Appendix one – provider licence compliance
The provider licence is split into six sections, which apply to different types of providers.
- General conditions (G) – general requirements applying to all licensed providers.
- Obligations about pricing (F) – obliges providers to record pricing information, check data for accuracy and, where required, charge commissioners in line with tariff. Applies to all licensed providers who provide services covered by national tariff.
- Obligations around choice and competition (C) – obliges providers to help patients make the right choice of provider, where appropriate, and prohibits anticompetitive behaviour where against patients’ interests. This applies to all licensed providers.
- Obligations to enable integrated care (IC) – enables the provision of integrated services and applies to all licensed providers.
- Conditions to support continuity of service (CoS) – allows NHS Improvement to assess whether there is a risk to services and to set out how services will be protected if a provider gets into financial difficulty. Applies to providers of commissioner requested services (CRS) only.
- Governance licence conditions for Foundation Trusts (FT) – provides obligations for Foundation Trusts around appropriate standards of governance. Applies to Foundation Trusts only.
Section one – general conditions
Licence provision
The Licensee shall furnish to NHSI such information and documents and shall prepare or procure and furnish to NHSI such reports, as NHSI may require.
Executive sponsor
Chief Strategy and Improvement Officer.
Compliance statement
The Trust has provided and published information during 2022/23 in line with the requirements of NHS Improvement/England (NHSI/E) and is therefore compliant with this licence condition.
Licence provision
The Licensee shall publish information about health care services provided for the purpose of the NHS and as to the manner in which such information should be published.
Executive sponsor
Chief Strategy and Improvement Officer.
Compliance statement
The Trust has provided and published information during 2022/23 in line with the requirements of NHS Improvement/England (NHSI/E) and is therefore compliant with this licence condition.
Licence provision
The Regulator is able to charge fees in relation to its Licensing function and for the maintenance of the Foundation Trust Register.
Executive sponsor
Interim Chief Finance Officer.
Compliance statement
Not applicable at the time of reporting.
Licence provision
This Condition requires that Licensees do not allow unfit persons to become or continue as Governors or Directors.
Executive sponsor
Chief Strategy and Improvement Officer.
Compliance statement
The Trust can confirm compliance with the fit and proper persons requirements for all members of the Board of Directors and Council of Governors.
Licence provision
The Licensee shall at all times have regard to guidance issued by NHSI.
Executive sponsor
Chief Strategy and Improvement Officer
Compliance statement
The Trust has had regard for guidance issued by NHSI/E and responds appropriately. Executives have responsibility to review guidance relating to their areas of responsibility and bring any matter to the attention of the other Executives and Board, and to Board Committees as appropriate.
Licence provision
The Licensee shall have systems and processes in place to ensure compliance with licence conditions and related obligations.
Executive sponsor
Chief Strategy and Improvement Officer.
Compliance statement
Confirmation of compliance with the provider licence is reported through to the Board as part of the year-end reporting requirements. A compliance schedule for the Provider Licence is maintained and reported to the Board to provide assurance to support the declaration of compliance.
Licence provision
This licence condition requires providers to be registered with the CQC.
Executive sponsor
Chief Strategy and Improvement Officer.
Compliance statement
The Trust holds a CQC registration.
Licence provision
This condition requires licence holders to set transparent eligibility and selection criteria for patients, and to apply these in a transparent manner.
Executive sponsor
Chief Operating Officer.
Compliance statement
The Trust’s website provides a service directorate for each service provided by the Trust. The Trust’s Waiting Times and Patient Access to Services Policy complies with NHSI/E guidance and best practice, and is published on the Trust’s website.
Licence provision
This Condition applies to Licensees where they provide ‘Commissioner Requested Services’. Licensees are required to notify the Regulator at least 28 days prior to the expiry of a contractual obligation if no renewal or extension has been agreed. Licensees are required to continue to provide the service on expiry of the contract until the Regulator issues a direction to continue service provision for a specified period or is advised otherwise by the Regulator.
Executive sponsor
Interim Chief Finance Officer.
Compliance statement
Contract performance is reported through the Trust Performance Report on a monthly basis to the Finance and Performance Committee and also to the Board of Directors. The outcome of discussions with commissioners to develop contracts, associated risks and financial implications are also reported to the Finance and Performance Committee.
The Finance Assurance Framework highlights the specific requirement to notify NHSE should a contract renewal or extension not be agreed. All contract variations (including the cessation of a service) require formal internal sign off through the Trust’s governance processes. Additionally, they are reported monthly through the Finance and Investment Group. The Trust holds a live contract register which includes all current contracts with expiry dates.
Section two – pricing
Licence provision
The Licensee shall obtain, record and maintain sufficient information about the costs which it expends in the course of providing services.
Executive sponsor
Interim Chief Finance Officer.
Compliance statement
The Trust has appropriate costing systems in place which adheres to national costing guidance (subject to national audit). PLICs continues to be implemented in accordance with regulatory timetables.
Licence provision
Having recorded the information in line with pricing condition 1 above, licensees can then be required to submit this information to NHSI.
Executive sponsor
Interim Chief Finance Officer.
Compliance statement
Annual recommendation of pricing framework is reported to the Board’s Finance and Performance Committee. Compliance with Standing Financial Instructions sets out detail of pricing contracts with commissioners.
Licence provision
This condition allows NHSI to oblige licensees to submit an assurance report confirming that the information that they have provided is accurate.
Executive sponsor
Interim Chief Finance Officer.
Compliance statement
The Trust provides assurance reports through submission to NHSI/E as required. Submissions of Monitoring Reports are aligned to Board reporting and therefore all submissions such as these and planning documents are scrutinised and approved at Board level.
Licence provision
This licence condition imposes an obligation on licensees to charge for NHS health care services in line with the National Tariff.
Executive sponsor
Interim Chief Finance Officer.
Compliance statement
There is at present no national tariff for our services. The Trust has responded to proposed steps to impose a national tariff for mental health and ensure compliance.
Licence provision
The Act allows for local modifications to prices. This licence condition requires licence holders to engage constructively with commissioners, and try to reach agreement locally before applying to NHSI for a modification.
Executive sponsor
Interim Chief Finance Officer.
Compliance statement
There is at present no national tariff for our services. The Trust has responded to proposed steps to impose a national tariff for mental health and ensure compliance.
Section three – choice and competition
Licence provision
The Licensee shall ensure that at every point a patient has a choice of provider under the NHS Constitution or a choice of provider conferred locally by Commissioner.
Executive sponsor
Chief Operating Officer.
Compliance statement
The Trust has in place a service directory setting out the services available. Commissioners monitor the Trust’s compliance with the legal right of choice as part of contract monitoring in line with NHS Standard Contract requirements.
Licence provision
This condition prevents providers from entering into or maintaining agreements that have the object or effect of preventing, restricting or distorting competition to the extent that it is against the interests of health care users. It also prohibits licensees from engaging in other conduct which has the effect of preventing, restricting or distorting competition to the extent that it is against the interests of health care users.
Executive sponsor
Interim Chief Finance Officer.
Compliance statement
The outcome of discussions with commissioners to develop contracts, associated risks and financial implications are reported to appropriate management oversight group and Board of Directors. The Trust has a team in place to pursue strategic service opportunities within statutory and accepted procurement, bidding and contracting practices, this ensures competition is not prevented, restricted or distorted by the Trust. Decisions are overseen by the Executive Team and Trust Board. The contracting team and procurement Team provide technical and professional advice. The provision of NHS Services are contracted through the NHS Standard contract which has inbuilt safeguards in place to prevent anti-competitive behaviour and practices.
Section four – integrated care
Licence provision
The licensee shall not do anything that could reasonably be regarded as detrimental to enabling integrated care.
Executive sponsor
Chief Executive.
Compliance statement
The Trust proactively works within the Lancashire and South Cumbria Integrated Care System and with wider health economy partners, through formal and informal mechanisms to foster and enable integrated care and is involved in projects aimed at developing new ways of working and new models of delivery. The Trust supported the development of the Lancashire and South Cumbria Integrated Care Strategy and has utilised it in its refresh of its own Trust Strategy.
Section five – continuity of services
Licence provision
This condition prevents licensees from ceasing to provide CRS, or from changing the way in which CRS, without the agreement of relevant commissioners.
Executive sponsor
Interim Chief Finance Officer.
Compliance statement
The Trust does not provide Commissioner Requested Services.
Licence provision
This licence condition ensures that licensees keep and up‐to‐date register of relevant assets used in the provision of CRS. It also creates a requirement for licensees to obtain NHSI’s consent before disposing of these assets when NHSI is concerned about the ability of the licensee to carry on as a going concern.
Executive sponsor
Interim Chief Finance Officer.
Compliance statement
The Trust holds an asset register. The Finance Assurance Framework details the requirement for NHSI/E and commissioner approval prior to the disposal of any associated property.
Licence provision
This condition requires licensees to have due regard to adequate standards of corporate governance and financial management.
Executive sponsor
Chief Strategy and Compliance Officer.
Compliance statement
The Trust has robust and comprehensive corporate and financial governance arrangements in place. The Trust complies wherever possible with corporate governance standards including the Code of Governance issued by NHSE.
The Trust maintains good financial governance process such that it can continue as a going concern, the Directors have reasonable expectations that the Trust has adequate resources to continue in operational existence for the foreseeable future. The Board receives assurance on the good financial governance from the Trust’s internal auditors.
Licence provision
This condition requires licensees to put in place a legally enforceable agreement with their ‘ultimate controller’ to stop ultimate controllers from taking any action that would cause licensees to breach the licence conditions. This condition specifies who is considered to be an ultimate controller.
Executive sponsor
Interim Chief Finance Officer.
Compliance statement
The Trust is a Public Benefit Corporation and neither operates or is governed by an Ultimate Controller arrangement so this licence condition would not apply.
Licence provision
This licence condition obliges licensees to contribute, if required, towards the funding of the “risk pool” – this is like an insurance mechanism to pay for vital services if a provider fails.
Executive sponsor
Interim Chief Finance Officer.
Compliance statement
The regulatory Risk Pool Levy has not come into effect to date.
Licence provision
This licence condition applies when a licensee fails a test of sound finances, and obliges the licensee to cooperate with Monitor (NHSI/E) in these circumstances.
Executive sponsor
Interim Chief Finance Officer.
Compliance statement
The Trust is aware it needs to co-operate with NHSI/E in such circumstances.
Licence provision
This condition required licensees to act in a way that secures access to the resources needed to operate CRS.
Executive sponsor
Interim Chief Finance Officer.
Compliance statement
The Trust has sound and robust processes and systems in place to ensure it has the resources necessary to deliver its services. Trust undertakes robust contract discussions and undertakes early identification of EIP schemes supported by impact assessments.
Section six - NHS foundation trust conditions
Licence provision
Licensees are required to provide the Regulator with:
• A current Constitution
• Most recent published annual accounts and Auditor’s report
• Most recent published Annual Report
Executive sponsor
Chief Strategy and Improvement Officer.
Compliance statement
See G1. The Trust has provided the information required under this provision.
Licence provision
As General Condition 3 (G3).
Executive sponsor
Interim Chief Finance Officer.
Compliance statement
See G3. Not applicable at the time of reporting.
Licence provision
Licensees shall comply with any request for information or advice.
Executive sponsor
Chief Strategy and Improvement Officer.
Compliance statement
The Independent Advisory Panel was disbanded in January 2017.
Licence provision
This condition will enable NHSI to continue oversight of governance of NHS Foundation Trusts.
Executive sponsor
Chief Strategy and Improvement Officer.
Compliance statement
The Trust has sound corporate governance processes in place and reviews of these arrangements are a core part of the internal audit annual work programme.