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Beaumont’s non-submission of compliance statement accepted as ‘exceptional’ measure

By Catherine Reilly - 18th Feb 2024

compliance statement
Beaumont Hospital

The HSE accepted late last year that the board of Beaumont Hospital in Dublin would not be required to submit an annual compliance statement (ACS) for 2021. This decision was made “on an exceptional basis due to a delay in submission”, according to a HSE spokesperson.

Beaumont Hospital is funded by the HSE under section 38 of the Health Act 2004. Under the funding arrangements it is required to provide the HSE with an ACS in respect of corporate governance standards.

The hospital is a State body that is also required to meet the requirements of the Code of Practice for the Governance of State Bodies.

In a draft statement on internal control (SIC) for 2022, the hospital board stated there was a substantial overlap between the obligations of the Code and the ACS, and each required documented processes to support any assertions made.

“The combined requirements of the Code and the ACS represent a significant compliance challenge to Beaumont Hospital,” according to the draft SIC for 2022. “Beaumont Hospital has not, as of yet, submitted an ACS for the year ended 31 December 2021 (ACS 21). Beaumont Hospital has initiated a dialogue with HSE to seek to determine if elements of the ACS obligations may be disapplied or otherwise satisfied by the submission of the Annual Financial Statements presented in accordance with the Code. As of the date of this report no agreement had been reached with HSE in this matter.”

In the board’s statements on internal control for 2020 and 2021 it acknowledged that the hospital was not in full compliance with the requirements of the Code in the matter of systems of internal controls. In the SIC for 2021, the board also confirmed that it had approved a governance compliance project in July 2022.

Full compliance with the requirements and obligations required a level of resources and expertise that is “challenging in terms of the balance of allocation of resources between service delivery obligations and governance”, according to the draft SIC for 2022.

The governance compliance project has identified the need for additional resources in terms of internal audit and risk management advice.

A HSE spokesperson told the Medical Independent it was “substantially satisfied” that the requirements as set out in the ACS are being implemented and monitored by the Beaumont board on an ongoing basis as required. “At this time there are no proposals by the HSE to change this contractual requirement in terms of the submission of the standard annual compliance statement by any of the service providers funded pursuant to section 38 of the Health Act, 2004.”

On whether it had provided funding to Beaumont to meet the requirements of the Code, the HSE spokesperson said: “The usual process for funding requests to the Acute Operations Division is from the hospital to the Hospital Group and then to the office of the National Director for Acute Operations – no request for Code of Practice funding has been received to date.”

Beaumont Hospital did not respond to a request for comment.

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