Freedom of Information – External assurance of NHS Board clinical governance: September 2026

Request details

Information:

Reference Number: 3143

Response Date: 14 September 2026

Document Type: Governance

Request

Freedom of Information (Scotland) Act 2002

Thank you for your email of 17 August 2026. You asked for recorded information, covering 1 January 2024 to 17 August 2026, about Healthcare Improvement Scotland’s role in independent assurance of NHS Board clinical governance.

Response

We have considered your request and our response is below.

1. HIS responsibility for Board-level clinical-governance assurance
Any current policy, framework, guidance, remit, methodology or other document defining HIS responsibility, if any, for independently assessing the effectiveness of:

  • an NHS Board overall clinical governance arrangements;
  • its Clinical Governance Committee or equivalent;
  • the quality of clinical-governance assurance reaching the NHS Board.

Response: HIS provides independent assurance of the quality and safety of care through inspection, regulation and review activities across NHS Scotland and independent healthcare services. Our Safe Delivery of Care inspection methodology is available here: Safe delivery of care: inspection methodology – Healthcare Improvement Scotland. HIS inspections are risk based, and intelligence led and may consider clinical and care governance within the individual service or setting being inspected.

However, responsibility for assuring NHS Board level clinical governance arrangements, including Clinical Governance Committees and Board level assurance, sits with NHS Boards. HIS does not independently assess the effectiveness of those arrangements.

The information you seek is therefore not held by HIS.

2. Use of the 2026 Clinical Governance Standards for external assurance

Any approved plans, proposals, methodologies, programme documents, or formal decisions concerning the use of the Clinical Governance Standards published in February 2026 for external quality assurance or assessment of NHS Boards.

Please include information showing:

  • whether external assessment against the standards is planned;
  • whether it will apply routinely to all NHS Boards or only where concerns/intelligence trigger review;
  • anticipated frequency;
  • who will perform the assessment;
  • whether results will be published

Response: HIS does not monitor NHS Board compliance with the Clinical Governance Standards, accordingly the information you seek is not held by HIS1. NHS Boards can use an online self-assessment tool, which can generate an improvement action plan. The self-assessment tool is publicly available on the Right Decision Service platform: Clinical Governance Standards | Right Decisions.

3. Clinical Governance Committee effectiveness

Any criteria, tools or methodologies currently used or proposed by HIS to assess the effectiveness of an NHS Board Clinical Governance Committee.

I am particularly interested in whether assessment includes:

  • quality of scrutiny and challenge;
  • effectiveness of non-executive participation;
  • quality of assurance provided to the full Board;
  • escalation of unresolved concerns;
  • triangulation of different sources of quality and safety intelligence.

Response: NHS Boards are responsible for assuring the effectiveness of their Clinical Governance Committees and wider clinical governance arrangements. HIS does not have a remit to inspect or monitor the effectiveness of an NHS Board’s Clinical Governance Committee. The information you seek is therefore not held by HIS.1

4. Development of the Clinical Governance Standards

Any formal development papers, option papers, consultation analysis papers or meeting minutes recording consideration of whether the new Clinical Governance Standards should explicitly assess:

  • the role and effectiveness of the NHS Board;
  • the role and effectiveness of Clinical Governance Committees;
  • the role of non-executive Board members in scrutiny and challenge;
  • independent validation of Board-level clinical-governance assurance.

Response: Appendix 1 of the standard details the approach taken to develop the standard. https://www.healthcareimprovementscotland.scot/wp-content/uploads/2025/07/20250609-Clinical-Governance-Standards.pdf

The scope of the Clinical Governance Standards was consulted on in 2025. It did not include the role or effectiveness of NHS Board internal clinical governance arrangements, non-executive Board scrutiny, or independent validation of Board-level clinical governance assurance. These matters were not considered as part of the scope; the information you seek is not held by HIS.1 You may find the consultation feedback on the scope of the standards helpful: Clinical-Governance-Standards-Scoping-report-May-2025.pdf

5. Independent assurance versus self-assessment

Any document setting out HIS’s position or approach regarding the respective roles of:

  • organisational self-assessment against the Clinical Governance Standards; and
  • independent external assessment or validation against those standards.

Response: NHS Boards are responsible for undertaking self-assessment, evidencing compliance, implementing improvements, and assuring their own governance arrangements. The information you seek is therefore not held by HIS.

6. Boundary with Audit Scotland and Scottish Government

Any formal reports, briefing papers, memoranda, agreed protocols or formal meeting records since 1 January 2024 dealing specifically with the division of responsibility between HIS, Scottish Government and Audit Scotland/external auditors for assessing NHS Board clinical governance.

Response: HIS does not have a remit to inspect or monitor the effectiveness of NHS Board clinical governance arrangements. The information you seek is therefore not held by HIS. The HIS operating framework sets out the respective responsibilities of HIS and the Scottish Government for scrutiny, assurance, escalation, and accountability in relation to NHS Boards. Please see: Operating Framework: Healthcare Improvement Scotland and Scottish Government – Healthcare Improvement Scotland

7. Identified assurance gaps

Any reports, risk papers, option papers or formal meeting records held by HIS which identify a potential gap, overlap or lack of clarity in arrangements for independent external assurance of NHS Board-level clinical governance.

Response: HIS does not have a remit to assess external assurance of NHS Board clinical governance arrangements. The information you seek is not held by HIS.

8. Routine assessment

If HIS does not currently operate a routine programme which independently assesses the overall effectiveness of the clinical-governance arrangements of each NHS Board, including its Clinical Governance Committee and Board-level assurance processes, please confirm whether recorded information describing such a programme is held.

Response: HIS does not independently assess the overall effectiveness of clinical governance arrangements of each NHS Board and we are not aware of an organisation that undertakes this role. The information you seek is not held by HIS.1

Applied exemptions

The following exemptions have been applied to this response. If you wish to learn more about the relevant exemptions please visit the Scottish Information Commissioners website using the links below.  You will leave the HIS website: FOISA exemptions

Section 17 – Information not held Information not held – Exemption 17

Reviews and Appeals

For more information on our reviews and appeals, please visit: Freedom of information reviews and appeals – Healthcare Improvement Scotland