Decision-Making Policy and Procedures

Effective date: 12 September 2023

Purpose of this policy

Healthwatch Derbyshire makes its decisions in an open and transparent way and ensures the interests of the people of Derbyshire are always put first. This policy and associated procedures outline the steps taken to ensure decisions are evidence-based and lead to substantive impact in the community.

The governing regulations and standards are: 

  • The NHS Bodies and Local Authorities (Partnership Arrangements, Care Trusts, Public Health, and Local Healthwatch) Regulations 2012 – referred to as Regulation 40 throughout this document
  • Freedom of Information Act 2000
  • Seven Principles of Public Life (Nolan Principles)

This policy applies to all relevant decisions made by Healthwatch Derbyshire.

Relevant decisions

Regulation 40 requires Healthwatch Derbyshire to have in place and publish procedures for making relevant decisions. Relevant decisions include:

  • How to undertake our activities
  • Which health and care services we are looking at covering with our activities
  • The amounts we will spend on our activities
  • Whether to request information
  • Whether to make a report or a recommendation
  • Which premises to Enter and View and when those premises are to be visited
  • Whether to refer a matter to Overview and Scrutiny Committee
  • Whether to report a matter concerning our activities to another person
  • Any decisions about sub-contracting.

Relevant decisions do not include day-to-day activities that may be required to carry out exploratory work prior to making a relevant decision.

Who may make such decisions? 

The Board of Directors has legal responsibility for how the organisation is run, and the Chief Executive is held to account by the Board of Directors for how this is done.

The Board of Directors is responsible, through the work of the Governance subgroup, for setting our strategy and agreeing on our strategic priorities. These priorities are progressed in an annual work plan, which is developed, monitored, and reviewed to deliver these priorities.  

Decision-making at Healthwatch Derbyshire is made according to prioritising the work activity that will deliver the most, in terms of outcomes and impact in line with our strategic priorities.  

This work plan, along with an update on new/emerging work activity is overseen by the Insight, Intelligence & Action (IIA) subgroup of the board. This subgroup is the mechanism for holding the Chief Executive to account for the way in which the annual work plan is prioritised and mobilised to have maximum impact.  

Key items for discussion from the IIA subgroup go forward to full board. Board minutes are published on Healthwatch Derbyshire’s website.

Involving lay persons or volunteers in such decisions

Healthwatch Derbyshire’s Board is composed solely of volunteers (a person who is not a paid employee of Healthwatch Derbyshire).

How are decisions made? 

The potential scope of the work of Healthwatch Derbyshire is vast, the remit has a responsibility for health and social care services for all adults, children, and young people in Derbyshire, including those who are most vulnerable or may be excluded. This means we must prioritise the issues we focus on. The main sources to inform our work program are likely to come from:

  • People’s experiences of health and social care services that they share with us
  • Evidence we proactively collect about specific areas of concern through the stories and enquiries we hear directly, including deliberative research, public surveys, and polls
  • National and local data sets that evidence issues affecting large numbers of the local population and the most excluded.

This list is not exhaustive and other relevant sources of data will be considered.

To prioritise, the Healthwatch Derbyshire IIA subgroup, with oversight from the Healthwatch Derbyshire Board, will carefully consider all sources of information and decide where it can add the most value. Areas to be considered include but are not limited to:

  • That the issues fit with our organisational role and responsibilities, ensuring Healthwatch Derbyshire delivers to its statutory remit
  • How much the issue matters to local people, it must be something they care about as we are here to be the voice of people in health and social care  
  • How much change Healthwatch Derbyshire can bring about. This enables us to make sure we are choosing areas where we can have the greatest impact. This is important to deliver the greatest return for our budget, maintain our independence and ensure we bring issues to the attention of the health and care system
  • Does the change need to come from Healthwatch Derbyshire - so we aren’t focusing on things that others can do more easily and effectively
  • Finally, the Board of Healthwatch Derbyshire will consider our work as a full set of priorities, as together they need to have the greatest impact on people using health and social care services.  

Board meetings are held quarterly, attended by the Board of Directors as voting participants, and the Chief Executive. Minutes of the meetings are taken and are available on the Healthwatch Derbyshire website.

Dealing with breaches of any procedure referred to in this policy

This includes circumstances in which a breach would be referred to the local authority.

Any negative feedback, breach of policy, or formal complaint is captured as part of feedback processes in our ISO9001 Quality Standard. The matter would be taken through the appropriate channel, depending on the nature of the event, and considered against staff contracts, volunteer handbook, etc depending on the specific event brought to light.

Equality, Diversity, and Inclusion Statement

Healthwatch Derbyshire is committed to ensuring all decisions made are free from any form of discrimination on the grounds of age, disability, gender, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, and sexual orientation, in accordance with the Equality Act 2010.

This element is reflected in our strategy and work plan, with work as part of this to audit, improve and embed this in all elements of the work we do, and the decisions we make.  

Review of policy document

The Board of Healthwatch Derbyshire will review this decision-making policy on an annual basis.  

The amended policy document will be published on the website of Healthwatch Derbyshire.


Healthwatch Derbyshire undertakes to carry out the following procedures:

  • Publish Healthwatch Derbyshire’s most up-to-date policy document on the Healthwatch Derbyshire website
  • Review and obtain Board approval of the Healthwatch Derbyshire Decision Making Policy on an annual basis
  • Ensure all Healthwatch Derbyshire staff are familiar with the policy  
  • Publish minutes from Board meetings in a timely manner on Healthwatch Derbyshire’s website. Where decisions are made outside of board meetings, they will be ratified at the subsequent Board meeting.

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