Annual Report 2003-2004: Internal Control Statement

Statement on Internal Control 2003/2004

Scope of Responsibility

The Board is accountable for internal control. As Accountable Officer and Chief Executive of this Board, I have responsibility for maintaining a sound system of internal control that supports the achievement of the organisation’s policies, aims and objectives. I also have responsibility for safeguarding the public funds and the organisation’s assets for which I am personally responsible as set out in the Accountable Officer Memorandum.

The system of internal control is designed to manage risk to a reasonable level rather than to eliminate all risk of failure to achieve policies, aims and objectives; it can therefore only provide reasonable and not absolute assurance of effectiveness. The system of internal control is based on an ongoing process designed to:

  • Identify and prioritise the risks to the achievement of the organisation’s policies, aims and objectives
  • Evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically.

The system of internal control has been in place in West Hertfordshire Hospitals NHS Trust for the whole year ended 31 March 2004, with the exception of the Assurance Framework which was in place by 1 April 2004 and up to the date of approval of the annual report and accounts.

The Risk and Control Framework

The Trust has been implementing a process for identifying, evaluating and managing the significant risks faced by the Trust throughout the financial year and up to the approval date of the annual accounts. The process is subject to regular review by the Board directly and via the Risk Management Committee and Audit Committee. In order to provide the appropriate control framework the Trust Risk Management Committee has the support of the following Trust Risk sub-committees:

  • Clinical Governance
  • Environment and Facilities
  • Finance and Systems
  • Health & Safety
  • Emergency Planning Group

Through this structure risks are identified, evaluated and controlled by each Division within the Trust. All significant risks, or changes in risk, are identified and described in the Trust’s Risk Register. They are then evaluated and prioritised so that an action plan can be devised for the most significant ones. The Risk Management Team reviews this process.

The Trust has completed Commission for Health Improvement (CHI) and Improving Working Lives (IWL) assessments in the last 12 months.

External audit recommendations are acted upon and updated to the Audit Committee.

Within the Trust there is a Patient and Public Involvement Steering Group, which is chaired by a current patient from the Patients Panel. There is membership also from other external representatives, which are made up from six patients from within the Trust.

Executive Directors

Executive Directors have overall responsibility for the implementation of the risk management policy. They are responsible for the overseeing of the processes for identifying and assessing risk, and for advising the Chief Executive as necessary. They ensure that so far as it is reasonably practical resources are available in order to manage risk.

Internal Audit

Internal Audit reviews the system of internal control throughout the year and reports accordingly to the Audit Committee.

Significant Internal Control Issues

Following a Health and Safety Executive visit and review, a number of risk areas were identified for the Trust. The Trust agreed an action plan to address these risk areas. These actions have been implemented during the course of the year and the Trust is continuing discussions with the Health and Safety Executive about any further measures that are required to ensure compliance.

A full copy of the statement on internal control can be obtained from Communications Department: by email on or telephone on 01442 287620.

David Law, 14 May 2004
Chief Executive
West Hertfordshire Hospitals NHS Trust

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