Standards of Business Conduct Policy

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1 Standards of Business Conduct Policy Author Steph Edusei-Basra, Authorisation Development Lead Owner Alistair Blair, Chief Clinical Officer (designate) Date: 28/09/2012 Version 1.0 Final Previous version & Date: 0.3 Draft 9 July 2012 Equality analysis undertaken 28/09/2012 on: Approved by CCG Board on: Planned review date: September

2 Section 1 Introduction 1.1 Introduction The Standards of Business Conduct Policy has been adopted by NHS Northumberland Clinical Commissioning Group (the CCG) as part of its corporate governance framework, which requires it to issue guidance to members, officers and employees on the acceptance of gifts/hospitality and the declaration of interests It is the duty of each NHS body to maintain standards of behaviour which can help ensure delivery of its strategic objectives. The CCG is committed to ensuring the highest standards of professional and ethical conduct and this policy is intended to enable these standards to be met. This policy enables the CCG to comply with the Standards of business conduct for NHS staff, Health service guidelines HSG (93)5, 1993, the Prevention of Corruption Acts 1906 and 1916 and the Seven Principles of Public Life (The Nolan Principles) This policy applies to all employees of the CCG, to CCG governors, to primary care clinicians, managers and other appointed to positions in the management structure of the CCG, and to the partners and employees of CCG s member practices with respect to the delivery of their commissioning responsibilities as members of the CCG This policy clarifies the responsibilities of members, officers and employees to ensure that their behaviour inside and outside work, and interests outside work do not conflict or appear to conflict with their CCG position, duties and responsibilities. NHS commissioners must be impartial and honest in the conduct of their business and remain above suspicion. 1.2 Duties and Accountability Chief Clinical Officer: as the accountable officer, the Chief Clinical Officer has overall responsibility for ensuring there are systems in place to promote honest, probity and accountability throughout the CCG and to ensure that this policy is implemented. The Chief Clinical Officer will ensure that a Register of Interests is established to record formally declarations of interests of: a) the members of the group b) the members of its governing body c) the members of its committees or sub-committees and the committees or 2

3 sub-committees of its governing body d) its employees Information from the register must be included in the CCG s annual reports and will be available to the public. The Chief Clinical Officer must take reasonable steps to bring the existence of the Register to the attention of local residents and to publicise arrangements for viewing it Directors and senior managers: all directors and senior managers have a corporate responsibility to promote honesty, probity and accountability with their departments and throughout the organisation including complying fully with the requirements of this policy and current standing orders and standing financial instructions. Individual directors also have lead responsibility for specific elements of the implementation of this policy Strategic Strategic Head of Corporate Affairs: is responsible for ensuring that an annual check of declarations of interests takes place throughout the CCG and for maintaining both the register of interests and a register of gifts and hospitality Chief Finance Officer: shall ensure that all staff are made aware of the CCG policy on acceptance of gifts and other benefits in kind All members, practice representatives and staff: it is the responsibility of all staff (irrespective of grade) to ensure that they are not placed in a position which risks, or appears to risk, conflict between their private interest and their duties as a member or employee of the CCG. Certain CCG employees and practice representatives are more likely to be exposed to these circumstances due to the nature of their responsibilities, for example: a) those who commit NHS resources directly by ordering goods b) those who are involved in the process of competitive tendering c) those who indirectly commit NHS resources by the prescription of medicines and or referral to services d) those staff who may have an interest in a private nursing home and who are involved with the discharge of patients to residential facilities It is also the responsibility of staff to ensure they do not abuse their official position for personal gain or to the benefit of family or friends. Neither should they seek to advantage or foster private business, or other interests, in the course of their official duties. 3

4 1.3 Guidance for member practices It is recognised that practices are independent contractors and therefore in the course of their work as providers of primary care they must take their own responsibility for action in relation to standards of business conduct and abiding by the standards set out in their professional code of conduct However, in the delivery of their commissioning responsibilities as members of the CCG they are expected to adhere to policies of the CCG, including this policy. The overriding principle must be that they act in good faith for the benefit of their patients/service users and the CCG and not for the benefit of themselves or practice/business. 1.4 Related documents The following documents are related to this policy: a) Northumberland CCG standing orders b) Northumberland CCG standing financial instructions c) NHS North of Tyne Whistleblowing public interest disclosure policy d) NHS North of Tyne Intellectual property rights policy e) NHS North of Tyne Clinical trials policy 2 Guiding principles 2.1 The seven principles of public life (The Nolan Principles) establish expected standards of conduct for all those in public life including members and senior officers of national health service bodies. The principles are: a) Selflessness Holders of public office should act solely in terms of the public interest. They should not do so in order to gain financial or other benefits for themselves, their family or their friends. b) Integrity Holders of public office should not place themselves under any financial or other obligation to outside individuals or organisations that might seek to influence them in the performance of their official duties. c) Objectivity In carrying out public business, including making public appointments, awarding contracts, or recommending individuals for rewards and benefits, holders of public office should make choices on merit. d) Accountability Holders of public office are accountable for their decisions and actions to the public and must submit themselves to whatever scrutiny is appropriate to their office. e) Openness Holders of public office should be as open as possible about all 4

5 the decisions and actions that they take. They should give reasons for their decisions and restrict information only when the wider public interest clearly demands it. f) Honesty Holders of public office have a duty to declare any private interests relating to their public duties and to take steps to resolve any conflicts arising in a way that protects the public interest. g) Leadership Holders of public office should promote and support these principles by leadership and example 2.2 The following information is provided to guide CCG members, staff and line managers in a range of situations that may arise. Whilst the policy tries to cover as many aspects of business conduct as possible, it is recognised that issues will arise which do not fit precisely into categories detailed in this document. In such cases, employees are advised to apply the same principles which are embodied in this policy. 2.3 If in any doubt, members and staff must always try to establish in advance the validity of a particular action (e.g. the acceptance of a gift) by seeking advice from their Locality Director or line manager. Where doubts continue to exist, the offer should be politely declined. 2.4 In cases where a member or employee feels that they initially acted in good faith but, on further reflection, feel that they may have acted against the spirit of this document; they should declare as appropriate and detail the circumstances. 2.5 Gifts There are occasions when practice members (in relation to their commissioning responsibilities) or CCG employees are offered gifts. Under no circumstances should gifts of any kind be solicited. In general all gifts should be politely but firmly declined, however there are some exceptions: a) Gifts that can be accepted and do not need to be declared: i. Gifts of low intrinsic value (i.e. not exceeding 25 in value per item) such as stationery items (e.g. diaries, pens, calendars etc.) or small tokens of gratitude from patient/service users or relatives (e.g. chocolates, sweets, flowers etc.) Where these types of articles are offered and are 25 or over in value (per item), they should be politely but firmly declined. However, the items above can only be accepted if it is clear that they are in no way connected with any business arrangements between the CCG and the supplier or any party related to the supplier. 5

6 b) Gifts that can be accepted and must be declared (appendix 1) i. Several low value gifts (i.e. under 25 per item, see point 2.5.1ai above) worth a total of over 100 received from the same or closely related source within a 12 month period ii. Gifts that have been accepted (for whatever reason) that do not fall into the categories set out in a above iii. Where the employee or member is unsure whether a gift should or should not be declared iv. Where a practice member or employee has been left something in a patient s/service user s will (this should be declared even if the gift is declined). Where a patient/service user makes a member or employee aware that they intend to name the member of staff as a beneficiary in their will, the member or employee must make his/her Locality Director or line manager aware of this as soon as possible and a declaration must be made Offers of money: all offers of monetary gifts (e.g. from a service provider or patient) must be politely refused. Patients/service users can, however, be advised that they can donate money to the CCGs charitable trust funds. Further information relating to this can be found in the CCG standing financial instructions Hospitality: before any member or employee can accept an offer of hospitality (includes travel, accommodation and entertainment), the offer must be notified and discussed with their Locality Director or line manager first and the declaration form (appendix 1) completed and forwarded to the Strategic Strategic Head of Corporate Affairs. a) Hospitality offered in the course of a working day (e.g. lunch) may be accepted provided it is incidental to the business activity and not the main purpose; and is of a commensurate value to that which the CCG would provide in similar circumstances. This type of hospitality does not have to be declared. b) Events that are partly entertainment/gift and partly work related are permissible but only with prior authorisation from their Locality Director or line manager who must be confident that there is benefit to the CCG. In all circumstances (whether accepted or not) these offers must be declared (appendix 1). c) Travel/accommodation costs: offers to individuals to pay the travel or accommodation costs associated with meetings, conferences etc. can only be accepted with prior authorisation from their Locality Director or line manager who must be confident that acceptance will not go against the principles of conduct set out in 2.1 and In all circumstances (whether accepted or not) these 6

7 offers must be declared (appendix 1). d) Entertainment: in some circumstances free tickets to sporting or other entertainment events can be accepted but only with prior authorisation from their Locality Director or line manager who must be confident that acceptance will not go against the principles of conduct set out in 2.1 and and that acceptance can in no way be perceived as being biased towards the third party offering the entertainment or a conflict of interest in relation to external organisations/companies. In all circumstances (whether accepted or not) these offers must be declared (appendix 1) It should be noted that for member practices this only applies to gifts, donations and hospitality offered in their commissioning role. For example, small gifts given to the practice from patients as an appreciation are done so in the provider role and therefore not the remit of this policy. 2.6 Declaration of Interests Governing body, committee, Joint Locality Executive Board members, staff, officers and group members must declare any relevant and material interests they (or a relative or friend) have, including any company, public sector organisation, other NHS employer, voluntary organisation or other body which may compete for an NHS contract to supply either goods or services. Interest should be declared either on commencing appointment or role, or when a new interest arises using the declaration form (appendix 2), to be sent to the Strategic Strategic Head of Corporate Affairs Interests which should be regarded as relevant and material are: a) a direct pecuniary interest: where an individual may financially benefit from the consequences of a commissioning decision (for example as a provider of services). b) an indirect pecuniary interest: for example where an individual is a partner, member or shareholder in an organisation that will benefit financially from the consequences of a commissioning decision. c) a non-pecuniary interest: where an individual holds a non-remunerative or notfor-profit interest in an organisation, that will benefit from the consequences of a commissioning decision (for example where an individual is a trustee of a voluntary provider that is bidding for a contract). d) a non-pecuniary personal benefit: where an individual may enjoy a qualitative benefit from the consequence of a commissioning decision which cannot be given a monetary value (for example a reconfiguration of hospital services which 7

8 might result in the closure of a busy clinic next door to an individual s house). e) where an individual is closely related to, or in a relationship, including friendship, with an individual in the above categories If Governing Body, committee or Joint Locality Executive Board members have any doubt about the relevance of an interest, this should be discussed with the Chair of the relevant group In addition the CCG will conduct an annual declaration of interests audit whereby all governing body, committee, Joint Locality Executive Board members, practice members, practice representatives, Locality Clinical Domain Leads and other appointed clinical/primary care officers, and all staff graded 8a and above are asked to return a declaration of interests form to the Strategic Strategic Head of Corporate Affairs. Any changes to circumstances throughout the year must be declared on the form (appendix 2) and returned to the Strategic Strategic Head of Corporate Affairs. 2.7 Other considerations Preferential treatment in private transactions: individual staff must not seek or accept preferential rates or benefits in kind for private transactions carried out with companies with which they have had, or may have, official dealing on behalf of the CCG (this does not apply to concessionary agreements negotiated with companies by NHS management, or by recognised staff interests, on behalf of all staff, e.g. NHS staff benefits scheme) Contracts: all staff who are in contact with suppliers and contractors (including external consultants), and in particular those who are authorised to sign purchase orders, or place contracts for goods, materials or services, are expected to adhere to professional standards of the kind set out in the Ethical Code of the Institute of Purchasing and Supply (IPS) Favouritism in awarding contracts: fair and open competition between prospective contractors or suppliers for NHS contracts is a requirement of NHS Standing Orders and of EC directives on Public Purchasing for Works and Supplies. This means that: a) no private, public or voluntary organisation or company should be given any advantage over its competitors in respect of the awarding of contracts. This applies to all potential contractors whether or not there is a relationship between them and the NHS employers, such as a long-running series of contracts. 8

9 b) each new contract should be awarded solely on merit, taking into account the requirements of the NHS and the ability of the contractors to fulfil them. c) CCG commissioners should ensure that no special favour is shown to current or former employees or their close relatives or associates in awarding contracts to private or other businesses run by them or employing them in a senior or relevant managerial capacity. Contracts may be awarded to such businesses where they are won in fair competition against other tenders but scrupulous care must be taken to ensure that the selection process is conducted impartially and that members, officers and staff that are known to have a relevant interest play no part in the selection Warnings to potential contractors: NHS employers will wish to ensure that all invitations to potential contractors to tender for NHS business include a notice warning tenderers of the consequences of engaging in any corrupt practices involving employees of public bodies Outside employment: staff must not engage in any outside employment which may conflict with their work for the CCG. Staff should inform their line manager if they think they may be risking a conflict of interest in this area (appendix 2) and the line manager will be responsible for judging whether the interest of the CCG could be harmed in line with the principles outlined in section Intellectual Property Rights: the CCG will identify potential intellectual property rights (IPR), as and when they arise, so that it can protect and exploit them properly, and thereby ensure that it receives any rewards or benefits (such as royalties), in respect of work commissioned from third parties, or work carried out by its employees in the course of their NHS duties. Most IPR are protected by statute; e.g. patients are protected under the Patents Act 1977 which gives employees to a right to obtain some reward for their effort, and the CCG will see that this is affected. To achieve this, the CCG will build appropriate specifications and provisions into any contractual arrangements entered into before the work is commissioned, or begins. The CCG will seek legal advice if in any doubt Rewards for Initiative: rewards may be given voluntarily to employees who, within the course of their employment, have produced innovative work of outstanding benefit to the NHS. Similar rewards will be voluntarily applied to other activities such as giving lectures and publishing books and articles. 9

10 2.7.8 Rewards for collaborative research and evaluative exercises: in the case of collaborative research and evaluative exercises with manufacturers, the CCG will obtain a fair reward for the input they provide including any reasonable reward or benefits to be passed on to the employee(s) concerned. Care will be taken that involvement in this type or arrangement with a manufacturer does not influence the purchase of other supplies from that manufacturer Commercial sponsorship for attendance at courses and conferences: employees, officers and members (when on CCG related business) may accept commercial sponsorship for attendance at relevant conferences and courses, but only where the individual seeks permission from their Locality Director or line manager who must be satisfied that acceptance will not compromise purchasing decisions in any way. If accepted a declaration must be made (appendix 1) Commercial sponsorship of posts - linked deals : companies may offer, wholly or partially, to fund a post for an NHS body. The CCG will not enter into such an arrangement, unless it has been made very clear to the company concerned that the sponsorship will have no effect on purchasing decisions. Where such sponsorship is accepted, monitoring arrangements will be established to ensure that purchasing decisions are not being influenced by the sponsorship agreement. Under no circumstances will the CCG agree to linked deals whereby sponsorship is linked to the purchase of particular products, or to commissioning from particular sources Commercial in-confidence: employees, officers and members should be particularly careful of using, or making public, internal information of a commercial in-confidence nature, particularly if its disclosure would prejudice the principle of a purchasing system based on fair competition. However this should not be a cause of excessive secrecy, nor should it inhibit the free exchange of data for medical audit purposes. In all circumstances the overriding consideration must be the best interest of patients/service users Pharmaceutical collaboration: where this is proposed collaboration with a pharmaceutical company, the specific regulations incorporated in the Medicines (Advertising) Regulations 1994 and the CCG Code of practice for pharmaceutical company representatives and Northumberland CCG executive members and staff with whom they interact must be complied with. 2.8 Non-adherence to the policy 10

11 2.8.1 The CCG is committed to the successful operation of this policy document. Officers, members and employees need to be aware that any breaches of this policy will be viewed most serious and could result in disciplinary action including summary dismissal (of employees or officers) and ineligibility from practice commissioning incentive schemes (for members) Employees, officer or members who suspect other employees, officers or members of having breached this policy should speak to their Locality Director, line manager or a staff side representative about their concerns. If they feel unable to speak to their Locality Director or line manager they should contact another Locality Director or a member of the Joint Locality Executive Board directly. More information and advice can be found in the CCG s Whistleblowing Public Interest Disclosure policy. 3 Approval, Implementation and Distribution 3.1 Approval and ratification This policy was formally approved by the Joint Locality Executive Board on The policy will be reviewed every three years or as and when significant changes make earlier review necessary 3.2 Implementation Implementation of this policy will be carried out via the following arrangements: a) members and staff will be reminded periodically of their obligations under the policy and the process of making declarations of interest and declaring gifts and hospitality b) an annual collection of declarations of interest from, governing body, committee, Joint Locality Executive Board members and all staff graded band 8a and above will be carried out by the Strategic Strategic Head of Corporate Affairs c) a register of all declarations of interests, gifts and hospitality from all staff will be kept by the Strategic Strategic Head of Corporate Affairs d) each Locality Director will ensure that member practices make new staff and partners aware of this policy e) each line manager will ensure that new staff are aware of this policy 4 Monitoring Compliance 11

12 4.1 Standards and key performance indicators Key performance indicators for this policy are: a) an annual audit of declarations of interest from governing body, committee or Joint Locality Executive Board members, practice members, practice representatives, Locality Clinical Domain Leads and other appointed clinical/primary care officers and all staff graded band 8a and above b) an annual audit of declarations of gifts and hospitality from all members, officers and staff c) reminders to members, officers and staff about this policy and the importance of compliance with it are to be issued at least twice a year d) an annual report of the findings of the audits described above will be presented to the governing body. 5 References Standards of business conduct for NHS staff, Health Service Guidelines HSG(93), 1993; Commercial Sponsorship Ethical Standards for the NHS, Department of Health, November 2000; Code of Conduct for NHS Managers, Department of Health, October CCG Standing Orders and Standing Financial Instructions. Responsibilities for meeting Patient Care Costs associated with Research and Development in the NHS, Health Service Guidelines, HSG(97)32, 29 May 1997 NHS Indemnity Arrangements for Handling Clinical Negligence Claims Against NHS Staff; Health Service Guidelines, NSG(96)48, 8 Nov Institute of Purchasing and Supply Ethical Code Medicines (advertising) Regulations

13 Appendix 1 Standards of Business Conduct Declaration Form Gifts & Hospitality (Please print in BLOCK CAPITALS) Name: Job title: Practice (if appropriate): Gifts / Hospitality All gifts, hospitality, travel, accommodation or sponsorship must be declared, whether accepted or not. Your Locality Director/line manager will decide whether acceptance is appropriate. Details of gift / hospitality / sponsorship: Value (where known): Date offered: By whom: (Please give as much detail as possible) Locality Director/ line Manager to Complete NB: Acceptance must be authorised before the gift/hospitality can be taken up by the member, officer or employee Declaration is ACCEPTABLE Comments: or UNACCEPTABLE (please delete as appropriate) Signature: Print Name: Date: Please complete this form in full and send to the Strategic Strategic Head of Corporate 13

14 Affairs 14

15 Appendix 2 Standards of Business Conduct Declaration Form Interests and Secondary Employment (Please print in BLOCK CAPITALS) Name: Job title: Practice (if appropriate): As a member, officer or employee of the CCG you are required to declare any interests under the following sections in accordance with the NoT Standards of Business Conduct Policy: Business interests which are, or may be, relevant to the work of the CCG Details of any other employment you have or may undertake Please complete the relevant sections of this form. Interests relevant to the work of the CCG Please give details of any relevant business or other interests held by you or a cohabiting spouse or civil partner: Name of Organisation (if relevant): When did the interest begin? Brief Details: How is this relevant to the work of the CCG? Additional Employment There should be no conflict of interest between your CCG duties and any other job. If you have another job but there is no conflict of interest, you must still declare it below (you will not be prevented from keeping it). Employer: Type of business: Signed: Dated: Please complete this form in full and send to the Strategic Strategic Head of Corporate Affairs. 15

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