Whistleblowing Policy

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1 Whistleblowing Policy Co-ordinator: Lead of Review Group Reviewer: GAPF Polices Subgroup Approver: Grampian Area Partnership Forum (GAPF) Date approved by GAPF: 9 February 2017 Review date: 9 February 2022 Uncontrolled When Printed VERSION 2 The provisions of this policy, which was developed by a partnership group on behalf of Grampian Area Partnership Forum, apply equally to all employees of NHS Grampian except where specific exclusions have been identified.

2 NHS Grampian Whistleblowing Policy This document is also available in large print and other formats and languages, upon request. Please call NHS Grampian Corporate Communications on Aberdeen (01224) or (01224) This Policy has undergone Equality and Diversity Impact Assessment. Revision History: Document Title Policy Version Date approved by GAPF Review Date 2

3 NHS Grampian Whistleblowing Policy Contents Contents Page 1. Introduction 4 2. Other Policies and Procedures 5 3. NHS Grampian s Commitment to Staff 6 4. The Confidence of Staff 6 5. Whistleblowing Champion 6 6. Independent Advice 7 7. Procedure Internal Mechanism Considering your options Stage I Stage II Stage III 9 8. How NHS Grampian will handle the matter Possible Outcomes Review and Evaluation External Mechanisms External Contacts Complaints about the Chief Executive Monitoring Oversight 12 Appendix 1(a) Stage I Flowchart 13 Appendix 1(b) Stage II Flowchart 14 Appendix 2 Record of Concern Form 15 Appendix 3 Whistleblowing Quick Reference Guide 17 Appendix 4 Further Information 18 3

4 NHS Grampian Whistleblowing Policy 1 Introduction NHS Grampian is committed to achieving the highest possible standards of service and ethical standards in health care and all aspects of practice. To achieve these ends, it encourages staff to use internal mechanisms for reporting any malpractice or illegal acts or omissions by its workers or ex-workers. This policy reflects the standards set out in the PIN Guideline published by the Scottish Partnership Forum. The intention of this policy is to encourage staff to raise concerns without fear of penalty or victimisation. Key to this is our commitment to a no blame culture and staff can be assured that concerns raised in good faith will be protected under the Public Interest Disclosure Act, 1998 (PIDA). What is Whistleblowing? A worker raising a concern about wrongdoing, risk or malpractice with someone in authority either internally and/or externally. This policy applies to all those who work for NHS Grampian: whether permanent, temporary, casual, contractors, full-time or part-time employees, self-employed, or employed through an agency or ex staff who have concerns relating to: the delivery of care; the health and safety of staff or visitors; or the impairment of the viability or integrity of the Organisation. Such concerns may relate to malpractice, including fraud, abuse in care, substantial poor performance or outcomes, danger to public safety or damage to the environment. The PIDA to which NHS Grampian is committed, ensures protection for an individual who raises a concern relating to any of the following: a criminal offence; a failure to comply with a legal obligation; a miscarriage of justice; endangering an individual s health & safety; damage to the environment; concealment of information relating to the above provided they are in the public interest as opposed to being interesting to the public. This policy should be used for any worker to raise a qualifying disclosure under the PIDA. This policy is available to all employees, workers and ex-employees of the organisation who have concerns about misconduct or wrongdoing. 4

5 Many staff will have concerns about what is happening at work. Usually these are easily resolved. However, when the concern feels serious because it is about a possible danger, professional misconduct or financial malpractice that might affect patients, colleagues, or NHS Grampian itself, it can be difficult to know what to do. Staff may be worried about raising such an issue and may think it best to keep it to themselves, perhaps feeling it is none of their business or that it is only a suspicion. Staff may also feel that raising the matter would be disloyal to colleagues, to managers or to the Board. It may be the case that a member of staff has said something but found that they have spoken to the wrong person or raised the issue in the wrong way and are not sure what to do next. NHS Grampian is committed to running the organisation in the best way possible. This is to reassure all staff that it is safe and acceptable to speak up. This will enable them to raise any concern which they may have at an early stage and in the right way. Rather than wait for proof, it is preferable if a matter is raised when it is still a concern. If a member of staff feels that something is of concern, and they feel that it is something which they think NHS Grampian should know about or look into, they should use this procedure. If, however, a member of staff wishes to make a complaint about their employment or how they have been treated, they should follow the Board s local policy developed in line with the Grievance policy or the Dealing with Bullying and Harassment policy. This can be obtained from their manager or on the intranet. This Whistleblowing Policy is primarily for individuals who work for NHS Grampian and have concerns where the interests of others or of the Board itself are at risk. If in doubt raise it! This policy does not remove the entitlements in terms and conditions of employment of some staff groups to publish and lecture without the prior consent of NHS Grampian. 2 Other Policies and Procedures NHS Grampian has a range of policies and procedures which deal with standards of behaviour at work. These include: Employee Conduct; Framework for Support for Medical and Dental Employees; Grievance; Dealing with Bullying and Harassment and Recruitment and Selection. Employees are encouraged to use the provisions of these procedures when appropriate. There may be times when your concern is not about your personal employment position and the matter needs to be handled in a different way. Examples include: malpractice, or ill treatment of a patient/client/customer by a member of staff; a criminal offence which has been committed, is being committed, or is likely to be committed; suspected fraud (please see The Prevention, Detection and Investigation of Suspected Fraud, Theft and Corruption Policy which details a number of contacts if you suspect fraud); disregard for legislation, particularly in relation to health and safety at work; 5

6 the environment has been, or is likely to be, damaged; a breach of standing financial instructions; undue favour being shown over a contractual matter; a breach of a code of conduct; instances of information on any of the above having been, being, or likely to be concealed; concerns that a patient/member of staff is being potentially radicalised. 3 NHS Grampian s Commitment to Staff The Board, the Chief Executive and the trade unions/professional organisations are committed to this policy. If a member of staff raises a genuine concern under this policy, they will not be at risk of losing their job or suffering any detriment (such as a reprisal or victimisation). NHS Grampian will not tolerate the harassment, or victimisation, of any member of staff who raises a concern (including informal pressures). NHS Grampian will treat any instances of such action as serious misconduct. Provided the staff member acts in good faith, it does not matter if they are mistaken or if there is an innocent explanation for their concerns. A member of staff raising a concern will not be asked to prove their claim. However, this assurance will not be extended to a member of staff who maliciously raises a matter they know to be untrue. 4 The Confidence of Staff With these assurances, the Board hopes that staff will raise concerns openly. However, it is recognised that there may be circumstances when staff would prefer to speak to someone in confidence first. If this is the case, the member of staff raising the concern should say so at the outset. If the organisation is asked not to disclose someone s identity, we will not do so without that person s consent unless required by law. Staff should understand that there may be times when the organisation will be unable to resolve a concern without revealing someone s identity e.g. where personal evidence is essential. In such cases, it will discuss with the member of staff whether and how the matter can best proceed. It should be remembered that if staff do not disclose their identity, it will be much more difficult for NHS Grampian to look into the matter. It will also not be possible to protect the staff member s position or give them feedback. Accordingly, a member of staff raising a concern should not assume that the Board can provide the same assurances where a concern is reported anonymously. 6

7 5 Whistleblowing Champion In line with all NHS boards in Scotland NHS Grampian has appointed a Non-Executive Board Member as the Board s Whistleblowing Champion. This role will act predominantly as an oversight and assurance mechanism. The Whistleblowing Champion will also act as a conduit to ensure that internal mechanisms within the Board are working effectively to support whistleblowing arrangements and staff in raising concerns. 6 Independent Advice If members of staff are unsure about raising a concern, they can get independent advice at any stage from their trade union/professional organisation, or from one of the organisations listed at the end of this Policy (Appendix 4). Staff should also remember that they do not need to have firm evidence before raising a concern. However, they should explain as fully as possible the information or circumstances that gave rise to the concern. General information and advice relating to the PIDA can either be obtained internally through the HR Operational Team, or from various external sources including Public Concern At Work, Scotland and the Advisory, Conciliation and Arbitration Service (ACAS). 7 Procedure 7.1 Internal Mechanism 7.1 (a) Before raising a concern under this policy, an individual should carefully consider: whether or not the concern is serious; whether or not there are issues of patient confidentiality; personal confidentiality for themselves and colleagues since anonymity may not always be possible. 7.1 (b) This policy ensures that individuals are protected from reprisals and victimisation, including unfair dismissal, as a consequence of raising a concern. This is provided that the person raising the concern: does so in good faith; reasonably believes that the concern raised, and the allegation it contains, are substantially true; does not do so for personal gain; believes that the concern is of a serious nature. 7

8 Individuals should be aware that if they maliciously raise unfounded allegations this may be treated as a disciplinary matter. However, individuals who come forward in good faith have nothing to fear and their concern will be looked into thoroughly and dealt with appropriately. It should be noted that victimising an individual who raises a serious concern in good faith will be treated as a disciplinary matter if proven. The act of discouraging someone from raising such a concern may also be treated as a disciplinary matter. 7.1 (c) An individual may raise a concern externally and still receive protection through PIDA provided that he or she: believes that if he/she were to disclose the matter to his/her employer they would be subject to a detriment; believes that evidence relating to the subject matter of the disclosure would be concealed or destroyed if disclosure were made to their employer; has already disclosed this information to their employer. 7.2 Considering your options/approach your line manager If, after due consideration of the above you decide to raise a concern, a number of options are open to you. In most cases you should approach your line manager in the first instance. However you may wish to pursue the issue through one of the alternative routes (see Appendix 1(a)) before raising the matter with your line manager. This may be done verbally or in writing. See Appendix Stage I Once you have decided that the issue of concern should be formally reported to your line manager, your manager may: deal personally with the issue; refer the issue to a more senior colleague; pursue the issue according to another relevant policy. Your line manager will inform you which course of action is being taken within 10 working days of you raising the concern formally. If for practical reasons this deadline cannot be met, you will be informed of the new timescale. While every effort will be made to deal with the issue as quickly as possible, this will not be at the expense of in-depth consideration. 8

9 Note: Appendix 1(b) illustrates Stage I and process in the form of a flow chart 7.4 Stage II If a member of staff feels unable to raise the matter with their line manager, for whatever reason, they should raise the matter with: Louise Ballantyne, Public Involvement and Feedback Manager l.ballantyne@nhs.net or Dr Stephen Stott, Associate Medical Director for Clinical Quality Assurance and Improvement sstott@nhs.net 7.5 Stage lll If these channels have been followed and the member of staff still has concerns, or if they feel that the matter is so serious that they cannot discuss it with any of the above, they should contact: Chief Executive, Medical Director/Responsible Officer, Director of Nursing, Midwifery and Allied Health Professions, or Integration Joint Boards(IJB) Chief Officers. NHS Grampian recognises its accountability within NHS Scotland. In light of this you can also contact: Scottish Government Health Directorate, St Andrew s House, Edinburgh, EH1 3DG Tel: (0131) How NHS Grampian will handle the matter Once a concern has been raised, it will be assessed and consideration will be given as to what action may be appropriate. This may involve an informal review, an internal inquiry or a more formal investigation. The member of staff raising the concern will be advised who will be handling the matter, how they can contact them, and what further assistance may be needed. The organisation will write to the member of staff summarising the concern and advising how they propose to handle it, and providing a timeframe for feedback. If the concern has been misunderstood, or there is any information missing, the member of staff should highlight this. When raising a concern, it will be helpful to know how the member of staff thinks the matter might best be resolved. If the member of staff has any personal interest in the matter, they should confirm this at the outset. If it is felt that the concern falls more properly 9

10 within the scope of one of the other of the Board s policies, this will also be explained to the member of staff. Managers will give feedback on the outcome of any investigation. It should be noted that it may not be possible to give details of the precise actions taken where this would infringe a duty of confidence owed to another person. While it cannot be guaranteed that all matters will be responded to in the way that the member of staff might wish, NHS Grampian will strive to handle the matter fairly and properly. If at any time throughout the investigation it becomes evident that formal disciplinary action may be a possible outcome, the investigation will be conducted in accordance with the provisions of the disciplinary procedure. Should it be thought necessary to suspend an employee during the course of any such investigation, the procedure outlined in the NHS Grampian Employee Conduct Policy/Framework for Support for Medical and Dental Employees will be followed. The investigation will be concluded without unreasonable delay. However, NHS Grampian allows for flexibility given the possible complexity of concerns raised. Timescales should be reasonable and communicated to all parties. At all stages of the process any employee involved will have the right to be accompanied by a colleague or trade union/professional organisation representative. 8.1 Possible Outcomes If the investigation concludes that there are grounds for further action against individuals, the appropriate policy and procedure should be followed It may also be appropriate, during the course of the investigation, to report concerns to external agencies e.g. Police Scotland, Social Services, the Scottish Environmental Protection Agency, the Health & Safety Executive etc. In such an event, it may be necessary to suspend internal investigations until the outcome of external investigations and/or criminal procedures are known Where the investigation concludes that the concerns raised are of a malicious nature, disciplinary action against the original complainant may be appropriate Where the concern is established as being unfounded, no action will be required. 9 Review and Evaluation The Record of concern form (Appendix 2) should be completed by any individual within sections 7.3 to 7.5 to whom a concern has been raised. Information from submitted forms will be collated and reported anonymously, enabling the overall picture to be monitored and managed appropriately. The policy and procedure will be subject to review and amendment through the Grampian Area Partnership Forum in the light of experience of its operation. 10

11 10 External Mechanisms 10.1 If these internal procedures work well there should be no need for any member of staff to contact external persons or agencies. If, however, an individual believes that the internal procedures have failed, or if there are exceptional circumstances, it is reasonable to contact external agencies It must be remembered that contacting an external agency, in particular the press or media, could result in a breach of confidentiality for individuals and patients. To be sure of gaining the full protection which the PIDA provides, staff should consider using internal mechanisms in the first instance rather than approaching an external agency. The choice of external agency may depend on the particular concern being raised and a list of some relevant external bodies is attached at Appendix If you decide to contact an external agency, you may wish to take advice from Human Resources, your Trade Union or Professional Organisation or the Corporate Communications Department on the best way to proceed. 11 External contacts While NHS Grampian hopes that this policy gives the reassurance needed to raise a concern internally, it recognises that there may be circumstances where a member of staff can properly report a concern to an outside body. NHS Grampian would rather staff raised a matter with the appropriate regulator than not at all. Trade unions/professional organisations will be able to advise on such a course of action. The NHSScotland Confidential Alert Line (telephone ), a dedicated service for NHS staff in Scotland, provides a confidential service to staff should they have any doubt about whether or how to raise a concern, or worry about doing so. This provides an additional safe space for staff to discuss concerns with legally trained staff and if appropriate, have these concerns passed to the appropriate Regulatory body on their behalf. Other external organisations include, but are not limited to: Regulatory Bodies; Professional Organisations; Trades Unions; Elected Representatives; Statutory Bodies; Legal; Media. 11

12 12 Complaints about the Chief Executive If the concern is specifically about the Chief Executive, then it should be made (in the first instance) to the Chair of the NHS Grampian Board, who will decide on how the investigation will proceed. 13 Monitoring Oversight The Board is responsible for this policy and will review it regularly. The operation of this policy will be monitored by the Grampian Area Partnership Forum. If members of staff have any comments or questions, these should be brought to the attention of trade union/professional organisation representatives. 12

13 Appendix 1(a) Whistleblowing Considering your options NHSScotland Confidential Alert Line Contact Human Resources or OHS Approach your Line Manager Issue of Concern Approach your Line Manager s superior Contact a Trade Union or Professional Organisation Representative Contact Public Concern at Work (see Appendix 4 for contact details) Discuss with a trusted colleague Pursue the matter through another relevant policy (found on the HR intranet) 13

14 Appendix 1(b) Whistleblowing Stage I Issue raised with line manager Submit concern formally in writing to line manager and request response Is there agreement that this is serious and in the public interest NO YES Seek advice from Public Concern at Work (see Appendix 4 for contact details) Manager takes further action based on discussion Manager asks for concern to be submitted in writing and takes further action Concern is progressed by manager, according to the relevant policy, or in discussion with senior colleague Concern unresolved contact Board member 14

15 Appendix 2 Strictly Confidential Record of concern (Whistleblowing Policy) Name of Recorder (Report Writer): Date of Meeting: Concerned Individual (Reporter may elect to be anonymous): (staff member/ex-staff member/other e.g. independent contractor, relative, advocacy worker) Reporter s Staff Group/Discipline & Service Area: Date(s)/Timescale of Incident(s): 1. Description of Concern (Examples: malpractice or ill treatment of a patient, a criminal offence is being committed, suspected fraud, disregard for health and safety at work legislation, danger to public safety where, when, etc) 2. Action Taken to Date (Examples: reported to anyone, trail, photographs taken, doctor called, etc) 15

16 3. Agreed Way Forward (Example: time to think over options, report to appropriate line manager, etc) Signed: Signed: Recorder Reporter (optional) Date: Date: This summary form should be completed by both parties. Thereafter it will be held centrally in a secure file for monitoring purposes please send completed form to the Staff Governance Manager. In addition to this form, a separate statement, providing specific details, will normally be requested. 16

17 Appendix 3 Quick Reference Guide Whistleblowing If you are worried that something wrong or dangerous is happening at work, please don t keep it to yourself. Unless you tell us about any concerns you may have about fraud, safety risks including clinical safety, or other wrongdoing, the chances are we won t find out until it s too late. As some of you may be nervous about raising such matters, here are some tips: Raise it when it s a concern we won t ask you to prove it; Keep it in perspective there may be an innocent explanation; It will help us if you can say how you think things can be put right; Stay calm you re doing the right thing; and If for whatever reason you are worried about raising it with your manager, please follow the steps shown below. How to raise a concern about serious malpractice We hope that you will feel able to tell your line manager; If for whatever reason you are uneasy about this or your manager s response doesn t seem right, you should contact: your manager s manager, Trade Union or Professional Organisation, a trusted colleague, HR Operational Team or the Senior Leadership Team; If you want to talk to them in confidence, just say so. If you prefer to put it in writing, that s fine but please tell them who you are; and If you want confidential advice first, you can talk to your local trade union/professional organisation representative. You may also wish to contact some of the independent organisations listed at the end of this policy. 17

18 Appendix 4 Further Information Further information may be available from: BSI Code of Practice on Whistleblowing Arrangements: Organisations can download a free copy of the 2008 British Standards Institution s Code of Practice on Whistleblowing Arrangements from Public Concern at Work For information about the Public Interest Disclosure Act 1998, please visit: NHSScotland Counter Fraud Service (CFS) Fraud Hotline on cfs.scot.nhs.uk Health Improvement Scotland Elliott House 8-10 Hillside Crescent Edinburgh EH7 5EA Call Audit Scotland 110 George Street Edinburgh EH2 4LH Tel:

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