WHISTLEBLOWING POLICY. HR05 Version: V01 Eve Rowlands Head of HR

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1 WHISTLEBLOWING POLICY Document Reference: Document Owner: Accountable Committee: Ratified by: Date issued: Target audience: HR05 Version: V01 Eve Rowlands Head of HR Document Author: Eve Rowlands Head of HR See reference guide Date Approved: 24 February 2010 Document Ratification Committee Date this document is posted on the intranet Trust Wide Date Ratified: 29 October 2011 Review date: February 2015 Equality Impact Assessment: 4 January 2010 Key points Process for outlining the trust s approach to managing complaints raised under the Whistleblowing procedure Page 1 of 18

2 CONTENTS 1.0 ASSOCIATED DOCUMENTS INTRODUCTION Statement of Intent Equality Impact Assessment Good Corporate Citizen Purpose Scope DUTIES DEFINITIONS PRINCIPLES INFORMATION WHICH MAY BE DISCLOSED UNDER THIS POLICY CONFIDENTIALITY ROLES OF THE TRADE UNIONS AND PROFESSIONAL ORGANISATIONS PROCEDURE FOR RAISING CONCERNS DISCLOSURE OUTSIDE THE TRUST CONSULTATION, APPROVAL AND RATIFICATION PROCESS DISEMINATION AND IMPLEMENTATION PROCESSES FOR MONITORING EFFECTIVE IMPLEMENTATION VERSION CONTROL SHEET APPENDICES Appendix Appendix Appendix Page 2 of 18

3 1.0 ASSOCIATED DOCUMENTS Agenda for Change Terms and Conditions Disciplinary procedure Grievance Procedure Respect at work policy Code of Conduct 2.0 INTRODUCTION All employees have not only a right but a duty to raise any matter of concern they may have about unacceptable conduct within the trust. This is sometimes referred to as `whistleblowing`. The Public Interest Disclosures Act 1998 came into force in July 1999 (Appendix 2). Its purpose is to protect workers from victimisation who want to raise concerns about malpractice, in good faith. The word `whistleblowing` in this policy refers to the disclosure, internally or externally by workers, of suspected malpractice, as well as illegal acts of omissions at work. 2.1 Statement of Intent The trust is committed to achieving the highest possible standards of service and the highest possible ethical standards in delivering this service. It is the responsibility of all employees to ensure that if they become aware that the actions of other employees of the trust or anyone working for, with or connected to it might compromise this objective, they will be expected to raise this matter. 2.2 Equality Impact Assessment As part of its development, this policy was analysed to consider its effect on different groups protected from discrimination by the Equality Act The requirement is to consider if there any unintended consequences for some groups, and to consider if the policy will be fully effective for all protected groups. This analysis has been undertaken and recorded using the trust s e-tool, and appropriate measures taken to remove barriers or advance equality in the delivery of this policy 2.3 Good Corporate Citizen As part of its development, this policy was reviewed in line with the Trust s Corporate Citizen ideals. As a result, the document is designed to be used electronically in order to reduce any associated printing costs. 2.4 Purpose The purpose of this policy is to outline the trust s approach to concerns raised under the Whistleblowing procedure as follows: Provide mechanisms for which staff can raise concerns under the Whistleblowing procedure. Page 3 of 18

4 Outline the rights and entitlements of staff raising a concern under the Whistleblowing procedure. Ensure that the Trust complies with the legal framework for managing concerns raised under the principles of Whistleblowing. 2.5 Scope This policy applies to all employees of the trust. 3.0 DUTIES 3.1 Chief Executive The Chief Executive has overall responsibility for the strategic and operational management of the organisation, including ensuring that the organisations policies and procedures comply with all legal, statutory and good practice guidance requirements. 3.2 Board of Directors The Board of Directors has a responsibility to ensure that the Whistleblowing policy is adhered to and to ensure that the Trust complies with all legal, statutory and good practice guidance requirements. 3.3 Human Resources The Human Resources Department will oversee the introduction, operation and monitoring of this policy. The Human Resources Department will ensure the provision of training, guidance and support to Managers on the operation of the policy. The Human Resources Department will support staff accessing the Whistleblowing policy. The Human Resources Department will guide managers and staff in the application of the policy. 3.4 Managers There should be an openness culture and free expression can contribute to improving the service for patients or clients in the future. Managers are therefore expected to ensure that all staff are given every opportunity to make their contribution. Moreover, they must feel that their legitimate views will be welcomed, appreciated and where appropriate, acted on positively. 3.5 Staff Employees have a duty to draw to the attention of their manager any matter that they consider to be damaging to the interests of a patient or client and to put forward suggestions which may improve their care. In the case of a client detained under the Mental Health Act staff can also raise concerns with the Mental Health Act Commission. Page 4 of 18

5 Employees have a duty to draw to the attention of the trust any concern or reasonable suspicion of damage or risk to the interests of patients, the public, or other staff of the trust. Employees who work under a professional code of ethics have a professional responsibility to raise concerns. This policy complements professional or ethical rules; guidelines and codes of conduct on freedom of speech, such as, for example, the NMC Code of Professional Conduct. It is not intended to restrict the publications of clinical or scientific research findings. The guidance complies with the NHS Executive s instruction that alternative reporting lines should be identified for the benefit of staff reporting suspected security etc. breaches by their superiors. 3.6 Duties within the Organisation The trust is absolutely committed to maintaining an honest, open and wellintentioned climate in order to fulfil its objectives and that of the NHS. It is therefore also committed to: ensuring that all business transactions and relationships with third parties are conducted with honesty and integrity; the elimination of fraud, deception or misuse of the trust s resources; and the rigorous investigation and punishment of any such cases. 4.0 DEFINITIONS Term NMC Code of Professional Conduct GMC (General Medical Council) Gagging Clauses Quangos (quasi-autonomous nongovernmental organisation) Secretary of State for Health Audit Commission CQC (Care Quality Commission) EAP (Employee Assistance Programme) Meaning Professional standards for nurses and midwives The GMC registers doctors to practice medicine in the UK. A part of an employment agreement that prevents an employee from providing information about their employer to the public An organisation to which a government has devolved power UK cabinet position responsible for the Department of Health Regulates the proper control of public finances by local authorities and the National Health Service in England The independent regulator of all health and social care services in England Confidential helpline providing support for the psychological wellbeing of staff. Page 5 of 18

6 5.0 PRINCIPLES 5.1 The key principles of this policy are that: the trust and its employees must act with honesty and integrity. the patient or client s individual interests must be paramount. 5.2 The trust is absolutely committed to maintaining an honest, open and wellintentioned climate in order to fulfil its objectives and that of the NHS. It is therefore also committed to: ensuring that all business transactions and relationships with third parties are conducted with honesty and integrity; the elimination of fraud, deception or misuse of the trust s resources; and the rigorous investigation and punishment of any such cases. 5.3 Any member of staff refusing an instruction from a superior to breach confidentiality will be protected. They are advised to speak to their union representative and report Under no circumstances will employees who express their views about health services issues in accordance with this policy be penalised in any way for doing so. The trust wishes to encourage anyone having reasonable suspicions of wrong doing to report them. The trust policy, which will be rigorously enforced, is that no employee should suffer in any way as a result of reporting reasonably held suspicions in accordance with this policy. Reporting suspicions in line with this policy will not affect future career or employment prospects. Even in the vent of a `false alarm`, any party honestly reporting a belief held in all sincerity is also protected. Under no circumstances will employees who raise concerns, about which they have an honest and reasonable suspicion and in accordance with this policy, be penalised for so doing. 6.0 INFORMATION WHICH MAY BE DISCLOSED UNDER THIS POLICY 6.1 The trust has a wide range of policies and procedures, which deal with standards of behaviour at work; including Disciplinary, Grievance and Respect at Work. Employees are encouraged to use the provisions of these procedures when appropriate. 6.2 There may be times, however, when the matter is not about your personal employment position and needs to be handled in a different way. 6.3 Examples may be: Malpractice or ill treatment of a patient by a senior member of staff Page 6 of 18

7 Repeated ill treatment of a patient despite a complaint being made A criminal offence has been committed, is being committed or likely to be committed Suspected fraud or financial irregularity Suspected bribery or other corrupt practices Disregard for legislation, particularly in relation to health and safety at work The environment has been, or is likely to be, damaged Breach of standing financial instructions Showing undue favour over a contractual matter or to a job applicant A breach of a code of conduct Patients, the public or other staff have been or may be put at unnecessary risk Information on any of the above has been, is being, or is likely to be concealed This list is not exhaustive 6.4 The trust will not tolerate any harassment or victimisation of a whistleblower (including informal pressures), and will treat this as a serious disciplinary offence, which will be dealt with under the Disciplinary Procedure. 7.0 CONFIDENTIALITY 7.1 All staff have a duty of confidentiality to patients, and also a duty of trust to their employer. These should not inhibit the raising of serious and genuine concerns in accordance with this policy with a Manager, Human Resources or Trade Union representatives. 7.2 The rules of patient confidentiality apply and unauthorised disclosure of personal information about any patient will be regarded as a most serious matter liable to result in disciplinary action. 7.3 Any disclosure to the media of a matter which is relevant to the employer s work and responsibilities, without the consent of the trust, might be seen therefore as damaging the relationship of mutual trust and could therefore represent a potentially serious breach of contract (whether or not there is an express term in the contract of employment). 7.4 Any employee who raises a concern in accordance with this policy (see section 7 below) may request that their anonymity be preserved throughout this process and the trust will use its best endeavours to ensure that this happens. Page 7 of 18

8 7.5 The trust will keep the employee informed of the outcome of any enquiries and investigations carried out. However, the trust will not be able to inform the employee of any matters which would infringe the trust s duties of confidentiality to others. 7.6 Employees are reminded that professional organisations e.g. NMC, GMC also have Codes of Conduct relation to the use and disclosure of privileged information and confidentiality. 7.7 The duty of confidence is not absolute, however: it may be claimed that the disclosure of confidential information was made in the public interest. This might be disputed; therefore any such claim would need to be defended by the individual making the claim and should therefore be soundly based. As a matter of prudence then, any employee who is considering making a disclosure of confidential information which they consider to be in the public interest should first seek specialist advice from an organisation such as their professional body, trade union or statutory body. 8.0 ROLES OF THE TRADE UNIONS AND PROFESSIONAL ORGANISATIONS 8.1 The trust recognises employees may wish to seek advice and be represented by their Trade Union or professional organisation when using the provisions of this policy, and acknowledges and endorses the role trade union/professional organisations play in this area. 9.0 PROCEDURE FOR RAISING CONCERNS 9.1 The trust hopes that most concerns can be resolved on an informal basis with a rapid response. The trust recognises however, that there might be circumstances when matters require to be handled more formally and it is in such cases that this policy and procedure will apply. All concerns must be raised as soon as possible and dealt with as soon as possible allowing the maximum amount of time to be as per the procedure below. 9.2 The formal procedure provides alternative routes by which an employee may choose to raise their concern, to ensure absolute protection and confidentiality for the person reporting their concerns. 9.3 Option 1 The matter should be referred to the Head of Department. This person will meet the member of staff within 5 days, will give thorough and fair consideration and will inform the member of staff of the outcome as soon as possible. The period could be extended by mutual consent. The outcome should be confirmed in writing. If the matter is not resolved to the satisfaction of the member of staff the matter should be referred to the appropriate Director or Chief Executive. Page 8 of 18

9 The Director/.Chief Executive should see the member of staff within 10 days, will give the matter thorough and fair consideration and inform the member of staff of the outcome as soon as possible. The period could be extended by mutual consent. The outcome should be confirmed in writing. If a member of staff remains dissatisfied after the above the individual may refer the matter to the chairperson, who will hear the concern within 21 days (or extended by mutual consent). The chairperson may deal with the matter personally or involve other board members as appropriate. The chairperson should respond as soon as possible and the outcome confirmed in writing. 9.4 Option 2 Raise concern with Designated Officer A member of staff may wish to refer concern to a `Designated Officer` directly (for example, where the concern is particularly serious). The Designated Officers in the trust are:- For nursing and AHP related matters Director of Nursing & Quality For professional and medical matters Medical Director For any other matters Director of Workforce The Designated Officer to whom the concern has been addressed will meet the member of staff within 10 days. The Designated Officer will aim to complete any investigations and respond to the member of staff as soon as is reasonably possible. 9.5 Option 3 Staff may also choose to raise their concern, if appropriate, direct with the Non Executive Chairperson of the Audit Committee who will endeavour to meet the member of staff within 10 days and to undertake any investigations and respond to the member of staff as soon and reasonably practicable. The Chairperson of the Audit Committee can be contacted, in confidence via the Health Trust Board Secretary or Director of Finance. The Board Secretary is under instruction not to tell anyone, even if ordered to, that anyone has asked to see the Chairperson of the Audit Committee, nor their names. If the concern is regarding the conduct of a member of the Executive team or the management of the organisation then an employee must write to the trust Chairman or Non Executive Director, 10.0 DISCLOSURE OUTSIDE THE TRUST The intention of this procedure is to provide a means by which concerns should be raised internally initially and the opportunity provided of resolving issues quickly and effectively. However, an employee who, having exhausted all the internal procedures, remains dissatisfied, has the right to pursue the matter in the public arena via Page 9 of 18

10 disclosure to prescribed bodies. Advice can be obtained from the independent charity Public Concern at Work ( ). Disclosure to prescribed bodies will be protected provided the employee honestly and reasonably believes the information and any allegation in it are substantially true. From 1 October 2009, Monitor will be prescribed as an organisation to which a protected disclosure may be made. To qualify for such protection, a worker or former worker must disclose the information to Monitor in good faith and reasonably believe that it relates to the regulation and performance of NHS foundation trusts or any other activities in relation to which Monitor exercises its functions under the National Health Service Act The information must also tend to show that certain harm is occurring, or will occur, including danger to the health or safety of an individual, bribery or corruption, breach of any legal obligation or deliberate concealment of such harm. The issues on which Monitor would expect to be contacted should relate to their regulatory role and specifically to concerns about the governance (financial or clinical) of NHS foundation trusts. Where the concerns of workers or former workers relate to the quality and safety of clinical services, the CQC is likely to be the most appropriate body with whom to make contact. You may also report your concerns to the Audit Commission on their confidential public interest disclosure line: If appropriate you may raise the matter with the Secretary of State for Health. If your concern is about fraud and/or corruption, you can also contact the trust s local counter fraud specialist on or or the NHS Fraud Hotline which allows information to be provided anonymously if necessary. Also as an employee you have access to the Employee Assistance Programme and can contact an appropriate advisor by telephoning This policy does not prevent staff from seeking the advice and guidance of their MP or Legal Professionals at any time. It will rarely, if ever, be appropriate to alert the media (or, for that matter, anyone other than the people/organisations referred to in this policy). Appendix 1 represents the procedure in diagram form CONSULTATION, APPROVAL AND RATIFICATION PROCESS The Whistleblowing policy has been developed in consultation with trust managers and staff side. Staff Forum are responsible for approving the policy DISEMINATION AND IMPLEMENTATION 12.1 Dissemination The Whistleblowing policy will be available on the Trust s intranet site. Page 10 of 18

11 12.2 Implementation The Human Resources department will brief divisions about the policy at divisional board meetings Training/Awareness Coaching will be provided to individuals requiring access to the Whistleblowing Policy from the Human Resources department PROCESSES FOR MONITORING EFFECTIVE IMPLEMENTATION Records will be kept for monitoring purposes of: Numbers of formal cases Records of cases and outcomes All data necessary for equality analysis review REFERENCES The Public Interest Disclosures Act 1998 Mental Health Act 2007 National Health Service Act 2006 Page 11 of 18

12 14.0 VERSION CONTROL SHEET Version Date Author Status Comment V01 February E Rowlands Complete 2011 V02 May R Walker Complete 2013 V2.1 Jan 2014 R Walker Remove reference to organisational change policy Page 12 of 18

13 15.0 APPENDICES Appendix 1 WHISTLEBLOWING POLICY PROCEDURE Staff concern related to trust business or health care matters. Option 1 Raise concern with Head of Department. A meeting will be arranged within 5 working days. An investigation will be carried out and a written response of the outcome will be provided. Option 1 continued If the matter is not resolved satisfactorily referral should be made to the appropriate Director or Chief Executive. A meeting will be arranged within 10 working days following the above process. If the matter still remains unsatisfactorily resolved referral may be made to the chairperson, who will hear the concern within 21 days. Option 2 Raise concern with Designated Officer (see 7). The designated officer will arrange a meeting within 10 working days. An investigation will be carried out if necessary and a written response of the outcome will be provided. Option 3 Serious concerns can be raised with the Non Executive Chairperson of the Audit Committee who will arrange a meeting within 10 days, investigate if appropriate and provide a written response of the outcome. Wider Disclosure If employee has exhausted all the above procedures and taken into account all advice given, then may wish to consult Whistleblowing Policy May with 2013 any other external/statutory body. See 7 Page 13 of 18

14 Appendix 2 Summary of the main provisions of the Public Interest Disclosure Act 1998 Malpractice The Act applies to people at work raising genuine concerns about crime, breach of legal obligation (including negligence, breach of contract, breach of administrative law), miscarriage of justice, danger to health and safety or the environment and any cover up of these. In the NHS this would include a worker raising concerns about risks to patients or about financial malpractice. It applies whether or not the information is confidential. Individuals covered In addition to employees, it covers other workers, trainees, agency staff, home workers and all self-employed NHS professionals (i.e. doctors, dentist, ophthalmologists and pharmacists). The usual employment law restrictions on minimum qualifying period and age do not apply. It does not cover the genuinely self-employed (other than in the NHS), volunteers, the intelligence services, the army or the police. Internal disclosures A disclosure to the employer will be protected if the whistleblower has an honest and reasonable suspicion that the malpractice has occurred, is occurring or is likely to occur. For the purposes of the Act, the employer of the self-employed NHS professionals is deemed to be the Health Authority. Where a third party is responsible for the malpractice this same test applies to disclosures made to it. Legal advice To ensure that people concerned about malpractice can get independent and confidential advice about the Act, disclosures to lawyers are protected. NHS and quangos To promote accountability in public life, the same protection as for internal disclosures applies where someone in the NHS or a public body blows the whistle direct to the sponsoring Department. There is no requirement that such concerns should be raised internally first. Regulatory disclosures Special provision is made for disclosures to bodies which are prescribed under the Act. Such disclosures will be protected where the whistleblower meets the tests for internal disclosures and, additionally, honestly and reasonably believes that the information and any allegation contained in it are substantially true. Wider disclosures Wider disclosures (eg. to the police, the media, MPs, and non prescribed regulators) are protected if, in addition to the tests for regulatory disclosures, they are not made for personal gain and if they satisfy a further two provisions. That is, the concern must have been raised with the employer or a prescribed regulator, unless, there was reasonable belief of victimisation, there was not a prescribed regulator and there was reasonable belief that there would be a cover up, and the matter was exceptionally serious. If one of these preconditions is met and the tribunal is satisfied that the disclosure was reasonable, the whistleblower will be protected. Page 14 of 18

15 Full protection Where a worker or employee is victimised for blowing the whistle in breach of the Act, they may bring a claim to an employment tribunal. Workers and employees who lose their jobs in breach of the Act will be fully compensated for the losses. Awards for victimisation short of dismissal will also be uncapped and based on what is just and equitable in all the circumstances. Gagging clauses Such clauses in employment contracts and severance agreements are void insofar as they conflict with the Act s protection. Page 15 of 18

16 Appendix 3 External Sources of Advice 1. Public Concern at Work Suite Baldwins Gardens London EC1N 7RJ Tel Fax E Mail Website (Public Concern at Work is an independent charity that provides free confidential advice for employees who wish to express concerns about serious malpractice or fraud) 2. Audit Commission The Audit Commission is an independent watchdog, driving economy, efficiency and effectiveness in local public services to deliver better outcomes for everyone. Bolton Audit Commission 2nd Floor, Aspinall House Aspinall Close Enterprise Park 3 Middlebrook Bolton BL6 6QQ Telephone: Fax: Leeds Audit Commission Kernel House Killingbeck Drive Leeds LS14 6UF Telephone: Fax: Website: 3. Care Quality Commission The Care Quality Commission is the independent regulator of health and social care in England. National Correspondence Citygate Gallowgate Newcastle upon Tyne NE1 4PA Telephone: Website Page 16 of 18

17 4. Monitor Monitor is the independent regulator of NHS foundation trusts. Monitor 4 Matthew Parker Street London SW1H 9NP Telephone: Fax: Website 5. Trade Unions for Non Medical Staff The list and addresses of all recognised trade unions may be obtained from the HR Department or the staff side secretary/staff side chair. 6. British Medical Association (BMA) Medical Staff can approach the BMA for advice on any concern. British Medical Association BMA Head Office BMA House, Tavistock Square, London WC1H 9JP Switchboard: Fax: North West Branch 35 Seymour Terrace Seymour Street Liverpool, L3 5PE Tel: Consultant and Non Consultant Career Grade Staff can also approach the Chairman of the Regional Consultants and Specialists Committee for advice regarding any concerns they may have regarding whistleblowing. The Chairman is contactable through the BMA office in Liverpool (phone number above). 7. Doctors for Doctors Doctors for Doctors has two parts to its service. The counselling service operates 24 hours a day, seven days a week. It is staffed by professional telephone counsellors who can deal with a variety of issues including the pressures and stresses of work, mental health, alcohol or drug misuse. Doctors for Doctors is an enhancement of the counselling service allowing doctors in distress or difficulty the choice of speaking in confidence to another doctor. The doctor advisers work to help enquirers to take a holistic approach to their situation, to gain insight into their problems as well as getting support and help. 8. General Medical Council Telephone: External Auditor Bolton Audit Commission 2nd Floor, Aspinall House Aspinall Close Page 17 of 18

18 Enterprise Park 3 Middlebrook Bolton BL6 6QQ Telephone: Page 18 of 18

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