NHS Grampian Assurance Board: terms of reference

Authority

The Assurance Board for the stage 4 escalation of NHS Grampian on the NHS Support and Intervention Framework for: financial sustainability and the deterioration of the Board’s financial position during 2024/25 and leadership and governance, is convened at the request of the Scottish Government Director General for Health and Social Care and Chief Executive of NHS Scotland, further to their letter of 12 May 2025 to the Chair and Chief Executive of NHS Grampian.

These terms of reference have been set by the Director General, further to consultation with the members of the Board.

Purpose and role of the Assurance Board

The purpose of the Board is:

• to support NHS Grampian in determining what steps are necessary to help mitigate the immediate concerns about the financial and operational pressures, and to stabilise the local system in NHS Grampian, and in doing so support robust basis for the wider local transformation work required over the longer term; in support of the new leadership
• to advise the Director General through agreed governance routes that such steps have been taken

In delivery of this, the Assurance Board will seek to:

• ensure appropriate governance is in place, particularly with regards to providing appropriate scrutiny of financial performance, leadership and governance
• scrutinise the NHS Grampian Improvement Plan and through assurance  meetings hold the leadership (i.e. NHS Grampian Executive Leadership Team and Chair of the NHS Grampian Board) to account for the effective delivery of these improvement actions and within the timescales agreed
• ensure that the leadership is operating in an effective manner, particularly when understanding and managing financial and performance issues in NHS Grampian
• consider the lessons learned that could be shared across NHS Scotland
• provide advice to the Director General about the future escalation status of NHS Grampian, including criteria for de-escalation

Background

Concerns have been raised in relation to a range of financial and performance related issues including the deterioration of NHS Grampians financial plans, Cardiology issues with Dr Gray’s Hospital, Unscheduled Care and the leadership for Medical Education. Whilst poor performance in any discrete area is of concern, effective governance and strong leadership is required to deliver sustainable change.

Stage 4 escalation came into effect from 12 May 2025, and brings direct formal oversight and coordinated engagement from Scottish Government (SG) in the form of the Assurance Board, chaired by Stephen Gallagher, Director of Mental Health.

Approach

As part of the standard sponsorship relationship, SG sets objectives and priorities for the NHS, signs delivery plans with each NHS Board, monitors performance, and supports Boards to ensure achievement of these key objectives.

The Assurance Board is carrying out this function solely in relation to NHS Grampians escalation for financial sustainability and the deterioration of the Board’s financial position during 2024/25 and leadership and governance. The Assurance Board will provide direct monitoring and support to NHS Grampian but the onus is on the NHS Board to commit to, and deliver on, improvement.

The Assurance Board will agree a programme of work in line with the purpose and role of the Assurance Board (section two). In doing so, it may establish sub-groups with necessary experts and other participants. The remit of the sub-groups will be set by the Chair of the Assurance Board, in consultation with Board members. The Board will receive reports and consider recommendations from the sub-groups.

In line with the NHS Scotland escalation process, NHS Grampian will work with the Assurance Board to develop an Improvement Plan and to take responsibility for delivery. The NHS Grampian Chief Executive as Accountable Officer continues to be responsible for matters of resource allocation connected to delivering actions agreed by the Assurance Board.

The Assurance Board works separately to the NHS Grampian Board and does not form part of internal governance structures within NHS Grampian.

The Assurance Board will ensure all work is conducted in a way that supports the values of Scottish Government and NHS Scotland.

The work of the Board will also be informed by engagement work undertaken with other stakeholder groups as required, in particular NHS Grampian staff, working in partnership with the Employee Director and Staffside.

The Board is focused on improvement. Board members, and sub-group members, will ensure a lessons-learned approach underpins their work in order that learning is captured and shared locally and nationally.

Meetings

The Board will meet fortnightly initially and will thereafter determine an appropriate schedule of meetings.

Secretariat support will be provided by officials from the Scottish Government Health & Social Care Directorates.

The circulation list for meeting details/agendas/papers/action notes will comprise Board members and relevant officials from the Health & Social Care Directorates..

The Chair and Chief Executive of NHS Grampian will also receive copies of the papers.

Regular reports will also be provided to the National Oversight for Performance and Planning Group (NPPOG).

Objectives, deliverables and milestones

The objectives for the Assurance Board are to:

• provide scrutiny and challenge to the NHS Grampian leadership team as they take forward action to improve financial management, leadership and governance at NHS Grampian

• to hold the leadership team of NHS Grampian to account for the development and delivery of an NHS Grampian Improvement Plan

Matters that are not related to the issues that gave rise to escalation are assumed not to be in scope, unless the work of the Board establishes a significant link to these issues.

In order to meet these objectives, the Board will retrospectively assess issues around the leadership and governance which have given rise to performance issues around financial management and the ability to effectively respond to persistent demand and pressures on local unscheduled and planned care.

Having identified these issues, they will develop and produce a gap analysis and work with NHS Grampian to seek assurance that they have already been resolved or that action is being taken to resolve them; compare systems, processes and governance with national standards; and make recommendations for improvement and how to share lessons learned across NHS Scotland.

The issues will be assessed with regards to the information available at the particular point in time and relevant standards that were extant at that point in time.

Consideration will also be given to any subsequent information or knowledge gained from further investigations and the lessons learned reported.

Governance

The Assurance Board will be chaired by Stephen Gallagher, Director of Mental Health, and will report to the Chief Operating Officer, NHS Scotland and Director General for Health & Social Care.

Full membership information can be found on the group page.

Members are not permitted to send deputies to the Assurance Board unless this is cleared by the Chair in advance of the meeting.

In addition to these members, the Chair may request the attendance of other attendees at meetings based on agenda items.

External support to NHS Grampian (as required)

SG External Support Team

KPMG will undertake an initial diagnostic programme on behalf of Scottish Government and report in July 2025.

Further support will be identified as necessary.

Purpose (for reference and development if required)

• lead and co-ordinate senior level external support to the Board
• work jointly with Scottish Government Directors, HIS, NES and other delivery partners to support the Grampian Senior Leadership Team to deliver the required improvements
• support and advise NHS Grampian in the development and delivery of a coordinated improvement plan across affected service areas which focusses on financial management, leadership and governance.
• support, advise and mentor the Executive Leadership Team (ELT) across the breadth of their portfolios in order to support delivery of the improvement plan.
• build relationships and develop an understanding of the current landscape of interactions between CEO, Chair and senior leadership team
• identify any gaps in the improvement plan and ensure these are addressed
• provide constructive and compassionate scrutiny, challenge and feedback to the NHS Grampian Senior Leadership Team and Chair
• feedback to NHS Grampian Senior Leadership Team and Chair with regard to progress
• report progress, concerns, assurance to the Assurance Board
• support the establishment of systems and processes to maintain and sustain improvements made through this overall approach

This will be achieved by:

• building relationships with:
  • medical and Nurse Directors and their teams in particular in terms of patient safety and quality of care
  • CEO and wider director team, Director of Finance in particular
  • other key stakeholders
• observational interventions
• specifically supporting and mentoring the Medical and Nurse Directors with regard to their portfolios, including quality of care and patient safety
• staff engagement, including staff side colleagues
• working closely with HIS QI expertise to support delivery of focussed improvement interventions
• a regular meeting structure of:
  • improvement support team meeting
  • meeting with CEO, Director of Finance, Medical and Nurse Directors (together and separately as required)

Reporting mechanisms

• weekly/fortnightly (as required) discussion with Assurance Board Chair
• fortnightly report to each Assurance Board meeting
• regular feedback to NHS Senior Leadership Team as required

Stakeholders

The Assurance Board recognises that a broad range of stakeholder groups have an interest in their work, and will seek to ensure their views are represented and considered.

In particular the Assurance Board will work with The Board, Senior Leadership and in partnership with staff of NHS Grampian, via the Employee Director and Staffside, as well as the Integrated Joint Boards and Local Authorities in the area of NHS Grampian.