Improvement focused governance: guidance for non-executive directors

Resource booklet for NHSScotland board members with an interest in improvement governance.

Annex A - NHSScotland Governance Guidance

Clinical and Care Governance

1. Clinical and care governance is the process by which accountability for the quality of health and social care is monitored and assured. It should create a culture where delivery of the highest quality of care and support is understood to be the responsibility of everyone working in the organisation - built upon partnership and collaboration within teams and between health and social care professionals and managers.

2. It is the way by which structures and processes assure Integration Joint Boards, Health Boards and local authorities that this is happening - whilst at the same time empowering clinical and care staff to contribute to the improvement of quality - making sure that there is a strong voice of the people and communities who use services.

3. Clinical and care governance should have a high profile, to ensure that quality of care is given the highest priority at every level within integrated services. Effective clinical and care governance will provide assurance to patients, service users, clinical and care staff and managers, Directors alike that:

  • Quality of care, effectiveness and efficiency drives decision making about the planning, provision, organisation and management of services;
  • The planning and delivery of services take full account of the perspective of patients and service users;
  • Unacceptable clinical and care practice will be detected and addressed.

4. Effective clinical and care governance is not the sum of all these activities; rather it is the means by which these activities are brought together into this structured framework and linked to the corporate agenda of Integration Authorities, NHS Boards and local authorities.

5. A key purpose of clinical and care governance is to support staff in continuously improving the quality and safety of care. However, it will also ensure that wherever possible poor performance is identified and addressed. All health and social care professionals will remain accountable for their individual clinical and care decisions.

6. Many clinical and care governance issues will relate to the organisation and management of services rather than to individual clinical decisions. All aspects of the work of Integration Authorities, Health Boards and local authorities should be driven by and designed to support efforts to deliver the best possible quality of health and social care. Clinical and care governance, however, is principally concerned with those activities which directly affect the care, treatment and support people receive.

Clinical and Care Governance Framework

NHS HDL (2001) 74 Clinical Governance Arrangements.
Scottish Executive

NHS MEL (2000) 29 Clinical Governance.
Scottish Executive

NHS MEL (1998)75 Clinical Governance
Scottish Executive

Staff Governance

Staff Governance Standard

Staff Governance focuses on how NHSScotland staff are managed and feels they are being managed. It is implemented through the Staff Governance Standard which is the key policy document and is enshrined in legislation as part of the NHS Reform (Scotland) Act 2004. The Staff Governance Standard sets out what staff can expect from their Boards and the corresponding responsibilities for all staff. These responsibilities relate to all stakeholders including colleagues, managers, staff, patients, their carers, the public, the Board. These responsibilities are evidenced through implementation of the Standard.

The Standard requires all NHSScotland Boards to demonstrate that staff are:

  • well informed;
  • appropriately trained and developed;
  • involved in decisions;
  • treated fairly and consistently, with dignity and respect, in an environment where diversity is valued; and
  • provided with a continuously improving and safe working environment, promoting the health and wellbeing of staff, patients and the wider community.

More information about Staff Governance in NHSScotland can be found at

Staff Governance Committee

Each Board's Staff Governance Committee acts as a guardian of the Staff Governance Standard on behalf of the Board's Partnership Forum. The Staff Governance Committee will ensure that arrangements are in place to ensure delivery of the Staff Governance Standard. Each element of the Framework will be assessed in relation to policy, targets and organisational effectiveness, with measurement of organisational success against the elements of the Framework being carried out locally.

Partnership Forums will be directly involved in assessing the performance of NHS Boards as employers through the use of the nationally agreed staff experience and staff governance monitoring arrangements. The assessment will not rely on a single form of measurement, and local health systems will have the flexibility to agree and set their own priorities.

Staff Governance Committee Responsibilities

  • oversee the commissioning of structures and processes which ensure that delivery against the Standard is being achieved;
  • monitor and evaluate strategies and implementation plans relating to people management;
  • approve any policy amendment, funding or resource submission to achieve the Staff Governance Standard;
  • take responsibility for the timely submission of all staff governance information required for national monitoring arrangements;
  • provide staff governance information for the statement of internal control;
  • provide assurance that systems and procedures are in place through the local Remuneration Committee* to manage senior manager pay as set out in MEL (1993) 114 (amended).

The Scottish Workforce and Staff Governance Committee ( SWAG)

Nationally, Scottish Workforce and Staff Governance Committee ( SWAG) supports the Scottish Government Health and Social Care Directorates in the development and implementation of employment policy and practice for NHSScotland. SWAG will therefore review each Board's performance against the Staff Governance Framework Scottish Workforce and Staff Governance Committee ( SWAG) as guardians of the Staff Governance Standard, on behalf of the Scottish Partnership Forum ( SPF).

Information Governance

This committee should consider the performance and improvement actions required to ensure that the NHSScotland Information Security Policy is reliably implemented. Details of this and related guidance can be found at

Educational Governance

Education and training of healthcare staff is an essential responsibility of health boards, Integrated Joint Boards and other providers of health and social care. Effective education ensures the future supply of well-trained professionals and underpins safe and effective services. Healthcare professionals in training also form an important part of the health and social care workforce, providing a range of vital services. The importance of high quality education and training in healthcare is reflected in the regulation, scrutiny and approval processes to which it is subject.

Given the pivotal importance of education, and the significant investment in education and training made by health and care providers, there is a strong imperative to ensure that is subject to effective governance. This is to ensure that organisations are accountable for aligning their educational activities with strategic and operational priorities, and that educational quality is maintained and continuously improved.

Educational Governance is an essential feature of an integrated system of governance that links together clinical and care governance, staff governance, research governance, audit, risk management and other board duties. This responsibility may be discharged through a discrete, board level Educational Governance Committee or, more usually, by ensuring that responsibilities for educational governance are explicitly delegated by the Board to relevant committees. Clinical & Care Governance and Staff Governance Committees each have a clear locus in education and training.

Boards and other healthcare organisations have a specific remit for ensuring that standards for education and training set by statutory regulators are met. Some regulatory bodies, including the General Medical Council, have a clear standard and a requirement that educational governance should be discussed and visible at board level, and that a named member of the board should be responsible for educational governance. This helps to ensure that the learning environment is of a high and improving standard, that trainees respond positively to their programmes, and that patient care and safety is not compromised.

The specific responsibilities of the Board and its committees in relation to Educational Governance include:

  • approving and monitoring an educational strategy that supports organisational priorities and quality improvement;
  • applying effective scrutiny of educational quality to ensure that regulatory and other standards are being met;
  • approving and monitoring the structures and processes for managing educational quality; and
  • ensuring compliance with statutory and mandatory training requirements.

NHS Education for Scotland ( NES) has a leading role in Educational Governance within NHSScotland. NES's own Educational Governance Framework can be found at:

Research Governance

Research is a core function of health and social care. It is essential for our health and wellbeing and for the care we receive. Research should improve the evidence base, reduce uncertainties and lead to improvements in future care. The current Research Governance framework can be found at: Scottish Executive Research Governance Framework for Health and Community Care.

At the time of publication, this document is currently being updated and a harmonised UK policy document is being produced. A copy of the consultation document is available at:

The UK policy framework for health and social care research sets out principles of good practice in the management and conduct of health and social care research that take account of legal requirements and other standards. These principles protect and promote the interests of patients, service users and the public in health and social care research, by describing ethical conduct and proportionate, assurance-based management of health and social care research, so as to support and facilitate high-quality research in the UK that has the confidence of patients, service users and the public.

Audit Committees

Good practice in relation to corporate governance requires that effective arrangements are in place to provide assurance on risk management, governance and internal control. In this respect, the Board should be independently advised by the Audit Committee.

The Audit Committee is required to provide assurance to the Board and Accountable Officer that appropriate systems of control are designed and operated within all areas of the health board so as to ensure:

  • the good stewardship of funds under control of the Board and, in particular, the safeguarding and proper accounting of public money;
  • that activities are conducted in accordance with all applicable laws, regulations and standards;
  • that financial statements are prepared in a timeous manner and reflect a true and fair view of the Board's financial position;
  • the economic, efficient and effective use of all resources; and
  • that reasonable steps and measures are taken to allow for the prevention and detection of fraud and/or any other irregularities.

The activities of the Audit Committee will include:

  • assisting in discharging the Board's responsibilities as they relate to management and internal controls, accounting policies and financial reporting;
  • the receipt of reports from the external auditors of the Board and the pursuit, where necessary, of any such issues arising from these reports;
  • the agreement of work programmes and remits of internal audit so as to satisfactorily discharge the committee's responsibility in ensuring systems of control; and
  • the receipt of any reports arising from executive management, external or internal audit - outwith the agreed programme - and ensuring that appropriate action is taken to introduce any remedial actions as are deemed necessary.

The key relevant documentation is set out below:

Scottish Public Finance Manual - guidance on the operation of audit committees

Audit Committee Handbook
Scottish Government, published July 2008

On Board - A guide for Board Members of Public Bodies in Scotland


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