Occupations and Terms of Reference › Legal counsel
Universal terms of reference · POS-016 · version 1.0 · status: draft · next review 2027-10-27
Legal counsel
To give sound legal advice, so that the organisation acts lawfully, manages legal risk, and protects patients, staff and the organisation's reputation.
Each part of this page links to the related trainings, competencies and policies. The links are the same for every facility, so an organisation can see at a glance what a role requires and what it is trained in.
Job description
Job summary. You advise the organisation on law. You review contracts, manage disputes and claims, advise on regulation and licensing, and make sure legal risk is understood and controlled.
Reports to: Chief executive officer.
Leads or supervises: No direct reports (may supervise external counsel).
What you do on a typical day
- Review contracts and agreements before signature.
- Advise managers on legal questions.
- Manage claims and disputes with insurers and external counsel.
- Support incident investigations with a legal view.
- Track changes in law and regulation that affect the organisation.
Working conditions and demands
- Advice is often urgent and sensitive.
- Must keep legal privilege and confidentiality.
- Works with clinicians, managers and the board.
What good looks like
- Contracts are reviewed before signature.
- Claims are handled within deadlines.
- Staff know when to ask for legal advice.
Place in the organogram
Reporting line, from the top: see the organogram on the Occupations page. The lines above and below this role are listed in section 3.
1. Golden rules
These rules apply in every setting.
- Every decision that affects patient safety is made on evidence and recorded.
- Patient safety and quality come before financial targets; no trade-off that puts patients at risk is accepted.
- Every staff member can raise a concern without fear of reprisal, and every concern is answered.
- Legal, licensing and accreditation duties are known, owned and reviewed.
- Finances, people and information are managed openly and within the law.
- Mandatory training and policies apply to the executive as much as to frontline staff.
2. Identification
| Item | Detail |
|---|---|
| Position code | POS-016 |
| ISCO-08 | 2611 (skill level 4) |
| ESCO | to map |
| Department | Governance |
| Facility types | Hospital, Ambulatory, Transport, Medevac, Fitness, Aesthetic |
3. Reporting line and working relationships
Reports to: POS-003. Supervises: .
| Works with | Nature of the relationship |
|---|---|
| Chief executive officer | Advice on major decisions and disputes. |
| Chief quality and safety officer | Legal aspects of incidents and claims. |
| Data protection officer | Data protection law and breaches. |
4. Key accountabilities
| Domain | Accountability | Evidence of delivery | Checked | Linked competencies | Linked trainings | Linked policies | Standards |
|---|---|---|---|---|---|---|---|
| Contracts | Reviews and approves contracts and agreements within legal risk limits. | Contract register complete; reviews recorded | Monthly | C-01 | T-06 | – | 1 |
| Claims | Manages claims and disputes within deadlines. | Claims tracked; reserves reviewed | Monthly | C-02 | T-06 | POL-INC | 1 |
| Regulation | Keeps the organisation informed of legal and regulatory requirements. | Regulatory update issued to leaders | Quarterly | C-03 | T-06 | – | 1 |
| Legal support to incidents | Supports serious incident investigations on legal questions. | Legal input recorded in serious incident reviews | Monthly | C-01 | T-05 | POL-INC | 2 |
5. Decision rights
| The post holder decides | Consults or escalates |
|---|---|
| Legal advice to the organisation | Major disputes or claims (CEO and board) |
| Choice of external counsel within budget | Matters with criminal or regulatory exposure (CEO and board) |
6. Qualifications and experience
| ID | Qualification | Mandatory | Validity |
|---|---|---|---|
| Q-01 | Law degree and licence to practise (bar or national equivalent) | Yes | Lifetime |
| Q-02 | Health law or regulatory qualification | No | Lifetime |
| ID | Experience | Minimum years | Mandatory |
|---|---|---|---|
| E-01 | Legal practice, ideally including health or regulatory law | 5 | Yes |
7. Training requirements
Recommended common practice. Each facility adapts the list to its national law. Essential items apply in every setting; recommended items apply where resources allow.
| ID | Training | Tier | When | Validity | Linked policies | Linked competencies |
|---|---|---|---|---|---|---|
| T-01 | Facility induction | essential | at_entry | Once | POL-WHISTLE · POL-EQUAL · POL-DATA | – |
| T-02 | Safeguarding adults | essential | periodic | Every 3 year(s) | POL-SAFEG | – |
| T-03 | Safeguarding children | essential | periodic | Every 3 year(s) | POL-SAFEG | – |
| T-04 | Data protection and confidentiality | essential | annual | Every 1 year(s) | POL-DATA | – |
| T-05 | Incident reporting and open disclosure | essential | periodic | Every 2 year(s) | POL-INC | – |
| T-06 | Governance, accountability and assurance | recommended | periodic | Every 3 year(s) | – | C-01 · C-02 · C-03 |
| T-07 | Emergency and major incident command | essential | annual | Every 1 year(s) | POL-INC | – |
| T-08 | Speaking up, inclusion and equality leadership | essential | periodic | Every 2 year(s) | POL-WHISTLE · POL-EQUAL | – |
8. Health, fitness and language
| ID | Requirement | Frequency | Tier | Minimum in low-resource settings |
|---|---|---|---|---|
| H-03 | Fitness-to-work assessment at entry and after serious illness or injury | Every 12 months | recommended | Fitness check at entry |
| Language | Level | Mandatory |
|---|---|---|
| Official language of the country of practice | professional | Yes |
| English | working | Yes |
9. Competencies by level
| ID | Competency | Foundation | Practitioner | Expert | Assessed by | Revalidate | Linked trainings |
|---|---|---|---|---|---|---|---|
| C-01 | Legal advice and contract review | Applies law in routine matters | Advises on complex matters | Sets legal standards for the organisation | Legal file review | Every 12 months | T-06 |
| C-02 | Claims and dispute management | Supports claims | Manages claims | Designs claims and dispute strategy | Claims review | Every 12 months | T-06 |
| C-03 | Health regulation and licensing | Knows key rules | Advises on licensing | Leads regulatory strategy | Regulatory review | Every 12 months | T-06 |
10. Performance evaluation
- Probation: 6 months, with a sign-off review (recommended value).
- Appraisal: every 12 months against the competencies and indicators below.
| ID | Indicator | Target | Data source | Frequency |
|---|---|---|---|---|
| PI-01 | Contracts reviewed before signature | 100% | contract register | Monthly |
| PI-02 | Claims handled within deadlines | 100% | claims register | Monthly |
| PI-03 | Regulatory updates issued on time | 100% | update log | Quarterly |
| PI-04 | Legal advice requests answered on time | set by facility | request log | Monthly |
11. Career ladder and promotion
| Level | Role | Minimum experience to move on | Qualifications | Competency minimums | Trainings required | Assessment |
|---|---|---|---|---|---|---|
| Executive | Legal counsel | 5 years (recommended) | Q-01 | C-01 expert, C-02 practitioner | T-06 | Executive appointment and performance review |
12. Policies the post holder follows
Each policy is a standard template that the facility adopts and adapts. Templates are maintained centrally, so every facility works from the same version.
POL-SAFEG · Safeguarding adults and children
Purpose: Protect patients from abuse, neglect and harm, and make sure every concern is recognised and acted on.
Scope: All staff, volunteers and contractors.
Key rules:
Scope: All staff, volunteers and contractors.
Key rules:
- Recognise signs of abuse and neglect and record them factually.
- Report every concern to the designated safeguarding lead the same shift.
- Do not investigate alone.
- Share information only as the safeguarding procedure allows.
POL-DATA · Data protection and confidentiality
Purpose: Keep patient and staff information private, secure and used only for care and legal purposes.
Scope: All staff who access records or systems.
Key rules:
Scope: All staff who access records or systems.
Key rules:
- Access only the records needed for your work.
- Keep records secure; do not leave screens or paper unattended.
- Do not share information without a lawful basis.
- Report any breach to the data protection officer within 24 hours.
Linked trainings: T-10 · Review every 12 months · Template 0.1 (draft)
POL-WHISTLE · Speaking up (whistleblowing)
Purpose: Let staff raise patient safety or conduct concerns without fear of reprisal.
Scope: All staff.
Key rules:
Scope: All staff.
Key rules:
- Raise a concern with your line manager or the named speaking-up officer.
- If that route fails, escalate to the board or the national regulator.
- Retaliation against anyone who speaks up is a disciplinary offence.
- Concerns are recorded, investigated and the outcome given to the person raising them.
Linked trainings: T-01 · Review every 12 months · Template 0.1 (draft)
POL-EQUAL · Equality, diversity and inclusion
Purpose: Give every patient and colleague fair access, respectful treatment and reasonable adjustments.
Scope: All staff and patients.
Key rules:
Scope: All staff and patients.
Key rules:
- Treat every person with dignity regardless of background.
- Make reasonable adjustments, including interpreters, for language and disability.
- Report discrimination through the speaking-up route.
- Monitor access and outcomes by group.
Linked trainings: T-01 · Review every 24 months · Template 0.1 (draft)
POL-INC · Incident reporting and open disclosure
Purpose: Report and learn from incidents and near misses, and tell patients honestly when things go wrong.
Scope: All staff.
Key rules:
Scope: All staff.
Key rules:
- Report every incident and near miss the same shift.
- Give the patient and family an honest account and an apology where appropriate (open disclosure).
- Take immediate action to protect others.
- Learn: contribute to the review and follow the agreed actions.
13. Standards that name this role
14. Record history
| Date | Change | Approved by |
|---|---|---|
| 2026-10-27 | Draft record, batch 1 of the position build | Awaiting approval |