Licence compliance requirements – guidance and support

Independent providers and NHS controlled providers should refer to this page for guidance on meeting the requirements of certain licence conditions, and support for completing self-certifications. This guidance is not relevant for foundation trusts (FTs). See guidance for NHS foundation trusts and NHS trusts for this.

This page replaces the original information and guidance previously hosted by Monitor on GOV.UK.

Self-certification guidance applicable to all licence holders

Condition G4: Fit and proper persons

Effective for periods ending on or after 31 December 2020, licensees will be required to self-certify against condition G4 on an annual basis, two months after their year-end. A template will be made available to support the self-certification process.

Condition G6: Systems for compliance with licence conditions and related obligations

Condition G6 requires licensees to take all reasonable precautions against the risk of failure to comply with the licence conditions, including:

  • the establishment and implementation of processes and systems to identify risks and guard against their occurrence; and
  • regular review of whether those processes and systems have been implemented and of their effectiveness.

Licensees are required to self-certify on an annual basis whether they are or are not satisfied, as the case may be, that they have complied with this condition in the financial year most recently ended.

For independent providers and NHS-controlled providers, a template is provided to support the self-certification process:

    • for providers self-certifying for the first time post licensing, please select this template
    • for providers self-certifying in subsequent years, please select this template

Self-certification guidance applicable to providers of commissioner requested services

The following documents are only applicable to providers of commissioner requested services (CRS).

NHS Improvement has a statutory duty to publish guidance for the providers of commissioner requested services (CRS). This covers all continuity of service (CoS) conditions in the provider licence and applies to both NHS foundation trusts and independent sector providers of CRS.

Condition CoS4:  Undertaking from the ultimate controller

As a licensed provider of CRS, your organisation may be controlled by another, such as a parent company. If this is the case, you are required to put in place a legally enforceable undertaking with each of your controlling organisations or companies – your ‘ultimate controllers’ – to protect your CRS services.

You must complete this template if all of the following statements are true:

  • your organisation provides ‘commissioner requested services’
  • your organisation is controlled by another, such as a parent company or sole shareholder
  • your organisation is not an NHS foundation trust

Guidance is available on on making an ultimate controller undertaking. Included within Annex A is a template for submission.

CoS 7: Availability of resources

As a licensed provider of CRS, you are required to submit an availability of resources certificate and accompanying statement of the main factors your Directors have taken into account in issuing that certificate. An initial certification is due within two months of the date of confirmation of CRS status. Thereafter the certification is due within two months of the end of each financial year.

Guidance on making the certification is contained within the licence condition. Enquiries can also be made by contacting NHSI.IP-Monitoring@nhs.net

Self-certification guidance applicable to NHS controlled providers

Condition CP1: Governance arrangements for NHS-controlled providers

Condition CP1 imposes requirements around good governance. This is equivalent to the requirement for foundation trusts to self-cert under FT4. Within three months of the end of each financial year NHS controlled providers are required to submit a corporate governance statement. Guidance on making the certification is contained within the licence condition. Enquiries can also be made by contacting NHSI.IP-Monitoring@nhs.net.

Other guidance for providers of commissioner requested services

Condition CoS2: Restriction on the disposal of assets

Condition CoS2 places an obligation on licensees to establish, maintain and keep up to date, an asset register which lists every relevant asset used by the licensee in the provision of CRS. The condition also establishes a safety net for exceptional circumstances where the disposal of such assets could pose a significant risk to the continued provision of CRS for patients. In the event that we find a licensee to be at risk of no longer remaining a going concern, restrictions are placed on them to prevent the disposal of relevant assets without our prior written consent.

Guidance is available on what comprises relevant assets, and on the principles in establishing and maintaining the register of relevant assets. It also sets out NHS Improvement’s approach to the disposal of CRS assets when a provider has been notified that it is at risk of not being a going concern.

The asset register and disposal of assets: guidance for providers of commissioner requested services

Condition CoS3: Standards of corporate governance and financial management

This guidance is relevant to licensed independent sector providers of commissioner requested services (CRS).

The continuity of services (CoS) licence conditions contained in Section 5 of the NHS provider licence provide regulatory protection which is specifically targeted at ensuring continuity of CRS.

The guidance brings together key elements of good practice to help providers of CRS adopt and apply adequate systems and standards of corporate governance and financial management as required by licence condition CoS3 (standards of corporate governance and financial management).

The guidance, issued by NHS Improvement, will continue to evolve as the working practices within the NHS evolve.

Please see below for a hub of support for licensed independent providers of CRS, comprised of links to existing guidance from bodies like the Healthcare Financial Management Association, other regulators (for example, The Charity Commission) and other relevant organisations.

The links provided below, in addition to the published guidance, should support licensed independent providers of CRS to meet the requirements of the CoS3 licence condition.

Hub of support for licensed independent providers of CRS

Guidance on enforcement

NHS Improvement can take action against healthcare providers who hold an NHS provider licence if there has been a breach of licence conditions that has been confirmed via an investigation.

Further information can be found under Monitoring and enforcement.