How we work

As a Foundation Trust we are accountable to our local community which means local people, patients and staff can have a real say in how the Trust is run by becoming members.

The Board

Our Trust board oversees the day-to-day running of the organisation, exercising its power through various sub-committees including:

  • Audit
  • Finance
  • Renumeration and terms of service
  • Charitable funds
  • Facilities and information
  • Trust governance and assurance
  • Quality and patient experience
  • Infection control
  • Mortality performance.

The Trust board meets every month to approve new polices, receive reports on performance and make decisions about how the Trust is run. The board then delegates actions to each of the sub committees.

Our members elect our Council of Governors (COG) to represent their interests while holding the Trust board of directors to account.

Trust Constitution“Read our Trust Constitution (650kb)
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About Foundation Trusts

NHS Foundation Trusts were created to devolve decision making from central government to local organisations and communities, with a strong and clear line of local democratic accountability. A new governance structure was designed specifically for Foundation Trusts, which ensures the direct participation of local communities, and provides and develops healthcare according to the core NHS principles of free care, based on need and not ability to pay.

Those living in constituencies that are served by the Trust can become members and from these members governors are elected to represent members’ interests in the running of the organisation. Members are able to engage in establishing the direction of services provision and ensure that hospital services more accurately reflect the needs and expectations of local people. We have been a Foundation Trust since May 2007, read about our history.

Compliance with licence declaration

NHS Foundation Trusts are required to self-certify whether or not they have complied with the conditions of the NHS Provider Licence (which itself includes requirements to comply with the National Health Service Act 2006, the Health and Social Care Act 2008, the Health Act 2009, and the Health and Social Care Act 2012, and have regard to the NHS Constitution). The following provides the declaration for 2019.

G6 (3): General Condition 6 – Systems for Compliance with Licence Conditions


Board statements Risks of certification Comments/mitigating actions
Response  (confirmed or not confirmed)
Following a review for the purpose of paragraph 2(b) of Licence condition G6, the Directors of the Licensee are satisfied that, in the Financial Year most recently ended, the Licensee took all such precautions as were necessary in order to comply with the conditions of the Licence, any requirements imposed on it under the NHS Acts and have had regard to the NHS Constitution. • The Trust remains in breach of its Provider Licence having been placed in financial and quality ‘special measures’ in 2017 (further details are provided below in respect of each of these areas). On the basis of the breaches identified, which raised concerns regarding the effectiveness of the Trust’s financial governance, quality and corporate governance arrangements, and having regard to its Enforcement Guidance, NHS Improvement (NHSI) have previously accepted Enforcement Undertakings from the Trust.
  • The expectations of the Board in terms of oversight and assurance are set out in Section 4 of the Enforcement Undertakings and cover requirements in respect of programme management, governance of the required improvement plans and reporting on progress internally and to NHSI.
  • The Trust’s response to both financial and quality ‘special measures’ is incorporated within the Trust’s Improvement Programme – ‘Improving Together’, which is supported by a Programme Management Office (PMO), which provides hands on, delivery support to front line teams to deliver the required improvements.  Review and refresh of how the support from the PMO is distributed across the Improvement Programme has been undertaken during 2018/19 and this remains under review to ensure the team are focussing on the priority areas.
  • Revised improvement support is being agreed with NHSE/I following changes to the special measures improvement teams.
  • There is bi-monthly reporting internally to the Trust Board and reporting monthly externally to NHSI and the System Improvement Board, allowing both increased oversight and challenge on the progress of the Improving Together’ Programme and the agreement of the necessary additional support.


Trust structure

Under our board of directors our organisation is split into divisions responsible for the different areas of our Trust from operations to organisational development and workforce.

Our commissioners

As a provider of health services we are accountable to our commissioners who are responsible for designing, developing and buying local health services for local people.

In April 2013 clinical commissioning groups, or CCGs, were introduced nationally as part of the government’s restructuring of health services which put local clinicians such as GPs and nurses in a position where they can develop the services their patients and local residents need.

As our three hospitals are in three different areas we work with three CCGs, North Lincs CCG  for Scunthorpe General Hospital, North East Lincs CCG for Diana, Princess of Wales Hospital and East Riding of Yorkshire CCG for Goole and District Hospital.

Trade Unions

Trade Union (Facility Time Publication Requirements) Regulations 2017
On 1 April 2017, the Trade Union (Facility Time Publication Requirements) Regulations 2017 came into force. The Regulations require the Trust, as an NHS body, to collate and publish on an annual basis, a range of data on the amount and cost of ‘facility time’ within the organisation. Facility Time is the provision of paid or unpaid time off from an employee’s normal role to undertake Trade Union duties and activities as a Trade Union representative.

NLaG facility hours 2017-18 (276kb)
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