Staff Governance

NHS Grampian

2003/04 Audit

Staff Governance

31 March 2004

Anne MacDonald CA – Senior Audit Manager

Audit Services Audit Scotland

Summerhill Education Centre

Stronsay Drive

Aberdeen AB15 6JA

Tel: 01224 346246

Fax: 01224 346247

Page

Executive Summary

Section 2

Action Plan

Section 3

Introduction

Section 4

Appendices

Executive Summary

Introduction

1.1Staff Governance introduced the third component of governance combining with financial and clinical governance to complete the governance framework within which NHS Boards and Special Health Boards are required to operate. Each Board has three standing committees covering these three critical areas. The Performance and Accountability Framework for NHS Scotland will ensure that Boards are equally accountable for how they behave as employers as well as their existing accountability for finance and clinical matters. Boards are expected to demonstrate that they are exemplar employers.

1.2The aim of the Standard is to improve the way staff are treated in NHS Scotland, to be clear on what staff should expect wherever they are in Scotland and to improve accountability for making this happen. This will be achieved by focusing on how staff are managed and how they feel they are managed. Staff across the whole of the country will be asked every two years in a systematic and professional way about how their employer runs their organisation and the quality of their working lives and environment.

1.3The NHS Reform (Scotland) Bill provides a legislative framework to enact the various commitments outlined in the White Paper, ‘Partnership for Care’. These commitments have recently been extended to make additional provision in the legislation for staff governance. Once the legislation is implemented, it is expected that NHS Boards will require to have arrangements in place to ensure compliance with the Staff Governance Standard.

Audit objectives

1.4With regard to the 2003/04 audit, the auditor had the following objectives in respect of staff governance :

• To validate and assess progress made against the action plan agreed at 31 March 2003.
• To confirm the robustness and credibility of the action plan agreed in March 2004 having ensured that the NHS body had considered progress made against the previous year, the self-assessment process and output from the staff survey.
• To provide assurance that in future the action plan is being delivered (year-on-year).
• To provide a summary status report of mandatory statistics collected by NHS Grampian and details for six data sets to enable benchmarking to be undertaken at a national level.

Audit approach

1.5Staff Governance has five key standards which employers are required to deliver, entitling staff to be:

• well informed
• appropriately trained
• involved in decisions which affect them
• treated fairly and consistently
• provided with an improved and safe working environment.

1.6Depending on each NHS Board’s progress with integration, these arrangements could be considered for each of the NHS bodies or for the NHS Board. With regard to Grampian, the action plan agreed at 31 March 2003 reflected planned activities at NHS Board level and therefore it was appropriate to continue on this basis in the current year.

1.7This review involved a series of four meetings with the Director of Human Resources, members of his management team and lead officers responsible for taking forward the five staff governance standards. As a result of these meetings, a range of evidence was identified for audit review which is considered in more detail in Section 4 of the report. In addition, one of the meetings was used to consider the results from the staff survey and arrangements were made for the collection of data with regard to the mandatory statistics.

Summary of Main Findings

Background

1.8On 1 April 2004, NHS Grampian will become a legal entity following the dissolution of the two Grampian NHS Trusts. It was helpful that an integrated Human Resources service was introduced with effect from 1 January 2003. However, the service has experienced a heavy agenda over the past 12 months in the transition towards single system working. In addition, many staff across Grampian have been heavily involved in the necessary preparatory work for the implementation of the Pay Modernisation Agenda (i.e. the new pay arrangements for medical consultants and general medical services i.e. general practitioners; and for non-medical staff through ‘Agenda for Change’). It is therefore important to take into account this backdrop of activity when considering NHS Grampian’s progress against the staff governance action plan.

Delivery of action plan agreed at 31 March 2003

1.9In total, 21 actions were agreed as part of last year’s plan. A summary of progress made by NHS Grampian against these actions is as follows:

• Number of planned actions completed (action achieved) – 11.5
• Number of actions partially achieved – 5.5
• Number of actions were work has been progressed but there is still much to be done to complete the task (Limited progress) – 4

1.10The main emphasis in NHS Grampian over 2003/04 has been the development of strategies, policies and frameworks across the spectrum of staff governance standards. In several cases, this involved the integration of documentation which has previously existed in the three NHS Grampian entities. While there has been clear action in the majority of cases, approximately half the actions have been completed with the remainder still in progress.

1.11At this stage, it is not possible to assess the impact of the above actions. The next stage is for NHS Grampian to implement the different strategies and policies across the organisation. Thereafter, it will be possible to give consideration to the impact of the new framework on the organisation.

Auditor Assessment

1.12Overall, good progress has been made but there is still much work to do to complete last year’s action plan. Thereafter, the many strategies and policies require to be implemented across the organisation. We are however pleased to note that these activities form the main focus of the action plan agreed in respect of 2004/05.

1.13Due to the nature of the work undertaken to date, it is too early to assess its impact. Once the different strategies and policies have been implemented and rolled out, their impact and an assessment of whether desired outcomes have been achieved will be clearer.

1.14The programme of work in 2003/04 has been led and co-ordinated by the Director of Human Resources and his team. This arrangement has been both appropriate and effective for the nature of work involved in developing strategies and policies. The next tranche of work however relates to the implementation of the frameworks which have been developed. This will require devolvement of responsibilities to managers across the new organisational structure. In addition, it will be those managers who will be required to demonstrate their success in implementing the various strategies and policies. It is therefore strongly recommended that these requirements are fully communicated to relevant staff at the outset so that appropriate mechanisms can be put in place for monitoring the staff governance action plan. In addition, managers should be reminded that the staff governance action plan links with the Performance Assessment Framework and forms part of the Scottish Executive Health Department Annual Accountability Review.

1.15This year’s self assessment provided an opportunity for the Human Resources Directorate and lead officers to re-consider the Self Assessment Audit Tool (SAAT). This ensured that work in progress from the previous year and the results from the staff survey could be incorporated in the assessment.

1.16We believe all the significant matters have been addressed in the updated action plan and note NHS Grampian’s commitment to a challenging plan of work for the next 12 months.

1.17Where available, the specified mandatory statistics have been produced in accordance with the Scottish Executive Health Department’s instructions. It should be noted that detailed information was only available in respect of 4 of the 6 requested mandatory statistics which will form the benchmarking exercise.

Action Plan

1.18The agreed action plan which forms Section 2 of the report is the combined outcome of:

• actions identified from the self-assessment process this year
• matters from last year’s action plan which have not yet been fully addressed

• the 2003 Staff Survey.

The main findings in Section 4 outline progress made during the year with appropriate cross references to the action plan in Section 2 where further work is required to implement actions. In addition, a progress report showing the organisation’s assessment of action taken during the year is included as Appendix 4.

Acknowledgements

1.19The contents of this report has been discussed with the Director of Human Resources of NHS Grampian to confirm factual accuracy.

1.20The assistance and co-operation afforded to us by all staff during the course of our audit is gratefully acknowledged.

Action Plan