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NHS Provider licence: Self-certification


The Health and Social Care Act 2012 introduced the concept of a Licence for providers of NHS services, and the NHS Provider Licence was subsequently introduced in February 2013.

Foundation Trusts were licensed from April 2013, with other providers being licensed from April 2014, but it was later confirmed that the Licence would not apply to NHS Trusts. Despite this, in April 2017, NHS Improvement (NHSI) confirmed that NHS Trusts must undertake a self-certification against the NHS Provider Licence, on the basis that, despite their exemption, directions from the Secretary of State required NHSI to ensure that NHS Trusts complied with conditions equivalent to the Licence, as it deemed appropriate.

As NHSI’s Single Oversight Framework (SOF) bases its oversight on the Licence, NHS Trusts are therefore legally subject to the equivalent of certain Provider Licence conditions, and must self-certify under these licence provisions.

These conditions are:

Condition G6

Condition G6(2) requires trusts to have processes and systems that:

  • a. identify risks to compliance
  • b. take reasonable mitigating actions to prevent those risks and a failure to comply from occurring.

Providers must annually review whether these processes and systems are effective.

Condition FT4

The Licensee shall apply those principles, systems and standards of good corporate governance which reasonably would be regarded as appropriate for a supplier of health care services to the NHS. Without prejudice to the generality of paragraph 2 and to the generality of General Condition 5, the Licensee shall:

  • a) have regard to such guidance on good corporate governance as may be issued by Monitor from time to time; and
  • b) comply with the following paragraphs of this Condition.

The Licensee shall establish and implement:

  • a) effective board and committee structures;
  • b) clear responsibilities for its Board, for committees reporting to the Board and for staff reporting to the Board and those committees; and clear reporting lines and accountabilities throughout its organisation


The Trust Board approved the 2016/17 self-certification for Condition G6 at its meeting on 01 June 2017 and delegated the Safety and Compliance Committee to review compliance with the requirements of condition FT4. Self certification can be accessed here.

The Safety and Compliance Committee considered the self-assessment at its meeting on 12 June 2017. The Board received an assurance report and endorsed a recommendation by the Safety and Compliance Committee on 06 July 2017 to approve the self-certification for Condition FT4. The self-certification can be accessed here.

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