The requester asked for Manx Care's financial and FOI policies, request statistics, and copies of all FOI replies since April 2021. The authority responded by providing the full Manx Care Financial Regulations document, which outlines statutory financial directions and practice notes.
Key Facts
Manx Care issued the Financial Regulations on 1 April 2021.
The regulations apply to all employees and officers of Manx Care without exception.
Financial Directions are statutory and issued under the Treasury Act 1985.
There are six Financial Directions covering areas such as governance, resources, and payments.
Financial Practice Notes are mandatory for the Chair, Directors, Officers, and employees.
Data Disclosed
1 April 2021
£1 billion
Treasury Act 1985
V01.2
6 Financial Directions
Original Request
Please provide the following
Manx Care Expenses Policy or procedure
Manx Care FOI Policy
Manx Care FOI Internal review procedure or policy
Total number of FOI requests Manx Care have received since april 1 2021
Copies of all foi replies Manx Care have answered, don't want the requestors name just all the replies including any attachments
Data Tables (320)
Introduction
3
Financial Directions
10
Financial Practice Notes
48
The Financial Directions
Table of Amendments
(to previous edition)
Direction
Ref.
Amendment
Financial Practice Notes
Table of Key Amendments
FPN
Amendments to Previous Version
Requirement
Authority to Approve Exemptions
Statutory Financial
Directions
The Treasury has the authority to approve an exemption
from any statutory financial direction.
Financial Practice
Notes
The Treasury, the Manx Care Board or Financial
Governance Officers, as nominated within the Financial
Directions, have the authority to approve an exemption
from any Financial Practice Note within their area of
designated responsibility.
Certain Specific
Requirements within
Financial Directions
& FPNs
To the extent prescribed:
Accountable Officers
Requirement
Authority to Approve Exemptions
Have the authority to approve an exemption from
specific requirements to the extent outlined.
Budget Holders/Delegated Officers
Have the authority to approve an exemption from
specific requirements to the extent outlined within these
Directions and Financial Practice Notes and subject to
their delegated financial authority limits.
Directions
Non-compliance may lead to prosecution under the Audit Act
2006 and may also lead to the award of costs and compensation
in relation to any unlawful actions taken.
It is also a requirement that any non-compliance is investigated
and progressed (as appropriate) under the applicable
disciplinary or capability procedure.
Financial Practice Notes
Compliance is mandatory and it is a requirement that any non-
compliance is investigated and progressed (as appropriate)
under the applicable disciplinary or capability code.
Version Control
Date of Treasury Approval
24th March 2021
Issue Date
1st April 2021
Financial Direction A: Financial Values & Governance
13
A 1. Applicability 15
A 2. Financial Values 15
A 3. The Acceptance of Gifts & Rewards 16
A 4. Financial Irregularities 16
A 5. Roles 17
A 6. Accountable Officers 18
A 7. Budget Holders 20
A 8. Designated Finance Officer 21
A 9. Delegated Officer 22
A 10. Officer 22
A 11. Training Requirements 22
A 12. Accountability for Non-Compliance 22
A 13, Internal Audit
23
Financial Direction B: Managing Resources
24
B 1. Objectives 26
B 2. Budget Planning 26
B 3. Budget Management 26
B 4. Financing of Expenditure 27
B 5. Guarantees, Indemnities & Contingent Liabilities 27
B 6. New Legislation with Financial Implications 27
Financial Direction C: Buying & Making Payments
29
C 1. Objectives 31
C 2. Insurance 31
Insurance
C 3. Using Internal Resources First 31
C 4. Only Spending What We Can Afford 32
C 5. Financial Thresholds For Procurement Decisions & Exemptions 32
C 6. Central Framework Agreements 32
C 7. Alternative Procedures for Specific Types of Procurement 32
C 8. Procurement of General Goods & Services Up to £100k 33
C 9. Procurement of General Goods & Services Over £100k 34
C 10. Evaluation of Suppliers for General Goods & Services Over £100k 35
C 11. Contracting for Goods & Services Over £100k 35
C 12. Additional Requirements for the Procurement of Specific Categories of 36
Goods & Services
C 13. Acquisition of Assets 36
C 14. Statutory Payments 36
Financial Direction D: Safeguarding and Optimising Assets
37
D 1. Objectives 39
D 2. Banking Arrangements 39
D 3. Management of Assets & Inventory 39
D 4. Optimisation of Assets 39
D 5. Insurances 39
D 6. Cash Management 40
D 7. Investments & Borrowings 40
D 8. Charitable & Third Party Funds 40
Financial Direction E: Paying Staff
41
E 1. Objectives 43
E 2. Payment of Salaries & Wages 43
E 3. Travel & Subsistence 43
Financial Direction F: Selling & Receiving Payments
44
F 1. Objectives 46
F 2. Setting Charges for Goods & Services 46
F 3. Collection of Monies 46
F 4. Selling/Disposal of Assets and Offering Opportunities to 3rd Parties 46
Subject
Page
A 1. Applicability
A 2. Financial Values
A 3. The Acceptance of Gifts & Rewards
A 4. Financial Irregularities
A 5. Roles
A 6. Accountable Officers
A 7. Budget Holders
A 8. Designated Finance Officer
A 9. Delegated Officer
A 10. Officer
A 11. Training Requirements
A 12. Accountability for Non-Compliance
A13. Internal Audit
15
15
16
16
17
18
20
21
22
22
22
22
23
Table TA.1
Role
Definition
Accountable Officer
The Accountable Officer of Manx Care is the person
whom Tynwald may call to account in respect of the
stewardship of the resources within the control of
Manx Care.
The Accountable Officer is personally responsible for
making certain financial decisions that are considered
high risk and where identified within statutory
financial directions.
They are also able to make certain compliance
exemptions in accordance with these statutory
financial directions.
The responsibilities of the Accountable Officer cannot
be delegated; however, the Accountable Officer must
ensure that they appoint an appropriate Deputy to
make decisions in their absence.
The Accountable Officer is also Manx Care’s Budget
Holder.
Budget Holder
The Accountable Officer of Manx Care is the Budget
Holder for Manx Care and is responsible for
maintaining sufficient & appropriate systems &
controls within Manx Care.
The Accountable Officer may delegate that authority
to other appointed Budget Holders within Manx Care
providing they do so in accordance with FPN A.04:
Delegating Financial Authority.
Chief Accountant
As designated by the Chief Financial Officer.
Chief Executive Officer
The most senior official of Manx Care.
Chief Financial Officer (CFO)
The Chief Officer of the Treasury and the principal
financial advisor to the Treasury, as appointed in
accordance with the Treasury Act 1985.
Delegated Officer
Any officer with a delegated financial authority to
make financial decisions.
As designated by a Budget Holder (within the
authorisation limits as set out within their own
delegation of financial authority) in accordance with
FPN A.04: Delegating Financial Authority.
Designated Finance Officer (DFO)
Manx Care must have an officer designated as
Designated Finance Officer. The role will be
designated by the Accountable Officer unless the
Table TA.1
Role
Definition
Chief Financial Officer otherwise directs. The
Designated Finance Officer must have direct
reporting access to the Accountable Officer in
relation to Manx Care’s financial governance.
Director of Audit Advisory
As designated by the Chief Financial Officer.
Director of Commercial Law
As designated by the Attorney General.
Executive Director, Government
Technology Services
As designated by the Chief Secretary.
Executive Director, Human
Resources
As designated by the Chief Secretary.
Executive Director - Financial
Governance
As designated by the Chief Financial Officer.
Head of the Financial Governance Division of the
Treasury, Designated Finance Officer of the Treasury
and a key advisor to the Chief Financial Officer.
Executive Director – Financial
Advisory
As designated by the Chief Financial Officer.
Head of the Financial Advisory Service of the
Treasury.
Officer
Any employee or office holder within Manx Care (see
introduction). Without limiting the generality of this
term, this includes all public servants, civil servants,
health and social care professionals and persons with
lawfully delegated powers and responsibilities of
Manx Care.
Tender Evaluation Panel Member
Any Officer who has been appointed onto any Tender
Evaluation Panel.
Table TA.2
Examples of when an Accountable Officer Must Seek a Direction
Table TA.2
• Regularity: if a proposal is outside the legal powers of Manx Care, Tynwald
authority, or Treasury delegations; or is incompatible with the agreed budgets
of Manx Care.
• Propriety: if a proposal would breach Tynwald control procedures or
expectations.
• Value for money: if an alternative proposal, or doing nothing, would deliver
better value - e.g. an outcome which is less expensive, of higher quality or
more effective.
• Feasibility: where there is significant doubt about whether the proposal can
be implemented effectively, sustainably, or to the intended timetable.
Table TA.3 Standards
Governance
• that their designated budget area conforms with the principles embodied
within the Corporate Governance Code of Conduct;
• has trustworthy governance and internal controls to safeguard, deploy and
record the use of resources as intended;
• operates with propriety and regularity in all of its transactions;
• gives timely, transparent and realistic accounts of its business and decisions.
Table TA.3 Standards
Financial Management
• uses its resources efficiently, economically and effectively, avoiding waste and
extravagance;
• plans the use of its resources, defined in the Mandate, to be affordable and
sustainable within Tynwald approved limits;
• carries out procurement and project appraisal objectively and fairly, using cost
benefit analysis and generally seeking good value for the public sector as a
whole;
• uses management information systems to gain assurance regarding value for
money and the quality of service delivery and so be able to make timely
adjustments;
• has practical, documented arrangements in place for controlling or working in
partnership with other organisations, as appropriate;
• uses internal and external audit to improve its internal controls and
performance.
Subject
Page
B 1. Objectives
B 2. Budget Planning
B 3. Budget Management
B 4. Financing of Expenditure
B 5. Guarantees, Indemnities & Contingent Liabilities
B 6. New Legislation with Financial Implications
26
26
26
27
27
27
USE
FD C11 Contracting for
Goods & Services Over
£100k
USE
FD C10 Evaluation of
Suppliers Over £100k
Subject
Page
C 1. Objectives
C 2. Insurance
C 3. Using Internal Resources First
C 4. Only Spending What We Can Afford
C 5. Financial Thresholds For Procurement Decisions & Exemptions
C 6. Central Framework Agreements
C 7. Alternative Procedures for Specific Types of Procurement
C 8. Procurement of General Goods & Services Up to £100k
C 9. Procurement of General Goods & Services Over £100k
C 10. Evaluation of Suppliers for General Goods & Services Over £100k
C 11. Contracting for Goods & Services Over £100k
C 12. Additional Requirements for the Procurement of Specific Categories of
Goods & Services
C 13. Acquisition of Assets
C 14. Statutory Payments
31
31
31
32
32
32
32
33
34
35
35
36
36
36
Table TC.1
Expenditure Category
Financial Practice Note
Vehicles and Plant
FPN C.03: Vehicle and Plant
Procurement
Land and Buildings (including leases)
FPN C.05: Land & Buildings Acquisitions
Utilities & Rates
FPN C.07 Ordering & Receiving elements
do not apply. Only the paying element of
C.07 applies.
Expenditure Category
The contract opportunity relates to a provision covered by a
previously advertised Central or Organisational framework
agreement approved by the Accountable Officer and the Director
of Commercial Law: then the opportunity must be sourced in
accordance with that agreement.
The contract relates to a professional service regulated on the Isle
of Man: then the requirement need only be advertised to those
parties already subject to the regulatory regime.
Table TC.2
Expenditure Category
Financial Practice Note
Consultants (not including medical consultant
appointments)
All capital projects, including all construction work,
engineering and other projects, which are wholly or
partially commissioned, funded or underwritten by
one or more designated bodies. (Regardless of the
source of funding.)
FPN C.02: Capital Procedure Notes
ICT Hardware & Software
FPN C.04: ICT Hardware & Software
Procurement
Subject
Page
D 1. Objectives
D 2. Banking Arrangements
D 3. Management of Assets & Inventory
D 4. Optimisation of Assets
D 5. Insurances
D 6. Cash Management
D 7. Investments & Borrowings
D 8. Charitable & Third Party Funds
39
39
39
39
39
40
40
40
Subject
Page
E 1. Objectives
E 2. Payment of Salaries & Wages
E 3. Travel & Subsistence
43
43
43
Subject
Page
F 1. Objectives
F 2. Setting Charges for Goods & Services
F 3. Collection of Monies
F 4. Selling/Disposal of Assets and Offering Opportunities to 3rd Parties
Details of contracts, commercial
interests or potential conflicts of
interests.
Action
taken i.e.
Accepted /
Refused /
Returned
Entered By
Entered
Date
Name of Senior
Officer notified
of offer.
24/02/2014
An Example
A Company
Lunch
Circa £25
None
Accepted
A Finance
24/02/2018
An Accountable
Officer
9/12/2015
All Finance
Officers
B Company
Round of Golf
Circa £25
None
Declined
A Officer
10/12/2018
A Finance Officer
Version Control
Date of Treasury Approval
24th March 2021
Issue Date
1st April 2021
Responsible Officer
Director of Audit Advisory
Table of Amendments
(to previous version)
Ref.
Amendment
Version Control
Date of Treasury Approval
24th March 2021
Issue Date
1st April 2021
Responsible Officer
Executive Director – Financial Governance
Table of Amendments
(to previous version)
Ref.
Amendment
Designated Budget Area
From
To
Comments
1 - Function
2 - Limits of
Authority
3 - Further Delegations
4 -
Budget
Holder?
Financial Direction A: Financial Values & Governance
The authority to appoint
additional Budget Holders
[is/is not9 permitted
within their Budget
Area]
[is/is not9 permitted to further
delegate this authority]
The authority to approve
Budget Holder exemptions
(where permitted by the
Financial Regulations)
[is/is not9 permitted for
their Budget Area]
[is/is not9 permitted to further
delegate this authority]
Financial Direction B: Managing Resources
Approval of Business
Cases
[Up to £]
[is/is not9 permitted to further
delegate this authority]
2 - Limits of
Authority
1 - Function
2 - Limits of
Authority
3 - Further Delegations
4 -
Budget
Holder?
Financial Direction C: Buying & Making Payments
Issuing orders/ approving
payment commitments
[Up to £]
Revenue: [Up to £]
*Capital: [Up to £]
Authorising Invoices - in
relation to
orders/commitments
made within the Budget
Area
[Up to £
(where the Delegated
Officer has not
authorised the order)]
Revenue: [Up to £]
*Capital: [Up to £]
Authorising
Invoices/Payments – in
relation to
orders/commitments
authorised external to
the Budget Area
[Up to £]
Revenue: [Up to £]
*Capital: [Up to £]
Purchase Card
Transaction Limit
[Up to £]
Purchase Card Monthly
Limit
[Up to £]
Financial Direction D: Safeguarding & Optimising Assets
Approval of the Write-Off
of assets, inventory or
stock
[Up to £]
[Up to £]
Authorisation of Imprest/
Petty Cash Payments
[Up to £]
[Up to £]
Financial Direction E: Paying Staff
Approval of Off-Island
Travel requests
Within the British Isles
[Up to £]
[is/is not9 permitted to further
delegate this authority]
[Up to £]
Approval of overtime &
enhanced payments
[Up to £]
[Up to £]
Approval of mileage,
travel & subsistence
claims
[Up to £]
[Up to £]
Financial Direction F: Selling & Receiving Payments
Approval of Credit
Facilities to 3rd Parties
[Up to £]
[Up to £]
Approval to write-off
individual debts
[Up to £]
[Up to £]
Other Financial Delegations
2 - Limits of
Authority
Delegated Officer:
(please print)
Line Manager (if not the authorising Budget
Holder):
(please print)
Signature:
Signature:
Date:
Date:
Authorising Budget Holder:
(please print)
Signature:
Date:
Designated Budget Area
From
To
Comments
1 - Function
2 - Limits of Authority
Financial Direction C: Buying & Making Payments
Issuing orders/ approving payment commitments
Revenue: [Up to £]
*Capital: [Up to £]
Authorising Invoices - in relation to
orders/commitments made within the Budget Area
Revenue: [Up to £]
*Capital: [Up to £] (where the
Delegated Officer has not authorised
the order)]
Authorising Invoices/Payments – in relation to
orders/commitments authorised external to the
Budget Area
Revenue: [Up to £]
*Capital: [Up to £]
Purchase Card Transaction Limit
[Up to £]
Purchase Card Monthly Limit
[Up to £]
Financial Direction D: Safeguarding & Optimising Assets
Authorisation of Imprest/ Petty Cash Payments
[Up to £]
Financial Direction E: Paying Staff
Approval of overtime & enhanced payments
[Up to £]
Approval of mileage, travel & subsistence claims
[Up to £]
Financial Direction F: Selling & Receiving Payments
Approval of Credit Facilities to 3rd Parties
[Up to £]
Approval to write-off individual debts
[Up to £]
Other Financial Delegations
Delegated Officer:
(please print)
Line Manager (if not the authorising Budget
Holder):
(please print)
Signature:
Signature:
Date:
Date:
Authorising Budget Holder:
(please print)
Signature:
Date:
Version Control
Date of Treasury Approval
24th March 2021
Issue Date
1st April 2021
Responsible Officer
Executive Director - Financial Governance
Table of Amendments
(to previous version)
Ref.
Amendment
Table 1 Mandatory Financial Training Requirements
Role
Training Requirement
Chair & Board Members of
Manx Care
Treasury’s financial training modules:
d) Financial Governance Foundation Course;
e) Budget Holders – Managing Public Money;
f) General Government Procurement;
g) Tendering;
h) Managing Capital Projects.
To be completed within 3 months of appointment and then
every 3 years.
All Officers
Treasury’s Financial Governance Foundation Course.
To be completed within 3 months of appointment and then
every 5 years.
Accountable Officers
Treasury’s financial training modules:
i) Financial Governance Foundation Course ;
j) Budget Holders – Managing Public Money;
k) General Government Procurement;
l) Tendering;
m) Sales, Receipts and Managing Debt;
n) Managing Capital Projects.
To be completed within 3 months of appointment and then
every 3 years.
Manx Care Finance Officers
Treasury’s financial training modules:
o) Budget Holders – Managing Public Money;
p) General Government Procurement ;
q) Tendering Module;
r) Sales, Receipts and Managing Debt;
s) Managing Capital Projects.
To be completed within 3 months of appointment and then
every 3 years.
All Budget Holders
Treasury’s financial training modules:
t) Budget Holders – Managing Public Money;
u) General Government Procurement.
To be completed within 3 months of appointment and then
every 3 years.
Table 1 (contd.) Mandatory Financial Training Requirements
In addition to the above and for all Officers, where their delegated authority includes
responsibility for the following, Officers are required to complete and pass the following
Treasury Financial Training Modules within 3 months of receiving the delegation of
authority and then every 3 years (unless otherwise stated):
Delegated Authority
Financial Training Module
General Procurement – up to £100k
General Government Procurement
General Procurement – over £100k
v) General Government Procurement;
w) Tendering.
Any Officer appointed to a Tender
Evaluation Panel
Tendering
(To be completed prior to undertaking any tender
responsibilities.)
Capital Projects
Managing Capital Projects
Agreement of Credit Terms and
authorisation of write-offs
Sales, Receipts and Managing Debt
Officers involved in handling
receipt of monies
General receipt of monies
Sales, Receipts and Managing Debt
Version Control
Date of Treasury Approval
24th March 2021
Issue Date
1st April 2021
Responsible Officer
• All parts except for the responsibilities of the Accountable
Officer: the Accountable Officer;
• The Responsibilities of the Accountable Officer: the Board
Table of Amendments
(to previous version)
Ref.
Amendment
Version Control
Date of Treasury Approval
Issue Date
Responsible Officer
• Where overall net expenditure of Manx Care remains within
Tynwald approved Mandated amounts and not including
Accountable Officer’s own responsibilities: The Accountable
Officer;
• Other instances where overall net expenditure remains
within Tynwald approved budgets: The Board;
• Where overall net expenditure of the Manx Care exceeds the
Tynwald approved budget: The Treasury.
Table of Amendments
(to previous version)
Ref.
Amendment
Version Control
Date of Treasury Approval
24th March 2021
Issue Date
1st April 2021
Responsible Officer
Total Project Costs (one-off costs + ongoing costs over the life of
the project):
• is less than £10,000 and costs can be met from within their
existing revenue budgets - by the Budget Holder;
• Up to and including £150,000 (and costs can be met from
within existing revenue budgets): Accountable Officer;
• is more than £150,000 and costs can be met from within
Manx Care’s budgets – Accountable Officer and the Board
• where costs cannot be met from within existing revenue
budgets: Accountable Officer, the DHSC and the Executive
Director - Financial Governance/Chief Financial Officer;
Table of Amendments
(to previous version)
Ref.
Amendment
Appendices to FPN B.03
Update to Business Case Templates to include Monies Requested
and Sources of Funding
Funding
Mechanism
*including how this
proposal meets its
Terms of Reference
Capital
Revenue
Other Fund *
Benefits expected
(if identifiable
and tangible)
Risks
Impact on the
environment
(including climate
change
implications) and
planned
mitigation
Are there Equality
Act implications?
Yes/No
[If the answer is Yes then please include a copy of the screening/impact
assessment with the business case, if the answer is No then provide a brief
rationale for the decision.]
Is a Data
Protection Impact
Assessment
Required?
Yes/No
[If the answer is Yes then please include a copy with the business case, if
the answer is No then provide a brief rationale for the decision.]
Impact on
Stakeholders and
any consultation
Inter-
departmental or
Cross
Departmental
implications
Timescales
Investment
appraisal –
expected payback
period
Costs (including
analysis between
on-going and
one-off costs and
costs related to
environmental
considerations)
and Personnel
implications
How will success
be measured?
(include plan for
review)
Specific costs identified to
minimise environmental
impacts
Total Bids
Section
Reference
Description
£
TOTAL £
Section
Reference
Description
£
TOTAL £
Name:
Title:
Comments:
Date:
Signature:
Name:
Title:
Comments:
Date:
Signature:
Version Control
Date of Treasury Approval
24th March 2021
Issue Date
1st April 2021
Responsible Officer
The Treasury
Table of Amendments
(to previous version)
Ref.
Amendment
3.2
Update of approval requirements
Fund
Page
BREXIT FUND (BXF)
100
CONTINGENCY FUND (CF)
102
DIGITAL STRATEGY FUND (DSF)
104
ECONOMIC DEVELOPMENT FUND (EDF)
106
HEALTHCARE TRANSFORMATION FUND (HTF)
108
INVEST TO SAVE FUND (ITSF)
111
LAND AND PROPERTY ACQUISITION RESERVE (LPAR)
113
LEGAL COSTS RESERVE (LCR)
115
MARKETING INITIATIVES FUND (MIF)
117
MEDICAL INDEMNITY FUND (MED)
119
TOWN & VILLAGE CENTRE REGENERATION FUND (TVRF)
120
BREXIT FUND (BXF)
Terms of Reference
OVERVIEW
1. The BREXIT Fund was established by Tynwald with effect from the 1st April 2017.
2. The purpose of the Fund is to meet unbudgeted costs in respect of matters arising from
the United Kingdom’s referendum decision to leave the European Union.
3. The Fund will be available to help Departments meet the additional costs in the lead up
to and shortly after Britain’s departure from the European Union, as well as for putting
measures in place to mitigate against the risks arising.
GOVERNANCE
4. All bids will require a business case outlining total set-up cost, ongoing revenue
implications and any savings profile. The business case template should be used to
support all submissions. All bids should have signed approval from Manx Care’s Finance
Officer, Accountable Officer and Minister (Ministerial approval requirement subject to a
de-minimus level of £100,000).
5. Should the intention be for some or all of the funds to be paid to a third party supplier,
it is essential that this expenditure complies with both Financial Regulations and the
open and fair principles that underpin public sector procurement. To this end where
third-party expenditure is being considered, Procurement Services must be engaged at
the very earliest opportunity and certainly in advance of any formal request for funds.
6. Bids up to £50,000 are subject to sign off by the Chief Financial Officer or Executive
Director - Financial Governance.
7. Bids between £50,000 and up to £100,000 require sign off by both the Executive
Director - Financial Governance and Chief Financial Officer. In the event that agreement
is not reached, or if the application is either politically sensitive or contentious, then the
application requires approval by the Treasury.
8. Bids between £100,000 and up to £250,000 are considered and approved by the
Treasury.
9. Any bids between £250,000 and £500,000 are considered and approved by the Treasury
with the Council of Ministers then informed of the decision.
10. Any Treasury approved bids over £500,000 also require formal approval from the
Council of Ministers.
ELIGIBILITY CRITERIA
11. All eligible projects must support the overall objectives of the BREXIT Fund specifically a
business case must be produced and signed off by Manx Care’s Finance Officer which
will include:
a) Financial Benefits – including a consideration of cashability
b) Social Benefits – Outcomes and long term strategy
c) Economic Benefits – Productivity and competitiveness
d) VAT, inter-departmental and contingency costs should not be included.
12. Drawdowns from the Fund will only be made available after it has been demonstrated
that Manx Care will not produce an under-spend within the current financial year.
13. All bids will be time-limited and extensions will require formal approval in line with the
governance framework outlined above. It is the responsibility of the Department to
ensure this.
14. Approvals are not transferrable between projects and a new business case will be
required for each new initiative.
Last Updated
26.02.10
CONTINGENCY FUND (CF)
Terms of Reference
OVERVIEW
1. The Contingency Fund was established by Tynwald with effect from the 1st April 2016.
The Fund arises from a need to ensure that funding is provided to meet any unexpected
or unplanned occurrences that are not included in Manx Care’s Revenue targets.
2. Bids are invited and considered where costs and any economic benefits are clearly
defined and measurable.
GOVERNANCE
3. All bids will require a business case outlining total set-up cost, ongoing revenue
implications and a robust savings profile if appropriate. The business case template
should be used to support all submissions. All bids should have signed approval from
the Finance Officer, Accountable Officer and Minister (Ministerial approval requirement
subject to a de-minimus level of £100,000).
4. Should the intention be for some or all of the funds to be paid to a third party supplier,
it is essential that this expenditure complies with both Financial Regulations and the
open and fair principles that underpin public sector procurement. To this end where
third-party expenditure is being considered, Procurement Services must be engaged at
the very earliest opportunity and certainly in advance of any formal request for funds.
5. Bids up to £50,000 are subject to sign off by the Chief Financial Officer or Executive
Director - Financial Governance.
6. Bids above £50,000 and up to £100,000 require sign off by both the Executive Director -
Financial Governance and Chief Financial Officer. In the event that agreement is not
reached, or if the application is either politically sensitive or contentious, then the
application requires approval by the Treasury.
7. Bids above £100,000 and up to £250,000 are considered and approved by the Treasury.
8. Any bids above £250,000 and up to £500,000 are considered and approved by the
Treasury with the Council of Ministers then informed of the decision.
9. Any Treasury approved bids over £500,000 also require formal approval from the
Council of Ministers.
Contingency Fund Continued….
CONTINGENCY FUND - ELIGIBILITY CRITERIA
10. All eligible projects must support the overall objectives of the Contingency Fund
specifically:
a) It must be of a temporary nature or is self-sustainable from ongoing
savings generated. Recurring expenditure is not eligible
b) Savings may be applied to Manx Care’s revenue targets
c) A business case must be produced and signed off by Manx Care’s
Finance Officer which will include:
i. Financial Benefits – including a consideration of cashability
ii. Social Benefits – Outcomes, intelligence, interventions and long term
strategy
iii. Economic Benefits – Productivity and competitiveness
iv. All benefits will be assessed annually.
v. VAT and interdepartmental costs should not be included.
11. Drawdowns from the Fund will only be made available after it has been demonstrated
that the Department will not produce an under-spend within the relevant financial year.
12. All bids will be time-limited and extensions will require formal approval in line with the
governance framework outlined above. It is the responsibility of Manx Care to ensure
this.
13. Approvals are not transferrable between projects and a new business case will be
required for each new initiative.
Last Updated:
26.02.19
DIGITAL STRATEGY FUND (DSF)
Terms of Reference
OVERVIEW
1. The Digital Strategy Fund was established by Tynwald with effect from the 1st April
2016. The Fund arises from a need to ensure that the delivery of the Digital Strategy
is fully implemented and savings arising are captured accordingly.
2. The objectives of the Digital Strategy Fund are defined as:
• A minimum financial saving of £5m to be achieved within 5 years ensuring the
programme is cost neutral across the period.
• Indirect savings and service improvements of £5m achieved within five years.
3. Savings will be identified, with
a. 50% of payback savings recouped from Manx Care and reimbursed back into the
Fund by Treasury at each year end for 5 years.
b. 25% of Manx Care’s recurring base budget savings will be clawed back and applied
to Manx Care’s revenue targets to allow resources to be returned to the general
reserve or realigned to new priorities as defined by the Council of Ministers.
c. Manx Care will be permitted to retain the remaining 25% of the annual savings
figure.
The nature of savings will be a mix of short/long term and financial, social and
economic. Bids may be considered that contribute to one of these categories. It is
expected that applications will provide ongoing benefits after the 5 year period.
4. The Fund replaces the now closed ICT Fund.
GOVERNANCE
5. All bids will require a business case outlining total set-up cost, ongoing revenue
implications and a robust savings profile. The business case template should be used
to support all submissions. All bids should have signed approval from the GTS
support officer and the Finance Officer, Accountable Officer and Minister (Ministerial
approval requirement subject to a de-minimus level of £100,000).
6. Should the intention be for some or all of the funds to be paid to a third party
supplier, it is essential that this expenditure complies with both Financial Regulations
and the open and fair principles that underpin public sector procurement. To this end
where third-party expenditure is being considered, Procurement Services must be
engaged at the very earliest opportunity and certainly in advance of any formal
request for funds.
7. Bids up to £100,000 are considered and approved by the Digital Strategy Group,
subject to cumulative approvals of up to £1M per annum. The Digital Strategy Group
is made up of officer representatives from the Cabinet Office and Treasury, and
unanimous support is required for a bid to be approved by the Group.
8. Bids over £100,000 and up to £250,000 are considered and endorsed by the Digital
Strategy Group and referred onto the Chief Financial Officer or Executive Director -
Financial Governance for approval.
9. Any bids over £250,000 are to be first endorsed by the Digital Strategy Group before
being passed for further approval from the Treasury Board. Bids approved in this
way for amounts between £250,000 and £500,000 also require notification to the
Council of Ministers. In addition projects over £250,000 will be reported to the
Strategic Assets and Capital Investments Committee and thereafter on a quarterly
basis for monitoring purposes.
10. Any Treasury approved bids over £500,000 also require formal approval from the
Council of Ministers.
11. Bids from Treasury will be endorsed by the Treasury Board but will require approval
from the Council of Ministers regardless of value.
ELIGIBILITY CRITERIA
12. All eligible projects must support the overall objectives of the Digital Strategy
specifically:
a) It must be of a transformational or temporary nature or is self-sustainable from
ongoing savings generated. Recurring or revenue expenditure is not eligible;
b) It must deliver tangible and pre-agreed, evidenced benefits. Savings will be applied
to departmental revenue targets;
c) A business case must be produced and signed off by the Finance Officer which will
include:
1. Financial Benefits – including a consideration of cashability
2. Social Benefits – Outcomes, intelligence, interventions and long term
strategy
3. Economic Benefits – Productivity and competitiveness
4. All benefits will be assessed annually.
d) it contributes to the overall objectives of the digital strategy and the benefits agreed
must be committed in the following five years.
e) VAT, inter-departmental and contingency costs should not be included.
13. Drawdowns from the Fund will only be made available after it has been
demonstrated that Manx Care will not produce an underspend within the current
financial year.
14. All bids will be time-limited and extensions will require formal approval from the
Digital Strategy Group. It is the responsibility of Manx Care to ensure this.
15. Approvals are not transferrable between projects and a new business case will be
required for each new initiative.
Last Updated:
26.02.19
ECONOMIC DEVELOPMENT FUND (EDF)
Terms of Reference
OVERVIEW
1. Originally established in 1999, the purpose of the Fund is to provide financial
assistance to organisations undertaking projects which are deemed to have a
positive contribution to the local economy yet are not eligible under any other
Government scheme.
2. Bids are invited and considered where costs and any economic benefits are
clearly defined and measurable.
GOVERNANCE
3. All bids will require a business case outlining total set-up cost, ongoing
revenue implications and a robust savings profile. The business case template
should be used to support all submissions. All bids should have signed
approval from the Finance Officer, Accountable Officer and Minister
(Ministerial approval requirement subject to a de-minimus level of £100,000).
4. Should the intention be for some or all of the funds to be paid to a third party
supplier, it is essential that this expenditure complies with both Financial
Regulations and the open and fair principles that underpin public sector
procurement. To this end where third-party expenditure is being considered,
Procurement Services must be engaged at the very earliest opportunity and
certainly in advance of any formal request for funds.
5. Bids up to £50,000 are subject to sign off by the Chief Financial Officer or
Executive Director - Financial Governance.
6. Bids above £50,000 and up to £100,000 require sign off by both the
Executive Director - Financial Governance and Chief Financial Officer. In the
event that agreement is not reached, or if the application is either politically
sensitive or contentious, then the application requires approval by the
Treasury.
7. Bids above £100,000 and up to £250,000 are considered and approved by the
Treasury.
8. Any bids above £250,000 and up to £500,000 are considered and approved
by the Treasury with the Council of Ministers then informed of the decision.
9. Any Treasury approved bids over £500,000 also require formal approval from
the Council of Ministers.
10. Bids from Treasury will be endorsed by the Treasury Board but will require
approval from the Council of Ministers regardless of value.
ELIGIBILITY CRITERIA
11. All eligible projects must support the overall objectives of the Economic
Development Fund specifically:
a) It must be of a transformational or temporary nature or is self-sustainable from
ongoing savings generated. Recurring or revenue expenditure is not eligible.
b) It must deliver tangible and pre-agreed, evidenced benefits. Savings will be
applied to Manx Care’s revenue targets.
c) A business case must be produced and signed off by the Manx Care’s Finance
Officer which will include:
i. Economic Benefits – Productivity and competitiveness
ii. Financial Benefits – including a consideration of cashability
iii. Social Benefits – Outcomes, intelligence, interventions and long term
strategy
iv. All benefits will be assessed annually.
d) It contributes to the overall objectives of the Economic Development Fund and
the benefits agreed must be committed in at least one of the five years up to
2020/21.
e) VAT, inter-departmental and contingency costs should not be included.
12. Drawdowns from the Fund will only be made available after it has been
demonstrated that Manx Carewill not produce an under-spend within the
current financial year.
13. All bids will be time-limited and extensions will require formal approval in line
with the governance framework outlined above. It is the responsibility of
Manx Care to ensure this.
14. Approvals are not transferrable between projects and a new business case
will be required for each new initiative.
Last Updated:
26.02.19
HEALTHCARE TRANSFORMATION FUND (HTF)
Terms of Reference
OVERVIEW
1. The Healthcare Transformation Fund was established by Tynwald with effect from the
1st April 2017, replacing the Health Inspection Fund.
2. The Fund arises from the need to support the controlled implementation of
transformational changes, which are necessary for the delivery of the DHSC’s Medium
Term Strategy. This will include initiatives to realise ongoing revenue savings, or
perhaps allow the double-running of services necessary to support realignment. Bids
can be made in respect of schemes which fall within the ambit of section 1 of the
National Health Service Act 2001.
3. Bids are invited and considered where the costs / potential revenue savings are clearly
defined and measurable, and where the key deliverables underpin the delivery of the
Department’s Strategy, which is built upon five pillars:
1. Prevention – enabling people to take greater responsibility for their own health
2. Community Care – helping people stay well in their own home / community
3. Acute Care – improving services for people that really need care in hospital
4. Protecting the vulnerable – provision of safeguards for people who cannot
protect themselves
5. Provision of good value Health and Social Care
4. Bids will be considered that clearly contribute to at least one of these. It is expected
that applications will provide payback savings within 2-3 years, although longer
periods may be considered in exceptional circumstances.
GOVERNANCE
5. All bids will require a business case outlining total set-up cost, ongoing revenue
implications and a robust savings profile. The business case template should be used
to support all submissions. All bids should have signed approval from relevant
departmental Finance Officer, Accountable Officers and Minister (Ministerial approval
requirement subject to a de-minimus level of £100,000).
6. Should the intention be for some or all of the funds to be paid to a third party
supplier, it is essential that this expenditure complies with both Financial Regulations
and the open and fair principles that underpin public sector procurement. To this end
where third-party expenditure is being considered, Procurement Services must be
engaged at the very earliest opportunity and certainly in advance of any formal
request for funds.
7. Bids up to £50,000 are subject to sign off by the Chief Financial Officer or Executive
Director - Financial Governance.
8. Bids between £50,000 and up to £100,000 require sign off by both the Executive
Director - Financial Governance and Chief Financial Officer. In the event that
agreement is not reached, or if the application is either politically sensitive or
contentious, then the application requires approval by the Treasury.
9. Bids between £100,000 and up to £250,000 are considered and approved by the
Treasury.
10. Any bids between £250,000 and £500,000 are considered and approved by the
Treasury with the Council of Ministers then informed of the decision.
11. Any Treasury approved bids over £500,000 also require formal approval from the
Council of Ministers.
ELIGIBILITY CRITERIA
12. All eligible projects must support the overall objectives of the Health Care
Transformation Fund specifically;
a) It must be of a transformational or temporary nature or is self-sustainable from
ongoing savings generated. Recurring or revenue expenditure is not eligible.
b) Savings may be applied to departmental revenue targets.
c) A business case must be produced and signed off by the sponsoring Department’s
Finance Officer which will include;
1. Financial Benefits – including a consideration of cashability
2. Social Benefits – Outcomes, intelligence, interventions and long term
strategy
3. Economic Benefits – Productivity and competitiveness
4. All benefits will be assessed annually.
d) Contributes to the overall objectives of the fund and the benefits agreed must be
committed within the 3 financial years following approval.
e) VAT, inter-departmental and contingency costs should not be included.
13. Departmental drawdowns from the Fund will only be made available after it has been
demonstrated that the Department will not produce an under-spend within the current
financial year.
14. All bids will be time-limited and extensions will require formal approval in line with the
governance framework outlined above. It is the responsibility of the Department to
ensure this.
15. Approvals are not transferrable between projects and a new business case will be
required for each new initiative.
Last Updated:
26.02.19
FUND NOT RELEVANT TO MCB – PLACEHOLDER THIS PAGE IS INTENTIONALLY
BLANK
INVEST TO SAVE FUND (ITSF)
Terms of Reference
OVERVIEW
1. The Invest to Save Fund was originally established by Tynwald with effect from the
1st April 2016. The Fund arose from the need to support the delivery of the Five Year
Financial Plan through the identification of change projects which facilitate the
opportunity to capture revenue target savings across Government.
2. The objective of the Invest to Save Fund is the provision of funding to enable the
implementation of upfront investment into projects which generate rapid revenue
savings.
3. Savings will be identified, with
a) 50% of payback savings recouped from Departments and applied to Departmental
revenue targets to allow resources to be returned to the general reserve or realigned
to new priorities as defined by the Council of Ministers.
b) Departments will be permitted to retain the remaining 50% of the annual savings
figure.
This element of the Terms of Reference was updated as part of the 2018/19 Budget
proposals.
4. The nature of savings will be a mix of short/long term and financial, social and
economic. Bids may be considered that contribute to one of these categories. It is
expected that applications will provide payback savings within 3-5 years, although
longer periods may be considered in exceptional circumstances. Ongoing savings
benefits after the payback period are expected.
5. The Fund replaced the Restructuring Fund, which was designed to support
Government’s Rebalancing the Budget Strategy.
6. This Fund is now designed to support the Five Year Financial Plan through the
delivery of projects that capture ongoing revenue savings. Applications for projects
that would otherwise have sought funding from the Restructuring Fund and the
Government Energy Initiatives Capital Fund now come to the Invest to Save Fund.
However funded items under the terms of the previous Restructure Fund do not
require the 50% ongoing revenue budget reductions.
GOVERNANCE
7. All bids will require a business case outlining total set-up cost, ongoing revenue
implications and a robust savings profile. The business case template should be
used to support all submissions. All bids should have signed approval from
relevant departmental Finance Officer, Accountable Officers and Minister
(Ministerial approval requirement subject to a de-minimus level of £100,000).
8. Should the intention be for some or all of the funds to be paid to a third party
supplier, it is essential that this expenditure complies with both Financial
Regulations and the open and fair principles that underpin public sector
procurement. To this end where third-party expenditure is being considered,
Procurement Services must be engaged at the very earliest opportunity and
certainly in advance of any formal request for funds.
INVEST TO SAVE FUND (ITSF)
Terms of Reference
9. Bids up to £50,000 are subject to sign off by the Chief Financial Officer or
Executive Director - Financial Governance.
10. Bids above £50,000 and up to £100,000 require sign off by both the Executive
Director - Financial Governance and Chief Financial Officer. In the event that
agreement is not reached, or if the application is either politically sensitive or
contentious, then the application requires approval by the Treasury.
11. Bids above £100,000 and up to £250,000 are considered and approved by the
Treasury.
12. Any bids above £250,000 and up to £500,000 are considered and approved by the
Treasury with the Council of Ministers then informed of the decision.
13. Any Treasury approved bids over £500,000 also require formal approval from the
Council of Ministers.
ELIGIBILITY CRITERIA
14. All eligible projects must support the overall objectives of the Invest to Save Fund
specifically:
o It must be of a transformational or temporary nature or is self-sustainable from
ongoing savings generated. Recurring or revenue expenditure is not eligible;
o It must deliver tangible and pre-agreed, evidenced benefits (e.g. Government
premises restructuring, staffing reorganisations, Mutually Agreed Resignation
Scheme payments etc.). Savings will be applied to departmental revenue
targets;
o A business case must be produced and signed off by the sponsoring
Department’s Finance Officer which will include:
financial benefits – including a consideration of cashability
social benefits – Outcomes, intelligence, interventions and long term
strategy
economic benefits – Productivity and competitiveness
all benefits will be assessed annually.
o It contributes to the overall objectives of the Invest to Save and the benefits
agreed must be committed in at least one of the next five years;
o VAT, inter-departmental and contingency costs should not be included.
15. Departmental drawdowns from the Fund will only be made available after it has
been demonstrated that the Department will not produce an under-spend within
the current financial year.
16. All bids will be time-limited and extensions will require formal approval from the
Treasury. It is the responsibility of the Department to ensure this.
17. Approvals are not transferrable between projects and a new business case will be
required for each new initiative.
Last Updated:
01.04.2020
LAND AND PROPERTY ACQUISITION RESERVE (LPAR)
Terms of Reference
OVERVIEW
1. The Land and Property Acquisition Reserve was established by Tynwald with effect
from the 1st April 2000.
2. The purpose of the Reserve is to provide additional funding to meet the cost of
acquiring land for the land bank and buildings for Government’s property asset
portfolio.
3. The Reserve is intended for the financing of expenditure on unplanned ad-hoc land
and building property transactions that do not form part of Government’s
approved Capital Programme.
4. Purchase transactions are financed through the Capital Account, with a
corresponding transfer from the Land and Property Acquisition Reserve to the
Capital Account by way of offset.
GOVERNANCE
5. All bids must demonstrate compliance with current Financial Regulations for land
acquisition and disposal.
6. Before considering submitting a bid for funding from the Reserve, Departments,
Boards and Offices must in the first instance consult with the Head of Asset
Management and Valuation.
7. All bids will require a business case outlining total set-up cost, ongoing revenue
implications and any savings profile. The business case template should be used to
support all submissions. All bids should have signed approval from relevant
Departmental Finance Officer, Accountable Officer and Minister (Ministerial
approval requirement subject to a de-minimus level of £100,000).
8. Bids up to £500,000 are subject to approval by the Strategic Assets and Capital
Investments Committee (SACIC), with Treasury then informed of the decision.
9. Bids above £500,000 and up to £1,000,000 are first considered by SACIC before
formal approval by Treasury.
10. Any Treasury approved bids over £1,000,000 also require formal approval from the
Council of Ministers.
11. Any capital receipts subsequently received from the sale of property originally
acquired with funds from the Land and Property Acquisition Reserve are credited
to the Capital Transactions Account as opposed to the Fund itself. Capital receipts
arising from the sale of any Government assets are not retained and ring-fenced
by Departments or other entities for their own future use. As the Reserve has no
source of income of its own (other than the year end allocation of interest on
balances held), it may need topping up from time to time with transfers from other
reserves or from the Operating Balance.
ELIGIBILITY CRITERIA
12. All eligible projects must support the overall objectives of the Land and Property
Acquisition Reserve specifically:
a. A business case must be produced and signed off by the sponsoring
Department’s Finance Officer which will include:
i. Economic Benefits – Productivity and competitiveness
ii. Financial Benefits – including a consideration of cashability
iii. Social Benefits – Outcomes, and long term strategy
b. VAT, inter-departmental and contingency costs should not be included.
13. All bids will be of a sufficiently urgent nature so as to prevent funding otherwise
being granted through the normal Capital Programme approval process.
14. Approvals are not transferrable between projects and a new business case will be
required for each new initiative.
Last Updated
26.02.2019
LEGAL COSTS RESERVE (LCR)
Terms of Reference
OVERVIEW
1. The Legal Costs Reserve was established by Tynwald in 2005. The Fund arises from a
need to ensure that funding is available to meet the cost of large and complex legal
cases, and other extraordinary legal costs, which would otherwise place undue strain
on the resources provided for prosecutions by the Attorney General’s Chambers, and
other areas of Government.
GOVERNANCE
2. All new bids will require a business case outlining the estimated cost profile excluding
VAT by financial year, together with any ongoing revenue implications. They should
demonstrate the exceptional and ad-hoc nature of the expense incurred. All bids
should have signed approval from the relevant departmental Finance Officer and
Accountable Officer.
3. Bids up to £50,000 are subject to sign off by the Chief Financial Officer or Executive
Director - Financial Governance.
4. Bids above £50,000 and up to £100,000 require sign off by both the Executive
Director - Financial Governance and Chief Financial Officer. In the event that
agreement is not reached, or if the application is either politically sensitive or
contentious, then the application requires approval by the Treasury.
5. Bids above £100,000 and up to £250,000 are considered and approved by the
Treasury.
6. Any bids above £250,000 and up to £500,000 are considered and approved by the
Treasury with the Council of Ministers then informed of the decision.
7. Any Treasury approved bids over £500,000 also require formal approval from the
Council of Ministers.
8. It is recognised that in practice, due to the nature of claims against this fund, there
are urgent circumstances whereby it will not be practical for the Attorney General to
secure funding approval or the opportunity to prepare a business case in advance of
the commitment to incur expenditure being given in Court. In such cases then the
subsequent sign off by the Chief Secretary, the Chief Financial Officer or the
Executive Director - Financial Governance is required. It is also recognised that the
full extent of funding requirement may not always be known in advance, in which
case an approval in principle will be required.
LCR Continued….
LEGAL COSTS RESERVE (LCR)
Terms of Reference
LCR ELIGIBILITY CRITERIA
9. All new claims for drawdown from the Legal Costs Reserve will be required to
demonstrate that they are of a one-off or exceptional nature and not intended to
fund an ongoing revenue deficit situation.
10. Departmental drawdowns from the Fund will only be made available after it has been
demonstrated that the Department will not produce an under-spend within the
current financial year.
Last Updated
06.03.2018
MARKETING INITIATIVES FUND (MIF)
Terms of Reference
OVERVIEW
1. The Marketing Initiatives Fund was established by Tynwald in 2005. The Fund arises
from a need to ensure that funding is provided for initiatives that promote the Island
to various markets and encourage access to business development opportunities.
2. The primary aim of the Fund is to provide funding for initiatives that promote the
Island to various markets and encourage access to business development
opportunities.
3. Bids are invited and considered where the costs and economic benefits are clearly
defined and measurable. Specifically, this includes exchequer benefits through income
tax, national insurance and where appropriate, spend into the local economy.
GOVERNANCE
4. All bids will require a business case outlining total set-up cost, ongoing revenue
implications, a robust savings profile and Key Performance Indicators (KPIs) for the
measurement of benefits and project success. The business case template should be
used to support all submissions. All bids should have signed approval from Manx
Care’s Finance Officer, Accountable Officer and Minister.
5. Should the intention be for some or all of the funds to be paid to a third party
supplier, it is essential that this expenditure complies with both Financial Regulations
and the open and fair principles that underpin public sector procurement. To this end
where third-party expenditure is being considered, Procurement Services must be
engaged at the very earliest opportunity and certainly in advance of any formal
request for funds.
6. Bids up to £50,000 are considered and approved by the Department for Enterprise.
This will require signed approval from the Accountable Officer and Minister. These
bids must be notified to Treasury.
7. Bids above £50,000 and up to £100,000 require sign off by both the Executive
Director - Financial Governance and Chief Financial Officer. In the event that
agreement is not reached, or if the application is either politically sensitive or
contentious, then the application requires approval by the Treasury.
8. Bids over £100,000 and up to £250,000 are considered and approved by the Treasury
following Departmental approval.
9. Any bids over £250,000 and up to £500,000 are considered and approved by the
Treasury with the Council of Ministers then informed of the decision.
10. Any Treasury approved bids over £500,000 also require formal approval from the
Council of Ministers.
11. A report on the activity of the Fund will be provided to Tynwald after the end of each
financial year. This will include a breakdown of income and expenditure for each
successful bid. Progress reports detailing outcomes achieved for approved bids are
MARKETING INITIATIVES FUND (MIF)
Terms of Reference
therefore sought from Departments each year. The report will also review the
ongoing purpose of the Fund and ensure it is updated or amended accordingly.
ELIGIBILITY CRITERIA
12. All eligible projects must support the overall objectives of the Marketing Initiatives
Fund specifically:
1. It must be of a transformational or temporary nature or is self-sustainable from
ongoing savings generated. Recurring or revenue expenditure is not eligible.
2. It must deliver tangible and pre-agreed, evidenced benefits. Savings may be
applied to departmental revenue targets.
3. A business case must be produced and signed off by the sponsoring Department’s
Finance Officer which will include;
a) Financial Benefits – including a consideration of cashability
b) Social Benefits – Outcomes, intelligence, interventions and long term
strategy
c) Economic Benefits – Productivity and competitiveness
d) All benefits will be assessed annually.
4. It contributes to the overall objectives of the fund and the benefits agreed must
be committed in at least one of the next five years.
5. VAT, inter-departmental and contingency costs should not be included
13. Departmental drawdowns from the Fund will only be made available after it has been
demonstrated that the Department will not produce an under-spend within the
current financial year.
14. All bids will be time-limited and extensions will require formal approval in line with the
governance framework outlined above. It is the responsibility of the Department to
ensure this.
15. Approvals are not transferrable between projects and a new business case will be
required for each new initiative.
Last Updated
01.03.2019
MEDICAL INDEMNITY FUND (MED)
Terms of Reference
OVERVIEW
1. The Medical Indemnity Fund was established by Tynwald in 1994.
2. The primary purpose of the Fund is to act as a cash-limited self-insurance fund to
meet the cost of valid claims for damages on behalf of patients against DHSC and
MCB staff working in the Island’s hospitals.
3. With effect from 1st April 2019, the Fund also makes provision for GPs and their
teams to be indemnified, for valid claims made by their patients for damages.
4. The Fund is not intended to cover liabilities arising from the operations at dentist
primary care surgeries, for which it is expected that those practices put in place their
own medical indemnity arrangements.
GOVERNANCE
5. The likelihood of claims resulting in payments and the timing of such payments is
difficult to predict. The Department of Health and Social Care and MCB monitors the
status of outstanding claims and assesses the probability risk of those claims and the
estimated liability risk arising.
6. Bids up to £1 million will require sign off by the Chief Financial Officer or Executive
Director - Financial Governance.
7. Bids over £1 million require consideration and approval by the Treasury.
8. Following consideration and endorsement by the Treasury, any bids over £3M then
require onward referral onto the Council of Ministers for formal approval.
ELIGIBILITY CRITERIA
9. Departmental drawdowns from the Medical Indemnity Fund will only be made
available after it has been demonstrated that the Department will not produce an
under-spend within the current financial year.
10. The Department must be in a position to demonstrate that any drawdown against the
Fund relates to actual costs incurred excluding VAT in relation to uninsured indemnity
claims.
Last Updated:
26.02.2019
MEDICAL INDEMNITY FUND (MED)
Terms of Reference
SEIZED ASSETS FUND (SAF)
Terms of Reference
OVERVIEW
1. The Seized Assets Fund was established by Tynwald in 1994. In 2009, the
Fund was reviewed by the Standing Committee on Public Accounts who
recommended that Government should consider the underutilisation of the
Fund and determine how this issue could be addressed.
2. The primary purpose of the Fund is to enable the proceeds of drug seizures
and other crimes to:
a) Be applied to the specific countering of all criminal activities, in particular the
damage caused to people and communities by serious and organised crime;
b) Be utilised to protect the public through the promotion and implementation of
community safety initiatives;
c) Fund Constabulary initiatives which are closely related to emerging threats and
developing issues, as defined by the Strategic Tasking and Co-ordinating Group
of the Constabulary;
d) Be used to provide grant assistance at Treasury’s discretion to assist with
community initiatives which are designed to counter the undesirable effects of
drugs and alcohol.
3. Bids are invited and considered where the costs and economic benefits are
clearly defined and measurable. Specifically, this includes investment into
projects, initiatives and operations that aren’t necessarily linked to drugs or
alcohol but do contribute towards the Constabulary’s vision of “Keeping People
Safe”.
GOVERNANCE
4. All bids will require a business case outlining total set-up cost, ongoing revenue
implications and a robust savings profile. The business case template should
be used to support all submissions. All bids should have signed approval from
the relevant departmental Finance Officer, Accountable Officer and Minister
(Ministerial approval requirement subject to a de-minimus level of £100,000).
5. Should the intention be for some or all of the funds to be paid to a third party
supplier, it is essential that this expenditure complies with both Financial
Regulations and the open and fair principles that underpin public sector
procurement. To this end where third-party expenditure is being considered,
Procurement Services must be engaged at the very earliest opportunity and
certainly in advance of any formal request for funds.
6. Following Departmental approval, applications are submitted to Treasury for
onward initial consideration by the Financial Intelligent Unit’s Board. The
Financial Intelligence Unit will provide advice to Treasury on all applications to
the Fund. Treasury has the final decision on approving applications from the
Fund.
7. Bids up to £50,000 are subject to sign off by the Chief Financial Officer or
Executive Director - Financial Governance, unless there is a difference of
opinion from the advice given by the Financial Intelligence Unit – in which case
referral to Treasury for a decision is required.
8. Bids between £50,000 and up to £100,000 require sign off by both the
Executive Director - Financial Governance and Chief Financial Officer. In the
event that agreement is not reached with all parties, or if the application is
either politically sensitive or contentious, then the application requires approval
by the Treasury.
9. Bids between £100,000 and up to £250,000 are considered and approved by
the Treasury.
10. Bids of between £250,000 and up to £500,000 require Treasury approval, with
Council of Ministers informed.
11. Bids of over £500,000, after consideration and approval by Treasury, require
ratification by Council of Ministers.
12. Bids from Treasury will be endorsed by the Treasury Board but will require
approval from the Council of Ministers regardless of value.
ELIGIBILITY CRITERIA
13. All eligible projects must support the overall objectives of the Seized Asset
Fund specifically:
i. They must be of a transformational or temporary nature or is self-sustainable
from ongoing savings generated. Recurring or revenue expenditure is not
eligible;
ii. They must deliver tangible and pre-agreed, evidenced benefits. Savings may
be applied to departmental revenue targets.
14. A business case must be produced and signed off by the sponsoring
Department’s Finance Officer which will include:
i) Financial Benefits – including a consideration of cashability;
ii) Social Benefits – Outcomes, intelligence, interventions and long term
strategy;
iii) Economic Benefits – Productivity and competitiveness;
iv) All benefits will be assessed annually;
v) It contributes to the overall objectives of the fund and the benefits agreed
must be committed in at least one of the five years up to 2020/21;
vi) VAT, inter-departmental and contingency costs should not be included.
15. Departmental drawdowns from the Fund will only be made available after it
has been demonstrated that the Department will not produce an underspend
within the current financial year.
16. All bids will be time-limited and extensions will require formal approval in line
with the governance framework outlined above. It is the responsibility of the
Department to ensure this.
17. Approvals are not transferrable between projects and a new business case will
be required for each new initiative.
Last Updated
5.11.2016
TOWN & VILLAGE CENTRE REGENERATION FUND (TVRF)
Terms of Reference
OVERVIEW
1. The Town & Village Centre Regeneration Fund was established in 2008 to provide
funding to revitalise the centres of the Isle of Man’s towns and villages, through
improvements to their retail environments. The reserve has been used to finance
construction schemes and also to provide grant assistance to businesses, charities,
local authorities and other agencies mainly outside Government, thereby contributing
towards wider economic development.
2. From 1st April 2016, the Fund will remain open for grant assistance applications but
funding for Government construction schemes has been transferred into the Capital
Programme.
3. The primary purpose of the Fund is to revitalise the centres of our towns and villages.
4. Bids are invited and considered where the costs and economic benefits are clearly
defined and measurable.
GOVERNANCE
5. The Governance for the Fund is determined by the Town and Village Centre
Regeneration Scheme 2013. The Scheme outlines in detail the purpose of the Scheme,
the criteria for eligibility for organisations intending to claim from the Fund, and the
methodology for seeking assistance under the Scheme.
6. Applications for assistance under the Scheme are submitted to and considered by the
relevant area’s Local Regeneration Committee established by the Chief Minister’s
Regeneration Steering Group.
7. Applications under £10,000 are determined by the Department for Enterprise following
recommendation by the Committee.
8. Applications over £10,000 are further subject to the Department’s recommendation to
the Chief Minister’s Regeneration Steering Group for decision.
9. No assistance exceeding £100,000 in total in respect of any one project may be made
without the consent of Treasury and approval from the Council of Ministers.
10. As of 1st April 2016 the Fund is closed for application of funding for construction
schemes. These are funded separately through Government’s Capital Programme,
though the governance surrounding the approval of such schemes remains consistent
with the Scheme’s regulations.
ELIGIBILITY CRITERIA
11. All eligible projects must support the overall objectives of the Town and Village Centre
Regeneration Fund, and must comply with the terms stipulated within the Town and
Village Centre Regeneration Scheme 2013.
Last Updated:
26.02.2019
Version Control
Date of Treasury Approval
24th March 2021
Issue Date
1st April 2021
Responsible Officer
Executive Director – Financial Governance
Table of Amendments
(to previous version)
Ref.
Amendment
3.2 b
Clarification that aggregated spend calculations should be based
on the greater of the last 3 years spend or the estimated next 3
years spend
Version Control
Date of Treasury Approval
24th Maarch 2021
Issue Date
1st April 2021
Responsible Officer
Total project value:
• Up to and including £250,000: the Executive Director -
Financial Governance;
• Over £250,000: The Treasury.
Table of Amendments
(to previous version)
Ref.
Amendment
Version Control
Date of Treasury Approval
24th March 2021
Issue Date
1st April 2021
Responsible Officer
Total contract value:
• Up to and including £150,000: Accountable Officer;
• Over £150,000 and up to and including £250,000:
Accountable Officer and the Executive Director - Financial
Governance/Chief Financial Officer;
• Over £250,000: The Treasury.
Table of Amendments
(to previous version)
Ref.
Amendment
WHOLE LIFE COSTINGS FOR 2014-2015
Small cars
Service/repairs costs taken from average costs from 5 recent service/repair events on vehicles aged between 1-4 years.
Fuel costs taken from average costs from 12 months usage. The average distance covered in sample was Note 4942 miles;
Depreciation value from Glass's guide, using Trade value against new full price cost
Pence per mile value assuming 10000 miles per year over 4 years. Actual mileages from fuel costs calculation may not be represent
10000 miles per year.
Citroen C3 VT 1.4HDi
Nissan Note 1.5dCi
Ford Fiesta D
Vauxhall Corsa 1.3D
Cost to DOI
£7,800.00
£8,700.00
£8,925.00
£8,450.00
Service/repairs
£155.00
£250.00
£375.00
£200.00
Fuel costs
£395.00
£395.00
£632.00
£490.00
Road tax
£0.00
£0.00
£0.00
£0.00
Depreciation
£5,200.00
£4,500.00
£5,300.00
£5,600.00
Running costs
£5,750.00
£5,145.00
£6,307.00
£6,290.00
Lifetime costs
£13,550.00
£13,845.00
£15,232.00
£14,740.00
Pence per mile
£0.34
£0.35
£0.38
£0.37
Car derived van
Service/repairs costs taken from average costs from 5 recent service/repair events on vehicles aged between 1-4 years.
Fuel costs taken from average costs from 12 months usage. The average distance covered in sample was 10671 miles
Depreciation value from Glass's guide, using Trade value against new full price cost
Pence per mile value assuming 10000 miles per year over 4 years. Actual mileages from fuel costs calculation may not be represent
10000 miles per year.
Citroen Berlingo 1.6HDi
Ford Transit Connect
Cost to DOI
£8,800.00
£9,900.00
Service/repairs
£395.00
£667.00
Fuel costs
£1,058.00
£727.00
Road tax
£0.00
£0.00
Depreciation
£8,000.00
£8,000.00
Running costs
£9,453.00
£9,394.00
Lifetime costs
£18,253.00
£19,294.00
Pence per mile
£0.46
£0.48
1 tonne panel van
Service/repairs costs taken from average costs from 5 recent service/repair events on vehicles aged between 1-4 years.
Fuel costs taken from average costs from 12 months usage. The average distance covered in sample was Vivaro 7706 miles;
Transit 5912 miles; Boxer 5919 miles
Depreciation value from Glass's guide, using Trade value against new full price cost
Pence per mile value assuming 10000 miles per year over 4 years. Actual mileages from fuel costs calculation may not be represent
10000 miles per year.
Vauxhall Vivaro
Ford Transit
Peugeot Boxer
Mercedes Benz Vito 110
Cost to DOI
£12,000.00
£12,500.00
£14,250.00
£15,750.00
Estimate
Service/repairs
£413.00
£688.00
£318.00
£350.00
Estimate
Fuel costs
£1,165.00
£880.00
£965.00
£1,100.00
Estimate
Road tax
£0.00
£0.00
£0.00
£0.00
Depreciation
£11,000.00
£11,000.00
£11,000.00
£11,000.00
Estimate
Running costs
£12,578.00
£12,568.00
£12,283.00
£12,450.00
Lifetime costs
£24,578.00
£25,068.00
£26,533.00
£28,200.00
Pence per mile
£0.61
£0.63
£0.66
£0.71
Manufacturer
& Model
Purchase
Price (ex
VAT)
Servicing,
Repairs &
Tyres
(1,2,3,4)
Road Fund
Licence (5)
Fuel (6)
Estimated
Residual
Value (7)
Total Life
Cost (Over 5
years)
Ford Transit
Connect
£11,470
£5,960
£720
£5,462
(£2,000)
£21,612
Vauxhall
Combovan
£13,814
£5,174
£720
£4,580
(£2,000)
£22,288
Mercedes Citan
£14,228
£5,935
£330
£4,498
(£3,000)
£21,991
Nissan eNV200
£17,550
£4,460
£75
£2,690
(£3,500)
£21,275
Vehicle and Plant Procurement Stage Approvals
Stage
Stage
Category 1
Vehicles
Category 2
Vehicles
Category 3
Vehicles
Category 3
Vehicles
<3 quotes
Category 4
Vehicles
Category 4
Vehicles
<3 quotes
Category 5
Plant and
Equipment
Category 5
Plant and
Equipment
<3 quotes
Decision to include
SFS in liaison with
Client Department
Representative
SFS in liaison with
Client Department
Representative
SFS/Client
Department
SEO/D600 or above
SFS/Client
Department
SEO/D600 or above
SFS/Client
Department
SEO/D600 or above
SFS/Client
Department
SEO/D600 or above
SFS/Client
Department
SEO/D600 or above
SFS/Client
Department
SEO/D600 or above
asset in
replacement
schedule
Business case
approval**
Business case
N/A
SFS D600 or above
SFS D600 or above
Director of Public
Transport,
>£250K Treasury
SFS D600 or above
Director of Public
Transport,
>£250K Treasury
SFS D600 or above
Director of Transport
Services,
>£250K Treasury
approval**
Specification
Development
SFS/Client
Department
Representative
SFS/Client
Department
Representative
SFS/Client
Department
Representative
SFS/Client
Department
Representative
SFS/Client
Department
Representative
SFS/Client
Department
Representative
SFS/Client
Department
Representative
SFS/Client
Department
Representative
Specification
SFS/Client
Department
Representative
SFS/Client
Department
Representative
SFS/Client
Department SEO or
above
SFS/Client
Department SEO or
above
SFS/Client
Department SEO or
above
SFS/Client
Department SEO or
above
SFS/Client
Department SEO or
above
SFS/Client
Department SEO or
above
agreed, formal
sign off **
Tender Process
SFS
SFS
SFS
SFS
SFS
SFS
SFS
SFS
Tender approval**
SFS
SFS D600 or above
Director of Public
Transport
Accountable Officer,
>£250K Treasury
Director of Public
Transport
Accountable Officer,
>£250K Treasury
Director of Public
Transport
Accountable Officer,
>£250K Treasury
Place Order
Place Order
SFS
SFS
SFS
SFS
SFS
SFS
SFS
SFS
Build Process
N/A
SFS
SFS
SFS
SFS
SFS
SFS
SFS
Commissioning
N/A
SFS/Client
Department
Representative
SFS/Client
Department
Representative
SFS/Client
Department
Representative
SFS/Client
Department
Representative
SFS/Client
Department
Representative
SFS/Client
Department
Representative
SFS/Client
Department
Representative
Delivery
SFS
SFS
SFS
SFS
SFS
SFS
SFS
SFS
Pre service checks
Dealer/SFS
Dealer/SFS
SFS/Supplier
SFS/Supplier
SFS/Supplier
SFS/Supplier
SFS/Supplier
SFS/Supplier
Introduction to
service/swap out
SFS/Client
Department
Representative
SFS/Client
Department
Representative
SFS/Client
Department
Representative
SFS/Client
Department
Representative
SFS/Client
Department
Representative
SFS/Client
Department
Representative
SFS/Client
Department
Representative
SFS/Client
Department
Representative
Category 1
Vehicles
Category 2
Vehicles
Category 3
Vehicles
Category 3
Vehicles
<3 quotes
Category 4
Vehicles
Category 4
Vehicles
<3 quotes
Category 5
Plant and
Equipment
Specification
Development
Introduction to
service/swap out
VEHICLE AND PLANT REPLACEMENT MATRIX
Award Criteria
Vauxhall
Mercedes
Ford
Citroen
Nissan
Price
Max Score
Value (£)
Total %
Value (£)
Total %
Value (£)
Total %
Value (£)
Total %
Value (£)
Total %
Vehicle Cost
15,000.00
16,000.00
14,000.00
13,000.00
17,000.00
Lowest value submission is awarded 10%, remaining submissions are expressed
as a % of the lowest bid = ((value of lowest bid/value of other bid)*30)
10%
9
8
9
10
8
IOM Whole Life Cost ppm or Industry Standard Whole Life Costs as applicable
0.34
0.35
0.32
Total whole life cost based on …….miles and replacement at………years
20%
20,000.00
21,000.00
18000.00
Lowest value submission is awarded 50%, remaining submissions are expressed
as a % of the lowest bid = ((value of lowest bid/value of other bid)*50)
50%
43
41
46
50
38
Total (Price)
80%
52
49
55
60
46
Quality
Weighting
Max
Weighted
Score
score
weighted
total
score
weighted
total
score
weighted
total
score
weighted
total
score
weighted
total
Compliance with Specification
3
20
4
12
3
9
3
9
4
12
3
9
Tender submission compliance
3
10
3
9
3
9
3
9
3
9
3
9
Availability
1
2
2
2
2
2
1
1
2
2
1
1
Training
1
3
3
3
2
3
1
1
1
1
1
1
Warranty
1
5
4
4
3
4
1
1
1
1
1
1
Total (Quality)
40
30
27
21
25
21
Highest quality score is awarded 20%, remaining scores are expressed as a %
of the highest score = ((score of other bid/highest score)*20)
20%
20.0
13.0
15.0
16.0
12.0
Total %
100%
72
62
70
76
58
Criteria for awarding score
Score
Completely fails to meet required standard or does not provide a proposal.
0
Proposal significantly fails to meet the standards required, contains significant
shortcomings and/or is inconsistent with other proposals.
1
Proposal falls short of achieving expected standard in a number of identifiable
respects.
2
Proposal meets the required standard in most material respects, but is lacking or
inconsistent in others.
3
Proposal meets the required standard in all material respects.
4
Proposal meets the required standard in all material respects and exceeds some
or all of the major requirements.
5
Version Control
Date of Treasury Approval
24th March 2021
Issue Date
1st April 2021
Responsible Officer
Total contract value:
• Up to and including £150,000: Executive Director GTS;
• Over £150,000: Executive Director - Financial Governance.
Table of Amendments
(to previous version)
Ref.
Amendment
4.2
Increase in the standard maximum contract length to 10 years,
subject to approval from the Executive Director of GTS.
Version Control
Date of Treasury Approval
24th March 2021
Issue Date
1st April 2021
Responsible Officer
Total contract value:
• Up to and including £250,000: the Executive Director -
Financial Governance/Chief Financial Officer;
• Over £250,000: The Treasury.
Table of Amendments
(to previous version)
Ref.
Amendment
Version Control
Date of Treasury Approval
24th March 2021
Issue Date
1st April 2021
Responsible Officer
Total contract value:
• £10,000 or less: the Budget Holder (subject to their
delegated authority);
• Over £10,000 and up to and including £100,000: Accountable
Officer
N.B. contract values over £100,000 are covered under Financial
Direction FD C9.
Table of Amendments
(to previous version)
Ref.
Amendment
3.3
Advertisment of opportunities to be via the AGC Portal
3.4
Quick Quote template introduced
Appendix 1
Stipulates a new advertisement period
Appendix 2
Quick Quote template added
Requirement4
Total charge for
provision of services
(per day)
£
£
Total
£
Score
Criteria for awarding Score
0
Completely fails to meet required standard or does not provide a proposal.
1
Proposal significantly fails to meet the standards required, contains significant shortcomings and/or
is inconsistent with other proposals.
2
Proposal falls short of achieving expected standard in a number of identifiable respects.
3
Proposal meets the required standard in most material respects, but is lacking or inconsistent in
others.
4
Proposal meets the required standard in all material respects.
5
Proposal meets the required standard in all material respects and exceeds some or all of the major
requirements.
Service Requirements
Req.
No.
Minimum
Scope
Score or
Pass/Fail
Question
1.0
Describe any experience of xxxxxxxxxxx.
Req.
No.
Service Requirements
Req.
No.
Minimum
Scope
Score or
Pass/Fail
Question
2.0
Provide a brief outline of xxxxxxxxxxxxxx
3.0
Provide copies of your certification for xxxxxxxxxxxxxx
4.0
Provide a brief outline of xxxxxxxxxxxxxx
Req.
No.
Environmental and Sustainability7
5.0
.0
The Isle of Man Government is committed to the reduction of
single use plastic. https://www.gov.im/about-the-
government/departments/environment-food-and-
agriculture/ecosystem-policy-and-energy/plastics/
In no more than [●] words, please identify how your Tender
Response supports this policy and provide details of your
organisation’s wider policies on environmental and sustainability
issues.
Local Economic Factors
6.0
.0
In no more than 400 words, please identify what benefits your
company would bring to the Isle of Man economy as a direct
result of undertaking this contract. This may include economic
contribution such as personnel, income tax, travel, bed nights or
social contribution such as training and development to the wider
community.8
Version Control
Date of Treasury Approval
24th March 2021
Issue Date
1st April 2021
Responsible Officer
Chief Accountant
Table of Amendments
(to previous version)
Ref.
Amendment
3.6
Text amended to state that where a purchase order is used it
must state that the purchase is subject to Standard Terms and
Conditions for the Purchase of Goods/Services
Ref
No.
Order
Date
Supplier
Item
Description
Date
Received
Amount inc VAT
VAT Category
E – Exempt
Z – Zero
S – Standard
R - Reduced
O/S – Outside scope
Monthly
Cumulative
Additional coding information (if this
transaction should not go to your
default cost centre)
E.g. Cost Centre
E.g. Job Number
E.g. Capital
Project
1
2
3
4
5
6
7
8
9
10
Version Control
Date of Treasury Approval
24th March 2021
Issue Date
1st April 2021
Responsible Officer
Total contract value:
• Up to and including £150,000: Accountable Officer;
• Over £150,000 and up to and including £250,000:
Accountable Officer and the Board;
• Over £250,000: The Treasury.
• In respect of tender process and stages the Director of
Commercial Law
Table of Amendments
(to previous version)
Ref.
Amendment
6.1
Tender process must be followed unless prior written approval
has been received
6.2
Tender process must not commence until written approval to
proceed has been given by the Director of Commercial Law
6.3
Requirement added for 3rd parties to run the tendering exercise
6.5 (e iii)
Requirements for the production of an appraisal report
6.5 (e vi)
Right of appeal to tenders undertaken by 3rd parties
6.8
Notification of site visits to the AGC
Version Control
Date of Treasury Approval
24th March 2021
Issue Date
1st April 2021
Responsible Officer
Director of Commercial Law
Table of Amendments
(to previous version)
Ref.
Amendment
Version Control
Date of Treasury Approval
24th March 2021
Issue Date
1st April 2021
Responsible Officer
Director of Commercial Law
Table of Amendments
(to previous version)
Ref.
Amendment
Appendix 1
Information Security – wording amended
Score
Criteria for awarding score
0
Completely fails to meet required standard or does not provide a proposal.
1
Proposal significantly fails to meet the standards required, contains significant
shortcomings and/or is inconsistent with other proposals.
2
Proposal falls short of achieving expected standard in a number of identifiable respects.
3
Proposal meets the required standard in most material respects, but is lacking or
inconsistent in others.
4
Proposal meets the required standard in all material respects.
Local Economic Factors
A
Please estimate what percentage of your tender price will be
delivered by Isle of Man based resources?
B
Please confirm approximately how many of the personnel engaged
to complete this project / service will be paying local income tax and
national insurance in Isle of Man?
C
Where applicable, please indicate the number of on/off island
movements you anticipate to fulfil this contract, and indicate
whether by sea or air.
D
Where applicable, please indicate the number of bed nights you
anticipate bringing to the Island to complete this project / service.
E
In no more than 400 words, please identify what benefits your
company would bring to the Isle of Man economy as a direct result
of undertaking this contract.
BENEFITS FOR THE LOCAL COMMUNITY
A
In no more than 400 words, please identify what benefits your
company would bring to the Isle of Man economy as a direct result
of undertaking this contract. This may include economic contribution
such as personnel, income tax, travel, bed nights or social
contribution such as training and development to the wider
community.
Version Control
Date of Treasury Approval
24th March 2021
Issue Date
1st April 2021
Responsible Officer
Chief Accountant
Table of Amendments
(to previous version)
Ref.
Amendment
Version Control
Date of Treasury Approval
24th March 2021
Issue Date
1st April 2021
Responsible Officer
Chief Accountant
Table of Amendments
(to previous version)
Ref.
Amendment
Asset Group
Asset Type
Asset Sub Group
Description
Code
Goodwill
Intangible
Goodwill
Amount above the value of
assets and liabilities.
Seperately identifiable
GDWL
Software
Intangible
Software
Purchased software
systems
SOFT
Licences
Intangible
Licences
Purchased licences
LICS
Land & Buildings
Tangible
Social housing
BDSH
Tangible
Land - Freehold
LANF
Tangible
Land - Leasehold
Purchase of a long term
lease
LANL
Tangible
Buildings - Freehold
BDGF
Tangible
Buildings - Leasehold
Purchase of a long term
lease
BDGL
Tangible
Other
BDOT
Tangible
Investment Properties
Investment properties –
Land and/or buildings
where construction work
and development have
been completed and which
is held for its investment
potential, any rental
income being negotiated
at arm’s length.
BDIN
Infrastructure
(Infrastructure assets
will not be liable to a
Tangible
Highways
INFH
Tangible
Street furniture
Traffic lights, street lights
etc
INFN
FRS102 process of
revaluations – All
road improvements
will be capitalised & a
life expectancy
attached to each
improvement.
Land Values to apply)
Tangible
Footpaths &
Permanent ways
INFP
Tangible
Bridges & constructs
INFB
Tangible
Coastal defences
INCD
Tangible
Water, Drainage &
Distribution systems
INWD
Tangible
Reservoirs
INFR
Tangible
Other
INOT
Vehicles, boats and
transport
Tangible
Motor vehicles
Cars, bikes and vans
VEHM
Tangible
Commercial &
Transport
HGV’s and buses, railway
vehicles
VEHC,
VEHP,
VEHR
Tangible
Boats
VEHB
Tangible
Specialist
VEHS
Plant & equipment
Tangible
Plant & equip. - short
term
Service life under 10 years
P&ES
Tangible
Plant & equip. - long
term
Service life over 20 years
P&EL
Furniture
Tangible
Furniture
FURN
Computers &
communications
Tangible
PC's & servers
COMP
Tangible
Communications
Phones & network
COMM
Tangible
Printers, faxes etc.
Pc peripherals and other
equipment
COEQ
Community assets
Tangible
Parks & allotments
CAPA
Tangible
Cemeteries
CACM
Tangible
Works of art/statues
CAWA
Tangible
Museum Exhibits
CAMU
Tangible
Castles, monuments
etc.
CACA
Acquisition
Department
Fixed Asset
Group
Fixed
Asset Sub
Group
Name
location
Leased
asset
Loaned
asset
Service
Life
(years)
Acquisition
date
Acquisition
cost
31/03/yy
Valuation
AX department
reference number (2
characters numeric -
nn)
Use Groups
specified in note.
Use Sub
Groups
specified in
note.
30
characters
- alpha/
numeric
10
characters
- alpha/
numeric
Yes or No
(Y or N)
Yes or No
(Y or N)
2
characters
numeric
dd/mm/yy
Value in
round pounds
i.e. 0,000's
Value in
round
pounds i.e.
0,000's
Revaluation
Disposal
Revaluation
date
Revaluation
amount
Disposal
Date
Disposal
Amount
Division
Search
name
Other Info
Valuation
method
Valuers
details
M a k e
Model /
Amount
Serial
Number
Fixed
asset
number
Comment
s
dd/mm/yy
Value in
round
pounds i.e.
0,000
dd/mm/yy
e.g.
31/03/10
Value in
round
pounds
i.e. 0,000
AX division
number - 4
characters
20 characters
-
alpha/numeric
260 characters
-
alpha/numeric
80 characters
-
alpha/numeric
80 characters
-
alpha/numeric
20
characters
- numeric
10
characters
-
alpha/num
eric
254
characters
-
alpha/num
eric
Class
Sub Class
Valuation Basis
Depreciation
Grouped
Software
Software purchased
Software purchased
Historical Cost
3 - 7 years
Individual/Grouped
Licences
Licences
Licences
Historical Cost
3 years /
Period of
licence
Individual
Class
Sub Class
Reporting Basis
Depreciation
Grouped
Community
Dwellings
Social housing
Fair Value
40 years
Individual
Other land &
Buildings
Land
Fair Value
None
Individual
Land - Freehold
Fair Value
None
Land - Leasehold
Fair Value
None
Buildings - Freehold
Fair Value
40 years
Individual
Buildings -
Leasehold
Fair Value
Over period of
lease
Individual
Other
Fair Value
20 - 40 years
Individual
Class
Sub Class
Reporting Basis
Depreciation
Grouped
Infrastructure
assets
Highways
Historical Cost
10 - 30 years
Grouped
Street furniture
Historical Cost
10 years
Grouped
Footpaths &
Permanent ways
Historical Cost
30 years
Grouped
Bridges &
constructs
Historical Cost
30 – 40 years
Grouped
Coastal defences
Historical Cost
40 – 60 years
Grouped
Water, Drainage &
Distribution
systems
Historical Cost
40 - 60 years
Grouped
Reservoirs
Historical Cost
150 years
Individual
Class
Sub Class
Reporting Basis
Depreciation
Grouped
Vehicles, boats
and transport
Motor vehicles
Historical Cost
5 years
Grouped
Commercial &
Transport
Historical Cost
5 years
Grouped
Boats
Historical Cost
5 years
Individual
Specialist
Historical Cost
5 - 10 years
Grouped/Individual
Class
Sub Class
Reporting Basis
Depreciation
Grouped
Plant &
equipment
Plant & equipment-
short term
Historical Cost
3 - 9 years
Grouped
Plant & equipment-
long term
Current value
10 – 30 years
Individual
Class
Sub Class
Reporting Basis
Depreciation
Grouped
Furniture
Furniture
Historic cost (Only on
grounds of
materiality)
3 years
Grouped
Class
Sub Class
Reporting Basis
Depreciation
Grouped
Computers &
communications
PC's & servers
Historic cost (Only on
grounds of
materiality)
3 years
Grouped
Communications
Historic cost (Only on
grounds of
materiality)
5 years
Grouped
Printers, faxes etc.
Historic cost (Only on
grounds of
materiality)
3 years
Grouped
Class
Sub Class
Reporting Basis
Depreciation
Grouped
Community
assets
Parks & allotments
Historical Cost
None
Individual
Cemeteries (land
only)
Historical Cost
None
Individual
Other
Historical Cost
None
Individual
Class
Sub Class
Reporting Basis
Depreciation
Grouped
Heritage Assets
Works of
art/statues
Historical Cost
None
Grouped
Museum Exhibits &
other
Historical Cost
None
Grouped
Historic buildings
(Operational)
Fair Value
40 years
Individual
Historic buildings
(Non-Operational)
Historical Cost
40 years
Individual
Class
Sub Class
Reporting Basis
Depreciation
Grouped
Investment
properties
Investment
properties
Current value
No
Depreciation
Individual
Class
Sub Class
Reporting Basis
Depreciation
Grouped
Assets under
construction
Assets under
construction
Historical Cost
No
Depreciation
Individual
Class
Sub Class
Reporting Basis
Depreciation
Grouped
Surplus assets
held for
disposal
Surplus assets held
for disposal
Fair Value
20 years
Individual
Version Control
Date of Treasury Approval
24th March 2021
Issue Date
1st April 2021
Responsible Officer
Executive Director - Financial Governance
Table of Amendments
(to previous version)
Ref.
Amendment
Version Control
Date of Treasury Approval
24th March 2021
Issue Date
1st April 2021
Responsible Officer
Chief Accountant
Table of Amendments
(to previous version)
Ref.
Amendment
Version Control
Date of Treasury Approval
24th March 2021
Issue Date
1st April 2021
Responsible Officer
Chief Accountant
Table of Amendments
(to previous version)
Ref.
Amendment
Version Control
Date of Treasury Approval
24th March 2021
Issue Date
1st April 2021
Responsible Officer
Chief Accountant
Table of Amendments
(to previous version)
Ref.
Amendment
Version Control
Date of Treasury Approval
24th March 2021
Issue Date
1st April 2021
Responsible Officer
The Executive Director of Human Resources
Table of Amendments
(to previous version)
Ref.
Amendment
Version Control
Date of Treasury Approval
24th March 2021
Issue Date
1st April 2021
Responsible Officer
Executive Director of Human Resources
Table of Amendments
(to previous version)
Ref.
Amendment
Version Control
Date of Treasury Approval
24th March 2021
Issue Date
1st April 2021
Responsible Officer
Chief Accountant
Table of Amendments
(to previous version)
Ref.
Amendment
Version Control
Date of Treasury Approval
24th March 2021
Issue Date
1st April 2021
Responsible Officer
Director of Operations and Infrastructure (GTS)
Table of Amendments
(to previous version)
Ref.
Amendment
Version Control
Date of Treasury Approval
24th March 2021
Issue Date
1st April 2021
Responsible Officer
Where the value is:
1. £250,000 or less: Executive Director - Financial
Governance
2. More than £250,000: Treasury
Table of Amendments
(to previous version)
Ref.
Amendment
Version Control
Date of Treasury Approval
24th March 2021
Issue Date
1st April 2021
Responsible Officer
Historical cost:
1. Up to and including £10,000: Budget Holder (up to their
delegated financial authority);
2. Up to and including £100,000: Accountable Officer.
Table of Amendments
(to previous version)
Ref.
Amendment
Legislation
Year and No
Commencement
Original
Current
Information created by an Authority
Information held by a third party on
behalf of an Authority
Information created by a third party and
obtained by an Authority
Information that an Authority holds
partly on behalf of itself and partly on
behalf of a third party
If an Authority’s resources are being used
If an Authority decides what information
is retained, altered or deleted
If an Authority provides clerical and
administrative support
If an Authority deals with enquiries and
requests
If information is included within an
Authority’s budget
An Authority has no access to, use for, or
interest in the information
Access to the information is controlled
by a third party
An Authority does not provide any direct
assistance at its own discretion in
creating, recording, filing or removing the
information
An Authority is merely providing storage
facilities, whether physical or electronic
Whether an Authority knows what it is
looking for and where it is logical to
search to identify if the information exists
and having conducted such a search no
information has been located
Whether the requested information does
not relate to matters that an Authority
is responsible for
Whether there has ever been a business
need for an Authority to record such
information
Whether it is not common practice for
an Authority to record information of
the type requested
Whether such information is included
within any of an Authority’s records
management policies
Abusive or aggressive
language
The tone or language of the Applicant’s correspondence
goes beyond the level of criticism that an Authority or its
employees should reasonably expect to receive.
Burden on an
Authority
The effort required to meet the request will be
disproportionate in terms of the strain on time and
resources, that an Authority cannot reasonably be expected
to comply, no matter how legitimate the subject matter or
valid the intentions of the Applicant.
Deliberate intention to
cause annoyance
The Applicant has explicitly stated that it is their intention to
cause disruption to an Authority, or is a member of a
campaign group whose stated aim is to disrupt an Authority.
Disproportionate
effort
The matter being pursued by the Applicant is relatively trivial
and an Authority would have to expend a disproportionate
amount of resources in order to meet their request.
Frequent or
overlapping requests
The Applicant submits frequent correspondence about the
same issue or sends in new requests before an Authority has
had an opportunity to address their earlier enquiries.
Futile requests
The issue at hand individually affects the Applicant and has
already been conclusively resolved by an Authority or
subjected to some form of independent investigation.
Intransigence
The Applicant takes an unreasonably entrenched position,
rejecting attempts to assist and advise and shows no
willingness to engage with an Authority.
Motive
This might be an important factor in determining
vexatiousness. A request may start as reasonable but lead to
further requests which become increasingly distant from the
Applicant’s starting point.
No obvious intent to
obtain information
The Applicant is abusing their rights of access to information
by using the Act as a means to vent their anger at a
particular decision, or to harass and annoy an Authority, for
example, by requesting information which an Authority
knows them to possess already.
Obsessive conduct
Conduct that harasses or distresses staff or uses
intemperate language, or which makes unsubstantiated
allegations or contains abuse.
Personal grudges
The Applicant is targeting correspondence towards a
particular employee or office holder against whom they have
some personal hostility.
Scattergun approach
The request appears to be part of a completely random
approach, lacks any clear focus, or seems to have been
solely designed for the purpose of “fishing” for information
without any idea of what might be revealed.
Unfounded
accusations within a
request
The request includes completely unsubstantiated accusations
against an Authority or specific employees.
Unreasonable
persistence
The Applicant is attempting to reopen an issue which has
already been comprehensively addressed by an Authority or
otherwise subjected to some form of independent scrutiny.
Repeated requests
based in a
fundamental
misunderstanding
Requests which do not fall within section 11(3)(e)(i) of the
Act but exist pursuant to a fundamental misunderstanding of
the role of an Authority and the information that it holds.
Following the provision of advice and assistance, the
Applicant continues to pursue an Authority for information,
failing to understand that the request cannot be fulfilled.
Unwillingness to
accept result
The Applicant believes that more information exists beyond
that which was requested and refuses to accept that either
an Authority does not hold the information or an Authority
does not hold any further information beyond that which has
already been provided.
Abusiveness
The request or any subsequent correspondence contains
abuse towards officers or a particular individual.
Blackmail
An Applicant includes within the request or subsequent
correspondence any suggestion for an Authority or an
employee of an Authority or any other person to do
something “or else”, that to a reasonable individual could be
interpreted as an unwarranted threat.
Harassment
The Applicant acts against an Authority either singularly or in
concert with others, in pursuit of a mischievous objective.
Unjustified persistence
The Applicant mounts an intensive campaign of overzealous
scrutiny creating a detrimental effect on an Authority and
intolerable working conditions.
Trivial
The subject matter is inane or of very little importance or
value.
Lack of purpose
The request appears to lack any serious purpose.
Not worthy of serious
attention
The request is made for the sole purpose of amusement or
nuisance value.
Other purpose
The request is made for a purpose other than seeking
access to information.
Reference
Freedom of Information Act - Compliance - Guidance
Date
9 Feb 2016
Author
Information Governance Team (IGT)
Approved by
Date
Version
Number
Revision Notes
Author
Service Area - to forward
request (including date
received) ASAP to IGT
Section 20
Information available by other means – Absolute Exemption
Section 21
Court Information - Absolute Exemption
Section 22
Parliamentary Privilege - Absolute Exemption
Section 23
Communications with the Crown - Absolute Exemption
Section 24
International Agreements - Absolute Exemption
Section 25
Personal Data - Absolute Exemption
Section 26
Information Provided in Confidence - Absolute Exemption
Section 27
Disclosure Restricted by Law - Absolute Exemption
Section 28
National Security and Defence
Section 29
International Relations
Section 30
Economy and Commercial Interests
Section 31
Investigations and Legal Proceedings
Section 32
Law Enforcement
Section 33
Audit Functions
Section 34
Formulation of Policy
Section 35
Conduct of Public Business
Section 36
Health and Safety
Section 37
Research and Natural Resources
Section 38
Qualified Exempt Communications with the Crown
Section 39
Qualified Exempt Personal Information
Section 40
Legal Professional Privilege
Section 41
Information for Future Publication
Year
Number of inductions
2018
267
2019
225
2020
261
Category 1
2018
10
2019
9
2020
4
Category 2
2018
84
2019
80
2020
79
Category 3
2018
28
2019
38
2020
24
Category 4
2018
98
2019
116
2020
91
Annual
Summary
2015
2016
2017
2018
2019
2020
Cortisol
1,336
1,545
1,449
1,395
1,492
1,468
Urine Cortisol
91
101
45
0
0
49
Month
Cortisol
Urine
Cortisol
Jan15
101
9
Feb15
83
4
Mar15
101
10
Apr15
121
9
May15
120
5
Jun15
141
12
Jul15
122
8
Aug15
88
6
Sep15
129
7
Oct15
105
5
Nov15
121
4
Dec15
104
12
Jan16
151
15
Feb16
111
10
Mar16
149
10
Apr16
95
4
May16
123
2
Jun16
123
6
Jul16
130
6
Aug16
135
8
Sep16
121
9
Oct16
162
11
Nov16
144
7
Dec16
101
13
Jan17
136
9
Feb17
136
9
Mar17
100
8
Apr17
120
7
May17
127
2
Jun17
118
7
Jul17
104
1
Aug17
140
2
Sep17
102
0
Oct17
127
0
Nov17
131
0
Dec17
108
0
Jan18
126
0
Feb18
101
0
Mar18
110
0
Apr18
132
0
May18
135
0
Jun18
100
0
Jul18
101
0
Aug18
119
0
Sep18
119
0
Oct18
126
0
Nov18
113
0
Dec18
113
0
Jan19
145
0
Feb19
96
0
Mar19
117
0
Apr19
118
0
May19
115
0
Jun19
87
0
Jul19
168
0
Aug19
134
0
Sep19
134
0
Oct19
127
0
Nov19
125
0
Dec19
126
0
Jan20
129
4
Feb20
96
6
Mar20
61
0
Apr20
61
1
May20
88
2
Jun20
124
4
Jul20
137
8
Aug20
118
8
Sep20
175
6
Oct20
126
4
Nov20
172
1
Dec20
181
5
Urgent Breast Surgery
Year Month Number of Average wait
Urgent referrals time (days)
2020 May 10 21
2020 June 18 12
2020 July 11 19
2020 August 12 17
2020 September 23 20
2020 October 26 24
2020 November 26 41
2020 December 25 38
2021 January 16 21
2021 February 16 22
2021 March 28 26
2021 April 21 33
TOTAL 232 26
Advertising Budget for 2021-22
Amount
Corporate
£10,000
Children & Family Services
£80,000
Primary & Community Care
£30,000
Noble’s
£50,000
Total
£170,000
Advertising Expenditure
Facebook
Professional Journal and
Recruitment
Mental Health
£60
Nobles Hospital
£38
£3,038
Year
Spend
Comment
2016-17
£5,425
Generic/Group training
2017-18
£0
2018-19
£1,338
Individual: practice nurse as on-island training was unavailable at the time
2019-20
£500
Individual: skills lab training as on-island training was unavailable at the time
2020-21
£0
IN GOVERNMENT
Departmental sustainability champions
Each department and agency has been asked to appoint a sustainability
champion who will lead on implementing the reduction of single use
plastics in their department. Champions are supported by senior
management and the Department of Environment, Food and Agriculture
(DEFA) provides training and technical support. A survey of single use
plastics across Government was completed in April 2018 in collaboration
with champions.
Reducing plastic at Government events
Reducing single use plastics has become part of the planning
process for Government events in 2018. The Overseas Territories
and Crown Dependencies Environment Ministers’ Summit in
February 2018 was single use plastics free and measures are in
place to reduce plastics at IsleExpo, Tynwald Day and the Isle of
Man Food and Drink Festival.
Schools
Through their partnership with UNESCO Biosphere Isle of Man,
many schools have plastic awareness and reduction programmes in
place. Innovative projects to recycle plastics and turn them into
artwork have recently been showcased in the press.
OUTSIDE GOVERNMENT
Plastics education – Working with our partners
DEFA and the Department of Infrastructure (DOI) already work with Beach
Buddies to remove plastic litter from the Government Estate. DEFA also works
with Beach Buddies and the Manx Wildlife Trust to educate the public on plastic
use and reducing marine litter. A new Plastics Education Programme is currently
being developed and will be rolled out over Summer 2019.
The message REDUCE – RE-USE – RECYCLE is key.
Removing plastics from the environment
A number of Government-funded initiatives assist in reducing plastics in the
environment. The majority of single use plastics generated are processed by the
Energy for Waste Plant, with minimal use of landfill. Recycling is promoted and
programmes such as Fishing for Litter and the agricultural plastic waste scheme
aim to reduce the impact of plastic waste from specific sectors.
Facilitating composting of packaging waste
DEFA has been working with the private sector to facilitate on-Island composting
of plastic-free packaging waste. Trials have been successful and there is scope for
compostable packaging waste to replace plasticized versions on a much wider
scale. This is subject to a high level of quality control by producers and operators.
What we will do
Why this is important
When
Build capacity of sustainability champions through training,
provision of resources and technical support.
Sustainability champions will be key in delivering plastics reduction across Government.
DEFA will train sustainability officers to support their work in their departments, to ensure
that have the best information available to them.
Immediately
Ensure single use plastics are minimised at events
Events often create large quantities of single use plastic waste and litter. Sustainable
alternative are available. Guidance will be given to departments and it is expected that
improvements can be made year on year.
Ban balloon releases by Government departments, agencies
and schools and by other parties on Government land
Whilst balloon releases by Government organisation are rare, they are still carried out in the
private sector. The intention is to minimise pollution and risk to wildlife.
Ensure easy access to tap water in Government buildings.
Enabling Government workers and others to easily access tap water in Government buildings
will minimise the use of plastic bottled drinks consumed.
Ban the use of specified single use plastic items across
Government. To include the following if single use plastic:
straws, cotton buds, cutlery, plates, cups, drinks stirrers.
Many of these items are either unnecessary or can easily be replaced by sustainable
alternatives. Not using these items will reduce plastic waste and wasteful use of resources.
Exceptions will be made where needed, e.g. for clinical use of straws.
By January 2019
Implement new procurement criteria considering single
use plastics, and encouraging the use of sustainable
alternative where appropriate
Whilst environmental issues are considered as part of procurement, this is an opportunity to
facilitate making sustainable choices and avoiding unnecessary single use plastic.
Departments will opt in to appropriate
elements of plastics guidance, taking into account their
operational requirements and any crucial exemptions required.
The guidance will outline best practice on single use plastics and targets that departments
will be able to opt into, according to operational requirements (ultimately facilitating
meeting the 2021 target for elimination of all unnecessary single use plastics)
Identify an officer in Government to lead on plastics
reduction and recycling
The delivery of the plastics plan will be enhanced by an officer who can lead on plastics
reduction as part of their role. This may link into advice on recycling and other sustainability
measures.
Establish a consistent recycling scheme across all Government
Buildings, where practical
Although some recycling is done in most Government buildings, there is currently no central
recycling scheme and some schemes are run by individuals.
Reduce plastic fragments from food and sewage waste
Removing all sources of plastic entering the marine environment from Manx sources is
important and finding a solution to plastic from waste disposal needs to be addressed.
January 2020
Eliminate all unnecessary single use plastics across
Government and replace with sustainable alternatives
Building on the initial bans of single use plastics and the opt in scheme for departments, this
gives the organisation a longer term target. Whilst plastics will continue to play an important
role, where appropriate, all unnecessary and unsustainable use will cease.
January 2021
Plastic Bag Levy
We reviewed the use of single use plastic bags and the operation of levies in
other jurisdictions. Since levies were introduced in neighbouring jurisdictions
there have been significant reductions in single use plastic bag use and the
numbers polluting the marine environment. The issue is complex, with single use
plastic bags reused as bin bags representing a more sustainable option than
alternatives under some circumstances. However, we recommend the
introduction of a levy on single use plastic bags. Depending on the legislative
route taken, this should be in place within 2 years.
Plastic Free Island – minimising use
As the only whole nation UNESCO Biosphere Region, we are in a unique position
to engage the community in some really innovative approaches to reducing
plastics and improving sustainability. By involving everyone in reducing plastics
and increasing sustainability we can make a real difference locally and an
important contribution to this global challenge. A plastics stakeholder forum and
seeking accreditation through existing plastic reduction programmes are
possible routes forward on this.
Recognising the challenge of marine plastic pollution
Whilst much of our plastic litter is processed by the Energy from Waste Plant, we
cannot be complacent about marine plastics entering the Manx marine
environment. Manx sources of marine litter include; littering and fly tipping;
rubbish from bins and receptacles being released into the environment by wind,
gulls or other sources; organised balloon releases; discarded fishing gear;
sewage related plastics in areas where sewage treatment is not yet in place;
agricultural waste if not disposed of properly. Further research and action on
local sources of marine pollution will help protect Manx waters and the global
marine environment.
Reducing food and drink packaging litter
A significant source of local litter is plastic packaging from take away and
convenience food. With the development of non-plastic alternatives, there is
scope to reduce the packaging waste produced. We will also explore
opportunities to work with food and drink vendors to ensure that problem waste
is reduced, and where necessary encouraging sources of packaging waste to take
responsibility for disposal. Education also plays a key part in reducing food
packaging litter.
Public health considerations
Based on our initial review of public health impacts of plastics in the environment and in our food, it is recommended that we further consider health implications of
plastics. The World Health Organisation recently committed to reviewing health risks associated with bottled water and scientists and medical organisations are
increasingly examining the evidence for a wide range of health risks potentially associated with plastics. We will continue to monitor international research and
policy in this area and work across Government to explore the Isle of Man implications.
Title
Discharge Polley
Author/ Contact Details
Transfer of care Co-ordinator & Project Team
Publication Date
April 2014
Target Audience
Department of Health staff -Noble's Hospital & Ramsey & District
Cottaqe Hosoital (RDCH)
Description
This policy aims to improve practice and provide consistency with the
Discharge process for all adult in-patients. Its purpose is to support
patients, carers and staff and to improve communication of relevant
information to patients and their carers.
It aims to reduce unnecessary delays in the Discharge process, therefore
having a beneficial effect on individual patients and carers, as well as
benefits to the Health and Social care System in respect of access to
services.
Has anticipated LOS/EDD been
discussed with oatient & carer?
2
Emergency social
oroblems
Any emergency social
oroblems created bv admission
If yes, T/ C referral to DSC?
□ Yes □ No (686179)
If yes, T/ C referral to DSC?
□ Yes □ No (686179)
3
Is patient registered with a GP
Ring service
5 Mental health Is patient currently known to
service?
Ring Central referral team
6 Diabetes Nurse Does patient have Diabetes?
Foot ulcer/care reauirements?
If yes, refer to service
Refer to oodiatrv service
Potential Discharge issues: Yes No Date Time Actions
Initial Initial
7 Existing services Does patient have any existing If yes, inform service (s) of
support services at home? admission & document in
records
8 Pre-admission Nursing assessment Simple □ (follow correct
abilities Comolex □ oathwav)
10 Referrals Is a referral required to: If yes, telephone referral:
Transfer of Care Co-ordinator 650722
(comolex health)?
-Physiotherapist? If yes, send /fax referral
-Occupational Therapist? If yes, send /fax referral
-Social Worker(complex social)? If yes, send/fax referral
-Housing (present or future) Ring: 685955 (advice)
-Other:
Within 24 -48 hours of admission Yes No Date Time State reason{s) If this has
{within 72 at RDCH) Initial Initial not happened
11 Estimated date of Has referred Interdisciplinary CJ Awaiting diagnostic tests
discharge (EDD) team (IDT) agreed treatment CJ Awaiting consultant's
decision
plan?
CJ Awaiting IDT decision
If no state reason
CJ Other state
Has Estimated date changed?
If yes new EDD:
Has revised EDD been
discussed with patient & carer?
EDD to be reviewed daily
AND at weekly IDM
12
Patient
information
Patient given appropriate
information e.g. condition. assess
Discharge Guide?
If no. whv:
Date Time State reason{s) if this has
not hannened
During admission Yes No
Initial Initial
13
Length of stay
(LOS)
No Date
Initial
15
Diagnosis Has patient had their condition
& treatment clan explained?
Written advice/leaflets/ given to
oatient?
Has patient had their condition
& treatment clan explained?
Record type of leaflets
aiven in oatient records
16
Patient&
carer
arrangement
Discharge arrangements
confirmed with natient/carers?
Is patient returning to their
usual olace of residence?
If no please inform
professionals of address
Has oatient oot a kev?
Has pt qot outdoor clothes?
Is there food at home?
Is the heatina on at home?
Support Discharge arrangements been
services confirmed with the seivice I
providers? a GP a DN
a Social Seivices a MOW
a Home care a Mental Health
team a Practice Nurse
a DAT a SLT a Dietietics
a DSN a Podiatrv a Other
I\
11
I I
-
Comments:
I
State:
Time of
Discharae
Transport
Is Patient being discharged
before middav?
If hospital transport is being
considered does patient meet
Hospital transport criteria?
If no, why& time:
24 hrs notice needed
Has transport been confirmed?
a Own/carer/relative a Taxi
a Other a Ambulance
a Patient transoort
20
Medication
Has patient medication/ TTO's /
outside scriot been ordered?
24 hrs notice needed
State:
Medication received from
oharmacv?
-�- -
Medication returned to patient?
21
Medical
certificate
Is a Medical (sick) form
reauired?
If yes, has it been Issued?
a Yes a No
22
Equipment
Has patient/carer been advised /
trained in safe use of any
aids/eauipment/medical device?
Arrangement made to deliver
eauipment to patient's home?
Outpatient appointment(s )
a Given to patient a oosted
a N/A Please state:
23
OPA
24
Information
Discharae auide aiven to natient
If no whv:
Day of Discharge
Yes
Initial
No Date
Initials
Time State reason if this
has not hannened
25
26
Medically fit
Medication
Patient assessed today as
medicallv fit/safe to discharae
Medication given & explained to
patient & or carer?
a Given to patient
a Faxed a emailed
FOI 1915369 Appendix 1
COVID-19 VACCINATION
Contents
What are the side effects?
Can I catch COVID-19 from
the vaccine?
Can I go back to normal activities
after having my vaccine?
What do I do next?
What should I do if I am not well
when it is my next appointment?
Will the vaccine protect me?
Can I give COVID-19 to anyone,
now I have had the vaccine?
Please read the product information
leaflet for more details on your vaccine,
including possible side effects, by
searching Coronavirus Yellow Card.
You can also report suspected side effects
on the same website or by downloading
the Yellow Card app.
coronavirus-yellowcard.mhra.gov.uk
2
Don’t forget your
COVID-19 vaccination
Don’t forget your
COVID-19 vaccination
Don’t forget your
COVID-19 vaccination
Make sure you keep this record
card in your purs e or wallet
For more information on the
COVID-19 vaccination or what
to do after your vaccination,
see www.nhs.uk/covidvaccine
Enjoy life. Protect yourself.
Inaccessible Incident / Other
Entrapments (Non-Traffic)
1
1
1
Expenses 1 April - 30 Sep 2021
Board Member
expenses subsistence
Andrew Foster, Chair
0
0
Teresa Cope, CEO
0
0
Andrew Guy, Non-Executive Director
0
0
Katie Kapernaros, Non-Executive Director
307
0
Sarah Pinch, Non-Executive Director
850
114
Vanessa Walker, Non-Executive Director
0
0
Nigel Wood, Non-Executive Director
0
0
Sree Andole - Medical Director
0
0
Anne Corkill - Director of HR Business
190
0
Jackie Lawless - Finance Director
0
0
John Middleton - Board Secretary
0
0
Paul Moore - Director of Nursing and Governance
0
0
Oliver Radford - Director of Operations
0
0
Barbara Scott - Director of Infrastructure
0
0
Sally Shaw - Director of Social Care
0
0
Richard Wild - Chief Information Officer
170
0
GOV.UK
Menu
Coronavirus (COVID-19) (/coronavirus)
Guidance and support
1. Home (https://www.gov.uk/)
2. Coronavirus (COVID-19) (https://www.gov.uk/coronavirus-taxon)
3. Healthcare workers, carers and care settings during coronavirus
(https://www.gov.uk/coronavirus-taxon/healthcare-workers-carers-and-care-settings)
4. COVID-19: infection prevention and control (IPC)
(https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-
and-control)
UK Health
Security
Agency (https://www.gov.uk/government/organisations/uk-health-security-agency)
Guidance
COVID-19: guidance for
maintaining services within
health and care settings –
infection prevention and control
recommendations
Updated 29 September 2021
Contents
1. Main messages and explanation of updates
2. Introduction
3. Governance and responsibilities
4. COVID-19 care pathways
5. Standard infection prevention control precautions (SICPs) - all pathways or settings
6. Aerosol generating procedures – procedures that create a higher risk of respiratory infection
transmission
7. Low risk pathway – key principles
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8. Transmission based precautions (TBPs)
9. Medium risk pathway – key principles
10. High risk pathway – key principles
11. Occupational health and staff deployment
12. Glossary of terms
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1. Main messages and explanation of updates
1.1 About this guidance
This guidance is issued jointly by the Department of Health and Social Care (DHSC), Public Health
Wales (PHW), Public Health Agency (PHA) Northern Ireland, Health Protection Scotland
(HPS)/National Services Scotland, Public Health England (PHE) and NHS England as official
guidance.
Amendments have been made to strengthen existing messaging and provide further clarity where
needed, including updates on the hierarchy of controls, clarity over the use of valved respirators, and
highlighting the need to protect those previously shielding and who are considered clinically
extremely vulnerable from coronavirus (COVID-19).
Following a clinical and scientific review, no changes to the recommendations, including personal
protective equipment (PPE), have been made in response to the new variant strains at this stage,
however this position will remain under constant review. Organisations who adopt practices that differ
from those recommended/stated in the national guidance are responsible for ensuring safe systems
of work, including the completion of a risk assessment approved through local governance
procedures.
All NHS organisations should ensure reliable application of all infection prevention and control (IPC)
recommendations and assurance on adherence, that PPE is available and in supply, and that all staff
training is up to date.
This guidance seeks to ensure a consistent and resilient UK wide approach, however some
differences in operational details and organisational responsibilities may apply in Northern Ireland,
England, Wales and Scotland.
Please note that this guidance is of a general nature and that an employer should consider the
specific conditions of each individual place of work and comply with all applicable legislation,
including the Health and Safety at Work etc. Act 1974
(https://www.legislation.gov.uk/ukpga/1974/37/contents).
The IPC principles in this document apply to all health and care settings including acute, diagnostics,
independent sector, mental health and learning disabilities, primary care, care homes, care at home,
maternity and paediatrics (this list is not exhaustive).
This guidance does not apply to adult social care settings in England. Adult social care providers in
England should refer to existing guidance (https://www.gov.uk/government/collections/coronavirus-covid-19-
social-care-guidance) already in place. DHSC/PHE will continuously review this guidance and update
as needed.
This IPC guidance will be updated in line with service need and as the evidence evolves. The
administrative measures outlined in the guidance are consistent with World Health Organization
(WHO) guidance (https://www.who.int/publications/i/item/WHO-2019-nCoV-IPC-2021.1).
1.2 Main messages
Local and national prevalence and incidence data will continue to guide services as advised by
country-specific/public health organisations. Identification of new variants of concern is inevitable and
on each new identification evidence for any change in transmissibility, mode of transmission, disease
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severity and any evidence of vaccine evasion will need to be considered as well as local incidence
and prevalence of any new variant of concern. It may be necessary to change the IPC measures
required on the basis of any new evidence.
For further information on the variants of concern:
Threat Assessment Brief: Emergence of SARS-CoV-2 B.1.617 variants in India and situation in
the EU/EEA (https://www.ecdc.europa.eu/en/publications-data/threat-assessment-emergence-sars-cov-2-
b1617-variants)
Investigation of SARS-CoV-2 variants of concern: technical briefings
(https://www.gov.uk/government/publications/investigation-of-novel-sars-cov-2-variant-variant-of-concern-
20201201)
For further guidance on investigating and managing variants of concern:
Guidance for investigating and managing individuals with a possible or confirmed SARS-CoV-2
Variant of Concern or Variant Under Investigation (https://www.gov.uk/government/publications/sars-
cov-2-voc-investigating-and-managing-individuals-with-a-possible-or-confirmed-case/guidance-for-
investigating-and-managing-individuals-with-a-possible-or-confirmed-sars-cov-2-variant-of-concern)
This data will continue to be used to ensure patients/individuals’ treatment, care and support can be
managed in the 3 COVID-19 pathways, which remain as:
high risk - this includes patients/individuals who are confirmed COVID-19 positive by a SARS-
CoV-2 polymerase chain reaction (PCR) test or are symptomatic and suspected to have COVID-
19 (awaiting result)
medium risk - this includes patients/individuals who are waiting for their SARS-CoV-2 PCR test
result and who have no symptoms of COVID-19 and individuals who are asymptomatic with
COVID-19 contact/exposure identified
low risk - this includes patients/individuals who have been triaged/tested (negative)/clinically
assessed with no symptoms or known recent COVID-19 contact/exposure
To ensure maximum workplace risk mitigation, organisations should undertake local risk
assessments based on the measures as prioritised in the hierarchy of controls. If an unacceptable
risk of transmission remains following this risk assessment
(https://www.england.nhs.uk/coronavirus/publication/every-action-counts/), it may be necessary to consider
the extended use of respiratory protective equipment (RPE) for patient care in specific situations. The
risk assessment should include evaluation of the ventilation in the area, and prevalence of
infection/new variants of concern in the local area.
Individuals who are clinically extremely vulnerable from COVID-19 will require protective IPC
measures depending on their medical condition and treatment whilst receiving healthcare, for
example priority for single room isolation.
Sessional use of single use PPE/RPE items continues to be minimised and only applies to extended
use of face masks (all pathways) or filtering face piece (FFP3) respirators (together with eye/face
protection) in the medium and high risk pathways for healthcare workers (HCWs) where airborne
precautions are indicated.
The use of face masks or face coverings across the UK remains as an IPC measure. In addition to
social distancing, hand hygiene for staff, patients/individuals and visitors is advised in both clinical
and non-clinical areas to further reduce the risk of transmission.
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Patients in all care areas should still be encouraged and supported to wear a face mask, providing it
is tolerated and is not detrimental to their medical or care needs.
Physical distancing of 2 metres remains in place as standard practice in all health and care settings,
unless providing clinical or personal care and wearing appropriate PPE.
Patients/individuals on a low-risk pathway require standard infection control precautions (SICPs) for
all care including surgery or procedures.
Triaging and SARS-CoV-2 testing must be undertaken for all patients either at point of admission or
as soon as possible/practical following admission across all the pathways.
The IPC measures recommended are underpinned by the National Infection Prevention and Control
Manual (NIPCM) practice guide and associated literature reviews (http://www.nipcm.hps.scot.nhs.uk/).
NHS England is using this an opportunity to introduce and adopt the NICPM as set out in the UK
Five-year Tackling Antimicrobial Resistance National Action Plan (2019 to 2024)
(https://www.gov.uk/government/publications/uk-5-year-action-plan-for-antimicrobial-resistance-2019-to-2024).
1.3 Explanation of the updates to IPC guidance
The guidance is issued jointly by DHSC, PHW, PHA Northern Ireland, HPS/National Services
Scotland, PHE and NHS England for health and care organisations as the UK moves to maintain
healthcare services. The content is consistent with the administrative measures outlined in WHO IPC
during healthcare when COVID-19 is suspected or confirmed: Interim Guidance, June 2020
(https://apps.who.int/iris/handle/10665/332879). In addition, the updates to this guidance are informed by
the paper produced for the Scientific Advisory Group for Emergencies Masks for healthcare workers
to mitigate airborne transmission of SARS-CoV-2 (23 April 2021)
(https://www.gov.uk/government/publications/emg-masks-for-healthcare-workers-to-mitigate-airborne-
transmission-of-sars-cov-2-25-march-2021).
Maintaining services continues to require ‘new ways’ of working during the ongoing pandemic.
Continual assessment of the available evidence/science and feedback from guidance users,
professional bodies and associations, has identified the amendments required to the guidance to
assist in supporting services in this ‘new and changing’ environment whilst COVID-19 remains a
threat. This is based upon emerging evidence, experience and expert opinion.
1.4 Main changes to the guidance
The main amendments to this version of the guidance are:
1. Inclusion of the hierarchy of controls as these apply to COVID-19, with definitions and
supporting materials for implementation. Also, where an unacceptable risk of transmission
remains following the hierarchy of controls risk assessment, it may be necessary to consider the
extended use of RPE for patient care in specific situations. The risk assessment should include
evaluation of the ventilation in the area, operational capacity, and prevalence of infection/new
variants of concern in the local area.
2. Further advice on the use of valved respirators with examples of sterile procedures in the clinical
setting.
3. Further advice on minimising sessional or extended use of gowns where cohorts of confirmed
COVID-19 patients are managed and there is a lack of single rooms/isolation rooms.
4. Amendment to the aerosol generating procedure (AGP) list to state ‘upper gastro-intestinal
endoscopy where open suction of the upper respiratory tract occurs beyond the oro-pharynx’.
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5. Individuals who are clinically extremely vulnerable from COVID-19 will require protective IPC
measures depending on their medical condition and treatment whilst receiving healthcare, for
example, priority for single room isolation.
. Introduction
.1 Scope and purpose
his document sets out the IPC advice for health and care organisations as the UK continues to
aintain healthcare services during the ongoing pandemic.
he IPC principles in this document apply to all health and care settings, including the
dependent/private sector, mental health and learning disabilities, primary care areas, care homes,
are at home, maternity and paediatrics (this list is not exhaustive, please refer to specific country
sources for setting specific guidance). It includes key IPC control recommendations and includes
sk assessed patient pathway scenarios to help guide the implementation of measures to provide
afe and effective care locally and is based on the best available evidence.
he challenge facing the NHS is to maintain healthcare services and manage NHS capacity whilst
roviding a safe and equitable service for staff, visitors and patients/individuals including those who
ay present with COVID-19, those who have recovered from COVID-19 and those with no history of
OVID-19, until public health strategies such as mass vaccination are complete.
aintaining services requires a continuous review of ways of working to respond to the pandemic
nd guidance for working in a changing environment requires continual and ongoing development
ased upon emerging evidence, experience and expert opinion.
hile this document seeks to ensure a consistent and resilient UK-wide approach, some differences
operational details and organisational responsibilities may apply, where current legislation,
uidance, for example, clinical definitions, already exists. Links can be accessed in the resources
elow.
his guidance does not apply to adult social care settings in England given existing guidance for
dult social care settings (https://www.gov.uk/government/collections/coronavirus-covid-19-social-care-
uidance) has already been provided and continues to be relevant. DHSC/PHE will continuously
view this guidance and update as needed.
his document does not provide links throughout the sections. Follow the country-specific resources,
r example visiting guidance, testing, discharge policies.
C COVID-19 resources for:
England can be found at Infection Prevention and Control supporting documentation
(https://www.england.nhs.uk/coronavirus/publication/infection-prevention-and-control-supporting-
documentation/) and coronavirus (COVID-19) (https://www.gov.uk/coronavirus)
Scotland can be found at COVID-19 compendium (https://hps.scot.nhs.uk/web-resources-
container/covid-19-compendium/) and Scottish COVID-19 Infection Prevention and Control
Addendum for Acute Settings (http://www.nipcm.hps.scot.nhs.uk/scottish-covid-19-infection-prevention-
and-control-addendum-for-acute-settings/)
Wales can be found at Health and social care professionals: coronavirus (https://gov.wales/health-
professionals-coronavirus)
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Northern Ireland can be found at Guidance for professionals and organisations
(https://www.publichealth.hscni.net/covid-19-coronavirus/guidance-professionals-and-organisations)
Further updates will be made to this document as new data/evidence emerges and as the COVID-19
alert levels change
(https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/884352/slide
s_-_11_05_2020.pdf). This is a scale of 1 to 5 which the UK government uses to reflect the degree of
threat to the country from the current COVID-19 pandemic.
3. Governance and responsibilities
Organisations and employers including NHS Trusts, NHS Boards, Health and Social Care Trusts
(Northern Ireland), local authorities, and independent sector providers, through their Chief Executive
Officer (CEO) or equivalent, must ensure:
monitoring of IPC practices, as recommended in this guidance, and ensure that resources are in
place to implement and measure adherence to good IPC practice. This must include all care
areas and all staff (permanent, agency and external contractors)
testing and self-isolation strategies are in place with a local policy for the response if
transmission rates of COVID-19 increase
training in IPC measures is provided to all staff, including: the correct use of PPE including a
face fit test if wearing a FFP3, respirator, and the correct technique for putting on and removing
(donning/doffing) safely
risk assessment(s) is undertaken for any staff members in at risk or clinically extremely
vulnerable groups, including pregnant and Black, Asian and Minority Ethnic (BAME) staff.
Guidance on carrying out risk assessments can be found by following the links to the country
specific resources in section 2.1
patients/individuals at high risk/extremely high risk of severe illness are protected from COVID-
19. This must include consideration of families and carers accompanying patients/individuals for
treatments/procedures
health and care settings are COVID-19 secure workplaces as far as practical, that is, that any
workplace risk(s) are mitigated maximally for everyone. This may entail local risk assessments
based on the measures as prioritised in the hierarchy of controls in the context of managing
infectious agents and should be communicated to staff
Disclaimer:
When an organisation adopts practices that differ from those recommended/stated in this national
guidance, that individual organisation is responsible for ensuring safe systems of work, including the
completion of a risk assessment(s) approved through local governance procedures, for example
Integrated Care System level, Health Board.
4. COVID-19 care pathways
These pathways are specific to the COVID-19 pandemic and are examples of how organisations may
separate COVID-19 risks. It is important to note that these pathways do not necessarily define a
service to a particular pathway and should not impact the delivery and duration of care for the patient
or individual. Moving patients between pathways should be based on their infectious status (testing
required), clinical need, availability of services and this should be agreed locally. Implementation
strategies must be underpinned by patient/procedure risk assessment, appropriate testing regimens
(as per organisations or country specific) and epidemiological data. Additional information on specific
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settings can be found in: NICE (2020) COVID-19 rapid guideline: arranging planned care in hospitals
and diagnostic services (https://www.nice.org.uk/guidance/ng179/resources/covid19-rapid-guideline-
arranging-planned-care-in-hospitals-and-diagnostic-services-pdf-66141969613765).
Triaging and testing within all health and other care facilities must be undertaken to enable early
recognition of COVID-19 cases. See Appendix 1
(https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1021294/202
10118_COVID-19_Infection_prevention_control_Appendix_1_Sample_triage_tool.pdf) for an example of
triage questions. Triage should be undertaken by clinical staff who are trained and competent in the
application of the clinical case definition (https://www.gov.uk/government/publications/wuhan-novel-
coronavirus-initial-investigation-of-possible-cases/investigation-and-initial-clinical-management-of-possible-
cases-of-wuhan-novel-coronavirus-wn-cov-infection) prior to arrival at a care area, or as soon as possible
on arrival, and allocated to the appropriate pathway. This should include screening for other
infections/multi-drug resistant organisms, including as per national screening requirements.
Infection risk and IPC precautions, for example SICPs or transmission based precautions (TBPs)
must be communicated between care areas/pathways, including when discharge planning.
Patients with respiratory symptoms should be assessed in a segregated area, ideally a single room,
pending test result to define the causative organism.
Individuals who are clinically extremely vulnerable from COVID-19 will require protective IPC
measures depending on their medical condition and treatment whilst receiving healthcare, for
example priority for single room isolation.
4.1 High risk COVID-19 pathway
Any care facility where:
a) Untriaged individuals present for assessment or treatment (symptoms unknown).
or
b) Confirmed SARS-CoV-2 PCR positive individuals are cared for.
or
c) Symptomatic or suspected COVID-19 individuals including those with a history of contact with a
COVID-19 case, who have been triaged/clinically assessed and are waiting test results.
or
d) Symptomatic individuals decline testing.
Examples of patient (individual) groups/facilities within this pathway (this list is not exhaustive):
designated areas within emergency/resuscitation departments
GP surgeries/walk-in centres
facilities where confirmed or suspected/symptomatic COVID-19 individuals are cared for, for
example:
emergency admissions to inpatient areas (adult and children)
mental health
maternity
critical care units
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renal dialysis units
4.2 Medium risk COVID-19 pathway
Any care facility where:
a) Triaged/clinically assessed individuals are asymptomatic and are waiting a SARS-CoV-2 PCR test
result.
or
b) Triaged/clinically assessed individuals are asymptomatic with COVID-19 contact/exposure
identified.
or
c) Testing is not required or feasible on asymptomatic individuals and infectious status is unknown.
or
d) Asymptomatic individuals decline testing.
Examples of patient (individual) groups/facilities within this pathway (this list is not exhaustive):
designated areas within emergency/resuscitation departments, GP surgeries and walk-in
centres
non-elective admissions
primary care facilities, for example general dental and general practice
facilities where individuals are cared for, for example:
inpatients (adult and children)
mental health
maternity
critical care units
outpatient departments including diagnostics and endoscopy
care homes*
prisons
*This guidance does not apply to adult social care settings in England.
4.3 Low risk COVID-19 pathway
Any care facility where:
a) Triaged/clinically assessed individuals with no symptoms or known recent COVID-19
contact/exposure.
and
Have a negative SARS-CoV-2 PCR test within 72 hours of treatment and, for planned admissions,
have self-isolated for the required period or from the test date.
or
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b) Individuals who have recovered (14 days) from COVID-19 and have had at least 48 hours without
fever or respiratory symptoms.
or
c) Patients or individuals are part of a regular formal NHS testing plan and remain negative and
asymptomatic.
Examples of the patient (individual) groups/facilities within this pathway (this list is exhaustive):
planned/elective surgical procedures including day cases
oncology/chemotherapy patients and/or facilities
planned inpatient admissions (adult and children), mental health, maternity
outpatients including diagnostics/endoscopy
care homes*
prisons
*This guidance does not apply to adult social care settings in England.
4.4 Administration measures for the pathways
1. Establish separation of patient pathways and staff flow to minimise contact between pathways.
For example, this could include provision of separate entrances and exits (if available) or use of
one-way entrance and exit systems, clear signage and restricted access to communal areas:
care areas (for example, ward, clinic, GP practice, care home) may designate self-
contained area(s) or ward(s) for the treatment and care of patients/individuals at high,
medium and low risk of COVID-19. Temporal separation may be used in clinics/primary
care settings
as a minimum in smaller facilities or primary care outpatient settings physical or temporal
separation of patients/departments at high risk of COVID-19 from the rest of the
facility/patients
2. Ensure that hygiene facilities, IPC measures and messaging are available for all
patients/individuals, staff and visitors to minimise COVID-19 transmission such as:
hand hygiene facilities including instructional posters
good respiratory hygiene measures
maintaining physical distancing of 2 metres at all times (unless wearing PPE due to clinical
care or personal care as per pathways)
increasing frequent decontamination of equipment and environment
considering improving ventilation by opening windows (natural ventilation) if mechanical
ventilation is not available
clear advice on use of face coverings and face masks by patients/individuals, visitors and
by staff in non-patient facing areas - this will include:
use of face masks/coverings by all outpatients (if tolerated) and visitors when entering
a hospital, GP/dental surgery or other care settings
use of a surgical face mask (Type II or Type IIR) by all patients across all pathways, if
this can be tolerated and does not compromise their clinical care, such as when
receiving oxygen therapy. This will minimise the dispersal of respiratory secretions and
reduce environmental contamination
extended use of face masks by all staff in both clinical and non-clinical areas within the
healthcare or care setting
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where visitors are unable to wear face coverings due to physical or mental health
conditions or a disability, clinicians/person in charge should consider what other IPC
measures are in place, such as physical distancing and environmental cleaning, to
ensure sufficient access depending on the patient’s condition and the care pathway
3. Where possible and clinically appropriate remote consultations rather than face-to-face should
be offered to patients/individuals.
4. Ensure restricted access between pathways if possible (depending on size of the facility,
prevalence/incidence rates), by other patients/individuals, visitors or staff, including patient
transfer and in communal staff areas (changing rooms/restaurant). If the prevalence/incidence
rates decline this may not be necessary between pathways providing the IPC measures are
reliably maintained.
5. Ensure areas/wards are clearly signposted, using physical barriers as appropriate to ensure
patients/individuals and staff understand the different risk areas.
6. Ensure local standard operating procedures detail the measures to segregate equipment and
staff, including planning for emergency scenarios, as the prevalence/incidence of COVID-19
may increase or decrease until cessation of the pandemic.
7. Ensure a rapid and continued response through ongoing surveillance of rates of infection within
the local population and for hospital/organisation onset cases (staff and patients/individuals).
Positive cases identified after admission who fit the criteria for a healthcare associated infection
should trigger a case investigation. If 2 or more cases are linked in time and place, an outbreak
investigation should be conducted. Refer to country-specific definitions.
8. If the prevalence/incidence rate for COVID-19 is high, where possible, assign separate teams of
health and other care workers, including domestic staff, to care for individuals in isolation/cohort
rooms or areas/pathways. If a member of staff is required to move between
sites/hospitals/cohort areas due to the unique function of their role, all IPC measures including
physical distancing must be maintained.
9. Providers of planned services should be responsive to local and national prevalence/incidence
data on COVID-19 and adapt processes so that services can be stepped-up or down. This can
be assessed using the respective countries weekly COVID-19 surveillance report/SARS-CoV-2
positivity data on admission, and local capacity and resources.
10. Safe systems of work outlined in the hierarchy of controls
(https://www.cdc.gov/niosh/topics/hierarchy/default.html) including elimination, substitution,
engineering, administrative controls and PPE/RPE are an integral part of IPC measures.
Organisations should undertake risk assessments based on these measures, prioritised in the
hierarchy of controls in the context of managing infectious agents. If an unacceptable risk of
transmission remains following a risk assessment taking these controls into account, it may be
necessary to consider the extended use of RPE for patient care in specific situations. The risk
assessment should include evaluation of the ventilation in the area, operational capacity, and
prevalence of infection/new variants of concern in the local area.
Supporting tools for local risk assessment are available at NHS England Every Action Counts
Resources (https://www.england.nhs.uk/coronavirus/publication/every-action-counts/).
4.5 Community settings
Areas where triaging for COVID-19 is not possible, for example community pharmacies:
signage at entry points advising of the necessary precautions
staff should maintain 2 metres physical distance with customers/service users, using floor
markings, clear screens or wear surgical face masks (Type IIR) where this is not possible
patients/individuals with symptoms should be advised not to enter the premises
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Outpatient/primary/day care
outpatient, primary care and day care settings:
where possible and appropriate, services should utilise virtual consultation
if attending outpatients or diagnostics, service providers should consider timed appointments
and strategies such as asking patients/individuals to wait to be called to the waiting area with
minimum wait times
patients/individuals should not attend if they have symptoms of COVID-19 or are isolating as a
contact/exposure and communications should advise actions to take in such circumstances for
example for patients/individuals receiving chemotherapy and renal dialysis
communications prior to appointments should provide advice on what to do if patients/individuals
suspect they have come into contact with someone who has COVID-19 prior to their
appointment
outpatient letters should be altered to advise patients/individuals on parking, entrances, IPC
precautions and COVID-19 symptoms
patients/individuals must be instructed to remain in waiting areas and not visit other parts of the
facility
prior to admission to the waiting area, all patients/individuals and accompanying persons should
be triaged for COVID-19 symptoms and assessed for exposure to contacts
patients/individuals and accompanying persons will also be asked to wear a mask/face covering
at all times
RS-CoV-2 confirmed positive patients/individuals or those self-isolating should still be assessed
d reviewed following the high/medium care pathway in these settings, to ensure urgent
atment/appointments are accommodated. This is important to avoid unwarranted poor patient
comes.
ome clinical outpatient settings, such as vaccination/injection clinics, where contact with
ividuals is minimal, the need for PPE items for each encounter, for example gloves and aprons are
y recommended when there is (anticipated) exposure to blood/body fluids or non-intact skin. Staff
ministering vaccinations/injections must apply hand hygiene between patients and wear a
sional face mask.
Standard infection prevention control precautions (SICPs) - all pathways or
ttings
Ps are the basic IPC measures necessary to reduce the risk of transmitting infectious agents
m both recognised and unrecognised sources of infection and are required across all COVID-19
hways. Sources of (potential) infection include blood and other body fluids secretions or
retions (excluding sweat), non-intact skin or mucous membranes and any equipment or items in
care environment that could have become contaminated.
e application of SICPs during care delivery is determined by an assessment of risk to and from
ividuals and includes the task, level of interaction and/or the anticipated level of exposure to blood
d/or other body fluids.
Ps must therefore be used by all staff, in all care settings, at all times and for all
ients/individuals, whether infection is known or not, to ensure the safety of patients/individuals,
ff and visitors. This section highlights the key measures for the COVID-19 pathways. Please refer
he practice guide* for additional information on the other elements which remain unchanged.
e elements of SICPs are:
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patient placement and assessment for infection risk (screening/triaging/testing)
hand hygiene
respiratory and cough hygiene
personal protective equipment
safe management of the care environment
safe management of care equipment
safe management of healthcare linen
safe management of blood and body fluids
safe disposal of waste (including sharps)
occupational safety: prevention and exposure management
maintaining social/physical distancing (new SICP due to COVID-19)
*Practice guides and literature reviews to support SICPs can be found for England and Scotland
(http://www.nipcm.hps.scot.nhs.uk/), Wales (https://phw.nhs.wales/services-and-teams/harp/infection-
prevention-and-control/nipcm/) and Northern Ireland (https://www.niinfectioncontrolmanual.net/).
5.1 Personal protective equipment (PPE)
For the purpose of this document, the term ‘personal protective equipment’ is used to describe
products that are either PPE or medical devices that are approved by the Health and Safety
Executive (HSE) and the Medicines and Healthcare products Regulatory Agency (MHRA) as
protective solutions in managing the COVID-19 pandemic.
Local or national uniform policies (https://www.england.nhs.uk/about/equality/equality-hub/uniforms-and-
workwear/) should be considered when wearing PPE.
All PPE should be:
located close to the point of use (where this does not compromise patient safety, for example,
mental health/learning disabilities). In domiciliary care PPE must be transported in a clean
receptacle
stored safely and in a clean, dry area to prevent contamination
within expiry date (or had the quality assurance checks prior to releasing stock outside this date)
single use unless specified by the manufacturer or as agreed for extended/sessional use
including surgical face masks
changed immediately after each patient and/or after completing a procedure or task (unless
sessional use has been agreed and local risk assessment undertaken)
disposed into the correct waste stream depending on setting, for example domestic
waste/offensive (non-infectious) or infectious clinical waste
discarded if damaged or contaminated
safely doffed (removed) to avoid self-contamination. See guidance on donning (putting on) and
doffing (removing) (https://www.gov.uk/government/publications/covid-19-personal-protective-equipment-
use-for-aerosol-generating-procedures)
decontaminated after each use following manufacturer’s guidance if reusable PPE is used,
specifically non-disposable goggles/face shields/visors
Gloves must:
be worn when exposure to blood and/or other body fluids, non-intact skin or mucous
membranes is anticipated or likely*
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be changed immediately after each patient and/or after completing a procedure/task even on the
same patient
be put on immediately before performing an invasive procedure and removed on completion
not be decontaminated with alcohol based hand rub (ABHR) or soap between use
Double gloving is not recommended for routine clinical care of COVID-19 cases.
*Vinyl medical gloves should only be worn in care situations where there is no anticipated exposure
to blood and/or body fluids.
Aprons must be:
worn to protect uniform or clothes when contamination is anticipated or likely
worn when providing direct care within 2 metres of suspected/confirmed COVID-19 cases
changed between patients and/or after completing a procedure or task
Full body gowns or fluid repellent coveralls must be:
worn when there is a risk of extensive splashing of blood and/or body fluids
worn when undertaking AGPs
worn when a disposable apron provides inadequate cover for the procedure or task being
performed (surgical procedures)
changed between patients/individuals and immediately after completing a procedure or task
Eye or face protection (including full-face visors) must:
be worn if blood and/or body fluid contamination to the eyes or face is anticipated or likely – for
example, by members of the surgical theatre team and always during AGPs
not be impeded by accessories such as piercings or false eyelashes
not be touched when being worn
Regular corrective spectacles are not considered as eye protection.
Fluid resistant surgical face mask (FRSM Type IIR) masks must:
be worn with eye protection if splashing or spraying of blood, body fluids, secretions or
excretions onto the respiratory mucosa (nose and mouth) is anticipated or likely
be worn when providing direct care within 2 metres of a suspected/confirmed COVID-19 case
be well-fitting and fit for purpose, fully cover the mouth and nose (manufacturer’s instructions
must be followed to ensure effective fit and protection)
not be touched once put on or allowed to dangle around the neck
be replaced if damaged, visibly soiled, damp, uncomfortable or difficult to breathe through
Surgical face masks Type II must be:
worn for extended use by HCWs when entering the hospital or care setting (Type IIR is also
suitable). Type I is suitable in some settings, refer to the country specific resources in section
2.1
Head/footwear:
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headwear is not routinely required in clinical areas (even if undertaking an AGP) unless part of
heatre attire or to prevent contamination of the environment such as in clean rooms
headwear worn for religious reasons (for example, turban, kippot veil, headscarves) are
permitted provided patient safety is not compromised - these must be washed and/or changed
between each shift or immediately if contaminated and comply with additional attire in, for
example, theatres
oot/shoe coverings are not required or recommended for the care of COVID-19 cases
may restrict communication with some individuals and other ways of communicating to meet
needs should be considered.
erosol generating procedures – procedures that create a higher risk of
iratory infection transmission
GP is a medical procedure that can result in the release of airborne particles (aerosols) from the
atory tract when treating someone who is suspected or known to be suffering from an infectious
transmitted wholly or partly by the airborne or droplet route.
s the list of medical procedures for COVID-19 that have been reported to be aerosol generating
re associated with an increased risk of respiratory transmission:
racheal intubation and extubation
manual ventilation
racheotomy or tracheostomy procedures (insertion or removal)
bronchoscopy
dental procedures (using high speed devices, for example ultrasonic scalers/high speed drills)
non-invasive ventilation (NIV); bi-level positive airway pressure ventilation (BiPAP) and
continuous positive airway pressure ventilation (CPAP)
high flow nasal oxygen (HFNO)
high frequency oscillatory ventilation (HFOV)
nduction of sputum using nebulised saline
espiratory tract suctioning*
upper ear, nose and throat (ENT) airway procedures that involve respiratory suctioning*
upper gastro-intestinal endoscopy where open suction of the upper respiratory tract* occurs
beyond the oro-pharynx
high speed cutting in surgery/post-mortem procedures if respiratory tract/paranasal sinuses
nvolved
available evidence relating to respiratory tract suctioning is associated with ventilation. In line
precautionary approach, open suctioning of the respiratory tract regardless of association with
ation has been incorporated into the current (COVID-19) AGP list. It is the consensus view of
K IPC cell that only open suctioning beyond the oro-pharynx is currently considered an AGP,
s oral/pharyngeal suctioning is not an AGP. The evidence on respiratory tract suctioning is
ntly being reviewed by the AGP Panel which is an independent panel set up by the 4 Chief
cal Officers (CMOs) to review new or further evidence for consideration.
in other procedures or equipment may generate an aerosol from material other than patient
tions but are not considered to represent a significant infectious risk for COVID-19. Procedures
category include administration of humidified oxygen, administration of Entonox or medication
ebulisation.
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The New and Emerging Respiratory Viral Threat Assessment Group (NERVTAG) advised that during
nebulisation, the aerosol derives from a non-patient source (the fluid in the nebuliser chamber) and
does not carry patient-derived viral particles. If a particle in the aerosol coalesces with a
contaminated mucous membrane, it will cease to be airborne and therefore will not be part of an
aerosol. Staff should use appropriate hand hygiene when helping patients to remove nebulisers and
oxygen masks. In addition, the current expert consensus from NERVTAG
(https://www.swast.nhs.uk/assets/1/cpr_as_an_agp_-
_evidence_review_and_nervtag_consensus.pdf#:~:text=NERVTAG%20consensus%20statement%20on%20Car
ute%20respiratory%20infections) is that chest compressions are not considered to be procedures that
pose a higher risk for respiratory infections including COVID-19.
Further information on AGPs for neonates (https://hubble-live-
assets.s3.amazonaws.com/bapm/redactor2_assets/files/729/COVID__FAQ_19.10.20.docx.pdf) and a
literature review for AGPs during COVID-19 (https://hps.scot.nhs.uk/web-resources-container/sbar-
assessing-the-evidence-base-for-medical-procedures-which-create-a-higher-risk-of-respiratory-infection-
transmission-from-patient-to-healthcare-worker/) are available.
7. Low risk pathway – key principles
This pathway applies to any care facility where:
a) Triaged/clinically assessed individuals with no symptoms or known recent COVID-19
contact/exposure.
and
Have a negative SARS-CoV-2 PCR test result within 72 hours of treatment and, for planned
admissions, have self-isolated for the required period or from the test date.
or
b) Individuals who have recovered (14 days) from COVID-19 and have had at least 48 hours without
fever or respiratory symptoms.
or
c) Patients or individuals are part of a regular formal NHS testing plan and remain negative and
asymptomatic.
Clinicians should advise people who are at greater risk of getting COVID-19, or having a poorer
outcome from it, that they may want to self-isolate for 14 days before a planned procedure. The
decision to self-isolate will depend on their individual risk factors and requires individualised care and
shared decision making.
Some individuals who have recovered from COVID-19 may continue to test positive for SARS-CoV-2
by PCR for up to 90 days from their initial illness onset. If they do not have any new COVID-19
symptoms and have not had a known COVID-19 exposure they are unlikely to be infectious.
However, advice should be sought from an infection specialist (infectious
disease/virologist/microbiologist) for severely immunosuppressed individuals who continue to test
positive.
Patients/individuals on a low risk pathway require SICPs for all care including surgery or procedures.
7.1 Maintaining physical distancing
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ll staff and other care workers must maintain social/physical distancing of 2 metres where possible
nless providing clinical or personal care and wearing PPE as per care pathway).
.2 Personal protective equipment
PE required for SICPs when following the low risk pathway is as follows:
SICPs/PPE (all
settings / all
patients/individuals
Disposable
gloves
)
Disposable
apron/gown
Face masks
Eye/face protection
(visor)
If contact with blood
and/or body fluids is
anticipated
Single use
Single use
apron (gown
if risk of
spraying /
splashing)
FRSM Type IIR
for direct patien
care and surgic
mask Type II* fo
extended use
Risk assess and use if
t required for care
al procedure/task where
r anticipated blood/body
fluids spraying/splashes
Sessional/extended use of face masks applies across the UK for HCWs in any health or other care
ettings.
irborne precautions are not required for AGPs on patients/individuals in the low risk COVID-19
athway, providing the patient has no other known or suspected infectious agent transmitted via the
roplet or airborne route.
.3 Safe management of environment/equipment and blood/body fluids
uring the pandemic, the frequency of cleaning of both the environment and equipment in care
atient) areas should be increased to at least twice daily, this includes frequently touched
tes/points and communal facilities such as shared toilets.
the low risk COVID-19 pathway, organisations may choose to revert to general purpose detergents
r cleaning, as opposed to widespread use of disinfectants (with the exception of blood and body
uids, where a chlorine releasing agent (or a suitable alternative) solution should be used).
.3.1 Safe management of waste
aste must be segregated in line with the respective countries’ national regulation and there is no
quirement to dispose of all waste as infectious waste in the low risk pathway.
.3.2 Operating theatres and procedure rooms
ithin the low risk COVID-19 pathway, standard theatre cleaning and time for air changes provides
ppropriate levels of IPC and there is no requirement for additional cleaning or theatre down time
nless the patient has another infectious agent that requires additional IPC measures.
.4 Aerosol generating procedures (AGPs): procedures that create a higher risk
f respiratory infection transmission
irborne precautions are not required for AGPs on patients/individuals in the low risk COVID-19
athway, providing the patient has no other known or suspected infectious agent transmitted via the
roplet or airborne route.
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ere is no additional requirement for ventilation or downtime in this pathway, providing safe systems
work, including engineering controls are in place.
.1 Critical care areas
oviding suspected/confirmed COVID-19 cases can be cared for in single rooms or isolation rooms,
department should no longer be classified as an AGP ‘hot spot’ or ‘high risk area’. This should be
fined locally depending on prevalence/incidence data and the subsequent pathway assigned. This
gates the requirement for the routine wearing of airborne PPE including a respirator in the low risk
VID-19 pathway.
.2 Operating theatres
tients/individuals in the low risk COVID-19 pathway do not need to be anaesthetised or recovered
the operating theatre if intubation/extubation (AGP) is required.
5 Visitor guidance
outlined in the administration measures for the pathways (section 4.4), hand hygiene and
spiratory hygiene, and the wearing of a face covering (if tolerated) along with social distancing
ould be encouraged and maintained. Therefore visitors require no additional PPE. Visitors should
triaged.
6 Discharge or transfer
ere is no restriction on discharge unless the patient/individual is entering a long-term care facility
ere testing may be required. If someone in the patient’s household has COVID-19 or is a contact
a COVID-19 case and is self-isolating, the discharge guidance will be provided by the clinician.
England, to ensure testing does not delay a timely discharge to a care home, all patients who have
eviously tested negative should be re-tested for SARS-CoV-2 again 48 hours prior to discharge.
munocompetent patients who have tested positive within the previous 90 days, and remain
ymptomatic, do not need to be re-tested. The information from the test results, with any supporting
re information, must be communicated and transferred to the relevant care home. No one should
discharged from hospital directly to a care home without the involvement of the local authority.
scharge arrangements may differ between countries, refer to country specific resources in section
.
Transmission based precautions (TBPs)
Ps are additional measures (to SICPs) required when caring for patients/individuals with a known
suspected infection such as COVID-19.
Ps are based upon the route of transmission and include the following precautions:
Contact precautions
ed to prevent and control infections that spread via direct contact with the patient or indirectly from
patient’s immediate care environment (including care equipment). This is the most common route
cross-infection transmission. COVID-19 can be spread via this route.
Droplet precautions
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Used to prevent and control infections spread over short distances (at least 3 feet/1 metre) via
droplets (>5µm) from the respiratory tract of individuals directly onto a mucosal surface or
conjunctivae of another individual. Droplets penetrate the respiratory system to above the alveolar
level. COVID-19 is predominantly spread via this route and the precautionary distance has been
maintained at 2 metres in care settings.
c) Airborne precautions
Used to prevent and control infection spread without necessarily having close patient contact via
aerosols (≤5µm) from the respiratory tract of one individual directly onto a mucosal surface or
conjunctivae of another individual. Aerosols penetrate the respiratory system to the alveolar level.
COVID-19 can spread via this route. This can be mitigated by safe systems of work outlined in the
hierarchy of controls. AGPs increase the risk of spread by the airborne route.
8.1 Transmission characteristics
Transmission of SARS-CoV-2 implications for infection prevention precautions is contained within the
WHO scientific briefing paper (https://www.who.int/news-room/commentaries/detail/transmission-of-sars-cov-
2-implications-for-infection-prevention-precautions) and CDC’s scientific brief
(https://www.cdc.gov/coronavirus/2019-ncov/more/scientific-brief-sars-cov-2.html).
Literature reviews to support evidence for transmission characteristics
(https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/979441/S116
9_Facemasks_for_health_care_workers.pdf) and TBPs (http://www.nipcm.hps.scot.nhs.uk/resources/literature-
reviews/) are available.
New SARS-CoV-2 variants of concern have been identified in the UK. For further information on the
variants refer to Threat Assessment Brief: Emergence of SARS-CoV-2 B.1.617 variants in India and
situation in the EU/EEA (https://www.ecdc.europa.eu/en/publications-data/threat-assessment-emergence-
sars-cov-2-b1617-variants) and Investigation of SARS-CoV-2 variants of concern: technical briefings
(https://www.gov.uk/government/publications/investigation-of-novel-sars-cov-2-variant-variant-of-concern-
202012011).
9. Medium risk pathway – key principles
This pathway applies to any care facility where:
a) Triaged/clinically assessed individuals are asymptomatic and are waiting a SARS-CoV-2 PCR test
result.
or
b) Triaged/clinically assessed individuals are asymptomatic with COVID-19 contact/exposure
identified.
or
c) Testing is not required or feasible on asymptomatic individuals and therefore infectious status is
unknown.
or
d) Asymptomatic individuals decline testing.
9.1 Maintaining physical distancing and patient placement
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It is important to:
maintain physical distancing of 2 metres at all times (unless the member of staff is wearing
appropriate PPE to provide clinical care) and to advise other patients/visitors to comply
ensure cohorted patients/individuals are physically separated from each other, for example with
screens and privacy curtains between the beds to minimise opportunities for close contact - this
should be locally risk assessed to ensure patient safety is not compromised
9.2 Personal protective equipment: patients/individuals with no COVID-19
symptoms and no test results
PPE required by type of
transmission/exposure
Disposable
gloves
Disposable apron/gown
Face masks
Eye/face
protection
(visor)*
Droplet/contact PPE for
direct patient care <2
metres
Single
use**
Single use apron (gown
required if risk of
spraying/splashing)
FRSM Type
IIR†
Single use
or
reusable*
Airborne PPE (when
undertaking or if AGPs
are likely)
Single use
Single use apron or gown
FFP3†† or
respirator/
hood for AGPs
Single use
or reusable
† FRSM can be worn sessionally if providing care for COVID-19 cohorted patients/individuals.
††FFP3 can be worn sessionally (includes eye/face protection) in high risk areas where AGPs are
undertaken for COVID-19 cohorted patients/individuals.
*Risk assess and use if required for care procedure/task where anticipated blood/body fluids
spraying/splashes.
**Gloves are not required when: undertaking administrative tasks, for example using the telephone,
using a computer or tablet, writing in the patient chart; giving oral medications, distributing or
collecting patient dietary trays.
9.3 Safe management of care environment/equipment/blood and body fluids
9.3.1 Equipment
Important considerations in the use of equipment are:
patient care equipment should be single use items where practicable
reusable (communal) non-invasive equipment should be allocated to an individual patient or
cohort of patients/individuals
all reusable (communal) non-invasive equipment must be decontaminated:
between each and after patient/individual
after blood and body fluid contamination
at regular intervals as part of routine equipment cleaning
decontamination of equipment must be performed using either:
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a combined detergent/disinfectant solution at a dilution of 1,000 parts per million available
chlorine (ppm av.cl.); or
a general-purpose neutral detergent in a solution of warm water followed by a disinfectant
solution of 1,000ppm av.cl.
alternative cleaning agents/disinfectant products may be used with agreement of the IPC
team/health protection team (HPT)
cleaning of care equipment as per manufacturer’s guidance/instruction and recommended
product ‘contact time’ must be followed for all cleaning/disinfectant solutions/products
an increased frequency of decontamination should be considered for all reusable non-invasive
care equipment when used in isolation/cohort areas
the use of fans in high and medium risk pathways should be risk assessed - refer to Estates
guidance
9.3.2 Environment
Important considerations for environmental cleaning and disinfection are:
cleaning frequencies of the care environment in COVID-19 care areas must be enhanced and
single rooms, cohort areas and clinical rooms (including rooms where PPE is removed) cleaned
at least twice daily
routine cleaning must be performed using either:
a combined detergent/disinfectant solution at a dilution of 1,000ppm av.cl.; or
a general-purpose neutral detergent in a solution of warm water followed by a disinfectant
solution of 1,000ppm av.cl
alternative cleaning agents/disinfectants may be used with agreement of the local IPC
team/HPT
the increased frequency of decontamination/cleaning should be incorporated into the
environmental decontamination schedules for all COVID-19 areas, including where there may
be higher environmental contamination rates, including for example:
toilets/commodes particularly if patients/individuals have diarrhoea
‘frequently touched’ surfaces such as medical equipment, door/toilet handles, locker tops,
patient call bells, over bed tables, bed rails, phones, lift buttons/communal touch points and
communication devices (for example, mobile phones, tablets, desktops, keyboards)
particularly where these are used by many people, should be cleaned at least twice daily
with solution of detergent and 1,000ppm chlorine or an agreed alternative when known to
be contaminated with secretions, excretions or body fluids
dedicated or disposable equipment (such as mop heads, cloths) must be used for environmental
decontamination
reusable equipment (such as mop handles, buckets) must be decontaminated after use with a
chlorine-based disinfectant or locally agreed disinfectant
single (isolation) rooms must be terminally cleaned as above following resolution of symptoms,
discharge or transfer (this includes removal and laundering of all curtains and bed screens)
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4 Aerosol generating procedures (AGPs): procedures that create a higher risk
respiratory infection transmission
Ps should only be carried out when essential and only staff who are needed to undertake the
ocedure should be present, wearing airborne PPE/RPE precautions (see information in the high
k pathway guidance).
4.1 Critical care areas
oplet precautions apply when within 2 metres and providing direct patient care. Airborne
ecautions are required when undertaking AGPs. However, consideration may need to be given to
e application of sessional use of FFP3 masks where the number of cases of suspected/possible
OVID-19 requiring AGPs increases and patients/individuals cannot be managed in single or
lation rooms that is patient cohort. Sessional use of FFP3 masks (includes eye/face protection)
ay be considered. All other items of PPE (gloves/gown) must be changed between patients and/or
er completing a procedure or task.
4.2 Operating theatres
tients/individuals should be anaesthetised and recovered in the operating theatre if
ubation/extubation (AGP) is required. For local, neuraxial or regional anaesthesia the patient is not
quired to be anaesthetised/recovered in theatre.
5 Duration of TBPs
Ps should only be discontinued in consultation with clinicians and should take into consideration
e individual’s PCR test results and clinical symptoms. If test results are not available (for example
e patient/individual declines) TBPs can be discontinued after 14 days (inpatients) depending on
ntact exposure and providing the patient/individual remains symptom free.
6 Visitor guidance
siting may be limited during increases in incidence and prevalence of COVID-19, however as cases
cline and restrictions ease, visitors should be permitted to enter the facility and be educated in the
C measures required as outlined in the information on administration measures for the pathways.
visitors should be triaged.
is includes accompanying individuals when attending outpatient appointments, such as antenatal
pointments and therapy groups.
7 Discharge or transfer
ere is no restriction on discharge if the patient/individual is well, unless the patient/individual is
tering a long-term facility and testing may be required. If someone in the patient’s household has
OVID-19 or is a contact of a COVID-19 case and is self-isolating, the discharge guidance will be
ovided by the clinician.
scharge information for patients/individuals should include an understanding of their need for any
lf-isolation, as well as their family members (where applicable).
bulance services and the receiving facilities must be informed of the infectious status of the
ividual.
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Discharge arrangements may differ between countries, refer to country specific resources in section
2.1.
In England, to ensure testing does not delay a timely discharge to a care home, all patients who have
previously tested negative should be re-tested for SARS-CoV-2 again 48 hours prior to discharge.
Immunocompetent patients who have tested positive within the previous 90 days, and remain
asymptomatic, do not need to be re-tested. The information from the test results, with any supporting
care information, must be communicated and transferred to the relevant care home. No one should
be discharged from hospital directly to a care home without the involvement of the local authority.
10. High risk pathway – key principles
This pathway applies to any emergency/urgent care facility where:
a) Untriaged individuals present for assessment or treatment (symptoms unknown*).
or
b) Confirmed SARS-CoV-2 (COVID-19) PCR positive patients are cared for.
or
c) Symptomatic or suspected COVID-19 individuals including those with a history of contact with a
COVID-19 case who have been triaged/clinically assessed and are waiting test results.
or
d) Symptomatic individuals decline testing.
*Once assessed, if asymptomatic with no contact history, patients/individuals may move to the
medium risk pathway awaiting test result.
10.1 Patient placement
If the patient/individual has symptoms or a history of contact/exposure with a case, they should be
prioritised for single room isolation or cohorted (if an isolation room is unavailable) until their test
results are known, for example use privacy curtains between bed spaces to minimise opportunities
for close contact between patients/individuals. This should be locally risk assessed to ensure this
does not compromise patient safety.
If single rooms are in short supply, priority should be given to patients with excessive cough and
sputum production, diarrhoea or vomiting and to those at high risk/extremely high risk of severe
illness.
Local risk assessments and clinical decisions must be made regarding placement of
patients/individuals with availability of single rooms taken into consideration.
10.2 Personal protective equipment (PPE): suspected/confirmed COVID-19
patient/individual
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PPE required by type of
transmission/exposure
Disposable
gloves
Disposable
apron/gown
Face
masks
Eye/face
protection
(visor)
Droplet/contact PPE
Single use
Single use apron
and gown if risk
of spraying /
splashing)
FRSM
Type IIR
for direc
patient
care†
Single use
t
or reusable
Airborne PPE (when undertaking or if
AGPs are likely)*
If an unacceptable risk of
transmission remains following
rigorous application of the hierarchy
of control**
Single use
Single use gown
FFP3††
respirato
/ hood fo
AGPs
or
r Single use
r or reusable
†FRSM can be worn sessionally (includes eye/face protection) if providing care for COVID -19
cohorted patients/individuals.
††FFP3 can be worn sessionally (includes eye/face protection) in high risk areas where AGPs are
undertaken for COVID-19 cohorted patients/individuals.
*Consideration may need to be given to the application of airborne precautions where the number of
cases of COVID-19 requiring AGPs increases and patients/individuals cannot be managed in single
or isolation rooms.
**Or if an unacceptable risk of transmission remains following rigorous application of the hierarchy of
control, taking these controls into account, it may be necessary to consider the extended use of RPE
for patient care in this situation.
10.2.1 Respiratory protective equipment (RPE)/FFP3 (filtering face piece or hood)
Respirators are used to prevent inhalation of small airborne particles arising from AGPs.
Respirators should:
be well fitting, covering both nose and mouth
always be worn when undertaking an AGP on a COVID-19 confirmed or suspected
patient/individual
not be allowed to dangle around the neck of the wearer or hang from one ear after or between
each use
not be touched once put on
be removed outside the patient’s/individual’s room or cohort area or COVID-19 ward
respirators can be single use or single session use (disposable or reusable) and fluid-resistant
all staff who are required to wear an FFP3 respirator must be fit tested for the relevant model to
ensure an adequate seal or fit (according to the manufacturer’s guidance)
where fit testing fails, suitable alternative equipment must be provided, or the HCW should be
moved to an area where FFP3 respirators are not required
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fit checking (according to the manufacturer’s guidance) is necessary when a respirator is put on
(donned) to ensure an adequate seal has been achieved
respirators should be compatible with other facial protection used (protective eyewear) so that
this does not interfere with the seal of the respiratory protection
the respirator should be discarded and replaced and not be subject to continued use if the facial
seal is compromised, it is uncomfortable, or it is difficult to breathe through
reusable respirators can be utilised by individuals if they comply with HSE recommendations -
reusable respirators should be decontaminated according to the manufacturer’s instructions
Valved respirators are not fluid-resistant unless they are also ‘shrouded’. Valved non-shrouded FFP3
respirators should be worn with a full-face shield if blood or body fluid splashing is anticipated. Valved
respirators should not be worn by an HCW/operator when sterility directly over the surgical field is
required, for example in theatres/surgical settings or when undertaking a sterile procedure, as the
exhaled breath is unfiltered.
Examples of sterile procedures include:
any surgical or invasive procedure that routinely requires maximal sterile barrier precautions to
prevent infection, for example sterile gowns, sterile gloves, face mask as required for surgical
antisepsis/ANTT - these are commonly but not exclusively undertaken in operating theatres,
critical care or emergency departments
those sterile percutaneous or invasive procedures such as interventional radiology/cardiac
catheterisation, PICC or other central venous catheter insertions
The ongoing use of valved respirators in theatres and surgical settings should be based on a local
risk assessment. The risk of an asymptomatic HCW transmitting COVID-19 infection if wearing a
valved respirator is considered ‘very small’, as the HCW would need to be excreting virus and the
patient would need to be negative for COVID-19 (FFP3 use is when an HCW is managing a
suspected/confirmed COVID-19 positive patient undergoing AGPs in the medium or high risk
pathway).
10.2.2 Full body gowns or fluid repellent coveralls
Full body gowns or fluid repellent coveralls must be:
worn when there is a risk of extensive splashing of blood and/or body fluids
worn when undertaking AGPs
worn when a disposable apron provides inadequate cover for the procedure or task being
performed for example, surgery changed between patients/individuals and immediately after
completing a procedure or task
Sessional or extended use of gowns must be minimised and only used in areas where cohorts of
confirmed COVID-19 patients are managed and there is a lack of single rooms/isolation rooms. If
sessional use is required, an individual patient risk assessment must be undertaken and reviewed
daily. Gowns are not required when moving around a unit or department.
10.3 Safe management of care environment/equipment/blood and body fluids
Please refer to information given in the medium risk pathway.
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In addition if there are clusters or outbreaks of COVID-19 (2 or more cases linked by time and place)
with significant respiratory symptoms in communal settings cleaning frequencies should be
increased.
10.4 Aerosol generating procedures (AGPs): procedures that create a higher risk
of respiratory infection transmission and operating theatres
10.4.1 Critical care
Droplet precautions would apply, however consideration may need to be given to the application of
airborne precautions where the number of cases of COVID-19 requiring AGPs increases and
patients/individuals cannot be managed in single or isolation rooms.
10.4.2 Operating theatres (including day surgery)
Patients/individuals should be anaesthetised and recovered in the theatre if intubation/extubation
(AGP) is required using airborne precautions. This is not required for regional, neuraxial or local
anaesthesia.
Ventilation in both laminar flow and conventionally ventilated theatres should remain in full operation
during surgical procedures where patients/individuals have suspected/confirmed COVID-19. Air
passing from operating theatres to adjacent areas will be highly diluted and is not considered to be a
risk.
10.5 Duration of precautions
In general, patients with COVID-19 who are admitted to hospital will have more severe disease than
those who can remain in the community, especially if they have been severely unwell or have pre-
existing conditions such as severe immunosuppression. Therefore, it is recommended that these
individuals should be isolated within hospital or remain in self-isolation on discharge for 14 days from
their first positive SARS-CoV-2 PCR test.
Whilst in hospital patients/individuals should remain in isolation/cohort with TBPs applied for at least
14 days after onset of symptoms and should be 48 hours without a fever (without use of antipyretic
medication) or respiratory symptoms. The decision to modify the duration of, or ‘stand down’ TBPs
(contact/droplet/airborne) should be made by the clinical team managing the individual’s care.
For clinically suspected COVID-19 patients who have tested negative or have not been tested for
SARS-CoV-2 and whose condition is severe enough to require hospitalisation, then the 14 day
isolation period should be measured from the day of admission.
Testing for virological clearance is encouraged in severely immunosuppressed patients. For these
patients, IPC measures should be continued unless there is evidence of virological clearance prior to
discharge or there has been a complete resolution of all symptoms. This is different to other advice
sections but reflects the complex health needs of such patients and likelihood for prolonged
shedding, with risk of spread in healthcare settings. Upon discharge such patients may be retested at
first follow-up appointment to help inform actions at any next medical appointment.
10.6 Visitor guidance
In this pathway, visiting should continue to be limited to only essential visitors, for example birthing
partner, carer/parent/guardian. Hospitals/organisations will provide advice and guidance to support
patients during these restrictions. Visitor guidance may differ between countries, refer to country
specific resources in section 2.1.
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Whilst face masks/coverings are recommended the need for visitors to wear additional PPE should
be individually assessed.
10.7 Discharge or transfer
Discharge from an inpatient facility can occur when the individual is well enough and the clinician has
provided them with discharge such as advice to self-isolate for at least 14 days from the date of the
positive SARS-CoV-2 PCR test (providing their symptoms resolve during this period). Refer to
country specific resources in section 2.1.
Advice should include written information, such as patients with a cough or a loss of, or change in,
normal sense of smell or taste (anosmia), may persist in some individuals for several weeks following
COVID-19 recovery, and is not currently considered an indication of ongoing infection when other
symptoms have resolved.
Prior to discharge (if the patient is within the 14 days) clinicians should ascertain if there are any
clinically extremely vulnerable individuals who live in the household and are currently not infected. If
so, it is highly advisable for patients to be discharged to a different home until they have finished their
self-isolation period. If these individuals cannot be moved to a different household, then ensure that
the discharged patient is advised on IPC measures as outlined in the Stay at home guidance
(https://www.gov.uk/government/publications/covid-19-stay-at-home-guidance/stay-at-home-guidance-for-
households-with-possible-coronavirus-covid-19-infection).
Advice on ongoing medical needs should be provided for patients who are discharged within their
self-isolation period. If patients deteriorate at home or in a care setting, they or their carer should
seek advice from NHS 111 online (https://111.nhs.uk/) or by telephone, or through pre-existing services
such as GP practice links with care homes. In an emergency, 999 should be called. In either case,
they should inform the call attendant that they have been recently discharged from hospital with
confirmed COVID-19.
Discharge information for patients/individuals to their own home should include an understanding of
their need for any self-isolation, as well as their family/household members.
Ambulance services and the receiving facilities must be informed of the infectious status of the
individual and the ongoing need to continue with infection control precautions.
Discharge arrangements may differ between countries as discharge to other areas is dependent on
testing and/or isolation facilities available. Refer to country specific resources in section 2.1.
In England, to ensure testing does not delay a timely discharge to a care home, patients who have
tested negative should be re-tested for SARS-CoV-2 again 48 hours prior to discharge. All SARS-
CoV-2 positive patients who are discharged within their 14 day self-isolation period will need to be
discharged to a designated setting. The information from the test results, with any supporting care
information, must be communicated and transferred to the relevant care home. No one should be
discharged from hospital directly to a care home without the involvement of the local authority.
11. Occupational health and staff deployment
Prompt recognition of cases of COVID-19 among healthcare staff is essential to limit the spread.
Health and social care staff with symptoms of COVID-19 or a positive COVID-19 test result should
not come to work. Refer to country specific testing requirements.
As a general principle, healthcare staff who provide care in settings for suspected or confirmed
patients/individuals should not care for other patients. However, this has to be a local decision based
on local epidemiology and the configuration of the organisation.
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A risk assessment is required for health and social care staff at high risk of complications from
COVID-19, or clinically extremely vulnerable groups, including pregnant and BAME staff. Guidance
on carrying out risk assessments can be found by following the links to the country specific resources
in section 2.1.
Employers should:
discuss with employees who are clinically extremely vulnerable, including those who are
pregnant and of BAME origin, the need to be deployed away from areas used for the care of
those who have, or are clinically suspected of having, COVID-19; or, in primary care settings,
clinics set up to manage people with COVID-19 symptoms
ensure that advice is available to all health and social care staff, including specific advice to
those at risk from complications
Bank, agency and locum staff who fall into these categories should follow the same deployment
advice as permanent staff.
As part of their employer’s duty of care, providers have a role to play in ensuring that staff understand
and are adequately trained in safe systems of working, including donning and doffing of PPE. A fit
testing programme should be in place for those who may need to wear respiratory protection.
In the event of a breach in infection control procedures, staff should be reviewed by occupational
health.
Occupational health departments should lead on the implementation of systems to monitor staff
illness, absence and vaccination against COVID-19.
12. Glossary of terms
Aerosol generating procedures (AGPs)
Certain medical and patient care activities that can result in the release of airborne particles
(aerosols). AGPs can increase the risk transmission of infections.
Airborne transmission
The spread of infection from one person to another by airborne particles (aerosols) containing
infectious agents.
Airborne particles
Very small particles that may contain infectious agents. They can remain in the air for long periods of
time and can be carried over long distances by air currents. Airborne particles can be released when
a person coughs or sneezes, and during AGPs. ‘Droplet nuclei’ are aerosols formed from the
evaporation of larger droplet particles (see droplet transmission). Aerosols formed from droplet
particles in this way behave as other aerosols.
Airborne precautions
Measures used to prevent and control infection spread without necessarily having close patient
contact via aerosols (less than or equal to 5μm) from the respiratory tract of one individual directly
onto a mucosal surface or conjunctivae of another individual. Aerosols can penetrate the respiratory
system to the alveolar level.
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BS/EN standards
Mandatory technical specifications created by either the British Standards Institute (BS) or European
Standardisation Organisations (EN) in collaboration with government bodies, industry experts and
trade associations. They aim to ensure the quality and safety of products, services and systems.
Clinically vulnerable or extremely clinically vulnerable
People who are defined as clinically extremely vulnerable
(https://www.gov.uk/government/publications/guidance-on-shielding-and-protecting-extremely-vulnerable-
persons-from-covid-19/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19#cev)
are at very high risk of severe illness from COVID-19. Those included in this category will been
identified by:
having one or more of conditions list, or
a clinician or GP has added the individual to the Shielded Patient List
Cohort area
An area (room, bay, ward) in which 2 or more patients (a cohort) with the same confirmed infection
are placed. A cohort area should be physically separate from other patients.
Contact precautions
Measures used to prevent and control infections that spread via direct contact with the patient or
indirectly from the patient’s immediate care environment (including care equipment). This is the most
common route of infection transmission.
Contact transmission
Contact transmission is the most common route of transmission, and consists of 2 distinct types:
direct contact and indirect contact. Direct transmission occurs when microorganisms are transmitted
directly from an infectious individual to another individual without the involvement of another
contaminated person or object (fomite). Indirect transmission occurs when microorganisms are
transmitted from an infectious individual to another individual through a contaminated object (fomite)
or person.
COVID-19
COVID-19 is a highly infectious respiratory disease caused by a novel coronavirus. The disease was
discovered in China in December 2019 and has since spread around the world.
Droplet precautions
Measures used to prevent and control infections spread over short distances (at least 1 metre or 3
feet) via droplets (greater than 5μm) from the respiratory tract of one individual directly onto a
mucosal surface or conjunctivae of another individual. Droplets penetrate the respiratory system to
above the alveolar level. COVID-19 is predominantly spread via this route and the precautionary
distance has been maintained at 2 metres in care settings.
Droplet transmission
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e spread of infection from one person to another by droplets containing infectious agents.
e or face protection
orn when there is a risk from splashing of secretion (including respiratory secretions). Eye or face
tection can be achieved using any one of:
a surgical mask with integrated visor
a full face visor or shield
goggles
id-resistant (Type IIR) surgical face mask (FRSM)
disposable fluid-resistant mask worn over the nose and mouth to protect the mucous membranes
the wearer’s nose and mouth from splashes and infectious droplets. FRSMs can also be used to
tect patients. When recommended for infection control purposes a ‘surgical face mask’ typically
notes a fluid-resistant (Type IIR) surgical mask.
id-resistant
erm applied to fabrics that resist liquid penetration, often used interchangeably with ‘fluid-repellent’
en describing the properties of protective clothing or equipment.
equently touched surfaces
rfaces of the environment which are commonly touched or come into contact with human hands.
althcare or clinical waste
ste produced as a result of healthcare activities, for example soiled dressings, sharps.
erarchy of controls
e hierarchy of controls is used to identify the appropriate controls with Elimination, Substitution,
gineering Controls, Administrative Controls, Personal Protective Equipment.
erarchy of Controls: The National Institute for Occupational Safety and Health (NIOSH), Centers for
ease Control and Prevention (CDC) (https://www.cdc.gov/niosh/topics/hierarchy/default.html)
gh-flow nasal cannula (HFNC) therapy
NC is an oxygen supply system capable of delivering up to 100% humidified and heated oxygen at
low rate of up to 60 litres per minute.
gher risk acute care area/units
ensive care units, intensive therapy units, high dependency units, emergency department
uscitation areas, wards with non-invasive ventilation, operating theatres, endoscopy units for
per respiratory, ENT or upper GI endoscopy, and other clinical areas where AGPs are regularly
rformed. Referred to as ‘AGP hot spots’.
ubation period
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The period between the infection of an individual by a pathogen and the manifestation of the illness
or disease it causes.
Induction of sputum
Induction of sputum typically involves the administration of nebulised saline to moisten and loosen
respiratory secretions (this may be accompanied by chest physiotherapy (percussion and vibration))
to induce forceful coughing.
Infectious linen
Linen that has been used by a patient who is known or suspected to be infectious and/or linen that is
contaminated with blood/other body fluids, for example faeces.
Long term health condition
This covers:
chronic obstructive pulmonary disease, bronchitis, emphysema or asthma
heart disease
kidney disease
liver disease
stroke or a transient ischaemic attack (TIA)
diabetes
lowered immunity as a result of disease or medical treatment, such as steroid medication or
cancer treatment
a neurological condition, such as Parkinson’s disease, motor neurone disease, multiple sclerosis
(MS), cerebral palsy, or a learning disability
any problem with the spleen, including sickle cell disease, or had spleen removed
a BMI of 40 or above (obese)
Personal protective equipment (PPE)
Equipment a person wears to protect themselves from risks to their health or safety, including
exposure to infectious agents. The level of PPE required depends on the:
suspected or known infectious agent
severity of the illness caused
transmission route of the infectious agent
procedure or task being undertaken
Respiratory droplets
A small droplet, such as a particle of moisture released from the mouth during coughing, sneezing, or
speaking.
Respiratory protective equipment
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espiratory protection that is worn over the nose and mouth designed to protect the wearer from
haling hazardous substances, including airborne particles (aerosols). There are 2 types of
spiratory protection that can be used, tight-fitting disposable FFP respirators and loose-fitting
owered hoods (TH2).
FP stands for filtering face piece. There are 3 categories of FFP respirator: FFP1, FFP2 and FFP3.
FP3 and loose-fitting powered hoods provide the highest level of protection and are recommended
hen caring for patients in areas where high risk AGPs are being performed.
espiratory symptoms
espiratory symptoms include:
rhinorrhoea (runny nose)
sore throat
cough
difficulty breathing or shortness of breath
egregation
hysically separating or isolating from other people.
ARS-CoV
evere acute respiratory syndrome coronavirus, the virus responsible for the 2003 outbreak of
uman coronavirus disease.
ARS-CoV-2
evere acute respiratory syndrome coronavirus 2, the virus responsible for the COVID-19 pandemic.
everely immunosuppressed
everely immunosuppressed is defined in the Green Book on Immunisation as:
immunosuppression due to acute and chronic leukaemias and lymphoma (including Hodgkin’s
lymphoma)
severe immunosuppression due to HIV/AIDS (British HIV Association advice
(https://www.bhiva.org/BHIVA-and-THT-statement-on-COVID-19-and-advice-for-the-extremely-vulnerable))
cellular immune deficiencies (such as severe combined immunodeficiency, Wiskott-Aldrich
syndrome, 22q11 deficiency/DiGeorge syndrome)
being under follow up for a chronic lymphoproliferative disorder including haematological
malignancies such as indolent lymphoma, chronic lymphoid leukaemia, myeloma and other
plasma cell dyscrasias
having received an allogenic (cells from a donor) stem cell transplant in the past 24 months and
only then if they are demonstrated not to have ongoing immunosuppression or graft versus host
disease (GVHD)
having received an autologous (using their own stem cells) haematopoietic stem cell transplant
in the past 24 months and only then if they are in remission
s://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control/covid-19-guidance-for-maintaining-servi… 33/35
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11/10
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991310 Appendix A
/2021, 15:27 COVID-19: guidance for maintaining services within health and care settings – infection prevention and control recommenda…
those who are receiving, or have received in the past 6 months, immunosuppressive
chemotherapy or radiotherapy for malignant disease or non-malignant disorders
those who are receiving, or have received in the past 6 months, immunosuppressive therapy for
a solid organ transplant (with exceptions, depending upon the type of transplant and the immune
status of the patient)
those who are receiving, or have received in the past 12 months, immunosuppressive biological
therapy (such as monoclonal antibodies), unless otherwise directed by a specialist
those who are receiving, or have received in the past 3 months, immunosuppressive therapy
including:
adults and children on high-dose corticosteroids (>40mg prednisolone per day or 2mg/
kg/day in children under 20kg) for more than 1 week
adults and children on lower dose corticosteroids (>20mg prednisolone per day or
1mg/kg/day in children under 20kg) for more than 14 days
adults on non-biological oral immune modulating drugs, for example methotrexate >25mg
per week, azathioprine >3.0mg/kg/day or 6-mercaptopurine >1.5mg/kg/day
children on high doses of non-biological oral immune modulating drugs
ndard infection control precautions (SICPs)
Ps are the basic IPC measures necessary to reduce the risk of transmission of an infectious
ent from both recognised and unrecognised sources of infection.
gle room
oom with space for one patient and usually contains (as a minimum) a bed, a locker or wardrobe
d a clinical wash-hand basin.
ff cohorting
en staff care for one specific group of patients and do not move between different patient cohorts.
tient cohorts may include for example ‘symptomatic’, ‘asymptomatic and exposed’, or
ymptomatic and unexposed’ patient groups.
nsmission based precautions
ditional precautions to be used in addition to SICPs when caring for patients with a known or
pected infection or colonisation.
MANX CARE FINANCIAL
REGULATIONS
Issued by the Treasury
Government Office
Douglas
Isle of Man
IM1 3PX
1 April 2021
FOI 2031913 - Appendix 1 - Manx Care Financial Regulations
Introduction
3
Financial Directions
10
Financial Practice Notes
48
FOI 2031913 - Appendix 1 - Manx Care Financial Regulations
Introduction
Table of Amendments
The tables below will show the latest main amendments that have been made in since V01.2
of the Financial Regulations. For an explanation of the financial regulations generally and
specific differences from Isle of Man Government Financial Regulations please see the
accompanying explanatory document. Further information in relation to amendments made
to each individual Financial Practice Note (FPN) can be found at the beginning of the relevant
FPN.
The Financial Directions
Table of Amendments
(to previous edition)
Direction
Ref.
Amendment
Financial Practice Notes
Table of Key Amendments
FPN
Amendments to Previous Version
Notes
where amendments have only been in relation to typographical, grammar or
formatting errors, they have not been included above.
Listed above are the changes from the Isle of Man Government Financial Regulations
which are required by the Health and Care Transformation Programme Boards
If there are any further amendments that any Manx Care Officer considers should be
considered by the Board for future updates to these Financial Regulations (either Financial
Directions or Financial Practice Notes) then they should be submitted to the Finance Business
Partner (FBP) for consideration.
If the FBP considers the proposed amendment to have merit it will be submitted to the Manx
Care Board for consideration and, on approval, then to Treasury for further consideration.
FOI 2031913 - Appendix 1 - Manx Care Financial Regulations
Introduction by the Treasury Minister
The Isle of Man Government receives and spends over £1 billion each year and it is essential
that we maximise the value generated by this significant investment in Manx Public Services.
The Treasury Act 1985 places an obligation on The Treasury “to supervise and control all
matters relating to the financial affairs of the Government” and these Financial Regulations
establish the statutory framework and mandatory requirements that are a key element in the
fulfilment of that obligation.
However, notwithstanding Treasury’s statutory oversight duties, good financial governance
and the delivery of best value is the responsibility of each and every Government employee,
and it is that financial culture that Treasury is actively promoting through its overarching
Financial Operating Policy and these Financial Regulations.
The Honourable Alfred Cannan MHK
Treasury Minister
FOI 2031913 - Appendix 1 - Manx Care Financial Regulations
THIS PAGE IS INTENTIONALLY BLANK
FOI 2031913 - Appendix 1 - Manx Care Financial Regulations
Scope – To Whom & What Do They Apply?
Who?
These Financial Regulations apply, without exception, to all employees and officers of Manx
Care.
What do they apply to?
These Financial Regulations apply to all financial transactions, monies, assets and liabilities
handled by Manx Care. They apply both to public monies and any monies/assets handled on
behalf of third parties.
The Financial Regulations comprise of two categories of instructions approved and issued by
The Treasury; being:
Financial Directions
There are six Financial Directions, which cover:
A. Financial Values & Governance
B. Managing Resources
C. Buying and Making Payments
D. Safeguarding and Optimising Assets
E. Paying Staff
F. Selling and Receiving Payments
Financial Directions are statutory and are issued in accordance with the Treasury Act 1985.
Financial Practice Notes
In addition, the six Financial Directions also make reference to Financial Practice Notes (FPNs)
which have also been approved individually by The Treasury and agreed by the Manx Care
Board.
Financial Practice Notes are mandatory for the Chair and all Directors, Officers and employees.
Exemptions – How to Obtain Approval
It is accepted that whilst prescriptive directions and procedures should be able to appropriately
cover the majority of situations, there will always be times when an alternative approach will
improve the management of our financial objectives and related risks.
Accordingly, there is provision for any requirement to be exempted, provided that the required
approval is obtained in advance of any related financial transaction being undertaken.
The relevant powers to approve exemptions are included within the Financial Directions,
however the generally adopted principle is:
Requirement
Authority to Approve Exemptions
Statutory
Financial
Directions
The Treasury has the authority to approve an exemption
from any statutory financial direction.
Financial
Practice
Notes
The Treasury, the Manx Care Board or Financial
Governance Officers, as nominated within the Financial
Directions, have the authority to approve an exemption
from any Financial Practice Note within their area of
designated responsibility.
Certain Specific
Requirements within
Financial Directions
& FPNs
To the extent prescribed:
Accountable Officers
FOI 2031913 - Appendix 1 - Manx Care Financial Regulations
Requirement
Authority to Approve Exemptions
Have the authority to approve an exemption from
specific requirements to the extent outlined.
Budget Holders/Delegated Officers
Have the authority to approve an exemption from
specific requirements to the extent outlined within these
Directions and Financial Practice Notes and subject to
their delegated financial authority limits.
Consequences of Non-compliance
All requirements of Financial Directions and Financial Practice Notes either must be fully
complied with or have received a prior approval for an exemption from them.
In addition to exposing the Isle of Man Government to unnecessary financial risks, non-
compliance will have the following consequences:
Directions
Non-compliance may lead to prosecution under the Audit Act
2006 and may also lead to the award of costs and compensation
in relation to any unlawful actions taken.
It is also a requirement that any non-compliance is investigated
and progressed (as appropriate) under the applicable
disciplinary or capability procedure.
Financial Practice Notes
Compliance is mandatory and it is a requirement that any non-
compliance is investigated and progressed (as appropriate)
under the applicable disciplinary or capability code.
FOI 2031913 - Appendix 1 - Manx Care Financial Regulations
Interpretation
In the Financial Regulations, the following interpretations will apply (see also the Roles as
defined at Financial Direction A 5:
“the Accountable Officer”
The officer designated by Treasury for the purposes of
the financial governance of Manx Care.
“the Board”
The Board itself in relation to a Statutory Board.
“Budget Holder”
A Budget Holder as delegated in accordance with these
Directions.
“Chief Executive Officer”
The Chief Executive Officer or functional equivalent by
whatever title appointed of Manx Care with strategic
and/or service responsibility for the body in question.
“Department”
A Government Department to which the Government
Departments Act 1987 applies. Unless the context
indicates otherwise references to Department are
References to Manx Care
“Delegated Officer”
An Officer with a financial authority delegated to them in
accordance with these Directions.
“Designated Body”
Any Designated Body as defined by the Treasury Act 1985
“FPN XX”
Relates to the relevant Financial Practice Note issued by
Treasury and referred to from within the Directions,
where “XX” refers to the reference number assigned to
each instruction. Whilst FPNs are issued separately by
Treasury, for ease of reference these are also set out at
the end of this Financial Operating Manual.
“Financial Governance Officers” Specific officers nominated within these directions.
“Internal Service”
A service that is routinely provided by a Designated Body
to other Designated Bodies.
“Member”
“Non-executive member”
A Member [To be read as non-executive member] (acting
in person) for Manx Care
Any one of non-executive members of Manx Care
“the Chair”
The Chair of Manx Care (acting in person) for Manx Care
“Officer”
Any officer or office holder within Manx Care as defined
by the Financial Regulations (see introduction). Without
limiting the generality of this term, this includes all public
servants, civil servants and persons with lawfully
delegated powers and responsibilities of Manx Care.
“PAC”
Public Accounts Committee which is The Standing
Committee on Expenditure and Public Accounts of
Tynwald.
“Treasury”
The Treasury Minister or the Treasury Minister and
Treasury political members in a meeting together, as
FOI 2031913 - Appendix 1 - Manx Care Financial Regulations
authorised by the Minister under section 3(2) of the
Government Departments Act 1987.
Any financial amount stated within these regulations should be deemed to be excluding VAT
(where applicable).
Additional Considerations
In addition to these Financial Regulations, Treasury may issue specific directions relating to a
given set of circumstances which are not covered, or not fully covered, by existing Directions
as set out within this document. The following procedure will govern how this process is
completed:
a) Every effort, including direct communication between the Treasury and the Chair and
Board of Manx Care, should be made to come to an acceptable agreement of
treatment before consideration is given to issuing an exceptional or new Direction.
b) These efforts should be concluded within a short but appropriate timescale.
c) The efforts to reach such agreement should be well documented and minutes taken
of all meetings. This should also apply where there is conflict between affected parties
d) When the Treasury is satisfied that all proportionate efforts have been made to reach
an agreement without success, the Treasury should write to the Board of Manx Care,
with a copy going to the DHSC, advising:
i.
The consideration that is being given to the issue of a Direction;
ii.
The reasons behind the decision to introduce a Direction;
iii.
The actions taken and progress made to try and reach an agreement; and
iv.
A request that the Board respond by a set date, setting out the action(s) it
intends to take to resolve the concern and the proposed timescale for
completion
e) The Direction should only subsequently be issued if:
i.
Treasury accepts Manx Care’s proposed actions but Manx Care fails to
implement them, or
ii.
Manx Care’s proposed actions are not deemed to be acceptable and
negotiations for an acceptable settlement fail.
f) If it is decided that a Direction must still be issued, Treasury will submit the Direction
letter to the Attorney General beforehand for advice.
These Financial Regulations are also applicable to anyone acting on behalf of Manx Care,
including contractors and consultants commissioned for specific purposes.
In addition to these Financial Regulations, the attention of Accountable Officers is drawn to
the Audit Act 2006 and the Accounts and Audit Regulations 2018.
FOI 2031913 - Appendix 1 - Manx Care Financial Regulations
FINANCIAL
DIRECTIONS
Version Control
Date of Treasury Approval
24th March 2021
Issue Date
1st April 2021
Contents
Financial Direction A: Financial Values & Governance
13
A 1. Applicability
15
A 2. Financial Values
15
A 3. The Acceptance of Gifts & Rewards
16
A 4. Financial Irregularities
16
A 5. Roles
17
A 6. Accountable Officers
18
A 7. Budget Holders
20
A 8. Designated Finance Officer
21
A 9. Delegated Officer
22
A 10. Officer
22
A 11. Training Requirements
22
A 12. Accountability for Non-Compliance
A 13, Internal Audit
22
23
Financial Direction B: Managing Resources
24
B 1. Objectives
26
B 2. Budget Planning
26
FOI 2031913 - Appendix 1 - Manx Care Financial Regulations
B 3. Budget Management
26
B 4. Financing of Expenditure
27
B 5. Guarantees, Indemnities & Contingent Liabilities
27
B 6. New Legislation with Financial Implications
27
Financial Direction C: Buying & Making Payments
29
C 1. Objectives
31
C 2. Insurance
Insurance
31
C 3. Using Internal Resources First
31
C 4. Only Spending What We Can Afford
32
C 5. Financial Thresholds For Procurement Decisions & Exemptions
32
C 6. Central Framework Agreements
32
C 7. Alternative Procedures for Specific Types of Procurement
32
C 8. Procurement of General Goods & Services Up to £100k
33
C 9. Procurement of General Goods & Services Over £100k
34
C 10. Evaluation of Suppliers for General Goods & Services Over £100k
35
C 11. Contracting for Goods & Services Over £100k
35
C 12. Additional Requirements for the Procurement of Specific Categories of
Goods & Services
36
C 13. Acquisition of Assets
36
C 14. Statutory Payments
36
Financial Direction D: Safeguarding and Optimising Assets
37
D 1. Objectives
39
D 2. Banking Arrangements
39
D 3. Management of Assets & Inventory
39
D 4. Optimisation of Assets
39
D 5. Insurances
39
D 6. Cash Management
40
D 7. Investments & Borrowings
40
D 8. Charitable & Third Party Funds
40
FOI 2031913 - Appendix 1 - Manx Care Financial Regulations
Financial Direction E: Paying Staff
41
E 1. Objectives
43
E 2. Payment of Salaries & Wages
43
E 3. Travel & Subsistence
43
Financial Direction F: Selling & Receiving Payments
44
F 1. Objectives
46
F 2. Setting Charges for Goods & Services
46
F 3. Collection of Monies
46
F 4. Selling/Disposal of Assets and Offering Opportunities to 3rd Parties
46
FOI 2031913 - Appendix 1 - Manx Care Financial Regulations
Financial Direction A: Financial Values &
Governance
Summary
This Financial Direction establishes the core financial values that must be adhered to by all officers,
notwithstanding any additional written instructions. It also establishes the overarching financial
governance framework within which all other Treasury directions operate.
FOI 2031913 - Appendix 1 - Manx Care Financial Regulations
Financial Direction A: Financial Values & Governance
Table of Contents
Subject
Page
A 1. Applicability
15
A 2. Financial Values
15
A 3. The Acceptance of Gifts & Rewards
16
A 4. Financial Irregularities
16
A 5. Roles
17
A 6. Accountable Officers
18
A 7. Budget Holders
20
A 8. Designated Finance Officer
21
A 9. Delegated Offi
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