Decision Making Policy Statement

Current policy lead: Deputy Chief Executive

Date of last review: February 2025

The Chief Executive has overall responsibility for implementing and monitoring this policy.  It will be reviewed on a regular basis following its implementation and additionally whenever there are relevant changes in legislation or to Healthwatch Norfolk’s working practices.

Reference to ‘Board’ throughout this document is the Governing Board of Trustees and Company Directors of Healthwatch Norfolk.

Healthwatch Norfolk makes its decisions in an open and transparent way and ensures the interests of the people of Norfolk are always put first. This policy and associated procedures outline the steps taken to ensure decisions are evidence-based and lead to substantive impact in the community.

The governing regulations and standards are:

• The NHS Bodies and Local Authorities (Partnership Arrangements, Care Trusts, Public Health and Local Healthwatch) Regulations 2012 – referred to as Regulation 40 throughout this document
• Freedom of Information Act 2000
• Seven Principles of Public Life (Nolan Principles)

 

This policy applies to all relevant decisions made by Healthwatch Norfolk

Relevant decisions

Regulation 40 requires Healthwatch Norfolk to have in place and publish procedures for making relevant decisions. Relevant decisions include:

• How to undertake our activities
• Which health and care services we are considering covering with our activities
• The amounts we will spend on our activities
• Whether to request information
• Whether to make a report or a recommendation
• Which premises to Enter and View and when those premises are to be visited
• Whether to refer a matter to the Overview and Scrutiny Committee
• Whether to report a matter concerning our activities to another person, agency or organisation
• Any decisions about sub-contracting

 

Relevant decisions do not include day-to-day activity that may be required to conduct exploratory work prior to making a relevant decision.

Who may make such decisions?

The Healthwatch Norfolk Trustee Board will be responsible for making relevant decisions. The Board will have the power to delegate some of the relevant decision-making to the Chief Executive of Healthwatch Norfolk.

All relevant decisions, including those delegated to the Chief Executive, will be recorded in the minutes of the Board meeting or Board Subgroup Meeting at which the decision was made. The minutes of all Board meetings are published on Healthwatch Norfolk’s website once the Board has agreed them as being a correct record of the meeting concerned.

Once a decision has been made, the staff team is responsible for implementation and delivery, with an agreed reporting process to the Board.

The Board of Healthwatch Norfolk will reconsider a decision where new data has become available, or if circumstances change, which might prompt it to reach a different decision, or where there is evidence that this decision-making process was not followed.

As a private company limited by guarantee and a registered charity, decision-making within Healthwatch Norfolk is also covered in our Articles of Association.

Involving lay persons or volunteers in such decisions

Healthwatch Norfolk’s Board is composed partly of lay persons (a person who is not a health or social care professional) and volunteers (a person who is not a paid employee of Healthwatch Norfolk). Healthwatch Norfolk intends to secure broad-based views on its activities wherever possible and involves others, particularly lay people and volunteers, in its decision-making.

How are decisions made?

The potential scope of the work of Healthwatch Norfolk is vast – it has a responsibility to cover health and social care services for all adults, children and young people in Norfolk, including those who are most vulnerable or may be excluded. This means we must prioritise the issues we focus on. The main sources to inform our work programme are likely to come from:

• People’s experiences of health and social care services that they share with us
• Evidence we proactively collect about specific areas of concern through the stories and enquiries we receive directly, including deliberative research, public surveys and polls
• National and local data sets that evidence issues affecting large numbers of the local population and the most excluded

 

This list is not exhaustive and other relevant sources of data will be considered

In order to prioritise, Healthwatch Norfolk’s Board will carefully consider all sources of information and decide where it can add most value. Areas to be considered include but are not limited to:

• That the issues of concern fit with our organisational role and responsibilities, ensuring Healthwatch Norfolk delivers to its statutory remit
• How much the issue matters to local people. It must be something they care about as we are here to be the voice of the people about health and social care
• How much change Healthwatch Norfolk can bring about. This enables us to make sure we are choosing areas where we can have the greatest impact. This is important to deliver the greatest return for our budget, maintain our independence and ensure we bring issues to the attention of the health and care system
• Does the change need to come from Healthwatch Norfolk, so that we aren’t focusing on things that others can do more easily and effectively?
• Finally, the Board of Healthwatch Norfolk will consider our work as a full set of priorities, as together they need to have the greatest impact for people using health and social care services

 

Board meetings are open to the public, and minutes recording decisions will be available via Healthwatch Norfolk’s website.

Dealing with breaches of any procedure referred to in this policy document, including circumstances in which a breach would be referred to the local authority

If a decision is taken in the name of Healthwatch Norfolk without authorisation in the manner set out in this policy document, the Board will determine what action is needed. This may be to either ratify the decision or to reverse it.

If the breach of the agreed procedure is considered to have also breached the contract between Healthwatch Norfolk and the Local Authority (Norfolk County Council), it will be reported to the Local Authority and further action agreed between the Local Authority and Healthwatch Norfolk. In each eventuality, actions will be minuted and published on Healthwatch Norfolk’s website.

Equality, Diversity and Inclusion statement

Healthwatch Norfolk is committed to ensuring all decisions made are free from any form of discrimination on the grounds of age, disability, gender, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex and sexual orientation, in accordance with the Equality Act 2010.

Healthwatch Norfolk will monitor this policy in order to identify whether it is having an adverse impact on any group of individuals and act accordingly.

Review of this policy document

The Board of Healthwatch Norfolk will review the effectiveness of the decision-making policy and procedures set out in this document every year. Any amendments to this policy and the procedures governing the making of relevant decisions will require a simple majority of board members voting in favour.

The amended policy document will be published on the website of Healthwatch Norfolk as soon as is practicable.

Procedures

Healthwatch Norfolk undertakes to conduct the following procedures:

• Publish Healthwatch Norfolk’s most up to date policy document on Healthwatch Norfolk’s website
• Review and obtain Board approval for Healthwatch Norfolk‘s decision-making policy every year
• Ensure all Healthwatch Norfolk staff are familiar with the policy and refresh their understanding and awareness of the need for open and transparent decision-making by reading the policy on a regular basis, at a minimum after the annual review by the Board
• Publish minutes from Board meetings where decisions are made in a timely manner on Healthwatch Norfolk’s website. Where decisions are made outside of board meetings, these will be ratified at the subsequent Board meeting