The Scottish Government

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Staff Governance Standard for NHSScotland employees

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Foreword

We are delighted to see the launch of the Staff Governance Standard for NHSScotland. It rightly puts a spotlight on how staff are managed and feel they are managed in the largest employer in Scotland.

For the first time staff across the whole of the country will be asked in a systematic and professional way about how their employer runs their organisation and the quality of their working lives and environment. The results will be shared publicly and looked at locally and nationally to help improve the way NHSScotland works. Progress will be tracked by following the changing views of staff over the years to come.

Each part of the Standard has been developed jointly by managers and trade unions/professional organisations working together. The same will apply to the process of evaluating the results and deciding what needs to happen as a result.

Our hope is that as many staff as possible take this chance to have their say and help shape the way forward in NHSScotland.

MARK BUTLER Joint Chair	MICHAEL FULLER Joint Chair
Scottish Partnership Forum	Scottish Partnership Forum

Contents

Introduction
Strategic Framework
Definition of Staff Governance
Definition of Standards
Evidence
Roles and Responsibilities

Introduction

The Scottish Health Plan Our National Health: a plan for action, a plan for change sets out a number of challenges for the service and in particular new NHS Boards. One of the key challenges was the establishment of a Staff Governance Standard for NHSScotland employees.

Following the principles of Our National Health:

Staff Governance introduces 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 will be expected to have three standing committees covering these three critical areas. The new Performance and Accountability Framework for NHSScotland will, for the first time, ensure that Boards are equally accountable for how they behave as employers (or as a family of employers) as well as their existing accountability for finance and clinical matters. Boards will be expected to demonstrate that they are exemplar employers.

Strategic Framework

Towards a New Way of Working, the Human Resources Strategy for the NHS in Scotland, which was launched in 1998, required a fundamental change in culture within the NHS and placed the concept of partnership working at the heart of how employment issues should be dealt with within the service. The introduction of a Staff Governance Standard requires consideration of progress made in delivering the staff management agenda set out in the Strategy.

A number of policies and agreements have since been agreed and organisations are expected to implement these:

Implicit in the implementation of the Staff Governance Standard is that all legal obligations are met.

As well as the implementation of existing policies and agreements organisations are asked to continuously improve in relation to the fair and effective management of staff and the definitions provided within this standard document. Measurement of success will be carried out locally but results will be submitted to the Scottish Executive Health Department under the new Performance Assessment Framework.

The Performance Assessment Framework will include the five standards which form the Staff Governance Standard. Each standard will be assessed in relation to policy, targets and organisation effectiveness. No one form of measurement will be utilised and there is flexibility for local health systems to agree and set their own priorities. Therefore, information will be submitted within this framework in the following way:

This process is reflected here

Given this, Staff Governance is part of a wider evolutionary process which can, and should, be viewed in the wider context in terms of responsibilities of the individual and the team within an organisation. The Standard definitions and evidence collected should be reviewed on an annual basis to take account of the evolutionary nature of staff governance and the differences between organisations. The Standard should also be set in the context of existing audits carried out by the Clinical Standards Board, CNORIS, Scottish Health Advisory Service and Audit Scotland.

The Staff Governance Standard sets out the minimum standard which must be achieved by each NHSScotland employer in the management of staff.

Definition of Staff Governance

Staff Governance is a system of corporate accountability for the fair and effective management of all staff.

The public values NHS staff, and the NHS must do the same. Staff Governance underpins the cultural change initiated with the national Human Resources Strategy which asks employers to recognise that investment in staff must be viewed as a direct investment in patient care. Staff Governance has five key standards which employers will be required to deliver, entitling staff to be:

Definition of Standards

Well informed

Appropriately trained

Involved in decisions which affect them

Treated fairly and consistently

Provided with an improved and safe working environment

Evidence

Evidence to measure success against the standard will be provided in three ways, the self- assessment audit tool will be completed and will provide the qualitative information required to measure against policy. Statistical returns, some of which are currently required, will provide the quantitive information required to measure progress towards targets and finally a staff survey will be conducted to gauge organisation effectiveness against the full standard.

As a minimum the tools provided will measure the following:

Well informed

Appropriately trained

Involved in decisions which affect them

Treated fairly and consistently

Provided with an improved and safe working environment

Roles and Responsibilities

NHS Board

Responsibility and accountability for performance against the Staff Governance Standard addressing the issues of policy, targets and organisational effectiveness will lie ultimately with the NHS Board. Boards will be expected to demonstrate achievement and progress towards the standard through:

This information will form part of the submission of the Board required for the Performance Assessment Framework which will inform regular discussions between the Health Department and NHS Boards in relation to their performance.

Staff Governance Committees will be established as standing committees of the NHS Board which, together with the Clinical Governance Committee and Audit Committee, will form the full governance arrangements for NHS Boards.

As a minimum the Staff Governance Committee will comprise of the Chair from each of the NHS employers within the Board area and the Employee Director. Membership of the Staff Governance Committee thereafter will be decided locally to meet the needs of the NHS Board.

Staff Governance Committee

The remit of the Staff Governance Committee is to support the creation of a culture within the health system, where, the delivery of the highest standard possible of staff management is understood to be the responsibility of everyone working within the system and is built upon partnership and collaboration. The Staff Governance Committee will require to introduce structures and processes which assure that this is happening.

Much of the monitoring and evaluation at this level will be done through the approval of strategies and implementation plans. This committee will support any policy amendment, funding/resource submission to achieve the Staff Governance Standard.

The committee will be responsible for the timely submission of all the data required as part of the Performance and Accountability Framework.

The Staff Governance Committee should establish a Remuneration Sub-Committee which will consider remuneration of the Executive Directors within the NHS Board area.

The Remuneration Sub-Committee may also consider the remuneration of staff employed under executive and senior manager pay arrangements where appropriate. Where this is not the case component organisations should put in place appropriate arrangements agreed with the Remuneration Sub-Committee to fulfil this responsibility.

Membership of the Remuneration Sub-Committee should comprise of the Chair of each component organisation and one further Board Non-Executive Director who will also receive appropriate training. It is a local decision whether this could appropriately be the Employee Director.

These arrangements also apply to Special Health Boards.

Local Partnership Forum

Local Partnership Forums are required to undertake a self-assessment audit to assess performance against the Staff Governance Standard. The audit report will form part of the return to the Scottish Executive Health Department under the Performance Assessment Framework.

From the audit report a Human Resources Strategy and Organisation Development Strategy should be produced at organisation level which will be submitted to the Area Partnership Forum for consideration together with nationally agreed initiatives in the development of the Local Health Plan.

To assess organisation effectiveness and the impact of this on staff a staff survey will be carried out. The Local Partnership Forum will play a key role in the promotion of the survey, the administration of questionnaires and feedback of results to staff. The Local Partnership Forum will work with local managers and staff to produce action plans in light of survey results. Action plans and summaries of survey results will be submitted to the Area Partnership Forum where a system of measurement for continuous improvement between surveys will be agreed. All of this information will be subject to approval of the Staff Governance Committee.

Area Partnership Forum

The Area Partnership forum within the NHS Board area will take an overview of local organisations and assure that best practice is shared across the area. It will also be a role of the Area Partnership Forum to recognise where a joint health system approach would be of optimum benefit. Policy development across the health system to support staff governance will also be carried out by the Area Partnership Forum.

Action plans, human resource strategies, organisation development strategies produced locally will be considered by the Area Partnership Forum together with the wider issues across the health system for inclusion in the Local Health Plan.

Likewise the results of the staff survey and action plans will be shared with the Area Partnership Forum which will be responsible for putting in place any interim measurement and monitoring arrangements required between surveys.

It should be noted that the Area Partnership Forum will be involved in issues beyond human resources.

The Area Partnership Forum will contribute to the development of the local health plan and assess the impact of decisions upon the staff governance agenda feeding in solutions/proposals as necessary.

The Area Partnership Forum will liaise with the Scottish Partnership Forum providing reports on progress within their area. This flow of information will be two way and the Scottish Partnership Forum will consult with the Area Partnership Forums on any proposals for policy development they are considering and any problems highlighted from statistical returns that require local attention or explanation.

Scottish Partnership Forum/Audit Scotland

Audit Scotland have recently issued Managing People in the NHS in Scotland which externally audits many areas of the Human Resources and Staff Governance agenda. To avoid any unnecessary duplication the Scottish Partnership Forum is in discussion with Audit Scotland exploring the possibility of external evaluation through visits in partnership.

Links between the Area Partnership Forums and the Scottish Partnership Forum will be strengthened to allow for any difficulties/problems that are unable to be resolved at local level to obtain support. This will provide the Scottish Partnership Forum with much of the information to support its agenda in formulation of policy and strategic direction to support the service in achieving national goals.

Staff Governance Standard Working Group

Chairman
Jonathan Best, Chief Executive, Yorkhill Hospital NHS Trust,

SecretaryCaroline Hutchinson, SEHD

Members

Alan Boyter, Director of Human Resources, North Glasgow University Hospitals NHS Trust
Ian Reid, Director of Human Resources, Greater Glasgow Primary Care NHS Trust
Patricia Leiser, Director of Human Resources, Lothian Primary Care NHS Trust
Alex Killick, Director of Human Resources, Tayside Primary Care NHS Trust
Anne Gent, Director of Development, Highland Primary Care NHS Trust
Elizabeth Stow, Society of Radiographers
Michael Fuller, MSF
Billy Parker, AEEU
John Gallacher, UNISON
Anne Thomson, RCN
Gillian Lenaghan, RCM
Paul Martin, Director of Nursing, Renfrewshire and Inverclyde Primary Care NHS Trust
Annie Ingram, Clinical Group Manager, Tayside University Hospitals NHS Trust
Elaine McCrae, General Manager, Intermediate and Rehabilitation Care, Forth Valley Acute Hospitals NHS Trust
Lynne Khindria, SEHD
Janet McGregor, SEHD
George McLachlan, SEHD