Chief Executive Officer or Executive Director
8.2 Engagement of Staff Not On the Establishment SOD 7
This is bound by the rules governing revenue expenditure including the need for quotation and
tender, and the Trust’s policy on the use of contract staff as owned by HR.
Non Medical Consultancy Staff:
Where aggregate commitment in any one year
(or total commitment) is less than £25,000
Where aggregate commitment in any one year
is more than £25,000
Director and Chief Financial Officer
Engagement of Trust's Solicitors
Chief Executive Officer or Executive Director
Chief Executive Officer and Chief Financial Officer
Booking of Bank or Agency Staff:
Medical Locums
Nursing and other Agency Staff
Medical Director or approved deputy
Budget Manager
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8.3 Additional Staff to the Agreed Establishment
With specifically allocated finance
Chief Financial Officer or Nominated Deputy
Without specifically allocated finance
Chief Executive Officer and Director of Human
Resources and Organisational Development
8.4 Fixed Term Contracts
Authorisation or renewal of fixed term
Contracts
General Manager/Director of Human Resources
and Organisational Development
8.5 Pay Increases/Decreases
8.5.1 Additional Increments
The granting of one additional increment
to staff within budget
Assistant Director and Director of Human
Resources and Organisational Development
The granting of more than one additional
increment to staff within budget
Chief Financial Officer
8.5.2 Upgrading and Regrading
All requests for upgrading/re-grading
will be dealt with in accordance with
Trust procedure.
Assistant Director of Human Resources and
Organisational Development
8.6 Pay Processes
Authority to complete standing data
forms effecting pay, new starters,
variations and leavers
Directorate Human Resources and Organisational
Development or Nominated Deputy
Authority to complete and authorise positive
reporting forms
Budget Holder or nominated deputy
Authority to authorise overtime
Budget Holder or nominated deputy
Authority to authorise waiting list payments
Divisional General Manager
Authority to authorise other additional payments Chief Financial Officer
Authority to authorise travel & subsistence
expenses
Budget Holder
Authority to authorise staff bank payments
MAPS System Manager or Bank Payroll Manager
Approval of Performance Related Pay
Remuneration Committee
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8.7 Leave
8.7.1 Approval of annual leave
Line/General Manager
Approval of carry forward of annual leave
(up to a maximum of 5 days or in the case of
Ancillary & Maintenance staff as defined in
their initial conditions of service)
Line/General Manager
Annual leave - approval of carry over in
excess of 5 days but less than 10 days
Assistant Director
Annual leave - approval to carry forward 10
days or more
Director
8.7.2 Compassionate leave up to 3 days
Line/General Manager
Compassionate leave up to 6 days
Director or Assistant Director
8.7.3 Special leave arrangements
- paternity leave
- carer’s leave - up to 3 days
- up to 5 days
Assistant Director of Human Resources and
Organisational Development
Director of Human Resources and Organisational
Development
8.7.4 Leave without pay
Director
Medical Staff Leave of Absence
- paid and unpaid leave - < 5 days
- paid and unpaid leave - > 5 days
Divisional Clinical Director
Medical Director and Chief Executive Officer
8.7.5 Time off in lieu
Line Manager/Assistant Director
8.7.6 Maternity Leave - paid and unpaid
Automatic approval within guidance
8.7.7 Sick Leave
Extension of sick leave on half pay up
three months
Development
Executive Director in conjunction with
Director of Human Resources and Organisational
Return to work part-time on full pay to
assist recovery from sick leave
Director or Assistant Director
Extension of sick leave on full pay
Director of Human Resources and Organisational
Development or Chief Executive Officer
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8.7.8 Study Leave
Line Manager
Study leave outside the UK
Chief Executive Officer
Medical staff study leave (UK)
Assistant Director or Executive
Director
Director or Assistant Director
All other study leave (UK)
8.7.9 Removal Expenses, Excess Rent and House Purchase Loans
Authorisation of payment of removal expenses incurred by officers taking up new appointments
(providing consideration was promised at interview):
Up to £8,000
Director of Human Resources and Organisational
Development
Chief Executive Officer
Over £8,000
8.8 Grievance Procedure
All grievances must be dealt with strictly in
accordance with the Grievance Procedure
and the advice of a Human Resources Officer
must be sought when the grievance reached
the level of Director.
Director of Human Resources and Organisational
Development
8.9 Authorised Car & Mobile Phone Users
Requests for new posts to be authorised as
car users
Director of Human Resources and Organisational
Development or Chief Financial Officer
Requests for new posts to be authorised as
mobile telephone users
Director of Human Resources and Organisational
Development or Chief Information Officer or
approved deputy
8.10 Staff Retirement Policy
Authorisation of extension of contract
beyond normal retirement age.
Director of Human Resources and Organisational
Development
8.11 Redundancy
Negotiation of a payment in full and final
settlement supported by a COT3 or
compromise agreement:
Up to £20,000
Up to £100,000
Over £100,000
Director of Human Resources and Organisational
Development or Chief Financial Officer
Chief Executive Officer and Director of Human
Resources and Organisational Development or
Chief Financial Officer
Director of Human Resources and Organisational
Development and Remuneration Committee
The Director of Human of Resources shall provide a written report to the Remuneration Committee
in retrospect for cases up to £100,000. The Trust will take legal advice and the decision to settle
must be assessed against the value for money for the Trust.
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8.12 Ill Health Retirement
Decision to pursue retirement on the grounds
of ill health.
Director of Human Resources and Organisational
Development
8.13 Dismissal
Dismissal
Dismissing Officers
8.14 Facilities for staff not employed by the
Trust to gain practical experience
Professional Recognition, Honorary Contracts,
Development
& Insurance of Medical Staff
Director of Human Resources and Organisational
Work experience students
Director of Human Resources and Organisational
Development
8.15 Reporting of Incidents to the Police SOD 12
Where a criminal offence is suspected
Of a violent nature
Security Officer on duty/Site Practitioner/Local
Security Management Specialist
On Call Manager
Other
Executive Director on call
Where a fraud is involved
Chief Financial Officer or Local Counter Fraud
Specialist
8.16 Fixed Term Contracts
Authorisation or renewal of fixed term
Contracts.
General Manager/Director of Human Resources
and Organisational Development
9 CHARITABLE FUNDS
9.1 Charitable Donations SOD 8 &17 SFI 15 & 29
The following criteria must be considered when making charitable donations from Trust funded
budgets:


Whether the donation is an appropriate use of NHS funds and the terms of the gift
Whether the donation directly supports the department’s objectives
Any donation for an amount greater than £5,000 must be countersigned by an Executive Director
and donations may only be made to arm’s length charities, i.e. charities that are not controlled by the
budget holder making the donation.
9.2 Charitable Expenditure
Up to £1,000 per request
Up to £5,000 per request
Up to £10,000 per request
£10,000 to £250,000 per request
Over £250,000 per request
Fundholder
Fundholder and Chief Financial Officer
Fundholder and Chief Executive Officer
Charitable Funds Committee
Charitable Funds Committee & Trust Board
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10 ESTATE MANAGEMENT
10.1 Agreements / Licenses & Leases
Preparation and signature of all tenancy
agreements/licenses for all staff subject to
Trust policy on accommodation for staff
Director of Human Resources and Organisational
Development or Chief Financial Officer
Approval of rent based on professional
assessment
Chief Financial Officer
Extension to existing leases
Director of Estates & Facilities or Chief Executive
Officer
Director of Estates & Facilities or Chief Executive
Officer
Letting of premises to outside organisations
10.2 Condemning & Disposal SFI 26
Items obsolete, obsolete, redundant, irreparable or cannot be repaired cost effectively:
with current purchase new price less than
£5,000
Chief Financial Officer
with current purchase new price greater than
£5,000
Chief Financial Officer
disposal of x-ray films (subject to estimated
income of £1,000 per sale)
Radiology Services Manager
disposal of x-ray films (subject to estimated
income exceeding £1,000 per sale)
Radiology Services Manager and Assistant
Director
disposal of mechanical & engineering plant
(subject to estimated sale proceeds of less
than £5,000 per sale)
Director of Estates and Facilities
disposal of mechanical & engineering plant
(subject to estimated sale proceeds not
exceeding £5,000 per sale)
Director of Estates and Facilities and Chief
Financial Officer
10.3 Review of Fire Precautions
Director of Estates and Facilities
10.4 Review of all statutory compliance
Director of Estates and Facilities
legislation and Health and Safety
requirements including control of
Substances Hazardous to Health Regulations
10.5 Review of compliance with environmental regulations, for example those
relating to clean air and waste disposal
Director of Estates and Facilities
10.6 Insurance policies & Risk Management Director of Estates and Facilities
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11 CORPORATE AFFAIRS
11.1 The keeping of the Declaration of
Interest Register
Board Secretary
11.2 Attestation of sealing in accordance
with Standing Orders
Board Secretary
11.3 The keeping of the Register of Sealing
Board Secretary
11.4 The keeping of the Hospitality Register Board Secretary
11.5 Receiving Hospitality
Applies to both individual and collective
hospitality receipt items. In excess of £25 per
received.
11.6 Retention of Records
Declaration required in Trust’s Hospitality Register
Chief Executive Officer
11.7 Patients’ & Relatives’ Complaints
11.7.1 Overall responsibility for ensuring that all
complaints are dealt with effectively
Chief Executive Officer
11.7.2 Responsibility for ensuring complaints
relating to a directorate are investigated
thoroughly
Executive Director or Assistant Director
11.8 Medico - Legal Complaints
Co-ordination of their management
Director of Nursing and Quality
11.9 Relationships with Press
Non-Emergency General Enquiries Within Hours and Outside Hours
Head of Communications
Emergency Within Hours and Outside Hours
Head of Communications
11.10 Review of Trust's compliance with the
Data Protection Act
Computer Records
Patient Records
Chief Information Officer
Medical Director (as Caldicott Guardian)
Staff Records
Director of Human Resources and Organisational
Other Corporate Records
Development
Chief Information Officer
11.11 Monitor proposals for contractual
Healthcare services arrangements between
the Trust and NHS bodies
Associate Director of Contracting
11.12 Review the Trust's compliance with the Chief Information Officer
Freedom of Information Act
11.13 Review the Trust's compliance code of Associate Director of Governance
Practice for handling confidential information
in the Healthcare contracting environment
and the compliance with "safe haven" per
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EL 92/60
12 CLINICAL AFFAIRS
12.1 Authorisation of New Drugs
Drugs and Therapeutics Committee
12.2 Authorisation of Sponsorship Deals
Chief Executive Officer, Medical Director, Ethics
Committee
Ethics Committee and Director of Research
12.3 Authorisation of Research Projects
12.4 Authorisation of Clinical Trials
12.5 Infectious Diseases & Notifiable
Outbreaks
Ethics Committee and Head of Clinical Risk and
Legal Services or Research and Development
Manager
Duty Executive Director or Control of Infection
Doctor
12.6 Extended Role Activities
Director of Nursing and Quality or Medical Director
Per Nurse/Midwives/ Health Visitors Act
Midwives Rules / Code of Practice UKCC
Code of Professional Conduct
12.7 Patient Services
Variation of operating and clinic sessions within
existing numbers.
Chief Operating Officer or Head of Site
Operations
All proposed changes in bed allocation and use
Chief Operating Officer or Head of Site Operations
12.8 Review of Medicines Inspectorate
Regulations
Medical Director
12.9 Clinical Governance
Director of Nursing and Quality and Medical
Director
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