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DESIGNATION AS AN ACCOUNTABLE OFFICER

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					               ACCOUNTABLE OFFICER MEMORANDUM FOR
                  CHIEF EXECUTIVES OF NHS TRUSTS

Introduction

1.   This Memorandum describes your responsibilities as an Accountable Officer. In
     doing so, it sets out:


         The responsibilities I have conferred on you;
         The exercise of your responsibilities in relation to the role of your NHS Trust,
          its governing Board and overall governance framework; and
         The direct relationship between your responsibilities as Accountable Officer,
          and my overall role and responsibility as additional Accounting Officer, for
          funds drawn by Welsh Ministers for the National Health Service in Wales.


Your specific responsibilities as an Accountable Officer


2.   The essence of your role as an Accountable Officer is a personal responsibility for
     the propriety and regularity of the public finances for which you are answerable.


3.   In particular, you are responsible for:


         the overall organisation, management and staffing of the Trust and its
          arrangements related to quality and safety of care as well as matters of
          finance, together with any other aspect relevant to the conduct of the Trust’s
          business in pursuance of the strategic direction set by the Trust Board, and in
          accordance with its statutory responsibilities;
         ensuring that all items of expenditure, including payments to staff, fall within
          the legal powers of the Trust;
         acting within the scheme of delegations and ensuring that you comply with
          guidance on classes of payment that you should authorise personally;
         ensuring that in delegating functions to officers you are satisfied of their
          ongoing capacity and capability to deliver on those functions, facilitating
          access to the information they need, ongoing training and development, as
          well as professional or specialist advice where appropriate;
   prudent and economical administration, for the avoidance of waste and
    extravagance, and for the efficient and effective use of all resources;
   ensuring that the assets for which you are responsible are properly
    safeguarded, particularly:
              information, including systems for maintaining the trust of patients
            and the public by ensuring that the Trust will store, share and use
            information, including their personal information safely, and securely,
            and
              land, buildings or other property (including stores and equipment);
   ensuring that, in the consideration of policy proposals relating to the
    expenditure or income for which you have responsibility, all relevant financial
    considerations (including any issues of propriety, regularity or value for
    money) are taken into account;
   ensuring that risks to the achievement of the Trust’s objectives and fulfilment
    of its statutory responsibilities are identified, that their significance is
    assessed, and that a sound system of internal control is in place to manage
    them;
   implementing an appropriate framework of assurance covering all aspects of
    Trust business, ensuring that research and evaluation work is planned so that
    strategic objectives and spending programmes for which you have
    responsibility are routinely evaluated to assess their effectiveness and value
    for money;
   ensuring, as a key source of your internal assurance, that you establish
    arrangements for internal audit in accordance with the International Standards
    for the professional practice of Internal Audit as adopted by the NHS in
    Wales, Welsh Assembly Government and HM Treasury, and ensuring that
    appropriate action is taken in response to reports produced by Internal Audit;
   ensuring that there are appropriate arrangements to counter fraud and that
    procedures for dealing with suspected cases of fraud are complied with;
   ensuring that the Trust co-operates fully with external auditors, regulators and
    inspectors - including the Wales Audit Office (WAO), Healthcare Inspectorate
    Wales (HIW), and the Care and Social Services Inspectorate Wales (CSSIW),
    and ensuring that appropriate action is taken in response to any reports
    produced by such bodies;
         signing the Trust’s accounts and, in doing so, accepting personal
          responsibility for their proper presentation fully supported by sound financial
          procedures and records, and in accordance with the Trust Accounts
          Directions issued by Welsh Ministers, ensuring that losses or special
          payments are properly identified and handled in accordance with defined
          requirements.


The exercise of your Accountable Officer role within the Trust framework


4.   Your role as Accountable Officer is to see that the Trust carries out its
     responsibilities in a way that fulfils its duty to ensure the quality and safety of
     healthcare and the proper stewardship of public money. In fulfilling your role as
     Accountable Officer, you must also take account of your corporate responsibilities
     and accountability to the Trust Board of which you are a member.


5.   In exercising your role as Accountable Officer therefore, you must do so in
     accordance with the principles set out within Managing Welsh Public Money and
     the framework and standards of good governance set for the NHS in Wales. You
     should also assist the Chair in ensuring that his/her establishment and
     implementation of the Trust’s governance framework accords with these standards
     and principles.


     Partnership working
6.   The Trust may work in partnership with other organisations to achieve its strategic
     aims and objectives. Your Trust may also contribute to a joined up activity led or
     hosted by another organisation in pursuit of its objectives. You must ensure that
     the wider impact of the activities for which you are responsible are properly
     identified and, where appropriate, taken into account in determining the
     governance and accountability arrangements overseeing such work. Specifically,
     you will need to ensure that the governance arrangements are formally recorded
     and that you put in place appropriate arrangements to provide you with assurance
     on those areas for which you are accountable.
7.   Accountable Officers may take joint responsibility for the delivery of a service
     through joint arrangements that involve the pooling of budgets. Such
     arrangements may be handled under a specific statutory authority, e.g., Section 33
     of the National Health Service (W ales) Act 2006. Where you and another
     Accountable Officer or Officers take joint responsibility, you will need to ensure that
     that there is absolute clarity on all aspects of the service for which you are
     responsible and accountable. Specifically, you must set down, in a formal
     agreement, the governance and financial accounting arrangements, including audit
     and assurance requirements, in accordance with any requirements determined by
     the Assembly Government. You are reminded of the guidance issued by the
     Assembly Government, which can be found at:
     http://new.wales.gov.uk/topics/improvingservices/poolbudgets/;jsessionid=s7hkJv0
     JWLnqpBV56hykHzhK2znyP4dppDnRLhc0JL4qNknk9KSD!-1130397166?lang=en


8.   You must ensure that where your Trust contracts with a third party for the provision
     of goods or services it does so in accordance with all relevant legislation together
     with any requirements determined by the Assembly Government. In doing so, you
     must make sure that appropriate systems are in place to provide assurance that
     such funds are allocated in accordance with the terms of the contract and are not
     misappropriated.


     Advice to the Board
9.   As Accountable Officer of the Trust, you have a responsibility to see that
     appropriate advice is tendered to the Board on all matters of financial propriety,
     regularity and value for money, and more broadly on all considerations of prudent
     and economic administration, efficiency and effectiveness. You will need to
     determine how and in what terms such advice should be given, and whether in a
     particular case to make specific reference to your own duty as Accountable Officer.
     You must inform me of any such issues that you consider to be of a novel and
     contentious nature, and of any action you propose to take before tendering advice
     to the Trust Board.


10. If the Board or the Chair is contemplating a course of action which you consider
     would infringe the requirements of propriety, regularity or value for money, you
     should set out in writing to the Chair and the Board your objection to the proposal,
     the reason for your objection and your duty to inform me and the external auditors
     if your advice is overruled. Wherever possible, you should inform me before the
     Board takes its decision. If it is not possible, due to the urgency of the situation, to
     notify me beforehand, and if the Board decides nonetheless to proceed against
     your advice, you should seek a written instruction to take the action in question.
     Your request for the instruction and the instruction itself should be communicated
     to me and to the external auditors without undue delay, and before the decision is
     implanted, so that I can if necessary intervene with the Board and inform Welsh
     Ministers.


     Absence of Accountable Officer
11. As an Accountable Officer you should ensure that you are generally available for
     consultation and that in any temporary period of unavailability, eg., due to illness,
     or during normal periods of annual leave, there will be a senior officer of the Trust
     who can act on your behalf if required.


12. If it becomes clear that you are so incapacitated that you will not be able to
     discharge these responsibilities over a period of four weeks or more, I should be
     notified so that I can formally designate an officer as Acting Accountable Officer
     pending your return. The same applies if, exceptionally, you plan an absence of
     more than four weeks during which you cannot be contacted.


The Relationship between the Chief Executive, NHS Wales as Accounting Officer
and Accountable Officers within NHS Wales


13. As Accounting Officer for the NHS in Wales, I am responsible for ensuring that
     there is a high standard of financial management across NHS Wales as a whole.


14. It is within that framework that you as an Accountable Officer are responsible for
     the Budgets assigned to you. I will hold you to account for the exercise of your
     responsibilities as Accountable Officer directly.
15. I may be summoned to appear before the Audit Committee or the Public Accounts
     Committee (PAC) to deal with questions arising from NHS accounts or from a
     wider examination into the economy, efficiency and effectiveness with which the
     NHS has used its resources.


16. I am regarded as the main respondent to any enquiries about matters relevant to
     the proper stewardship of funds within the NHS in Wales, especially where the
     issues are wider than an individual Trust although I may require you to accompany
     me. The Audit Committee or the PAC may call other witnesses, and you may be
     required to appear before the Committee separately, in your own right, depending
     on the matter under consideration. I shall in any event look to you for support and
     information in my dealings with the National Assembly for Wales, its Audit
     Committee and the PAC.


17. In practice, you will have delegated authority widely within your Trust, but cannot
     on that account disclaim responsibility. Nor, by convention, can you decline to
     answer any questions where the events took place before your designation. The
     Audit Committee and the PAC may be expected not to press personal
     responsibility in circumstances where matters it is considering relate to a period
     before your designation.


18. High importance is attached to accuracy of evidence and the responsibility of
     witnesses to ensure this. You must provide me with, and ensure that you are
     yourself adequately and accurately briefed on matters that are likely to arise at the
     meeting. Either Committee may be asked for leave to supply information not within
     your immediate knowledge by means of a later note. If it is discovered
     subsequently that the evidence provided to the Committee has contained errors,
     these should be made known to the Committee and rectified at the earliest
     possible moment.


July 2009

				
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