POLICY FOR THE DEVELOPMENT
AND IMPLEMENTATION
OF PROCEDURAL DOCUMENTS
NO. RM08
Applies to:
All employees developing formal NHSLA
procedural documents, e.g. policies and
procedures
Date of Board Approval:
2 November 2011
Review Date:
31 October 2014
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Policy for the Development and Implementation of Procedural Documents - version 3.A
Policy for the Development and Implementation of Procedural
Documents
CONTENTS
Paragraph
1
4
6
7
9
13
22
25
29
37
40
41
42
43
44
45
46
Introduction
Statement of Intent
Definitions
Equality Impact Assessment
Good Corporate Citizen
Duties
Policy Register
Writing a New Procedural Document
Getting Procedural Documents Approved and
Implemented
Updating and Reviewing Procedural Documents
Local/Team Procedures
Stakeholders
Communication with Stakeholders
Process for Monitoring Effective Implementation
Support
Other Relevant Procedural Documents
References
Appendices
Appendix 1 Allocation of Unique Identifiers for Procedural
Documents
Appendix 2 Procedural Document Development Checklist
Appendix 3 Procedural Document Format
Appendix 4 Procedural Document Consultation and Approval
System
INTRODUCTION
1
Organisations need formal written documents which communicate
standard organisational ways of working. These help clarify strategic
and operational requirements and bring consistency to day to day
practice. In addition they can improve the quality of work and increase
the successful achievement of objectives.
2
A common format and approval structure for such documents helps to
reinforce corporate identity and, more importantly, helps to ensure that
policies and procedures in use are current and reflect an organisational
approach.
3
It also helps to avoid confusion and to assist employees in identifying
key issues within such a document.
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Policy for the Development and Implementation of Procedural Documents - version 3.A
STATEMENT OF INTENT
4
The Board is committed to ensuring that employees, other workers and
other stakeholders are fully aware of the NHSLA’s objectives and the
way employees must operate to achieve these objectives. The
“Policy for the Development and Implementation of Procedural
Documents” aims to define the standard approach to communicating
these requirements.
5
Other than as set out in paragraph 40, this document does not apply to
Local/Team Procedures.
DEFINITIONS
6
For the purposes of this policy, the term “procedural document” refers
to (and this policy applies to) the following document types:
Strategy: A detailed plan for achieving organisational success.
Policy: A statement of the Board’s agreed position and governing
principles relating to particular issues or situations.
Procedure: A set of actions which is the official or accepted way of
doing something. Reasons for deviation from the procedure should be
recorded. A Standing Operating Procedure (SOP) is a laid-down
procedure for doing something. Very often SOPs are written to
minimise health & safety risks. Senior management authority must be
obtained for any proposed deviation. SOPs are used to manage
financial matters.
Guidance: A document setting out a preferred method of operation.
Other methods are not prohibited but a reason for deviation from
guidance should be fully justifiable and line management agreement
sought in all cases of any doubt.
In general, strategy and policy define what an organisation wants to do
whilst procedure and guidance define how the organisation wants to do
it.
EQUALITY IMPACT ASSESSMENT
ALL PROCEDURAL DOCUMENTS
7
In line with the Public Sector Equality Duty, every procedural document
will be screened by the person responsible for its development, to
consider whether there is an equality dimension or whether any
adjustments are necessary to comply with the duty to promote equality
and diversity. This should involve consultation with stakeholders
appropriate to the aims of the individual document. The equality
screening process and any wider impact assessment should be
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Policy for the Development and Implementation of Procedural Documents - version 3.A
recorded within the document, using the heading “Equality Impact
Assessment”.
Policy on Procedural Documents
8
As part of its development, this policy and its impact on equality have
been reviewed in consultation with trade union and other employee
representatives in line with the Authority’s Equal Opportunities Policy
and the Public Sector Equality Duty. The purpose of the assessment is
to minimise and if possible remove any disproportionate impact on
employees and service users in relation to the protected
characteristics: race, sex, disability, age, sexual orientation, religious or
other belief, marriage and civil partnership, gender reassignment and
pregnancy and maternity. No detriment was identified.
GOOD CORPORATE CITIZEN
ALL PROCEDURAL DOCUMENTS
9
In line with the Authority’s Good Corporate Citizen Action Plan, all
procedural documents will be reviewed as part of the consultation
process in relation to their contribution to delivering the five principles
of the government’s sustainable development strategy:

Ensuring a strong, healthy and just society

Promoting good governance

Achieving a sustainable economy

Living within environmental limits

Using sound science responsibly
10
The results of the review, including any changes made to the document
as a result, will be recorded within the policy in a separate section
headed “Good Corporate Citizen”.
11
Whilst it is expected that procedural documents will usually be stored
and used in electronic format, areas of blank space should be
minimised within all documents in order to reduce any associated
printing costs.
POLICY ON PROCEDURAL DOCUMENTS
12
As part of its development, this policy was reviewed in line with the
Authority’s Good Corporate Citizen Action Plan. As a result, it is
expected that all procedural documents will undergo an appropriate
consultation.
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Policy for the Development and Implementation of Procedural Documents - version 3.A
DUTIES
Board
13
Responsible for approving all strategies and policies. Depending on
the nature of a procedural document, the Board may also be asked to
approve procedures. The Director responsible for a procedural
document will, on request, advise the manager responsible for
developing the document whether Board authorisation is required.
Committees
14
To consider and comment on relevant documents.
Director of Finance
15
Responsible for developing, proposing and implementing IT &
Facilities, Family Health Services Appeal Unit and Finance strategy,
policy, procedure and guidance.
Risk Management Director
16
Responsible for developing, proposing and implementing Risk
Management, Information Governance and Business Continuity
strategy, policy, procedure and guidance.
Director of Human Resources
17
Responsible for developing, proposing and implementing Human
Resources strategy, policy, procedure and guidance and leading on
consultation with employee representatives.
Technical Claims Director
18
Responsible for developing, proposing and implementing Claims
Management strategy, policy, procedure and guidance.
Line Managers
19
Responsible for contributing to the development of strategy, policy,
procedure and guidance, including following the consultation process
set out within this policy, as well as ensuring implementation,
monitoring and reporting of exceptions and adverse experiences to
those responsible for the document as appropriate.
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Policy for the Development and Implementation of Procedural Documents - version 3.A
Risk Management Team
20
Responsible for:

updating the Policy Register;

posting a copy of the approved document, and any related forms,
on the intranet;

where appropriate, posting a copy of the approved document on the
internet;

archiving an historical version of each document within the relevant
section of the intranet.
Employees and Other Workers
21
Responsible for contributing to the development of strategy, policy,
procedure and guidance as per the consultation process set out within
this document, as well as following all applicable policy, procedure and
guidance and reporting any adverse experience to their line manager.
POLICY REGISTER
22
All strategies, policies, procedures and guidance are recorded on a
Policy Register which is maintained and kept up to date by the Risk
Management Team. The Register is available to employees via the
intranet under file path Document Database > Policies and Procedures
and is also available to all external stakeholders via the website.
23
The manager responsible for each document will allocate a unique
identifier (Policy/Procedure No.) to each new document created. All
versions of documents on the same subject will keep the same unique
identifier, with a different version number being used for each update.
A list of the prefixes to be used as part of the unique identifier for all
documents is provided at Appendix 1.
24
The manager responsible for the procedural document will ensure that
the Risk Management Team is notified when the Board has approved a
document and a copy of the document, and separate version of any
related forms provided, to enable the Policy Register, intranet and
internet to be updated. The Risk Management Team must also be
advised where a document has not been renewed, has been
withdrawn, or has been merged with another document.
WRITING A NEW PROCEDURAL DOCUMENT
25
A strategy is a detailed plan for achieving organisational success and is
therefore devised dependant upon intent. Policies, procedures and
guidance should communicate standard organisational ways of working
in line with organisational objectives, relevant legislation (which should
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Policy for the Development and Implementation of Procedural Documents - version 3.A
be referenced) and requirements. New and revised documents should
be checked for conflict with those already in existence before approval
and implementation.
26
An optional Procedural Document Development Checklist is provided
at Appendix 2 to assist those responsible for the development of all
new and revised strategies, policies and organisation wide procedures
which should be written using the template format at Appendix 3.
Headers and footers should be populated appropriately with each
version change. Document main body text should be at least size 12
“Arial” font and in a style which is concise and clear, using
unambiguous terms and language. Abbreviations should only be used
after they have been fully clarified. Where appropriate, associated
documentation should be available within appendices.
27
No specific format is stipulated for guidance or local/team protocols but
the format chosen should be appropriate to the subject matter and the
intended audience.
28
Within all documentation produced, areas of blank space should be
minimised in order to reduce any associated printing costs.
GETTING PROCEDURAL DOCUMENTS APPROVED AND IMPLEMENTED
CONSULTATION PROCESS:
Whom to Consult
29
Draft procedural documents should be shared widely to ensure that
they are complete, correct and acceptable. Comments generated from
this consultation should be considered by the manager responsible for
developing the policy.
30
Where Board approval is required, consultation will take place as
outlined within the Procedural Document Consultation and Approval
System set out at Appendix 4.
Board Consultation
31
Normally, draft and revised documents will initially be circulated to the
Board and other directors for comment, for 30 calendar days before the
consultation with employee representatives begins. Once the
consultation process has finished, draft documents will be submitted to
the Board for final approval, prior to implementation.
Employee Consultation
32
As part of the Authority’s commitment to employee involvement and the
partnership agreement with Unison, draft and revised documents which
have an impact on employees and their working lives (not just HR
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Policy for the Development and Implementation of Procedural Documents - version 3.A
documents) are subject to consultation with the Joint Negotiating
Committee (JNC) for 30 calendar days.
33
The Director of Human Resources will, on request, advise the manager
responsible for developing a document whether consultation with
employee representatives should be conducted.
Committee Consultation
34
Where there is a relevant committee, draft documents should be
presented to the committee for review, in line with The Procedural
Document Consultation and Approval System at Appendix 4.
Committee members are required to ensure that full strategic
consideration of the document’s implications and requirements has
been carried out and to report any concerns to the Director or manager
responsible for development of the document, who will agree any
changes with the Committee.
APPROVAL PROCESS:
35
Once the Committee and employees consultation stage is over, the
Board is required to approve the procedural document before it is
adopted for use. The Board will consider the document proposed and
approve it or recommend changes as appropriate.
IMPLEMENTATION PROCESS:
36
On final Board approval of the procedural document, the manager
proposing the document is then responsible for its implementation.
This includes the following:

providing a copy of the approved document, and any related forms,
to the Risk Management Team;

informing employees of the new/updated document by e-mail,
including a brief summary of the document's purpose and any major
changes;

where appropriate, ensuring that roll out of the document to
employees is undertaken;

ensuring that review of each document occurs prior to the review
date assigned to the document.
UPDATING AND REVIEWING PROCEDURAL DOCUMENTS
37
All procedural documents will be dated using the date of Board
approval, or other suitable date where a document did not require
Board approval.
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38
A review date, to be determined by the Director responsible for the
document but no more than three years from the date of approval, will
also be included. The relevant Director will ensure that a review of the
document is carried out in the event of a change in circumstances or
immediately prior to the expiry date.
39
To assist those considering revisions to existing documents, changes
should be highlighted in some way e.g. by use of track changes.
LOCAL/TEAM PROCEDURES
40
Managers are responsible for the development, maintenance and
implementation of procedures specific to their area. As a minimum,
such procedures should be:
 Developed in consultation with team members
 Brought to the attention of all team members and others who
may be affected by the procedure e.g. another team
 Supported by training, if necessary
 Given a clear title (and possibly a unique identifier)
 Dated, including a review date
 Recorded on a list which is kept up to date, including those
procedures which have lapsed or been replaced or withdrawn,
and posted on the intranet
 Posted on the intranet
 Archived on the intranet
STAKEHOLDERS
41
Key stakeholders, to be considered in document development and
communication, include:
 employees
 trade unions
 contractors: panel solicitors, risk management contractors,
actuaries, etc
 Department of Health
 member NHS trusts, NHS foundation trusts and primary care
trusts and other NHS organisations, including strategic and
special health authorities
 independent sector providers of NHS care when covered by the
NHSLA
 FHSAU panel members
 public (including claimants and their representatives)
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COMMUNICATION WITH STAKEHOLDERS
42
It is important that systems of communication are in place with
stakeholders. These include:
 the intranet, upon which strategies, policies, procedures and
guidance are available to employees;
 the website: www.nhsla.com available to the public via the
internet, where news and a variety of corporate documents can
be found, including the Policy Register and all procedural
documents listed therein.
PROCESS FOR MONITORING EFFECTIVE IMPLEMENTATION
43
The effective implementation of this Policy will be monitored by the
Board and relevant committees, on review of the procedural documents
developed in line with the Policy. Furthermore, the effective
implementation of this Policy will be monitored via the Staff Survey,
relevant forum discussions upon the intranet and other methods such
as incident reports and internal audit.
SUPPORT
44
Those responsible for developing and maintaining procedural
documents may request advice from the Risk Management Team
should they require support with the implementation of this policy.
OTHER RELEVANT PROCEDURAL DOCUMENTS
45
HR01 – Equal Opportunities Policy
RM01 – Risk Management Strategy
RM02 – Information Governance Strategy
REFERENCES
46

Guidelines at the NHS Identity Website: http://www.nhsidentity.nhs.uk

Promoting Equality and Human Rights in the NHS – Guide for NonExecutive Directors of NHS Boards (2005) Department of Health

The Plain English Campaign: http://www.plainenglish.co.uk
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Appendix 1
Allocation of Unique Identifiers for Procedural Documents
Each procedural document will be given a unique identifier. The first figures
will be letters determined by the subject of the document, in accordance with
the list below, followed by the next available sequential number for such
documents starting with 01, e.g. RM08.
Prefix
CP
FH
FP
HR
ITFA
RM
Document subject
Claims
Family Health Services Appeals Unit
Finance
Human Resources
Information Technology & Facilities,
including Health & Safety
Risk Management
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Appendix 2
Procedural Document Development Checklist (optional)
1.
Developed using the style and format of the approved template
2.
Where existing documents are being revised, changes should be
highlighted in some way
3.
Definitions of terms used are provided
4.
Clearly and concisely written
5.
Relevant duties of directors, managers, employees and other workers
described
6.
Relevant duties of the Board and committees described
7.
Equality Impact Assessment completed if screening deemed applicable
8.
Good Corporate Citizen review carried out
9.
Other linked policies or information sources as references are included
10. Process for monitoring implementation and effectiveness described
11. Submitted to relevant committee for comment, if applicable
12. 30 calendar days of Board consultation when initial draft completed
13. After initial Board consultation, 30 calendar days of employee
consultation completed
14. After employee consultation, committee consultation completed if
required
15. Board approval sought
16. Reviewed by the review date assigned
17. Approved copy forwarded to the Risk Management Team to enable
update the Policy Register to be updated and for display on the intranet
and internet (if appropriate), with request to archive the historical copy
within the relevant section of the intranet
18. Employees informed of new/updated document, supported by roll out
where appropriate
Checklist completed by:
Name:
Title:
Date:
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Appendix 3
Procedural Document Format
(this style is recommended, but as a minimum the document produced
should usually contain the headings described throughout this
template)
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PROCEDURAL DOCUMENT NAME
NO.___
(please refer to the NHSLA Policy and Procedure Register to identify a new
procedural document number)
………
Applies to:
…………….
Date of Board Approval:
………………….
Review Date:
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Procedural Document Name
CONTENTS
Paragraph
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Introduction – including an outline of the procedural
document, its scope and statement of intent, any
relevant legislative and organisational requirements
Equality impact assessment
Good corporate citizen
Definitions
Duties (responsibilities)
Procedure
Training/Support
Other relevant procedural documents
References (as evidence base)
Appendices
Appendix 1
Appendix 2
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Appendix 4
Procedural Document Consultation and Approval System
New or revised document drafted
Draft document circulated by
email to relevant committee
members for comment within
14 calendar days, other than
for new documents or
significant changes to existing
documents which should be
discussed at a meeting
No relevant
committee,
e.g. HR
document
Draft document
circulated by email to
Board members and
directors for comment
within 14 calendar days
Draft document circulated to Joint Negotiating
Committee for comment within 30 calendar days
If significant change, draft
document re-submitted to
relevant committee
Draft document submitted to Board for approval:
a) by email within 14 calendar days for updates to existing
documents with minimal changes
b) at meetings for new documents and significant updates to
existing documents
Minor changes to current procedural documents e.g. to reflect changes within
the NHSLA or the introduction of new national guidance or laws, which will
have no impact on employees and their working lives, may be approved by
the Strategic Management Team.
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