Our Policies


Shropshire Clinical Commissioning Group (CCG) has adopted some of the policies of the former Shropshire Primary Care Trust.  It is indicated if the policy listed below is a PCT policy - these are in place until superseded by a CCG policy.  If there is a particular policy you are unable to find, please Contact Us.

Medicines Management
- Secondary care medicines management policies and pathways
Clinical Governance and Patient Safety
Infection Prevention and Control
Health and Safety
Human Resources
Information Governance
Risk Management
Other Policies

Medicines Management

Antibiotic Prescribing Guidance Primary Care - May 2015[pdf] 519KB

Guidance for GPs on antibiotic prescribing.

Sativex® Oromucosal Spray for spasticity in multiple sclerosis.pdf [pdf] 217KB 
Shropshire Clinical Commissioning Group has considered the evidence relating to the prescribing of Sativex for patients with Multiple Sclerosis.

Anticoagulant use in Stroke Prevention in Atrial Fibrillation - January 2015 [pdf] 229KB
Guidance for GPs on anticoagulant use in stroke prevention in Atrial Fibrillation (NOACs guidance).

Patient Group Directions (PGDs) are published here.

NICE Notification Templates are published here.

Shared Care Agreements are published here.


Value Based Commissioning Policies (formerly Policy for Procedures of Limited Clinical Value) - version 30a[pdf] 1MB
This policy provides the list of interventions ‘not routinely funded’ by Shropshire CCG and the specified criteria required for the funding of certain other interventions.

Individual Funding Requests Policy [pdf] 330KB 
Individual Funding Requests Form (Appendix 1) [docx] 57KB
A small number of requests for treatment are made by individual patients each year that are not covered by a Service Level Agreement or other contract. These requests are considered under this policy. This policy seeks to ensure and demonstrate that the CCG has robust processes by which these decisions are taken.

Consultant to consultant referrals policy [pdf] 160KB
The purpose of this policy is to ensure that patients are referred to appropriate services within secondary care.

Policy on silk garments for eczema / atopic dermatitis [pdf] 214KB 
Commissioning policy for the prescribing of silk garments for eczema / atopic dermatitis.  The funding of these garments will only be considered in exceptional circumstances through the Individual Funding Request route (see IFR policy above). 

Choice Policy [pdf] 251KB
From April 2012, all patients referred for a first consultant-led outpatient appointment have been able to choose to be treated by a member of a named consultant led team.  This policy defines the exceptions to these statements and Shropshire CCG’s principles relating to patient choice.

Policy for defining the boundaries between NHS and private healthcare [pdf] 321KB
This policy defines the boundaries between privately funded treatment and entitlement to NHS funding, under a range of circumstances.

Ethical framework for priority setting and resource allocation [pdf] 287KB
This ethical framework should underpin and be applied to priority setting processes carried out by Shropshire CCG with delegated authority.

Policy for experimental and unproven treatments [pdf] 346KB
It is standard practice for commissioners not to fund treatments which are still considered experimental, irrespective of the ‘potential’ health benefit for either individuals or groups of patients.  This policy sets out circumstances where a commissioner may wish to fund an experimental treatment.

Policy for in-year service developments and CCG's approach to treatments not yet assessed and prioritised [pdf] 213KB
This policy outlines the criteria which will be used by Shropshire CCG to determine whether it will fund an in-year service development.

Policy for the implementation and funding of NICE guidance [pdf] 244KB
The CCG's policy for the implementation and funding of guidance produced by the National Institute for Care and Excellence (NICE).

Policy for ongoing access to treatment following a trial not sanctioned by Shropshire CCG [pdf] 192KB
Policy for ongoing access to treatment following a ‘trial of treatment’ which has not been sanctioned by Shropshire CCG for a treatment which is not routinely funded or has not been formally assessed and prioritised.

Policy for ongoing access to treatment following industry trials or funding [pdf] 220KB
Policy for ongoing access to treatment following the completion of industry sponsored clinical trials or funding.

Policy for ongoing access to treatment following CCG funded trial [pdf] 191KB
Policy for ongoing access to treatment following the completion of a trial explicitly funded by Shropshire Clinical Commissioning Group.

Policy for ongoing access to treatment following non-commercial funded trial [pdf] 219KB
Policy for ongoing access to treatment following the completion of non-commercially funded clinical trials.

Policy for patients changing responsible commissioner [pdf] 208KB
Where responsibility for providing NHS services to the patient has been transferred to Shropshire CCG, the CCG will, subject to the terms of this policy, honour existing funding commitments made by the patient’s previous NHS commissioner.  The terms of this policy outline the circumstances where NHS Shropshire CCG will and will not honour existing funding commitments.

Policy and Protocol for the management of fertility treatment in Shropshire[pdf] 472KB
Policy and protocol for the management of fertility treatment in Shropshire.  Please note that this policy is currently under review.

Secondary care medicines management policies and pathways

Policy on Iloprost infusion for the management of severe Symptomatic Peripheral Ischaemia [pdf] 298KB
Policy on Iloprost infusion for the management of severe symptomatic peripheral ischaemia in patients with secondary Raynaud’s Disease or systemic scleroderma to prevent limb amputation.


Business Continuity Plan [pdf] 1MB
?This Business Continuity Plan describes how NHS Shropshire Commissioning Group (CCG) will discharge its functions in the event of a major incident that causes serious interruption of business operations involving one or more sections/service areas. This is a corporate level business continuity plan which would be implemented when any incident cannot be contained and managed within a single section/directorate/service area.

Policy and Procedure for the Recording Investigation and Management of Complaints Comments Concerns and Compliments.pdf [pdf] 482KB  
Provides all service users with the opportunity to seek advice, raise concerns, make a formal complaint and provide a compliment about any of the services commissioned by the CCG.

NHS SCCG Conflicts of Interest September 2016 .pdf [pdf] 787KB
Sets out how the CCG will manage conflicts of interest arising from the operation of the organisation.  The policy applies to members of the CCG’s Governing Body (clinical, executive and lay), committee and sub-committee members, localities and their members, and all those involved in commissioning, contracting and procurement processes and decision-making.

Policy and Guidance for joint working with the pharmaceutical industry (including rebate schemes) and commercial sponsorship of meetings and training events [pdf] 692KB 
This document provides a framework to assist the organisation and NHS staff in determining when commercial sponsorship or a joint agreement is appropriate when working with the pharmaceutical industry. 

Raising Concerns at Work (Whistleblowing) Policy September 2016 .pdf [pdf] 384KB
This policy sets out the process for dealing with Whistleblowing concerns raised. It also contains the procedure to be followed when employees or members of the public wish to raise concerns in relation to Shropshire Clinical Commissioning Group or the services it commissions.

Policy on the management of CCG policies and documents [pdf] 384KB 
This policy is for all CCG staff and has been developed to provide a clear process for the production of CCG-wide policies, procedures and strategies.

Learning and Development Policy [pdf] 390KB 
The policy aims to ensure that all employees and Governing Body Board members are able to undertake their work competently and effectively in line with the organisational objectives, by defining an equitable and consistent decision making process for accessing personal development and learning opportunities.

Clinical Governance and Patient Safety

End of Life Plan: Caring for adult patients in the last few hours and days of life [pdf] 391KB
This plan has been written by Shropshire Clinical Commissioning Group, Telford and Wrekin Clinical Commissioning Group, Shrewsbury and Telford Hospital NHS Trust, Shropshire Community Health NHS Trust, Severn Hospice and Shropshire Partners in Care.  It has been created to address the holistic needs of the dying person by providing supportive and compassionate person-centred care.

Clinical Audit Policy [pdf] 652KB
Please note this is a PCT policy, for interim use until a CCG policy has been ratified.

Development and Management of Patient Information Policy [pdf] 749KB
Please note this is a PCT policy, for interim use until a CCG policy has been ratified.

National Reports and Guidance Policy [pdf] 105KB
Please note this is a PCT policy, for interim use until a CCG policy has been ratified.

?Infection Prevention and Control

Infection Prevention and Control Policy [pdf] 346KB
This policy exists to help protect CCG staff, the public and other stakeholders from the risks of infection and for Shropshire Clinical Commissioning Group to comply with national guidance and legislation including Health and Safety at Work Act 1974 and the Control of Substances Hazardous to Health Regulations 2002.


Declaration of Gifts, Hospitality and Sponsorship – Anti-Bribery Policy and Procedure.pdf [pdf] 423KB
This document sets out Shropshire CCG’s policy and procedure for dealing with the requirements of the Bribery Act 2010, regarding the acceptance of gifts, hospitality and corporate sponsorship.

Policy and Guidance for joint working with the pharmaceutical industry (including rebate schemes) and commercial sponsorship of meetings and training events [pdf] 692KB 
This document provides a framework to assist the organisation and NHS staff in determining when commercial sponsorship or a joint agreement is appropriate when working with the pharmaceutical industry. 

Safeguarding Policies

Safeguarding Children Policy.pdf [pdf] 113KB
This policy demonstrates how Shropshire CCG will discharge its corporate accountability for safeguarding children. It provides advice and guidance to all CCG members and is specifically aimed at the continual improvement of services for children and young people.

Safeguarding Supervision Policy.pdf [pdf] 2MB
This policy demonstrates and explains how Shropshire CCG provide safeguarding adults/children supervision and how staff can access safeguarding supervision. This recognises the CCG role in supporting staff with safeguarding concerns. 

Safeguarding Strategy.pdf [pdf] 126KB
This Document sets out the vision for the agreed strategic approach to maintain a safe effective safeguarding service and to strengthen arrangements to safeguard both children and adults in Shropshire.

Children Looked After Framework.pdf [pdf] 288KB

Shropshire and Telford & Wrekin Partnership Data Sharing Framework Protocol.pdf [pdf] 3MB
This sets out the terms on which the Shropshire and Telford & Wrekin Partnership signatories agrees to share data with the data recipient.

Safeguarding training policy.pdf [pdf] 364KB 
This strategy aims to ensure that the CCG's employees and staff working in those services commissioned and contracted by the CCG understand their role and responsibilities regarding safeguarding children, young people and adults and the training that must be carried out.

Safeguarding GP resource pack 2015.pdf [pdf] 1MB
'General Practice Child Safeguarding Supporting Development at Level 3: GP Child Safeguarding Competencies'.  This document is intended as an aide memoire for GPs to support them in reaching some of the competencies at level 3.

West Midlands Adult Safeguarding Policy and Procedures.pdf [pdf] 2MB
This is the Adult Safeguarding Policy for all partners in the West Midlands and has been written on behalf of all agencies by the editorial Board. It provides details on policy and procedures as well as explaining information pertinent to best practice guidance and details of the underpinning legislation contained within the Care Act 2014.
N.B. Remember if you wish to make a safeguarding referral for an adult in Shropshire this should be made to Shropshire Council - telephone 0345 6789 021 (office hours) or 0345 6789 040 (out of hours).

KASISB Guidance The Safeguarding Process in Shropshire.doc [doc] 1MB
This is the process that has been ratified by the Keeping Adults Safe in Shropshire Board. It explains the process that should be followed when you feel an adult requires safeguarding, what needs to be done immediately, how to raise a concern, and then explains the process of checks, enquiry and planning to safeguard the adult with care and support needs. It also gives advice in Appendix 4 on page 18 as to how to record situations that require remedial action, but which are to be managed outside of a safeguarding enquiry.

Keeping Adults Safe in Shropshire Board Constitution 2016.pdf [pdf] 658KB
This paper highlights the principles that underpin the Shropshire approach to safeguarding adults as well as explaining the governance arrangements that apply to the objectives of the Board; its accountability and challenge arrangements, the approach it takes towards decision making in order to deliver its strategic objectives, and other key areas such as funding and managing complaints.

KASiSB Induction pack.pdf [pdf] 633KB
This members Induction Pack has been produced as a guide to all members of the 'Keeping Adults Safe in Shropshire Board'. Its purpose is to remind all of the organisations who make up the Board how they should implement and build upon the partnership arrangements, the knowledge and skills required as well as the guidance about information sharing and confidentiality. It also provides a useful summary about what adult safeguarding is and the contribution that the members can make.

Safeguarding Concern Referral Form.docx [docx] 135KB
Safeguarding concerns can be sent to the Local Authority Adult Safeguarding Team using this referral form.  They can also be submitted using an online form on the Shropshire Council website.

SSAB Strategic Plan 2015-18.pdf [pdf] 365KB
The Shropshire Safeguarding Adults Board (SSAB) Strategic Plan sets the tone and purpose for the coming three years.  The document will be reviewed and developed annually but gives definition to what is important for adult safeguarding in Shropshire and how the Safeguarding Adults Board will work to ensure that everything is being done to prevent abuse and that a timely and proportionate response is made when it occurs.

SSAB Guidance Risk assessment and risk management.pdf [pdf] 444KB
Shropshire Safeguarding Adults Board (SSAB) guidance on risk assessment and risk management within the Adult Safeguarding process.

Failed Contact Protocol.pdf [pdf] 42KB
This protocol is to be used by clinical staff when unable to make contact with or obtain access to a client.  (NB This is a PCT policy, for interim use until a CCG policy has been ratified.)

Policy for managing safeguarding allegations against staff.pdf [pdf] 364KB 
This policy relates to circumstances when an allegation is made that a child/young person or adult with care and support needs is suffering or likely to suffer harm caused by an employee/worker from Shropshire Clinical Commissioning Group (CCG) or that an employee’s behaviour indicates they are unsuitable to work with children or vulnerable adults.

Mental Capacity Act Deprivation of Liberty Safeguards - Multi - Agency Guidance and Procedure 2015.pdf [pdf] 605KB 
This policy is the culmination of the multi-agency Shropshire and Telford Mental Capacity Act operational group that had local authority, independent sector and NHS representation. It provides an update for all those within the health and social care economy regarding their duties to uphold lawful procedures in identifying potential deprivations of liberty and to practise in a way to ensure actions are the least restrictive possible and are in the best interests of the patient. This references the changes required in practice following the Supreme Court’s decisions in 2014 regarding Cheshire West and Re: X.

Commissioning Compliance-Requirements - MCA 2005 and DOLS 2015.pdf [pdf] 548KB
This policy highlights the roles and responsibilities of the CCG in order to ensure it is complying with both NHS England and legal guidance regarding the Mental Capacity Act (MCA). It summarises both MCA and DOLS regulations as well as the contracting requirements the CCG must ensure are in place when creating and reviewing contracts with NHS providers.

Mental Capacity Act: The Court of Protection - process to follow for CCG Staff when action is contemplated.pdf [pdf] 663KB
This policy is intended to be a practical guide for staff, explaining the main purposes of the Court of Protection and its functions, as well as advising CCG staff on the steps it should take to alert the wider CCG at the very earliest opportunity when action is contemplated. This is to ensure that the proper process of escalation and permissions are in place (see flow chart) as well as affording an opportunity to scrutinise proposals and were applicable agree preventative measures to reduce the need for court interventions in accordance with MCA Code of Practice guidance.

Shropshire Multi-Agency Mental Capacity Act Guidance 2015.pdf [pdf] 747KB
This policy is the culmination of the multi-agency Shropshire and Telford Mental Capacity Act operational group that had local authority, independent sector and NHS representation. Its main purpose was to update all within the health and social care economy of their duties under the MCA ensuring that all staff understand their duty to assess capacity and to act within the principles of best interest. There are particularly useful appendices regarding how to assess and record capacity, a capacity checklist and how to hold and record best interest decisions.

The latest version of the IMCA referral form can be found below

POhWER IMCA referral form March 2016.docx [docx] 88KB P

Prevent Duty Guidance Policy 2015 updated.pdf [pdf] 1MB
This Policy is based upon the draft Prevent Policy guidance issued by NHS England. It explains the purpose of the government’s Counter Terrorism strategy and the specific Prevent duties of all NHS organisations in the Counter Terrorism and Security Act. It explains the CCG’s obligations as a commissioner, the requirements to train staff and the process to be followed when colleagues identify patients and other individuals for whom there are concerns that they may be subject to exploitation through radicalisation.

Shropshire CCG Health and Safety and HR policies

Health and Safety

Display Screen Equipment Policy[pdf] 972KB
The aim of this policy is to ensure that staff are not subjected to unacceptable levels of risk to their health or safety when using display screen equipment (DSE).

Fire Safety Policy [pdf] 704KB
The fire safety policy is available to all employees in order to help them become aware of potential fire risks and hazards.  The fire safety policy also informs employees of what to do in the outbreak of a fire and how best to ensure the safety of employees and others.

Health and Safety Policy[pdf] 505KB
The purpose of this policy is to ensure, as far as is reasonably practicable, the health, safety and welfare of CCG staff and other persons, for example contractors, visitors, general public who may be affected by CCG’s activities including travelling on CCG business and at non NHS sites.

Health and Wellbeing Management policy[pdf] 841KB
The purpose of this policy is to create a working environment where the good mental health and well-being of its employees is paramount and where colleagues feel valued and protected.

Lone Working Policy [pdf] 542KB
The purpose of this policy and guidelines it contains is to reduce and prevent risks involved to members of staff undertaking lone working as part of their daily work routine for the CCG.

Office Safety Procedure[pdf] 649KB
The CCG wishes to ensure that all office environments within its operations are both managed and used in a manner that is conducive to the safety of all CCG employees and other parties who may have cause to work in the offices, for whatever reason.

Human Resources (HR)

Modern-Day-Slavery-2015.pdf [pdf] 120KB

This document shows the CCGs position on the Modern Day Slavery Act 2015.

Absence Management Policy [pdf] 75KB
This policy sets out the procedure for reporting sickness absence and the support that employees can expect when they are unwell to ensure the management of sickness absence in a fair and consistent way.

Annual Leave Policy [pdf] 148KB
The aim of the Annual Leave Policy and Procedure is to ensure a uniform and equitable approach to the calculation of annual leave and general public holiday entitlements which take into account the arrangements as defined under NHS Terms and Conditions.

Appraisal Policy [pdf] 164KB
This policy is designed to provide a framework across the CCG for a well-planned and effective staff appraisal system.

Apprenticeship Policy [pdf] 59KB
This policy sets out how the CCG approach to apprentices.

Dignity and Respect at Work Policy [pdf] 147KB
This policy aims to ensure that all staff are treated with dignity and applies to staff at all levels, regardless of their status.

Disciplinary Policy [pdf] 272KB
This policy sets out the CCG’s approach to the management of disciplinary issues. It applies primarily to issues of conduct or inappropriate behaviour such as violence or aggression. 

Flexible Working Policy [pdf] 131KB
This policy sets out the approach to the handling of flexible working requests.

Grievance Policy [pdf] 153KB
This policy sets out the approach to the handling of individuals’ grievances. It seeks to secure satisfactory resolution of problems, issues and concerns and aims to encourage both employees and managers to resolve issues at the earliest possible opportunity and at the lowest level available, through open and honest discussion.


Long Service Award Policy.pdf [pdf] 637KB

This policy recognises those staff who have reached certain service ‘milestones’ by providing a system of awards for long service, achieved whilst still in service with the CCG.

Managing Performance Policy [pdf] 138KB
This policy provides a framework for dealing with lack of capability on a fair and consistent basis.

Maternity Policy[pdf] 330KB
This policy is designed to provide a framework across the Organisation for a consistent and timely approach to the new and expectant mother.

Maternity Risk Assessment - Advice for Managers and Assessment [pdf] 253KB

Organisational Change Policy [pdf] 123KB 
This policy sets out the approach to organisational change within the Clinical Commissioning Group.

Professional Registration Policy [pdf] 106KB
This policy aims to ensure that all staff required to be registered with a statutory regulatory organisation/body to practise their speciality/field, are fully aware of their contractual obligation to be registered.

Probation Period Review Policy [pdf] 45KB
This document describes the approach of the Clinical Commissioning Group (CCG) to the use of probationary periods for new employees.

Retirement Policy [pdf] 114KB
This policy is designed to assist employees who are considering or have taken the decision to retire and outlines the options available and support that can be expected from management.

Recruitment and Selection Policy [pdf] 194KB
The Recruitment and Selection Policy is designed to support managers in providing a fair, consistent and effective approach to the recruitment of all employees and to help managers deal with recruitment and selection effectively and consistently.

Shared Parental Leave Policy [pdf] 368KB 
This policy outlines the statutory right to take shared parental leave (SPL) to care for a child born or placed for adoption on or after 5 April 2015.  It also outlines the arrangements and notification requirements before a period of SPL and the entitlement to pay during SPL.

Special Leave Policy[pdf] 319KB
This policy sets out the approach to the handling of balancing the demands of domestic and work responsibilities. 

Volunteer Policy[pdf] 167KB
This policy sets out how the CCG will place and support volunteers during their experience to ensure it is useful for both parties.

Shropshire CCG IG and Risk Policies

Information Governance

SCCG Conflicts of Interest Policy October 2017.doc [doc] 414KB

The aim of this policy is to protect both the organisation and individuals involved from impropriety or any appearance of impropriety by setting out how NHS Shropshire CCG will manage conflicts of interest to ensure there can be confidence in the probity of commissioning decisions and the integrity of the clinicians involved with the work of the CCG.

NHS Care Record Guarantee [pdf] 128KB
In the National Health Service in England, we aim to provide you with the highest quality of healthcare. We also aim to gain evidence that will improve health and care through research.

Information Governance Policy[pdf] 622KB
This policy provides assurance to the CCG and to individuals that personal information is dealt with legally, securely, efficiently and effectively, in order to deliver the best possible care.

Information Governance Handbook [pdf] 1MB
This handbook is designed to provide a central place for all staff to access the Information Governance Procedures they are required to work to in order to ensure compliance with Information Governance legislation and national and local guidance.

National Fraud Initiative.pdf [pdf] 144KB

Shropshire CCG is required [by law] to protect the public funds it administers. It may share information provided to it with other bodies responsible for; auditing, or administering public funds, or where undertaking a public function, in order to prevent and detect fraud.

Information Quality Assurance Policy [pdf] 67KB
Please note this is a PCT policy, for interim use until a CCG policy has been ratified.

Standard Operating Procedure for the Management of Subject Access Requests [pdf] 462KB
This procedure applies to Shropshire CCG for records for which they are the Data Controller.  The CCG must ensure there is a procedure in place to respond to requests made under the Data Protection Act 1998 and Access to Health Records Act 1990.

Shropshire CCG Fair Processing Notice v.3.1.pdf

This fair processing notice sets out to you what information we collect and how we use it.  

Leaflet: Collecting information to improve the quality of care for people with learning disabilties and/or autism [pdf] 7MB
This leaflet explains how NHS England collects information to help improve NHS care and treatment for people with learning disabilities and autism.  The collection of this information is called ‘Assuring Transformation Data’ and it helps NHS England check that people are getting the right care, in the right place.

Guidance for the Inclusion of Information Governance Requirements within Third Party Contracts [pdf] 499KB
This policy aims to provide effective Information Governance in relation to both clinical and non-clinical contracts taken out with third party contractors by any procuring department across the CCG.

Risk Management

Risk Management Policy and Strategy [pdf] 467KB
This document sets out Shropshire Clinical Commissioning Group’s commitment to ensuring that it has in place structures, in line with its key principles, that will effectively manage risks of all kinds.

Incident Reporting Policy [pdf] 177KB
Please note this is a PCT policy, for interim use until a CCG policy has been ratified.

Communicating Patient Safety Incidents with Carers Policy [pdf] 90KB
Please note this is a PCT policy, for interim use until a CCG policy has been ratified.

Risk Assessment Policy [pdf] 209KB
Please note this is a PCT policy, for interim use until a CCG policy has been ratified.

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