Key Documents

These are the important documents which provide the guidelines and directions we require to carry out our work, and to keep you informed of our activities. Please read them and contact us if you require further information or clarification.

Our Guiding Principles

National and local documents which set out how we work,

Strategies and Plans

National and local documents which shape and describe our vision for the future of health services

Operational Policies and Procedures

Documents detailing how we manage a wide range of clinical and operational issues. Please note that policies that subject to review on or before 2017/18 will be done as part of the partnership work between North East Hampshire and Farnham CCG, South East Hampshire CCG, Fareham and Gosport CCG, and North Hampshire CCG.

Individual Funding Requests (IFR)

Treatments which are not routinely commissioned, or are restricted by clinical criteria, may be requested via an Individual Funding Request (IFR) from the appropriate clinician, such as a GP or secondary care consultant. All IFR requests for should be in writing using the appropriate IFR funding application forms.

The NHS South, West, and Central Commissioning Support Unit (CSU) manages the IFR service on behalf of the Hampshire CCGs; related policy, forms and advice are available via their dedicated IFR resource webpage

  • The Policy and Procedure for Individual Funding Requests - provides guidance about those treatments which might be accessed via the IFR route
  • IFR short list - This is the short form list of procedures which are either restricted to clinical criteria or excluded. There's a reference to the relevant page in the main policy for further information
  • IFR referral form for primary care
  • IFR referral form for secondary care
  • IVF (Assisted Conception treatments) referral form
  • Dermatology Life Quality Index (adults) - This is the application form to complete for removal of any skin lesion in secondary care for adult patients
  • Dermatology Life Quality Index (children) -This is the questionnaire to complete to seek prior approval for a child to have a lesion excised in secondary care

SHIP (Southampton, Hampshire, Isle of Wight, Portsmouth) Priorities Committee

The SHIP (Southampton, Hampshire, Isle of Wight, Portsmouth) Priorities Committee works on behalf of its constituent commissioners to develop and agree clinical policies using an ethical decision making framework and standard procedures, supported by Solutions for Public Health. Their recommendations are advisory but become active policy following consultation with, and endorsement by, the constituent CCGs.

The NHS South, West, and Central Commissioning Support Unit (CSU) IFR resource webpage

  • SHIP Priorities Committee Clinical Policies 2008 – 2012

    This is the full document list detailing all clinical policies recommended by the SHIP Priorities Committee between 2008 and 2012 to the former Primary Care Trusts of Hampshire and the Isle of Wight. NB – Many of these policies will relate to specialised services and may have been superseded by NHS England national policies, others by NICE Technology Appraisal Guidance. This document should therefore be treated as an archive only and not necessarily be used to inform clinical practice or referral decisions.

  • Priorities Committees Policies - policy statements issued by the SHIP area Priorities Committee serving CCGs in Hampshire and Isle of Wight from 2014 onwards, which have been endorsed as policy verbatim by the individual CCGs.
  • Please contact the IFR team if you need any further guidance or advice on these policies: southcsu.ifrs@nhs.net 02380 623254/5/6

The SHIP Priorities Committee has made the following recommendations which have been endorsed as a policy verbatim by the CCG:

CEC15/001 Interventional Procedure for Varicose Veins.

CEC15/002 Sept 2016 REISSUE Assisted Conception Services (IVF) Policy Recommendation 002 (2)

CEC15/003 The Use of Partial Knee Arthoplasty in patients with Osteoarthritis of Knee.

CEC15/004 Treatments for Patients with Lymphoedema.

CEC15/005 Functional Electrical Stimulation in the Management of Drop Foot of Central Neurological Origin.

CEC16/001 Arthroscopy for Hip Impingement

CEC16/002 Adenoidectomy for Children with Upper Urti

CEC16/003 CGM for Adults with Diabetes

CEC16/004 Tx for People Who Snore

CEC16/005 Arthroscopy in Knee Pain

CEC16/006 Flexi Sig in Colorectal Cancer

CEC16/007 Cholecystectomy for Patientss with Asymp Gallstones

CEC16/008 CEC16/008 Bariatric Surgery Procedures in Severely Obese Adults

Policy Title Policy Statement Valid From Review Date

Hampshire CCGs CHC & FNC Operational Policy (NHCCG)


The Operational Policy for NHS Continuing Health Care (CHC) and Funded Nursing Care (FNC) details the process for referring, assessing and agreeing eligibility for NHS CHC and for providing that care. This policy ensures that the model and processes are consistent, robust and are timely in their response.

November 2016

April 2017

Hampshire CHC Choice and Equity Policy (NHCCG)


 This policy describes the way in which the Hampshire Continuing Healthcare Team (CHC) on behalf of CCG’s will provide care for people who have been assessed as eligible for fully funded NHS Continuing Healthcare.

November 2016

April 2017

NHCCG Policy for Adoption and Implementation of NICE Guidance and Policy Recommendations


This policy, updated in October 2016, describes the way in which NHCCG implements NICE guidance, but also the way it utilises the outputs of the SHIP Priorities Committee in the setting of its commissioning priorities. NICE Guidance In Relation To Clinical Policies

28 October 2014

October 2019

NHS Continuing Care – Refreshed Redress Guidance

This document is the final refreshed Redress Guidance for NHS Continuing Healthcare for CCGs. This now reflects guidance from the Parliamentary and Health Ombudsman for all public sector bodies, on calculating interest on redress payments

April 2015


Policy Title Policy Statement Valid From Review Date

Policy for the Development, Review, Approval and Implementation of Policies and Standard Operating Procedures


This document sets out how the CCG will prepare, approve, ratify, implement and review its policies and standard operating procedures. It contains templates for staff to use in their own policy drafting. For this purpose an MSWord version can be found  HERE

January 2015

December 2017

Policy for the Management of Complaints

This policy sets out the process for handling complaints, compliments and concerns generated by patients, carers and the general public by North Hampshire CCG.

December 2017

December 2019

Business Continuity Management Policy


CCG's are Category 2 responders and are required by the Civil Contingencies Action 2004 to have Business Continuity Plans, which have been exercised and reviewed on a regular basis.  There are also requirements in both the Use of Resources and Information Governance Tool Kit to demonstrate that effective business continuity plans and testing are in place. March 2018 March 2019

NHCCG Business Continuity Plan V2.40


CCG's are Category 2 responders and are required by the Civil Contingencies Action 2004 to have Business Continuity Plans, which have been exercised and reviewed on a regular basis.  There are also requirements in both the Use of Resources and Information Governance Tool Kit to demonstrate that effective business continuity plans and testing are in place. March 2018 March 2019

Adults Safeguarding
The Mental Capacity Act 2005 is a vitally important piece of legislation, and one that will make a real difference to the lives of people who may lack mental capacity. NHS North Hampshire CCG is committed to the welfare of those who do not necessarily have the capacity to make decisions for themselves now or in the future. Our responsibilities as a CCG are described in our Safeguarding Adults Strategic Framework which uses The Act and its subsequent amendments as its reference point.

The Act is supported by practical guidance such as the Code of Practice issued by the Lord Chancellor on 23 April 2007. It explains how the Act will operate on a day-to-day basis and offers examples of best practice to carers, practitioners and our staff here at the CCG.

Equality & Diversity
In order to meet our Public Sector Equality Duty, the CCG needs to both report annually on its equality indicators (as set against the NHS Equality Delivery System) and publish one or more of its objectives to the public. We published our first equalities data in our first Annual Report for the year 2013/14.

Our Equality & Diversity Strategy and Plan has been reviewed and updated and sets out our objectives to 2016 to support the CCG's commitment to ensuring Equality and Diversity is considered in our work with local patients, carers and communities, as well as for our staff.

Integrated Governing Body Assurance & Risk Management Framework


The Integrated Governing Body Assurance (GBAF) and Risk management Framework describes the principal risks that relate to the organisations strategic objectives and is intended to provide assurances to the CCG Governing Body in relation to the management of risks that threaten the ability of the organisation to achieve these objectives. March 2014  March 2017
On-Call Policy


The aim of this Policy is to outline the On-Call arrangements in place for North Hampshire CCG so to ensure there are robust plans in place for ‘On-Call’ relating to system-wide resilience and an escalation route to Executive Director level in relation to major incidents, including out-of-hours serious media enquiries and significant business continuity issues.

May 2017 May 2019
Risk Management Policy


The purpose of this policy is to act as a simple support document to NHCCG Integrated Governing Body Assurance (GBAF) and Risk management Framework to enable staff to undertake effective risk management.

June 2014 June 2016
NHCCG Incident Response Plan


The aim of this plan is to provide a framework by which NHS North Hampshire CCG will prepare for and undertake its role in a major incident. This Incident Response Plan details the planning and response of the Clinical Commissioning Group during a Major Incident.

September 2014 TBA
Social Value Policy


This policy outlines the approach that the CCG will take in relation to the procurement for healthcare and non-healthcare related expenditure and its obligation to consider social value.

28 Oct 2016 Jan 2017
CCG/SOEPS Procurement Guide


The purpose of this document is to share the advice of NHS South of England Procurement Services (SoEPS) with the CCG so those undertaking a procurement are aware of their obligations when conducting procurement activity.

28 January 2016 28 January 2017
Security Policy - Staff, Premises and Assets


This policy covers the security of staff and property within North Hampshire CCG and focuses on sustaining and improving existing physical and personal security. It supports the legal duty to provide a safe and secure environment.

8 September 2016 September 2017
Policy for the Sponsorship of Activities and Joint Working with the Pharmaceutical Industry


This document sets out North Hampshire CCG policy for joint working with the pharmaceutical industry, to ensure the benefits that this could bring to patient care and the difference it can make to their health and well-being, are clearly advantageous.

January 2018 December 2018
Policy Title Policy Statement Valid From Review Date

CCG HR Framework


This Framework is to set out the employer related responsibilities and commitments of the NHS North Hampshire Clinical Commissioning Group

To view this policy on the ConsultHR website click here

17 October 2016 October 2019
Managing Conflicts of Interests Policy

This policy sets out how NHCCG will manage conflicts, and potential conflicts of interest to ensure that the decisions taken by the CCG are without any possibility of external or private influence. Jan 2018 Jan 2020
If you are in any doubt as to how the business conduct policy or other guidance regarding avoiding conflicts of interest may relate to your role in CCG business, please explore the links below:

The Nolan Principles
Code of Conduct for NHS Managers (2002)
Standards for members of NHS boards and CCG governing bodies in England
Best Practice Guidelines for Working with the Pharmaceutical Industry
Code of Practice for the Pharmaceutical Industry (2015)
NHS Business Services Authority guidance Standards of Business Conduct Procedure
Managing Conflicts of Interest: Statutory Guidance for CCGs (2016)
Code of Conduct: Managing conflicts of interest where GP practices are potential providers of CCG-commissioned services (2012)

Leave and Flexible Working Policy



  • HR/005/v1.00 Leave Policy
  • HR/006/v1.00 Flexible Working Policy
This policy serves as a guide to managers in determining fair and reasonable practices in the provision of leave and flexible working arrangements.

To view this policy on the ConsultHR website click here

March 2016 March 2018
Local Fraud and Corruption Policy


This policy deals with the reporting of suspected fraud and corruption so that colleagues feel that they work within an open and well-intentioned atmosphere. 5 November 2015 November 2017
Payroll Over & Under Payments Policy


The organisation has a responsibility to ensure that employees are paid correctly and that over and under-payments are identified and either recovered or paid on a timely basis. 2 September 2014

August 2017

Probationary Periods Policy


This policy can be viewed on Consult HR here. April 2017 April 2018
Alcohol and Substance Misuse at Work Policy



This policy outlines the standards on the use and misuse of alcohol, drugs and other harmful substances and actions to be taken where a potential issue is identified. This is an HR policy.

To view this policy on the ConsultHR website click here

17 October 2016

October 2019

Maternity Paternity and Adoption Leave Policy



  • HR/013/v1.00 Maternity, Paternity, Adoption Leave and Pay Guidance

This policy outlines clear guidance for managers and staff concerning maternity, paternity and adoption leave and associated pay.

To view this policy on the ConsultHR website click here

March 2016

March 2018

Organisational Change Policy



  • HR/014/v1.00 Organisational Change Policy

The purpose of this document is to ensure that robust recruitment and exit procedures operate across North Hampshire Clinical Commissioning Group and are implemented in a consistent manner.

To view this policy on the ConsultHR website click here

March 2016 February 2018

Recruitment Exit Procedure



  • HR/015/v1.00 Job Evaluation Policy
  • HR/017/v1.00 Recruitment Policy and Procedure
  • HR/019/v1.00 Temporary Promotion Policy
  • HR/020/v1.00 Secondment Policy
  • HR/024/v1.00 Leaving and Exit Interview

This policy sets out the framework for the management of organisational change.

To view this policy on the ConsultHR website click here

March 2016 March 2018

Lone Working Policy


The aim of this policy and the guidelines is to eliminate the potential risks associated with lone working and where this is not possible, the risks will be minimised to the lowest possible level so far as is reasonably practicable.

To view this policy on the ConsultHR website click here

5 September 2016  

31 August 2019

Relocation Policy and Procedure


This policy provides management guidelines when relocation becomes necessary. It considers the types of relocation that could take place, the issues that need to be considered and the support that will be available to employees who are applicable.         

The purpose of these guidelines is to ensure that financial support represents good value, is equitable and that there is applicable financial control in place.

To view this policy on the ConsultHR website click here

 17 October 2016

October 2019

Concerns and Whistleblowing Policy


This policy outlines actions to be taken by the manager or a member of staff when a concern arises. The policy provides guidance on management or staff action which may lead to formal action being taken under the following:

  • Investigation Procedure
  • Disciplinary Procedure (Conduct)
  • Suspension procedure
  • Performance Management Procedure (Capability)
  • Absence Management Procedure
  • Grievance Procedure
  • Harassment and bullying at Work Procedure
  • Whistleblowing Procedure
  • To view this policy click here

26 January 2017 January 2018

Policy for Performance and Development Reviews, and Pay Progression


This policy can be viewed on Consult HR here. April 2017 April 2018
Travel and Expenses Policy


The purpose of this policy and procedure is to outline the rules set out for the reimbursement of travel and expenses that are necessarily incurred by any individual engaged on business approved by the CCG, or in the case of relocation, excess miles.

To view this policy click here here

1 April 2016  

January 2018

Policy/Procedure Title Policy Statement Valid From Review Date
Information Governance Navigator This document describes our Information Governance Framework and Responsibilities N/A N/A
Freedom of Information Policy


This policy is a statement of the framework within which the NHS North Hampshire Clinical Commissioning Group (CCG) will work to ensure compliance with the Freedom of Information Act 2000 (FOIA).

December 2016

December 2018

Information Governance Policy


This policy sets out how the CCG will meet IG legislation requirements

November 2017

April 2018

Information Governance Framework and Strategy


This framework sets out how the CCG will effectively manage IG

November 2017

April 2018

Information Governance Staff Handbook

This guide sets out main ‘do’s and don’ts’ of IG for staff

June 2017

June 2018

How We Use Your Information Leaflet

A guide for the public on how we use and how they can access their personal information

20 March 2015

March 2018

Records Management Code of Practice for Health and Social Care

This Records Management Code of Practice for Health and Social Care 2016 (from this point onwards referred to as the Code) is a guide for you to use in relation to the practice of managing records. This Code is relevant to organisations who work within, or under contract to NHS organisations in England. This also includes public health functions in Local Authorities and Adult Social Care where there is joint care provided within the NHS.

July 2016

Records Management Policy


This Policy is written to give the CCG a clear Records Management framework which includes advice and guidance and to inform staff of their operational and legal responsibilities.

20 February 2015

April 2018

Records Retention Schedule This document uses the NHS corporate records retention schedule to help us with our records management, and has been divided up into the schedules for the different functions of the CCG. N/A N/A
Safe Haven Policy


This Policy is written to give the CCG a clear Safe Haven framework

March 2015

April 2018

Freedom of Information Act 2000 Staff Guidance Leaflet North Hampshire CCG

Sets out advice and guidance to CCG staff to enable them to manage enquiries received under the Freedom of Information Act 2000

 December 2016

 December 2017

Confidentiality Policy - Data Protection Act 1998


This policy describes the CCG’s responsibilities under the Data Protection Act 1998 and ensures all employees abide by the legal duty of confidence to protect personal confidential data.

20 February 2015

April 2018

Data Subject Access Request Policy


This policy informs staff of the process for supplying individuals with the right of access to personal data under the Data protection Act 1998.

23 February 2015

April 2018

Information Risk Management Policy & Strategy


Information risk management is the process of understanding and responding to factors that may lead to a failure in the confidentiality, integrity or availability of an information system.  The purpose of this document is to establish relevant lines of responsibility and conduct for all members of the CCG staff regarding information risk management.

16 March 2015

March 2018
Information Incident Management and Reporting Procdures To assist staff in the identification, reporting and management of information incidents within the CCG

 August 2017

August 2018
Information Incident Report Form For internal use by staff in the event of an information incident.

 June 2017

June 2018
NHCCG Privacy Impact Assessment Guidance V2.0


Privacy Impact Assessment (PIA) is a process which enables organisations to anticipate and address the likely impacts of new initiatives on an individual’s privacy, patients or staff.

 17 April 2017

 April 2018
PIA Screening Questions Examples of screening questions


Privacy Impact Assessment Template V2.0 Privacy Impact Assessment Procedure Template

 15 April 2017

 April 2018
ICT Acceptable Use Policy



This policy ensures that users of the CSU IT service computer systems do so in a secure, lawful and responsible manner and covers: Internet, E-mail, equipment, remote working, identities and passwords, sensitive information storage, offensive and inappropriate material and physical security.

 March 2015

March 2017

ICT Antivirus Policy



This policy provides information on antivirus protection measures in place, required compliance and actions to take in respect of non-compliance.

 March 2015

 March 2017
ICT Clear Screen and Desk Policy


 This policy defines how employees should act responsibly by ensuring the integrity and confidentiality of the information displayed at their workstation and defines how desks should be kept clear of sensitive printed material

 March 2015

 March 2017
ICT Password Policy



This Policy provides the detailed password policy statements that support the overall IT security objectives of the CSU as set out in the security statement in the ISMS.

 March 2015

 March 2017
Remote Working and Portable Devices Policy



This Policy protects information that is processed remotely or is stored on portable devices.

 March 2015

 March 2017
Registration Authority (RA) Policy

Draft v1.0

This Policy defines the processes in place to ensure that staff members and those working on behalf of the organisation issue with an NHS Smartcard comply with the terms and conditions of use.

 March 2015

 March 2017
NHS South IT Security Policies

The CCG is assured by the following policies provided by the NHS South Commissioning Support Unit as part of its electronic computer and network systems support:  Access Control Policy, Business Continuity Plan (CSU IT), Information Security Assurance Plan, Information Security Framework, Information Security Workplan,  Information Security Policy, Network Security Policy, Security Incident Handling Policy

 March 2015

 March 2017
Hampshire & Isle of Wight Health and Social Care Information Sharing Framework

Version 2.2 September 2016

To facilitate the appropriate exchange of information in order to fulfil the duties imposed upon public authorities and other parties.  The Framework is intended to give the participating parties the confidence that when they share information, all parties will be operating to a common standard that complies with relevant legislation and guidance.

 September 2016

September 2017 
Policy/Procedure Title Policy Statement Valid From Review Date

Safeguarding Adults Policy


This policy seeks to set out the CCG's responsibility for Safeguarding Adults as an NHS body, and the responsibility of every member of staff working within NHS North Hampshire CCG. May 2016 May 2017

Hampshire Safeguarding Adults Board (HSAB)Multi Agency Safeguarding Adults

This policy, guidance and toolkit has been developed by the Local Safeguarding Adults Boards (4LSAB) covering Hampshire and the Isle of Wight (including Portsmouth and Southampton) to meet the requirements of the Care Act 2014 and the Department of Health Statutory Guidance published in October 2014. It is designed to support current good practice in adult safeguarding and outlines the arrangements which apply to the whole of the 4LSAB area. May 2015 Ongoing

Hampshire and Isle of Wight Safeguarding Adults Communication Protocol

This joint protocol sets out how communication relating to enquiries and statements about specific safeguarding cases, the role of the LSAB’s and general safeguarding adult topics will be managed.

February 2015


Safeguarding Children Policy

CLIN-008-Version 4.10

NHS North Hampshire CCG has a statutory duty to safeguard and promote the welfare of children and young people.  This safeguarding children policy outlines corporate and individual responsibilities in accordance with legislation, guidance and standards. May 2017 July 2018
Safeguarding Guidance and Useful Information

Hampshire Modern Slavery Partnership
Care Act (2014)
Domestic Violence Helpline
Female Genital Mutilation
Forced Marriage
Honour Based Violence
Radicalisation of Vulnerable People to Terrorism

The CCG’s Concerns and Whistleblowing Policy sets out the procedure at Section 7 to be followed in the circumstance of any allegation that an employee of the CCG may have caused harm to a child or adult.

To view this policy on the ConsultHR website click here

Publications and Corporate Documents

Our annual reports, annual accounts, audit letters and other corporate documents.